“Discovery”. New Team Member Self Learning Packet 2013. Self Learning Packet Objectives. This self learning packet will discuss AtlantiCare’s: Strategy Map Quality Improvement Process Essential Work Requirements (EWRs) Upon completion of this course, you should be able to:
New Team Member
Self Learning Packet
This self learning packet will discuss AtlantiCare’s:
Upon completion of this course, you should be able to:
KEEPING ATLANTICARE FIRST
·Customer Experience Index
·Patients Cared for by Our Physician Network
Starting at the bottom of the map, our mission is to deliver health and healing to all people through trusting relationships. This is done by living our values of safety, teamwork, integrity, respect and service (STIRS). By assuring all members of the AtlantiCare family act on our values, we are able to focus on the performance excellence commitments of our “5 Bs”. These include Best People and Workplace, Best Customer Service, Best Quality, Best Growth, and Best Financial Performance. Our attention to these details will move us closer to our vision of building healthy communities.
Consider how your work will contribute to these commitments.
AtlantiCare has a set of values that guide our actions and behaviors.
Safety is our top priority.
We work together to achieve our goals.
Our behaviors consistently reflect the highest ethical standards.
We treat each individual with dignity and compassion.
We create loyalty by delighting those we serve.
AtlantiCare Regional Health Services
AIT – AtlantiCare Information Technology
AtlantiCare Heath Solutions
AtlantiCare Health Services
AtlantiCare Regional Medical Center
AtlantiCare Health Engagement
AtlantiCare Surgery Center LLC
AtlantiCare Behavioral Health
South Jersey Oncology Property LLC
AtlantiCare Physician Group
AtlantiCare Home Care
Health Care Delivery
In line with our Strategic Objective of Best Quality, AtlantiCare constantly strives to improve how we do what we do. We regularly look for ways to save money, reduce waste, increase our customer service, and improve clinical outcomes etc. We consistently evaluate our performance measurement system for opportunities to improve while remaining flexible to change.
The PDCA Cycle
We understand that improvement does not happen by accident. That is why we use the PDCA cycle as part of our Quality Improvement Process. The PDCA Cycle emphasizes and demonstrates that improvement must begin with careful planning, followed by specific action and coordinated follow-up.
Excellent customer service is the ability of an organization to constantly and consistently exceed customer’s expectations
Customers may be called
All customers have the same expectations for service excellence
… is greatly impacted by how PEOPLE facilitate the PROCESSES to deliver PRODUCTS to the customer.
…is driven by the customer’s experience with PEOPLE, PRODUCTS and PROCESSES.
… is built whenPEOPLE make emotional connections while facilitating the PROCESSES to deliver PRODUCTS to the customer.
willingly refer other customers to AtlantiCare.
may refer other customers to our competitors.
view AtlantiCare as a partner.
view AtlantiCare as a commodity.
Determine how we deliver our service
Guide the way we should act when we are providing service
Support our mission, vision, values and the Five Bs of our Performance Excellence Commitments
Should be incorporated into all we do
You only get ONE chance to make a first impression.
This is what people or customers view about you or your business: clothes, neatness, hair, posture, calm and organized
This is the tone of your voice, pitch of voice, volume, rate, pauses, emphasis and emotion.
What we say, words we use and choose, phrasing and language.
Key Words at Key Times are the variables we plug into the AIDET formula to make our words both efficient and impactful. By taking advantage of everyday opportunities to communicate with intent, we maximize our potential for improving clinical outcomes while generating customer loyalty.
Speaking positively about coworkers, reduces patients’ anxiety about their next provider of care and puts them more at ease with the coordination of their care because it suggests strong teamwork among providers.
“Hello Mrs. Woldow. I will be your physician today. I see that Mary is your nurse. We will be working together to make sure that we deliver excellent care. I have worked with her for almost 10 years. Mary and I will take excellent care of you during your stay with us at ARMC”
Managing up also gives your co-workers a head start in winning the confidence and trust of the patient. If the patient trusts you, they will value your opinions regarding other providers. Here are some examples of managing up a coworker or department at the hospital.
“Hello Mrs. Woldow. I have ordered a CT today. Our radiology department has state of the art technology and highly skilled staff . They are aware you are coming to their department and will take good care of you during your procedure.”
Listen to their concern without interrupting them. Ask questions for clarification and to assure you understand their situation.
Recognize & Respond by rephrasing what is concerning them about the service they received.
