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Catholic Health. Welcome to the first part of your orientation to Catholic Health. Please review the following slides. If you have questions regarding the material please bring them up when you attend you in class general orientation session. Catholic Health Corporate Compliance. Anne Mason

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Catholic health
Catholic Health

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

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

Catholic health corporate compliance
Catholic Health Corporate Compliance

Anne Mason

Compliance &

Privacy Officer

Principles of corporate compliance
Principles of Corporate Compliance

Promotes Ethical, Professional, and Legal conduct

“Doing what is right”

Defines Responsibility/Accountability

Supports CHS Standards

Assurance of Quality Care

Catholic health system standards
Catholic Health SystemStandards

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 corporate compliance
Important Keys to CHS Corporate Compliance

Standards of Conduct

Deal 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 Interest

We 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 Billing

Must be accurate and complete

Catholic health system standards of conduct
Catholic Health SystemStandards 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 system standards of conduct1
Catholic Health SystemStandards of Conduct

All associates are expected to follow standards for:

Legal and Regulatory Compliance

Business Ethics

Conflict of Interest

Appropriate Use of Resources


Professional Conduct


And follow the Code of Ethics

Gifts and other free items
Gifts 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


    social or entertainment events,

    or free meals

    associates must consult with their supervisor.

    See CHS Policy for further information

Conflict of interest
Conflict of Interest

If 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


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 inaccurate documentation
Insufficient or InaccurateDocumentation

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 act governs fraud waste abuse
False Claims ActGoverns 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 participation
Medicare Conditions of Participation

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 high quality services and upholding patient s rights
Providing High Quality Services and 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 compliance policies
Catholic Health Compliance 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

Catholic health

Language Assistance Program

  • 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 program
Language Assistance Program

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

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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 information phi
Protected Health Information (PHI)

  • Names

  • Full face photos

  • Medical Record Number

  • Health plan Number

  • Account Numbers

  • Certificate/License Numbers

  • Vehicle identifiers

  • E-mail and webaddresses

  • 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 providers share
What Information Can Providers Share?


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 safeguards
HIPAA 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 hipaa safeguards
Additional HIPAA Safeguards

  • Telephones

    - Be careful with phone

    call pertaining to patient


  • 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 sensitive information
Sending e-mail with Sensitive 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 disclosure of patient information

Curiosity 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


    Individuals do NOT have the right

    to look up their own health records

    Your computer use can be monitored

Other catholic health compliance concerns
Other Catholic HealthCompliance 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 reporting ch compliance concerns
3 Steps for ReportingCHCompliance Concerns

Immediate supervisor or appropriate department

Higher level manager

Compliance Officer

Compliance Line 1-888-200-5380 available 24/7

Confidential and Anonymous (if desired)

Report behavior issues, HR policy violations,

and union contract matters to Human Resources

Catholic health non retaliation policy
Catholic Health Non-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 health associate s responsibility
Catholic HealthAssociate’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 Investigation

be truthful

preserve documentation or records relevant to ongoing investigations

Possible consequences for non compliance
Possible Consequences for Non-Compliance

For the Associate and CHS Managers/Supervisors/Administrators

  • Fines and Prisonsentences

  • Corrective Action

    includes termination of employment for violations or failure to report concerns

    For Catholic Health System

  • Exclusionfrom government funded insurance programs(Medicare/Medicaid)

  • Fines

Things to remember
Things to Remember

  • Adhere to CHS code of conduct,

    policies & procedures, and other standards

  • Duty to report Compliance/HIPAA concerns

    as soon as aware of situation

  • Do the right thing

    apply ethical decision making

  • If uncertain…

    Always Seek Knowledge (A.S.K.)

