Directions

1. Directions • Welcome to Bay Regional Medical Center • You are responsible for the information contained in this orientation • Review all of the following information • When you are finished follow directions on last slide. • You may print a certificate indicating completion of required on-line orientation. (for individuals not participating in “on-line digital documentation this certificate must be presented to individual you report to at BRMC

2. Bay Regional Medical Center Student Orientation

3. Mission McLaren Health Care Corporation, through its affiliates, will be Michigan’s best value in healthcare as defined by quality, outcome and cost

4. Vision To be the healthcare system of choice for : Employees Physicians Patients

5. Core Values • Patients are the reason we exist • People are the source of our success • Each person is unique, is to be valued, and will be treated with dignity and respect • Our community is whom we serve • Strategic Initiatives: Customer service, Quality, Financial, Human Resources, Market Growth and Physicians

6. Bay Regional Medical Center System-wide Emergency Codes 2009

7. Code Red – Fire Code Weather Alert – Tornado/Severe Weather Watch Code Weather – Tornado/Severe Weather Warning Code Blue – Cardiac Arrest Adult Code Blue Pediatric – Cardiac Arrest Pediatric Code Triage External Alert – Potential External Disaster Code Triage External – External Disaster Code Triage Internal – Internal Disaster Code Yellow Alert – Bomb threat has been received Code Yellow – Suspicious item has been found Code Pink – Infant Abduction Code Purple – Pediatric Abduction Code Orange – Hazardous Material Response Code Green – Biological/Chemical Response Code Silver – Hostage Situation’ Dr. Strong – Additional personnel needed Rapid Response Team – Multi-disciplinary emergency team Stroke Response Team – Stroke patient Dr. Heart – Acute Myocardial Infarction Condition H – Family/Patient initiated Rapid Response Code Clear – All Clear BRMC Emergency Codes

8. Important Steps in an Emergency • Stay in your department/unit. If away, return immediately. Assess situation, be alert to surroundings, protect your patients. • Refer to your department/unit/hospital emergency plan. Maintain communication with RN responsible for your patient and rest of staff.

9. Code Red (Fire) • Return to department/unit immediately RACE • Rescue those in danger • Activate fire alarm • Confine the fire by closing doors • Extinguish fire (if small)/Evacuate PASS • Pull pin on extinguisher • Aim • Squeeze • Sweep

10. Code Blue(Adult Medical Emergency) • Assess patient’s airway, breathing and circulation • Call emergency number • Initiate CPR • Do not leave patient

11. Code Blue Pediatric(Pediatric Medical Emergency) • Assess patient’s airway, breathing and circulation • Call emergency number • Initiate CPR • Do not leave patient

12. Code Pink (Infant Abduction < 1 yr old) • Monitor hallways, stairwells and elevators • Observe for person: • carrying a bag large enough to hold an infant • carrying a coat/baby blanket • or person, in a nurse’s uniform/scrubs, carrying an infant, without appropriate identification • Note identifying characteristics of person, take down license number of vehicle • Call emergency number immediately

13. Code Purple (Child Abduction > 1 yr old) • Monitor hallways, stairwells and elevators • An abductor can be a stranger, or family member, such as a non-custodial parent • Children, may or may not be able to verbally communicate a threatening situation • Note identifying characteristics of person, take down license number of vehicle • Call emergency number immediately

14. Code Weather (Warning) • Return to department/unit • Close all doors, blinds, drapes, if possible • Move ambulatory patients and visitors to inner hallways, away from windows and doorways • Pull cubicle curtain around non-ambulatory patients to minimize potential for glass injuries from broken windows • Reassure patients and visitors

15. Dr. Strong (Combative Person) • Established to provide a backup to Security during a disaster or disturbance at the East Campus after it is determined that additional personnel are needed.