Apologize no matter who is at fault, and never place blame.Ask what we can do to make the situation right
Correct the Failure - Brainstorm ideas with them, and select one that is appropriate and reach agreement
Appreciatethe customer by telling them that their honesty in bringing the issue forward gave us the opportunity to fix a failure
The HCAHPS survey is how CMS measures the Quality around a patient’s experience
The Survey is based on a ‘Frequency’ scale;
Always, Usually, Sometimes and Never
Only ‘Always’ answers score points; we do not receive credit for any other answers
Survey results are used to calculate a portion of our reimbursement from CMS.
HCAHPS are near me. Measurements
Management of Information
Provides AtlantiCare with system –wide services with authority to act with respect to all entities, subsidiaries and cost centers.
Responsibilities require unlimited and unrestricted access to all data during audit and investigation.
Continuous assessments of the effectiveness of AtlantiCare’s compliance and internal control environment.
Corporate Compliance – independent support function of AtlantiCare reporting directly to the Board and administratively to Corporate Counsel.
Privacy Compliance – AtlantiCare HIPAA compliance reporting directly to Corporate Counsel.
Deficit Reduction Act (DRA) of 2005.* Mandates that employees and agents be educated about the:
NJ Conscientious Employee Protection Act (CEPA)
Federal False Claims Act
Federal Program Fraud Civil Remedies Act of 1986
NJ Medical Assistance and Health Services Act
State false claims legislation
NJ Conscientious Employee Protection Act (CEPA)
Prohibits an employer from taking any retaliatory action against an employee because the employee discloses an activity that the employee reasonably believes is in violation of a law or regulation or constitutes improper quality of patient care.
* Policy distributed
Establishes standards for the transmission and usage of health care information.
Laws and Regulations
administrative & financial data
electronic formats, code sets and identifiers
Mandated by federal, state and local agencies.
OIG / OCR / IRS
CMS / EEOC / FDA
NJDOH / JCAHO
Penalties for non-compliance are significant.
Civil and criminal penalties for the organization and possibly individuals inside the organization, resulting in fines, possible termination, and prison time.
Possible exclusion from Medicaid and Medicare programs.
Obey all laws and regulations governing business conduct.
Be honest, fair, and trustworthy in all activities and relationships.
Avoid all conflicts between business and personal affairs.
Strive to be a role model for ethical conduct.
Strive to create a safe workplace .
Do not use AtlantiCare property/systems for personal use.
Protect the intellectual property of AtlantiCare and its vendors.
Audits are routine and ongoing, no expectation of privacy
Not participate in any activity that conflicts or appears to conflict with your responsibilities to AtlantiCare.
A conflict of interest occurs if the activities or personal interests appear to or directly influence the business or professional decisions required by the employee.
For example, an employee (or a family member, relative) should not:
receive a financial benefit from any decision or action he/she takes;
have a financial interest in an organization that does business or is seeking to do business with AtlantiCare;
accept or solicit gifts or entertainment or receive special discounts for the purchase of items or services for personal use from any outside organization or individual;
make a decision that results in an improper or illegal gain for the employee or a third party or is harmful to the interests of AtlantiCare.
Maintain confidentiality of all protected health information
Properly dispose of confidential information (paper, disk/electronic).
Access information on a minimum necessary /need to know level for job performance.
System access – keep user names and passwords confidential.
Security measures are in place protecting our network and information systems.
Report suspicious email messages to InfoShare Customer Service Help Desk.
Ensure competency of staff. All licenses are kept current.
Treat all patients equally in the provision of care.
Ensure all patients receive appropriate care within the scope of AtlantiCare.
NOT deny admission/testing for non-elective services based on ability to pay.
Maintain complete and accurate records of care provided.
Obtain informed, written consent prior to providing care.
Properly dispose of medical waste and hazardous materials.
Refer to the Guidelines for Reporting Compliance /Privacy Complaints/Concerns Policy
Compliance/Privacy Phone Line (609 - 407 -7788 or internally 4-7788) or online www.MyComplianceReport.com
All are documented and investigated
Corporate Compliance Director / Corporate Legal - all Corporate Compliance concerns
Chief Privacy Officer / Corporate Legal – all HIPAA concerns
Strict confidentiality protections are in place
At AtlantiCare, everyone must comply
Laws, regulatory and accreditation requirements
AtlantiCare’s Policy and Procedures
Are on the Intranet for your review *
Leadership / Compliance / Management of Information
Understanding your rights and responsibilities is the best way to safeguard our patients and customers, ourselves and our organization.
Harassment Free Workplace
In line with our Strategic Objective of Best People / Best Workplace, AtlantiCare is a Harassment Free Workplace. As an organization, we prohibit harassment based on any of the following:
We also prohibit sexual harassment which includes behavior such as unwelcome sexual advances, request for sexual favors and other lewd conduct such as lewd talk, inappropriate jokes or suggestive comments.