    Use Associate Booklet as reference

    on CHS website

Chs contacts
CHS Contacts

Compliance/HIPAA Privacy Officer

Anne Mason 821-4469



HIPAA Security Analyst

Sally O’Brien 862-1938

Corporate Compliance Hotline

1-888-200-5380 (available 24/7)

All reports are confidential

New york state patient bill of rights

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

Catholic health1

Catholic Health


What is risk management

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


Loss prevention educational programs through chs university department specific inservices


Loss Prevention

Educational Programs through

CHS University

Department specific inservices

Four elements of risk management1


Claims Management

Investigating & reporting occurrences and claims made to insurance carriers

Assist with discovery requests for lawsuits

Claims management

Claims Management

Assist with Summons & Complaints and Subpoenas




Claims management1

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)



Four elements of risk management2


Risk Financing

Obtaining & maintaining appropriate insurance coverage:

HPL (Healthcare Professional Liability)

GL (General Liability)

D&O (Directors & Officers)

Property & Casualty



Fiduciary (Finance)

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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.

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What are sources of an Occurrence?

Patient harm/potential for harm like

falls, med errors

Visitor injury

Patient related equipment


Security issues like elopement crime altercations lost or damaged property

What are sources of an Occurrence?

Security issues like elopement, crime,


Lost or damaged property

Catholic health

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

Who can complete 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.


What happens to the occurrence report

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 Quality & Patient Safety Dept or Security as indicated in the

Risk Management process

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 liability

Risk Management will manage claim as indicated

Documenting an occurrence in the medical record
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




Emtala regulations


EMTALA is the Emergency Medical Treatment and Active Labor Act

(aka COBRA)

EMTALA provides a

Guideline for safely and


transferring patients in

accordance with

Federal regulations.

Emtala regulations1


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.




Identity theft


Fair and Accurate Credit Transactions Act of 2003


“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 theft1


  • 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 theft2


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 health2

Catholic Health


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

Legal Services Administrative Assistant

What is workplace violence
What is Workplace Violence??

  • 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.

Types of violent acts
Types of Violent Acts

  • 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.

Who is violent
Who is Violent?

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

When does violence occur
When Does Violence occur?

  • 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

Who is at risk
Who is at Risk??

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

Case reports
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.

Where may violence occur
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

What are the effects of violence
What are the Effects of Violence??

  • Effects range in intensity and may include:

    • Minor physical injuries

    • Serious Physical injuries

    • Temporary and permanent physical disabilities

    • Psychological trauma

    • Death

Effects of violence
Effects of Violence

  • Violence can have a negative effect on an organization as reflected by:

    • Low morale

    • Increased job stress

    • Increased worker turnover

    • Reduced trust of management or co-workers

    • Hostile working environment

Risk factors
Risk Factors

  • Contact with violent people or those with history of violence

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

  • Contact with people having psychotic diagnoses

  • Contact while transporting patients

  • Contact with people perceiving a long wait for service

  • Working alone

Safety tips
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

Be alert
Be Alert

  • Assess current demeanor 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

Diffusing anger
Diffusing Anger

  • Present a calm, caring attitude

  • Don’t match the threats

  • Avoid giving commands

  • Acknowledge a person’s feelings

  • Avoid behavior that may be interpreted as aggressive

If potential for violence occurs
If potential for violence occurs

  • Remove yourself from the situation

  • Call security for HELP if needed

  • Report any potential or actual violent incidents to dept manager


  • No universal strategy exists to prevent violence

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

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

Catholic health

‘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
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

Catholic health

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 equinox1
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 equinox2
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 equinox3
Welcome to Equinox

  • Questions - contact….

Catholic health system

Catholic Health System

General Orientation Level 1

Quality and Patient Safety

What is performance improvement
What is Performance Improvement?

It is a Focused approach to identify, evaluate and improve strategic clinical processes to realize our overall goals of improving patient safety and clinical outcomes

What does catholic health focus on
What does Catholic Health Focus on?

Strategic “Dashboard” Categories Include:

  • Patient Satisfaction (e.g. willingness to recommend, overall rate of experience etc.)

