Catholic Health n Welcome to the first part of your orientation to Catholic Health. n Please review the following slides. If you have questions regarding.

Catholic HealthCatholic Health

Welcome to the first part of your orientation Welcome to the first part of your orientation to Catholic Health.to Catholic Health.

Please review the following slides. If you Please review the following slides. If you have questions regarding the material please have questions regarding the material please bring them up when you attend you in class bring them up when you attend you in class general orientation session.general orientation session.

Catholic Health Catholic Health Corporate ComplianceCorporate Compliance

Anne Mason

Compliance &

Privacy Officer

Principles of Principles of Corporate ComplianceCorporate Compliance

• Promotes Ethical, Professional, and Legal conduct

• “Doing what is right”

• Defines Responsibility/Accountability

• Supports CHS Standards

• Assurance of Quality Care

Catholic Health SystemCatholic Health SystemStandardsStandards

Attain Compliance by:

• Embracing our Mission and Values

• Adherence to Policy and Procedures Found in Compliance 360

• Maintaining High Standards of Business and Ethical Conduct

Important Keys to CHS Important Keys to CHS Corporate ComplianceCorporate Compliance

Standards of ConductDeal openly and honestly with others

Maintain high standards of conduct in accordance to the CHS mission, directives of the Catholic Church, and applicable

federal, state and local laws and regulations

Conflict of InterestWe have a responsibility to act on the best interests of Catholic

Health. We need to avoid situations that lead to actual or perceived conflicts of interest

Documentation and BillingMust be accurate and complete

Catholic Health SystemCatholic Health SystemStandards of ConductStandards of Conduct

Associate Compliance Guidebook

provides information on the Standards of Conduct

and is available on CHS website

An observation of failure to follow Standard of Conduct, Policy or Procedures, or observation of an error requires reporting.

Associates can face disciplinary action and even termination for failure to report such events.

Catholic Health SystemCatholic Health SystemStandards of ConductStandards of Conduct

All associates are expected to follow standards for:• Legal and Regulatory Compliance• Business Ethics• Conflict of Interest• Appropriate Use of Resources• Confidentiality• Professional Conduct• Responsibility

And follow the Code of Ethics

Gifts and other Free itemsGifts and other Free items

• Associates may NOT accept any cash gifts or cash equivalent gifts (gift cards) from any person or business conducting or seeking to conduct business with CHS

• Prior to receiving work related gifts, social or entertainment events, or free meals

associates must consult with their supervisor.

See CHS Policy for further information

Conflict of InterestConflict of InterestIf working on behalf of CHS do your actions or activities result in

personal gain or advantage, potential adverse effect for CHS, or the potential to interfere with professional judgment, objectivity or ethical responsibilities?

Potential Conflicts of Interest Relationships

include financial relationship for yourself or your immediate family member or secondary employment

– Consultant– Speakers’ bureau– Advisory Panel– Administrative positions with Pharm or DME– Third party payor– Other entities doing business with CHS

All potential Conflicts of Interest must be reported

Insufficient or InaccurateInsufficient or InaccurateDocumentationDocumentation

It is fraudulent to either document services that were not performed or to submit claims for services without appropriately documenting those services.

• Missing clinical notes (dates, signatures, orders, care or service rendered) or test results

• Incomplete, or illegible documents• Improper billing and coding

can be interpreted as fraud or abuse and lead to a

false claim with the government resulting in penalties.

Reimbursement can only be sought for services or items that have been provided and appropriately documented.

If it’s not documented, it’s not done

False Claims ActFalse Claims ActGoverns Fraud, Waste & AbuseGoverns Fraud, Waste & Abuse

It is a crime to knowingly make a false record, file, or submit a false claim with the government for payment

A false claim can include billing for service that:• was not provided or documented• not ordered by a physician• was of substandard quality • Improperly coded or billed

It is also unlawful to improperly retain overpayments

Allows for Qui Tam Relator –notification to government with protection(Whistleblower provision)

Medicare Conditions of Medicare Conditions of ParticipationParticipation

Government Sanctions

• Individuals or entities can be excluded from participation in Medicare and Medicaid programs.