If you witness harassment taking place, you can file a report with your supervisor, Human Resources or any other member of AtlantiCare’s Management team.
What does Harassment mean?
“To disturb, torment or pester on a persistent basis.”
What is Sexual Harassment?
Sexual harassment includes behavior such as unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature, such as name-calling, suggestive comments, or lewd talk and jokes.
What is Sexual Harassment?
There are two forms:
Quid Pro Quo harassment ("This for That" harassment)
Environmental harassment (hostile work environment)
You are required to immediately report to Human Resources any information that reasonably indicates another health care professional has demonstrated:
The condition of being unable to perform as a consequence of physical or mental unfitness.
Human Resources can assist those with disabilities by working our reasonable accommodations
Employee Assistance Program (EAP) can assist those with mental, emotional and substance abuse through
You can reach AtlantiCare’s EAP by calling
1-800-260-0808Help is Available
You may use AtlantiCare’s “Starfish”, to find the policies on:
If you have any additional questions, please contact a representative from Human Resources.
Stroke Awareness: working our reasonable accommodations
What is F-A-S-T?
Any employee who has concerns about the safety or quality of care provided in the hospital may report these concerns to our Safety Officer, Debra Fox at 572-8310.
You may contact the New Jersey Department of Health directly with complaints:
Or by mail:
NJ Department of Health
PO Box 367 LL
Trenton, NJ 08625
You may also contact the
From 8:30 am to 5 pmSafety & Quality of Care – Reporting Concerns
Safety is one of AtlantiCare’s organizational values. With this in mind, we all play a very important role when it comes to keeping our work environment safe. In the event of a fire, it would be helpful to remember the RACE acronym:
Rescue people in immediate danger.
Alarm (pull a fire alarm and follow other departmental procedures for reporting an emergency).
Confine the fire by closing the appropriate doors.
Extinguish the fire (if it is a small one) or Evacuate to a safe location.
If it is possible for you to extinguish a fire, such as a small one in a garbage can, the PASS acronym should help you remember how to properly use a fire extinguisher.
After taking the fire extinguisher out of it’s holder and setting it onto a flat surface, hold it by it’s 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 burning material.
Magnetic Resonance Imaging (MRI) Safety with complaints:
At AtlantiCare, we use the most cutting edge equipment to provide exceptional service to our customers. One tool in our arsenal is Magnetic Resonance Imaging (MRI). Considering the fact that this piece of equipment is essentially a very large magnet, there are some very specific safety practices that must be adhered to while being around it.
Code Ten Community member injured on premise
Met Team Rapid response to assess patient
Equitable Health Care means that every person we care for, regardless of their race, culture, spoken language, or any other differences, receive an equally respectful and quality health care experience.
Culture with complaints:
We encourage an atmosphere that allows each person to:
We recognize that the culture of our customer population is changing. We also understand that disparities in healthcare delivery exist between various races. In line with our value of Respect and our Strategic Objective of Best Community Health, AtlantiCare offers the following services to help meet the language and cultural needs of our customers:
Telephonic Interpreter Services through the use of Language Line Phones
The nurse and the patient can interact with each other by using this service.
Contracted Interpreter Services
A translator can be requested to be physically present to assist in the transfer of information. Customer Relations can assist with interpreters at no cost to patients.
Patient education materials and vital consent forms can be translated.
We believe that ALL people should be treated with dignity and respect.
Best Financial Performance with complaints:
Bringing together best in quality, customer service, workplace/people and community helps us enrich our profits in a not for profit organization. Our revenue is invested in the education of our employees, improvement in services and the expansion of locations within AtlantiCare. This commitment creates our financial success.
The Emergency Medical Treatment and Active Labor Act (EMTALA) is a federal law that was adopted in 1986 and was originally designed to stop hospitals from refusing to treat patients based on their ability to pay for services. This legislation deals with various requirements around transferring patients and discharge.
Here are some of the important things to know about this law:
The documentation that should go with a patient during a transfer is supposed to be in RAAMPS format.
Reason for transfer
Acknowledgement of acceptance of patient by staff member
Method of transfer
Personnel accompanying patient
Summary of patient’s condition
This is also known as the NJ Universal Transfer Form.
Failure to comply with EMTALA can lead to several serious consequences for AtlantiCare including negative attention, increased legal scrutiny, fines and possibly loss of Medicare/Medicaid eligibility.
The information presented in this course and much more can be found in your Employee Pocket Guide as well as on the AtlantiCare Starfish.
Please be sure you take the time to complete the post-test for this course and return it to your manager. Both pieces, viewing this course and completing the post-test, are required parts of the orientation process.