  • Patient Safety Indicators (Healthcare Acquired MRSA, Central Line infections, Medication Reconciliation, Restraints…)

  • Publicly Reported Indicators (30 day Mortality Rates – AMI, HF,AMI, Pneumonia, Surgical Care Infection Prevention)

  • Quality Incentive Indicators (Reduction of Unreconciled Medications, Avoidable Delays)

Culture of safety
Culture of Safety

At CHS we believe that the patients and associates safety are our main concern. As a result we have focused our efforts to strengthen our Culture of Safety with the ultimate goal of eliminating medical errors to our patients and injuries to our associates.

How? By raising our expectations of our Board, Leaders, Physicians and Associates.

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We expect every ASSOCIATE, LEADER and PHYSICIAN to:

  • Pay Attention To Details

  • Communicate Clearly and Directly & Perform Effective Handoffs

  • Have a Questioning Attitude

  • Work Together With Your Team

  • Follow the Rules

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Additional Patient Safety Initiatives:

National Patient Safety Goals

The Catholic Health System fully endorses and supports the Joint Commission (JC) standards wherein any employee who has concerns about the safety or quality of care provided in the hospital may report these concerns to the JC. Furthermore, CHS demonstrates it’s commitment by taking no disciplinary action against any associate who reports a safety or quality of care concern to the JC. Any employee can also feel free to report these concerns to the Quality and Patient Safety Department in their facility

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  • Infection Prevention

  • is

  • everyone’sresponsibility!

  • Together we can prevent and reduce the risk of

  • infection in healthcare for our patients, associates,

  • families and visitors.

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The Infection Control Program is

designed with prevention in mind…

Compliance and guidance is primarily from

these agencies:

New York State Department of Health

Center for Disease Control

Occupational Health and Safety

Joint Commission

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How are infections transmitted?

Dependent on the type of infection

Respiratory infections are transmitted

through coughing, sneezing and talking by

someone who is ill.

Other infections may occur from:

Direct skin to skin contact

Contaminated inanimate objects

A strong immune system is extremely important in

keeping healthy.

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Transmitted through respiratory secretions

Includes seasonal, H1N1 and others

Practice respiratory etiquette and hand


Meticulous hand hygiene

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  • Traditional Hand Washing

  • Use running water and soap. Remember to keep the water temperature comfortable.

  • 15-20 seconds is needed for effective Hand washing. Sing “Happy Birthday”!!

  • Apply friction to all surfaces.

  • Rinse and dry; turn off faucets with a paper towel.

  • THAT’S IT!!!

    Hand Hygiene

  • Waterless Hand Sanitizer is available and is just as effective as soap and water except

    when taking care of patients with C-diff.

  • Waterless Hand Sanitizer dispensers are conveniently located throughout the building.

  • Waterless Hand Sanitizer should not be used when your hands are visibly soiled

    because you need the mechanics of hand washing.

  • * Artificial fingernails of any sort are not to be worn in the clinical areas.

  • Catholic health


    Associates should not work while ill

    Prior to returning to work after illness, associates must be ever free for 24hrs and off antipyretics

    Annual Health Assessment/PPD

    Obtain vaccines (eg. Influenza, Hepatitis B)

    Report any potential communicable illness exposure (eg. Chicken Pox) for appropriate guidance

    Catholic health


    Two Plans:

    Pandemic Influenza


    • Both are addendums to the Emergency

    • Management Plan

      • Information available at:

        • Compliance360/Emergency Management /Surge Capacity

    Catholic health

    Click on the Bug… Easy as 1, 2, 3!!!!!

    • 1. Open Internet Explorer

    • 2. Click on Favorites / CH Enterprise Links / Click on the Bug

    • 3. Right click and Create Shortcut for easy desktop access!

    Catholic health

    • Hand Hygiene

      • Hand washing

      • Hand Sanitizer

        • Foam in Foam out

        • Gel in Gel out

    • Before and after every patient contact

    • Before donning and after removing gloves

    Catholic health

    • Additional prevention strategies** exist for :

      • Ventilator associated pneumonia

      • Central line bloodstream infection

      • Surgical site infection

      • Catheter associated urinary tract infection

    • **Please consult with nursing education or the infection control department