• CHS must not submit any claims to Medicare and/or Medicaid in which a sanctioned individual

or entity provided care or services.

• If sanctioned, the person must provide notification immediately to the Compliance Officer.

Providing Providing High Quality Services High Quality Services

and Upholding Patient’s Rightsand Upholding Patient’s Rights

• Follow CHS Policies and Procedures

• Offer Language Assistance Services

to those in need

• Ensure patient privacy and confidentiality

is maintained (HIPAA and HITECH regulations)

Catholic Health Catholic Health Compliance PoliciesCompliance Policies

Compliance Policies and Procedures are available on Compliance 360 (or in an on-site reference manual)

and apply to all CHS associates

Additional compliance policies are also applicable to: – Home Care– Clinical Laboratory– Physician Practices– Nursing Facilities– Coding & Billing– Home Health Agency– PACE Program

Language Assistance Language Assistance ProgramProgram

• Ensures that limited English proficiency, or hearing impaired persons utilizing CHS services are able to understand and communicate with CHS associates and physicians

• Provided FREE of charge to the patient

Language Assistance Program Policy is found in Compliance 360

Language Assistance Language Assistance ProgramProgram

• Mandatory service by law

• Family may NOT routinely interpret

• Offered upon initial contact AND every time medical information is provided

• Documentation is vital to compliance

See Policy for additional information

HIPAA/ HITECHHIPAA/ HITECH

HEALTH

INSURANCE

PORTABILITY

ACCOUNTABILITY

ACTand HITECH

Health Information Technology for Economic and Clinical Health Act

Privacy and Security Policies are in Compliance 360

What is Protected by HIPAA?What is Protected by HIPAA?

Individually identifiable health information

Also known as

Protected Health Information (PHI)

Transmitted or maintained in any

form or medium

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

Names Full face photos Medical Record Number Health plan Number Account Numbers Certificate/License Numbers Vehicle identifiers E-mail and web addresses

Biometric Identifiers Geographic subdivisions

smaller than a state All elements of dates

related to birth date, admission, discharge, or date of death, ages over 89

Telephone and fax numbers Social Security Number

Any other unique identifying data

What Information Can What Information Can Providers Share?Providers Share?

for:

Treatment, Payment or

Health Care Operations

• Only access portions of PHI necessary to carry out your duties or to fulfill request

• Disclose minimum necessary for your job function based on need for the information

• If unable to obtain patient consent, may use professional judgment to share information with a patient’s family and friends

HIPAA SafeguardsHIPAA Safeguards

• Be aware of surroundings– Be conscious of who is in the immediate area when

discussing sensitive patient information or at your computer terminal

• Secure area when not attended– Close out of computer screens containing PHI before leaving

the area– Close medical records/chart when not in use– Do not allow other associates to utilize your ID and

password– Don’t leave papers with PHI in plain view– Report theft or loss of computer devices immediately

Additional Additional HIPAA SafeguardsHIPAA Safeguards

• Telephones- Be careful with phone call pertaining to patient information

• Fax machines and Scanners- Pick up faxed or printed PHI immediately- Use fax cover sheet, verify # & receipt - Scan PHI only to CHS e-mail accounts

• E-mail- Make sure to encrypt if being sent outside CHS- Careful forwarding and replying

• Mail- Double check name/address and

material prior to sending

Sending e-mail with Sending e-mail with Sensitive InformationSensitive Information

All e-mails sent to a CHS web address are encrypted and therefore secure.

Each e-mail sent outside the CHS system,

will need to be encrypted if it contains sensitive information.

For instructions on a sending external encrypted

email type “encryption” in the search box of Compliance 360.

UNAUTHORIZED ACCESSING AND UNAUTHORIZED ACCESSING AND DISCLOSURE OF PATIENT DISCLOSURE OF PATIENT

INFORMATIONINFORMATIONCuriosity can be a normal human trait

– However accessing health information on yourself, family members, friends, co-workers, persons of public interest or any others that you are not involved in the care of or …

– Disclosing PHI inappropriately

are...VIOLATIONS of HIPAA

Individuals do NOT have the right

to look up their own health records

Your computer use can be monitored

Other Catholic HealthOther Catholic HealthCompliance ConcernsCompliance Concerns

• Lack of integrity • Ethical concerns• Theft or misuse of services• Improper Political Activity• Breech of Corporate Confidentiality• Improper use of Proprietary Info.• Environmental Health and Safety Issues• Dishonest Communication (spoken or documents)• Improper Business Arrangements• Failure to follow Record Retention policy• Receipt of incentives for patient referrals

The Associate Guidebook or your supervisor can provide additional info.