16. Code Silver (Weapon / Hostage) • A weapon is defined as any firearm, knife, or instrument that can cause bodily harm or injury • If a person is found (or suspected) of having a weapon, call emergency number immediately • If someone is being held hostage call emergency number immediately. • Seek cover and warn others of the situation

17. Code Orange (Hazardous Material Spill) • Isolate area • If spill is small and containable, use appropriate spill kit for cleaning. • If spill/release is large, evacuate the area and contact HazMat Team or outside contractor

18. Code Yellow (Bomb Threat) • If you receive a bomb threat: • Call the emergency number immediately • Give your name, phone number and location • Gather as much information as possible: • Description of bomb, location, when it will explode • Listen to voice, speech patterns, accents, noises • Don't go looking for it on your own • If you find a suspicious package or device: • Do not touch it • Call emergency number immediate.

19. Code Green (Biological/Chemical Response) • A Code Green has been established to provide a hospital-wide mobilization plan designed to manage a hazardous material response in the community.

20. Code Triage – Internal (Disaster) • An event that causes disruption in our ability to care for patients. • Return to department/unit immediately. • Department/unit/hospital emergency plan is initiated. • All breaks/meals are suspended until released by department management. • Staff may be re-deployed, by management, to other areas. • Staff (completing their shift), are not to leave until released by management, or the disaster alert is cancelled.

21. Code Triage – External (Disaster) • An event that throws upon the healthcare system, a sudden excess of patients in urgent need of emergency treatment, at a rate greater than the system is equipped to normally accommodate. • See Code Triage Internal

22. Rapid Response A rapid response is initiated by the RN when a patient’s condition is deteriorating, the nurse has a “bad feeling”, or can’t get a hold of a Dr. for orders etc. It’s intention is that staff can intervene before the patient’s condition deteriorates to the point of a cardiac or respiratory arrest When paged, the “Rapid Response” Team responds and functions according to protocols.

23. Condition H This is a situation that is paged when a patient or family member feels that the patients’ condition is deteriorating and their concerns are not being addressed by the staff or Dr.’s When paged, the RN, supervisor and manager respond to the patients’ room

24. Corporate Compliance

25. Reporting Compliance Violations Open Communication helps to respond to compliance problems If you see something that seems to violate the law or BRMC’s policies & procedures you should: 1. Report the problem to your instructor and RN responsible for your patient 2. Report the problem to Mike Jamrog, the compliance officer@894-3849 3. Report the problem on the compliance Hot Line - 894-3945

26. Noncompliance & It’s Ramifications What is fraud? • Crimes of guile & Deceit • Material false statements or representations made to obtain some benefit to which one is not entitled • Act performed knowingly, willing and intentionally

27. What is Abuse? Abuse Includes: • Negligent or careless practices resulting in inappropriate billing or increased costs • Overuse of medical services, products or both • Medically unnecessary services or products • Provision of services inconsistent with professional standards • Unfair or unreasonable pricing • Restrictions of Patient choice • Restrictions in competition • Accepting cash or equivalents from patients or their family • Taking hospital property for personal use

28. Standards of Conduct • Purpose – All MHCC Board members, employees, physicians, volunteers, contractors following the same guidelines • Governing board supports • Leadership must support and lead by example • Standards are the outward/public sign of BRMC compliance to legal and ethical behavior • State a commitment to do the right thing in all our operations

29. Standards of Conduct • A Commitment to Providing Patient Care • A Commitment to Our Community – Your are BRMC to the public • A Commitment to Environmental Health and Safety – Protect our patients and employees • A Commitment to Proper Employment Practices – Establish a public trust, do not accept gifts of any kind from patients or their families • A Commitment to Ethical Business Conduct – Honest, accurate and ethical business practices

30. Standards of Conduct • A Commitment to Accurate Coding and Billing Transactions • A Commitment to Physician Relations – Apply privileging requirement equally to all physicians • A Commitment to Confidentiality and Electronic Security – Privacy of and security of every patients information • A Commitment to Laws and Regulations – operate in accordance with current and future rules and regulations • A Commitment to Ongoing Monitoring – Report any situation that does not seem right to you

31. What Does This All Mean to Me? • Our patients and our community have a right to expect we will always operate in keeping with all Federal, State and Local laws & regulations • It is the responsibility of every employee, volunteer, physician & student to perform their job in a fair and honest manner

