Corporate Compliance Program

1. Corporate Compliance Program • To understand the ethical, professional, and legal obligations we have and our role in meeting these obligations • To promote honest, ethical behavior in the day to day operations • To identify, correct and prevent illegal conduct 1

2. Principles of Compliance • As healthcare professionals and providers, we are dedicated to caring for and improving the health and well being of the people we serve in the community • Compliance means doing what is right, not just what is required 1

3. Benefits of Compliance Program • Structure to manage compliance with laws and regulations • Potentially reduces fines and penalties if effective • Avoidance of negative publicity • Improve clinical quality and fiscal performance 1

4. Corporate Compliance • Code of conduct • Conflict of interest • Documentation and billing • Questionable behaviors 1

5. Questionable Behaviors • Discrimination and harassment • Dishonest communication • Violations of confidentiality • Conflicts of interest • Inappropriate gifts • Stealing/misuse of assets • Fraud, abuse and false claims • Improper lobbying • Misuse of proprietary information 1

6. Corporate Compliance Reporting • Report activity to immediate supervisor • Report to higher level manager • Report to Corporate Compliance Officer: Anne Mason, 821-4469 • CHS Compliance line 1-888-200-5380, 24/7, confidential and, if desired, anonymous 1

7. Language Assistance ProgramREQUIRED BY LAW • LEP Patient = non-English speaking • An interpreter must be provided to LEP patients emergency - within 10 minutes • non-emergency - within 20 minutes • CHS has phone interpreter services available 24/7 • Free of charge • CHS staff may not serve as an interpreter • Family members under the age of 16 may not be used as interpreters except in emergency situations until an interpreter is contacted 1 1

8. Language Assistance ProgramSecure an Interpreter • Identify LEP patient • Determine pt language - wall poster or brochure • CHS trained staff will contact an interpreter via instructions located at their respective workstations. • Pt will be notified of FREE interpreter service • Patients who present to security stations or front lobby should be taken to Admissions, Registration, ED, Patient Representative or Nursing Supervisor for further assistance. 1 2

9. Language Assistance ProgramChart Documentation • Any provision or refusal of LEP services MUST BE DOCUMENTED in the patient chart. • Specificdocumentationguidelines must be followed. • Documentation guidelines can be found in the Language Assistance for Limited English Proficient (LEP) Persons and Hearing Impaired Policy and Procedure and are located on Compliance 360. • Staff should always contact an interpreter to ensure quality patient care and to minimize liability to individual staff members as well as the organization. 1 3

10. 19 Bill of Rights They are posted in all patient care areas They are available in Spanish as well as English If they don’t understand their rights, someone needs to explain them Receive treatment without discrimination Receive considerate and respectful care in a clean safe environment free from unnecessary restraints Receive needed emergency care Know the names and positions of people caring for them, and refuse their treatment Know who the MD is who is in charge of your hospital care A non smoking room Receive complete information about their diagnosis, treatment and progress Receive all information for informed consent Receive all information to give informed consent regarding do not resuscitate Refuse treatment and be informed of effect Refuse to take part in research Privacy in the hospital and confidentiality of all information and records of your care Participate in decision making about their care, including discharge Review of their medical record Receive an itemized bill with explanation of charges Complain without fear of reprisal Authorize family members to visit Make known your wished regarding anatomical gifts New York State Patient Bill Of Rights 1

11. Catholic Health System RISK MANAGEMENT 1

12. 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 hospital system. 1

13. 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 1

14. FOUR ELEMENTS OF RISK MANAGEMENT Loss Prevention Educational Programs through CHS University Department specific inservices 1

15. FOUR ELEMENTS OF RISK MANAGEMENT Claims Management Investigating & reporting occurrences and claims made Assist with Summons & Complaints and Subpoenas *** REMEMBER TO NOTIFY RISK MANAGEMENT IMMEDIATELY UPON RECEIPT OF SUMMONS OR SUBPOENA Assist with discovery requests for lawsuits 1

16. FOUR ELEMENTS OF RISK MANAGEMENT Risk Financing Obtaining & maintaining appropriate insurance coverage HPL (Healthcare Professional Liability) GL (General Liability) D&O (Directors & Officers) Property & Casualty Auto Crime Fiduciary (Finance) 1

17. What is an Occurrence? 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. 1

18. What is anOccurrence? An occurrence is not consistent with the accepted standard of care or the routine operation of a facility and has the potential to or already has had an untoward effect on patient care. 1

19. What are sources of an Occurrence? Patients Visitors Patient/Family Complaints Security reports Equipment “failure” 1

20. What is an Occurrence Report? An occurrence report is a factual account of the details of an occurrence. It is prepared and reviewed for the purpose of enhancing the quality of patient care, providing a safe environment, and identifying potential liability. 1

21. What is the purpose of an Occurrence Report? • Enhance the quality of patient care • Assist in providing a safe environment • Quick notice of potential liability 1

22. 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 1

23. What happens to the Occurrence Report? The completed Occurrence Report is to be forwarded to the Department Manager Who will investigate the occurrence and forward to either PI or Security as indicated in the Risk Management process 1

24. Risk Management Process Patient and visitor safety are assessed from both clinical and environmental perspectives Notify Performance Improvement of patient occurrences Notify Security of visitor or property occurrences Risk Management will be notified by PI or Security and will participate in evaluation of occurrence Risk management will report occurrences to insurance carrier in cases of potential liability Risk Management will manage claim as indicated 1

25. 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 1

26. 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. 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.