3 Steps for Reporting3 Steps for ReportingCHCH ComplianceCompliance Concerns Concerns

Immediate supervisor or appropriate department

Higher level manager

Compliance Officer

Compliance Line 1-888-200-5380 available 24/7Confidential and Anonymous (if desired)

Report behavior issues, HR policy violations, and union contract matters to Human Resources

Catholic Health Catholic Health Non-Retaliation PolicyNon-Retaliation Policy

• Protects associates from adverse action when they do the right thing and report a genuine concern

• Reckless or intentional false accusations by CHS associates are prohibited

• Reporting the possible violation does not protect the constituent from the consequences of their own violation or misconduct

Associates have a duty to report HIPAA/Compliance concerns

Catholic HealthCatholic HealthAssociate’s ResponsibilityAssociate’s Responsibility

• Upholding CHS Mission and Values, Adhering to Code of Conduct, Policies & Procedures, and the Law

• Completing education and employment requirements

• Constant Monitoring for Concerns

• Duty to Report Concerns and Support Non-retaliation

• During an Investigationo be truthful o preserve documentation or records relevant to ongoing

investigations

Possible Consequences Possible Consequences for Non-Compliance for Non-Compliance

For the Associate and CHS Managers/Supervisors/Administrators

• Fines and Prison sentences

• Corrective Action includes termination of employment for violations or failure to report concerns

For Catholic Health System

• Exclusion from government funded insurance programs (Medicare/Medicaid)

• Fines

Things to RememberThings to Remember

• Adhere to CHS code of conduct,policies & procedures, and other standards

• Duty to report Compliance/HIPAA concernsas soon as aware of situation

• Do the right thingapply ethical decision making

• If uncertain…Always Seek Knowledge (A.S.K.)

Use Associate Booklet as reference on CHS website

CHS ContactsCHS Contacts

Compliance/HIPAA Privacy Officer Anne Mason 821-4469

CHS HIPAA Hotline 862-1790

HIPAA Security AnalystSally O’Brien 862-1938

Corporate Compliance Hotline 1-888-200-5380 (available 24/7)

All reports are confidential

New York State Patient Bill Of New York State Patient Bill Of RightsRights

19 Bill of Rights19 Bill of Rights

They are posted in all They are posted in all patient care areaspatient care areas

They are available in They are available in Spanish as well as EnglishSpanish as well as English

If they don’t understand their rights, If they don’t understand their rights, someone needs to explain themsomeone needs to explain them

Receive treatment without discriminationReceive treatment without discrimination Receive considerate and respectful care in a Receive considerate and respectful care in a

clean safe environment free from clean safe environment free from unnecessary restraintsunnecessary restraints

Receive needed emergency careReceive needed emergency care Know the names and positions of people Know the names and positions of people

caring for them, and refuse their treatmentcaring for them, and refuse their treatment Know who the MD is who is in charge of Know who the MD is who is in charge of

your hospital careyour hospital care A non smoking roomA non smoking room Receive complete information about their Receive complete information about their

diagnosis, treatment and progressdiagnosis, treatment and progress Receive all information for informed Receive all information for informed

consentconsent Receive all information to give informed Receive all information to give informed

consent regarding do not resuscitateconsent regarding do not resuscitate Refuse treatment and be informed of effectRefuse treatment and be informed of effect Refuse to take part in researchRefuse to take part in research Privacy in the hospital and confidentiality of Privacy in the hospital and confidentiality of

all information and records of your careall information and records of your care Participate in decision making about their Participate in decision making about their

care, including dischargecare, including discharge Review of their medical recordReview of their medical record Receive an itemized bill with explanation of Receive an itemized bill with explanation of

chargescharges Complain without fear of reprisalComplain without fear of reprisal Authorize family members to visitAuthorize family members to visit Make known your wished regarding Make known your wished regarding

anatomical giftsanatomical gifts

Catholic Health Catholic Health

RISK MANAGEMEN

T

What is “Risk Management”?