32. What Does This Mean to Me? Trust your instincts. If a situation doesn’t seem right, it probably isn’t. Stop and ask for clarification from your instructor, RN, Nurse Manager, Supervisor, compliance representative or Compliance Officer

33. What Does This Mean to Me? • Report any activity you know or suspect to be in violation of compliance policies • Do not accept gifts from patients or their family or vendors • Declare any conflict of interest that may arise

34. What Does This Mean to Me? • Violations of compliance policies can result in disciplinary actions up to including discharge or your removal from BRMC as a student Compliance is everyone’s responsibility!!

35. Health Insurance Portability and Accountability Act • HIPAA • Regulates the use and disclosure of what is known as protected health information or “PHI” • PHI is any information that can be used to identify the past, present or future healthcare of an individual or the payment for that care

36. PHI • Virtually all information about a patient, whether written on paper, saved on a computer or spoken aloud. This includes their: • Name • Address • Age • Social Security Number • Other personal information • License plate numbers • Fax machine numbers

37. HIPAA Confidentiality • HIPAA privacy also protects the following: • The reason the patient is sick or in the hospital • The treatments & medications he or she receives • Caregiver’s notes • Information about past health condition

38. Use of protected health information Before looking at a patient’s health information ask yourself: “Do I need to know this to do my job?” If the answer is “Yes” proceed. If the answer is “No” you need to STOP immediately.

39. Use of electronic protected health information (ePHI) • HIPAA security rules apply only to ePHI stored, maintained or transmitted in an electronic format • ePHI is the same information as PHI • Monitor the use of cellular phones • Information and images (ePHI) can be sent over the internet • It is not allowed to send ePHI over the e-mail system

40. Use of ePHI • Use E-mail and Internet access appropriately • Workforce member (including students) should remember that e-mails sent to or from BRMC’s computers are not considered private • BRMC can and does audit e-mail and Internet usage

41. Use of ePHI • Never share your password • Sign off computer appropriately • If you believe your password has been compromised, call the HELP desk immediately (49572) Tell them your concern and ask for a new password

42. What does HIPAA mean to me? • Our patients have a right to expect we will keep their information confidential. Their information includes anything that could identify or be used to find out the identity of the patient or their medical condition

43. What does HIPAA mean to me? • As students you come into contact with many forms of patient information, i.e. surgical lists, lab draw lists, patient census lists, etc. • You need to understand what are acceptable use of this information

44. What does HIPAA mean to me? • Follow the “need to know” rule: • Ask yourself: “do I need to see patient information to perform my job” If the answer is “Yes”, you have nothing to worry about. If the answer is “no”. STOP

45. What does HIPAA mean to me? • The cafeteria or elevator is not the place to discuss the medical condition or other aspects of a patient’s care • Information you have access to must not be the subject of conversations with family, friends or neighbors

46. What does HIPAA mean to me? • Violations can also result in personal civil penalties of up to $25,000 per person and criminal penalties of up to $250,000 and/or 10 years in prison • Report privacy violation to Mike Jamrog, Privacy Officer 894-3849, call the Compliance Hot Line - 894-3945 or the Privacy line - 894-3970

47. Patient Confidentiality • NO names or identifying information may leave the patient care unit on ANY form • Information may not be given to any person, friend or family member unless they know the PIN number • This number is given to the patient upon admission. Patients are instructed to share this number with anyone who they want information released to.

48. ANY BREACH OF PATIENT CONFIDENTIALITY MAY RESULT IN YOUR REMOVAL FROM DOING CLINICALS AT BAY REGIONAL MEDICAL CENTER

49. Infection Control

50. Transmission Based Precautions; Respiratory Respiratory precaution rooms will have a bright pink sign on the patient’s door. Patients in respiratory precaution require a private room that have negative pressure, where the air is exhausted outside. Rooms with negative pressure at BRMC are 215, 293,295,329,331,429 and 431 Keep patient’s door closed at all times