27. EMTALA REGULATIONS 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 1

28. Catholic Health System RISK MANAGEMENT DEPARTMENT Carol Ahrens, RN, BSN 821-4462 Director, Risk Management Joanne Ricotta, RN, BSN 821-4463 Risk Management Coordinator Linda McGavin 821-4467 Risk Management Technical Assistant Valerie Pizarro 821-4468 Administrative Assistant 1

29. Violence in the Workplace 1

30. Introduction • According to the Bureau of Labor Statistics (BLS), 2,637 nonfatal assaults on hospital workers occurred in 1999. • Rate in hospitals is 8.3 assaults per 10,000 workers *(2000 statistics report increase to 25 per 10,000) • Rate in private sector industry is 2 per 10,000 workers 1

31. Introduction • Violence takes place • During times of high activity such as meal time or visiting hours or patient transportation • When service is denied • When a patient is involuntarily admitted • When limits are set regarding eating, drinking, tobacco or alcohol use 1

32. What is Workplace Violence?? • Wide range from offensive or threatening language to homicide • NIOSH (National Institute for Occupational Safety and Health) defines workplace violence as violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty. 1

33. Examples • Threats: Expressions of intent to cause harm, including verbal threats, threatening body language, and written threats. • Physical assaults: Attacks ranging from slapping and beating to rape, homicide, and use of weapons such as firearms, bombs, or knives. • Muggings: Aggravated assaults, usually conducted by surprise and with intent to rob. 1

34. Case Reports • An elderly patient verbally abused a nurse and pulled her hair when she prevented him from leaving the hospital to go home in the middle of the night. • An agitated psychotic patient attacked a nurse, broke her arm, and scratched and bruised her. • A disturbed family member whose father had died in surgery walked into the E.D. and fired a handgun, killing a nurse and an EMT and wounding a physician. 1

35. Case Reports • Workplace violence in general is most often related to robbery • Workplace violence in hospitals usually results from patients and occasionally from family members who feel frustrated, vulnerable, and out of control. 1

36. Who is at Risk?? • Nurses and nursing assistants have the most direct contact with patients and are at a high risk. • Other hospital personnel includes emergency response personnel, hospital safety officers, and all health care providers. 1

37. Where May Violence Occur?? • Anywhere in the hospital but it is most frequent in the following areas: • Psychiatric wards • Emergency rooms • Waiting areas • Geriatric units 1

38. What are the Effects of Violence?? • Effects can range in intensity and include: • Minor physical injuries • Serious Physical injuries • Temporary and permanent physical disabilities • Psychological trauma • Death 1

39. Effects of Violence • Violence can have a negative organizational outcome reflected by: • Low morale • Increased job stress • Increased worker turnover • Reduced trust of management or co-workers • Hostile working environment 1

40. Risk Factors • Working directly with violent people; those under the influence of drugs, alcohol or have a history of violence or psychotic diagnosis • Working when understaffed • Transporting patients • Long wait for service • Overcrowded, uncomfortable waiting rooms • Working alone 1

41. Risk Factors • Poor environmental design • Inadequate security • Lack of guidelines for preventing and managing crisis • Drug and alcohol abuse • Access to firearms • Unrestricted movement of the public • Poorly lit corridors, rooms, parking lots 1

42. General Prevention Strategies • Environmental: • Alarms • Security devices • Escorts to parking lots at night • Good lighting • Design waiting areas • Staff restrooms and exits • Enclosed nurses’ stations 1

43. General Prevention Strategies • Administrative controls: • Staffing patterns to prevent personnel from working alone • Prevent patient waiting time • Restrict movement of public in hospitals • Security personnel alert system 1

44. General Prevention Strategies • Behavioral Modifications • recognizing and managing assaults • resolving conflicts • maintaining hazard awareness 1

45. Dealing with violence • Provide open communication • Develop written procedures for reporting and responding to violence • Offer and encourage counseling 1

46. Safety Tips • Watch for signals of impending violence: • Verbally expressed anger and frustration • Body language such as threatening gestures • Signs of drug or alcohol use • Presence of weapons 1

47. Diffusing Anger • Present a calm, caring attitude • Don’t match the threats • Don’t give orders • Acknowledge a person’s feelings • Avoid behavior that may be interpreted as aggressive 1

48. Be Alert • Evaluate when you enter a room or begin to relate to a patient or visitor • Be vigilant throughout the encounter • Don’t isolate yourself with a potentially violent person • Keep an open path for exiting 1

49. To Diffuse the Situation QUICKLY.. • Remove yourself from the situation • Call security for HELP • Report any violent incidents to management 1

50. Strategies that have worked… • Metal detector in a Detroit hospital during a 6 month period prevented entry of: • 33 handguns • 1,324 knives • 97 mace sprays 1