Risk Management is the systematic review

of events that present a potential for harm and could result in loss for the

system..

FOUR ELEMENTS OF RISK MANAGEMENT

Risk Identification

Review Occurrence Reports Review Patient/Visitor Complaints Participate in Root Cause Analysis Review concerns expressed by CHS staff

Loss Prevention

Educational Programs through CHS University Department specific inservices

FOUR ELEMENTS OF RISK MANAGEMENT

FOUR ELEMENTS OF RISK MANAGEMENT

Claims Management

Investigating & reporting occurrences and claims made to insurance carriers

Assist with discovery requests for lawsuits

Claims Management

Assist with Summons & Complaints and Subpoenas

**NOTIFY RISK MANAGEMENT IMMEDIATELY

UPON RECEIPT OF A SUMMONS OR SUBPOENA

Claims Management

Within CHS, a process server is to be directed to Administration of the facility in order to serve a Summons or a Subpoena. (HIM may accept subpoenas for hospital records)

***INDIVIDUAL DEPARTMENTS SHOULD NOT ACCEPT,

EVEN IF IT IS FOR SOMEONE IN THE DEPT

FOUR ELEMENTS OF RISK MANAGEMENT

Risk FinancingObtaining & maintaining

appropriate insurance coverage:

HPL (Healthcare Professional Liability) GL (General Liability) D&O (Directors & Officers) Property & Casualty Auto CrimeFiduciary (Finance)

OCCURRENCE REPORTING

An occurrence is an event that was unplanned, unexpected and unrelated to the natural course of a patient’s disease process or routine care and treatment.

What are sources of an

Occurrence?

Patient harm/potential for harm like Patient harm/potential for harm like

falls, med errorsfalls, med errors Visitor injuryVisitor injury Patient related equipmentPatient related equipment

“ “failure”failure”

What are sources of an

Occurrence?

Security issues like elopement, crime,Security issues like elopement, crime,

altercationsaltercations Lost or damaged propertyLost or damaged property

Enhance the quality of patient care

Assist in providing a safe environment

Quick notice of potential liability

What is the purpose of an Occurrence Report?

Who can complete an Occurrence Report?

Any associate or physician who discovers, witnesses or to whom an

occurrence is reported, is responsible for documenting the event

immediately by means of the Occurrence Report. Anyone who

requires assistance should contact the department manager.

DO NOT MAKE COPIES OF AN OCCURRENCE REPORT

What happens to the Occurrence Report?

The completed Occurrence Report is to be forwarded

to the Department ManagerWho will investigate the

occurrence and forward to either Quality & Patient

Safety Dept or Security as indicated in the

Risk Management process

Risk Management Process

Patient and visitor safety are assessed from both clinical and

environmental perspectives

Notify Quality & Patient Safety of patient occurrences Notify Security of visitor or property occurrences Risk Management will be notified by QPS or Security and will participate in evaluation of occurrence Risk Management will report occurrences to insurance carrier in cases of potential liabilityRisk Management will manage claim as indicated

Documenting an Occurrencein the medical record

•Date (MM/DD/YY) and time (military)•State facts, be clear and concise•Your own observations•If event described to writer, use quotes or “according to…”•Do not place blame in the record•DO NOT REFER TO OCCURRENCE REPORT IN THE MEDICAL RECORD

EMTALA REGULATIONS

EMTALA is the Emergency Medical Treatment and Active Labor Act (aka COBRA)

EMTALA provides a Guideline for safely and appropriately transferring patients in accordance with Federal regulations.

EMTALA REGULATIONS

The law provides for a medical screening exam (MSE) to all individuals seeking emergency services on hospital property. Hospital property includes the driveway, parking lot, lobby, waiting rooms and areas within 250 yards of the facility.If an emergency medical condition is found, it will be stabilized within the hospital’s ability to do so, prior to the patient’s transfer or discharge.If a patient does not have an emergency medical condition, EMTALA does not apply.

*** IMPORTANT: NEVER SUGGEST THAT A PATIENT GO ELSEWHERE FOR

TREATMENT

IDENTITY THEFT

Fair and Accurate Credit Transactions Act of 2003

or“RED Flag Rules”

Hospitals that maintain covered accounts must develop and implement written policies and procedures to identify, detect, prevent, and mitigate identity theft.

IDENTITY THEFT“RED FLAGS”

•Alerts, Notifications, Warnings •Presentation of Suspicious information •Suspicious Activity•Notice from patient, law enforcement, etc

**Patient Access, Health Information, Finance, IT Depts primarily involved

IDENTITY THEFT

You can help reduce opportunities for Identity Theft by keeping PHI confidential

and out of public view.

If you believe someone is presenting suspicious documents or acting in a

suspicious manner, notify your supervisor who will notify Risk Management

Catholic Health Catholic Health RISK MANAGEMENT

DEPARTMENT

Carol Ahrens, RN, BSN 821-4462Director, Risk Management

Joanne Ricotta, RN, BSN 821-4463Risk Management Coordinator

Linda McGavin 821-4467Risk Management Technical Assistant

Valerie Pizarro 821-4468Legal Services Administrative Assistant

Violence in the WorkplaceViolence in the Workplace

What is Workplace Violence??What is Workplace Violence??

NIOSH (National Institute for Occupational NIOSH (National Institute for Occupational Safety and Health) defines workplace Safety and Health) defines workplace violence as violent acts (including physical violence as violent acts (including physical assaults and threats of assaults) directed assaults and threats of assaults) directed toward persons at work or on duty.toward persons at work or on duty.

Types of Violent ActsTypes of Violent Acts

Threats: Expressions of intent to cause harm, Threats: Expressions of intent to cause harm, including verbal threats, threatening body including verbal threats, threatening body language, and written threats.language, and written threats.

Physical assaults: Attacks ranging from slapping Physical assaults: Attacks ranging from slapping and beating to rape, homicide, and use of and beating to rape, homicide, and use of weapons such as firearms, bombs, or knives.weapons such as firearms, bombs, or knives.

Muggings: Aggravated assaults, usually conducted Muggings: Aggravated assaults, usually conducted by surprise and with intent to rob.by surprise and with intent to rob.

Who is Violent?Who is Violent?

Workplace violence in hospitals usually Workplace violence in hospitals usually results from patients and occasionally from results from patients and occasionally from family members who feel frustrated, family members who feel frustrated, vulnerable, and out of control.vulnerable, and out of control.

When Does Violence occur?When Does Violence occur?

Violence takes placeViolence takes place– During times of high activity such as meal time During times of high activity such as meal time

or visiting hours or patient transportationor visiting hours or patient transportation– When service is deniedWhen service is denied– When a patient is involuntarily admittedWhen a patient is involuntarily admitted– When limits are set regarding eating, drinking, When limits are set regarding eating, drinking,

tobacco or alcohol usetobacco or alcohol use

Who is at Risk??Who is at Risk??

Hospital personnel having direct contact Hospital personnel having direct contact with patients and families are at increased with patients and families are at increased risk. risk.

Case ReportsCase Reports

An elderly patient verbally abused a nurse and An elderly patient verbally abused a nurse and pulled her hair when she prevented him from pulled her hair when she prevented him from leaving the hospital to go home in the middle of leaving the hospital to go home in the middle of the night.the night.

An agitated psychotic patient attacked a nurse, An agitated psychotic patient attacked a nurse, broke her arm, and scratched and bruised her.broke her arm, and scratched and bruised her.

A disturbed family member whose father had died A disturbed family member whose father had died in surgery walked into the E.D. and fired a in surgery walked into the E.D. and fired a handgun, killing a nurse and an EMT and handgun, killing a nurse and an EMT and wounding a physician.wounding a physician.

Where May Violence Occur??Where May Violence Occur??

Anywhere in the hospital but it is most Anywhere in the hospital but it is most frequent in the following areas:frequent in the following areas:– Psychiatric wardsPsychiatric wards– Emergency roomsEmergency rooms– Waiting areasWaiting areas– Geriatric unitsGeriatric units

What are the Effects of What are the Effects of Violence??Violence??

Effects range in intensity and may include:Effects range in intensity and may include:– Minor physical injuriesMinor physical injuries– Serious Physical injuriesSerious Physical injuries– Temporary and permanent physical disabilitiesTemporary and permanent physical disabilities– Psychological traumaPsychological trauma– DeathDeath

Effects of ViolenceEffects of Violence

Violence can have a negative effect on an Violence can have a negative effect on an organization as reflected by:organization as reflected by:– Low moraleLow morale– Increased job stressIncreased job stress– Increased worker turnoverIncreased worker turnover– Reduced trust of management or co-workersReduced trust of management or co-workers– Hostile working environmentHostile working environment

Risk FactorsRisk Factors

Contact with violent people or those with history Contact with violent people or those with history of violenceof violence

Contact with those under the influence of drugs Contact with those under the influence of drugs and/or alcoholand/or alcohol

Contact with people having psychotic diagnosesContact with people having psychotic diagnoses Contact while transporting patientsContact while transporting patients Contact with people perceiving a long wait for Contact with people perceiving a long wait for

serviceservice Working aloneWorking alone

Safety TipsSafety Tips

Watch for signals of impending violence:Watch for signals of impending violence:– Verbally expressed anger and frustrationVerbally expressed anger and frustration

– Body language such as threatening gesturesBody language such as threatening gestures

– Signs of drug or alcohol useSigns of drug or alcohol use

– Presence of weaponsPresence of weapons

Be AlertBe Alert

Assess current demeanor when you enter a Assess current demeanor when you enter a room or begin to relate to a patient or visitorroom or begin to relate to a patient or visitor

Be vigilant throughout the encounterBe vigilant throughout the encounter Don’t isolate yourself with a potentially Don’t isolate yourself with a potentially

violent personviolent person Keep an open path for exitingKeep an open path for exiting

Diffusing AngerDiffusing Anger

Present a calm, caring attitudePresent a calm, caring attitude

Don’t match the threatsDon’t match the threats

Avoid giving commandsAvoid giving commands

Acknowledge a person’s feelingsAcknowledge a person’s feelings

Avoid behavior that may be interpreted as Avoid behavior that may be interpreted as aggressiveaggressive

If potential for violence occursIf potential for violence occurs

Remove yourself from the situationRemove yourself from the situation

Call security for HELP if neededCall security for HELP if needed

Report any potential or actual violent Report any potential or actual violent incidents to dept managerincidents to dept manager

SummarySummary

No universal strategy exists to prevent No universal strategy exists to prevent violenceviolence

All hospital workers should be alert and All hospital workers should be alert and cautious when interacting with patients and cautious when interacting with patients and visitorsvisitors

Staff need to be aware of polices and Staff need to be aware of polices and procedures relating to violence preventionprocedures relating to violence prevention

‘The process of transforming CHS into

an organization with a superior ability to

deliver patient-centered, quality,

compassionate healthcare through

outstanding professionals and

innovative technology.’

Welcome to Equinox

Equinox - Why? Individual Hospitals – “grew-up” with their

own process, culture, technology Need for Electronic Health Record (EHR)

Improve Quality Enhance Patient Safety

Equinox – How? Comprehensive effort to standardize and

improve processes Standardized Clinical Practices

New and innovative technology like Soarian

Welcome to Equinox

Equinox - When? Now! Process started in 2004 and is

ongoing Strategic Alliance with Siemens Medical

Solutions – 10 year agreement Drive toward “meaningful use” of EHR

Equinox – Who? Everyone – directly and indirectly!

Welcome to Equinox

Examples of Equinox in Action: Soarian Clinical Technologies Clinical Standardization Process Financial Process Redesign Mercy Hospital Emergency Center

Process – New triage/registration Culture – Patient-centered focus Technology – Computers at the bedside,

integrated wireless communication

Welcome to Equinox

Your Role… Stay informed Ask questions Identify ways to “do it better” always

with the patient in mind Embrace change!

Welcome to Equinox

Questions - contact….

[email protected]