Employee Assessment Manual


Oct 30, 2013 (5 years and 10 months ago)


Employee Assessment Manual

Hold Ctrl and L Click on the Subject Title to take you to that area of Study:

Abuse and Neglect

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Advance Directives

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Customer Satisfaction

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Disaster Preparedness/Fire Safety

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Haz Mat

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Hospital Incident Command System (HICS)

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Infection Control

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Infection Control 2

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Bloodborne Pathogen

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Lifting and Body Mechanics

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Phone and FAX Usage

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Resident and Patient Rights

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Risk Management/Performance Improvement

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Hold Ctrl and L Click the “Go Home” option at the beginning or the end of each study guide area
or test page to bring you back to this page.

You may access the assessment tests through th
e links given above, or choose the one provided
at the end of each study guide section. Hold down the Ctrl key and left click the mouse to access
the links.

Printed manuals contain
ing the study guides, tests, answer sheet, Handwashing
Competency Checklist

and Cleaning Product Use Review Sheet

are located at the hospital
nurses station, CLC nurses station, dietary department, or are available for checkout from
the Public Relations office.

When you are ready to begin testing, get a printed answer sheet fro
m your department OR
hold Ctrl and L Click here to go to the Answer Sheet

Choose FILE > Print from the tool bar at
the top of the computer screen and specify to print ONLY pages

on the Page
Range given on the printer screen if you choose to print your own answer sheet.
to print page 148

for the Handwashing Comptency Checklist Sheet or print page 14

the Cleaning Product Use Review Sheet.

Record your answers on your pri
nted answer sheet using a pen or pencil by circling the
best answer choice. BE SURE to write your full name, date and last 4 digits of your SS #
on your answer sheet. W
hen you are finished with all 15

assessment tests, place your
answer sheet in the Publ
ic Relations mailbox in the front office. Your test will be graded
within a few days. If it is necessary for you to retake a test to reach the 80% passing
score, you will be notified by your department manager.

If you would like to know which questions

you missed, please contact
Becky Wilson

Public Relations.


Abuse & Neglect

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To ensure the facility has in place an effective system that will prevent mistreatment, abuse,
and neglect of residents/patients or misappropriation of their property.

The facility will promptly investigate and report all identified i
ncidents of alleged or suspected
abuse/neglect of patients or misappropriation of their property.

To ensure all identified incidents involving injury of unknown origin are promptly investigated
to determine the cause of injuries and reported to the Charg
e Nurse.

To ensure a review of incidents are investigated and documented.

To review suspicious bruising of resident/patient, occurrences, or trends that may be abuse.

To determine the direction of the investigation.

To ensure the resident/patient i
s not subjected to abuse by anyone including, but not limited
to, facility staff, another resident or patient, consultant, volunteer, family member, legal
guardian, friends or others.


Each resident/patient at Decatur

County Hospital/Cedar Living Center has the right to be free
from abuse, corporal punishment, and involuntary seclusion. Residents/patients must not be
subjected to abuse by anyone, including, but not limited to, facility staff, other
consultants or volunteer staff of other agencies serving the
resident/patient, family members or legal guardians, friends or other individuals.



Decatur County Hospital/Cedar Living Center will not knowin
gly hire any individual who has a
history of abusing other persons. This facility will conduct pre
employment reference checks,
abuse registry and other registry checks as deemed necessary on individuals making
application for employment within this facili


1. Department Manager will conduct reference checks on persons making application for
employment. Reference checks will be completed prior to employment offer.

2. For all certified nurse aide applicants, the state nurse aide reg
istry will be contacted to
determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of
property have been entered into the applicant’s file.

3. For any licensed professional individual applying for a position, his/her respect
ive licensing
board will be contacted to determine if any sanctions have been assessed against the
applicant’s license.

4. Human Resource Department will conduct an O.I.G. check on each new employee.

5. Prior convictions of offenses other than abuse, neg
lect, mistreatment of individuals, and/or
theft of property may not necessarily disqualify an applicant from employment with our
facility. Serious consideration will be given to the position applied for, the seriousness of the
offense, and how recently the

offense was committed.

6. Employment drug screening will be conducted on all new employees.


All Decatur County Hospital/Cedar Living Center employees will receive periodic in
training relative to residents/patient rights and
the facility’s abuse prevention policies and
procedures. This in
service training shall be held annually, but may be done more often if
deemed necessary.


1. All new employees will receive a copy of the residents/patient rights and fac
ility abuse
prevention policy during orientation.

2. All employees are required to complete an annual in
service. In
service on abuse
prevention will be provided which will include:

Appropriate interventions to deal with aggressive and/or catastrophic r
eactions of

How staff should report their knowledge related to allegations without fear of reprisal

How to recognize signs of burnout, frustration and stress which may lead to abuse

What constitutes abuse, neglect and misappropriation of resid
ent/patient property


Decatur County Hospital/Cedar Living Center will strive to provide a safe environment for all


1. Family, residents, patients, and staff will be provided information on how and to whom

they may report concerns, incidents and grievance without fear of retribution.

2. Residents/patients who are cognitively impaired or who do not have active family or friend
involvement will be assessed to assure their needs and behaviors are properly mon
and appropriate interventions are reflected in the care plan.

3. Case Management at Cedar Living Center will meet weekly to review all resident issues
and make recommendations. Discharge Planning will meet three times a week to review all
Decatur C
ounty Hospital Patients.

4. The Performance Improvement Committee will meet weekly to review all resident/patient
incidents and make recommendations where appropriate.


Decatur County Hospital/Cedar Living Center will not condone
any form of resident/patient
abuse or neglect. To aid in abuse prevention, all personnel are to report any signs of
abuse/neglect to their supervisor, Case Managers, or Chief Nursing Office



1. Sign of Actual Physical Abuse:

∙ Welts or bruises

∙ Abrasions or lacerations

∙ Fractures, dislocations or sprains of questionable origins

∙ Black eye or broken teeth

∙ Improper use of restraints

∙ Sexual exploitation

∙ Rape

∙ Excessive exposure

to heat or cold

∙ Involuntary seclusion

∙ Any burns or human bites

2. Signs of Actual Physical Neglect:

∙ Malnutrition and dehydration (unexplained weight loss)

∙ Poor hygiene

∙ Inappropriate clothing

(soiled, tatte
red, poor fitting, lacking, inappropriate for season)

∙ Decayed teeth

∙ Improper use/administration of medication

∙ Inadequate provision of care

∙ Caregiver indifferent to resident/patient personal care and needs

∙ Failure to
provide privacy

∙ Left alone but needs supervision

3. Signs/Symptoms of Psychological Abuse/Neglect:

∙ Resident/patient clings to abuser/caregiver

∙ Paranoia

∙ Depression

∙ Confusion

∙ Disorientation

∙ Withdrawal

∙ Inconsistent injury explanation

∙ Low self esteem

∙ Anger

∙ Suicidal


The Performance Improvement Committee will review all abuse or neglect incidents involving
a resident/patient. The Committee will determ
ine the level of follow up required based on the
answers to the Reportable Incident Checklist on the back of the Incident Report and upon
the initial investigation. All alleged abuse situations would be investigated and reported as



The Social Service Director will coordinate the investigation. In the event of his/her
absence, the CEO will appoint a Coordinator. The Coordinator will report the event to the
Kansas Department of Health and Environment at the earliest possible time.


An investigation team, made up of the Chief Nursing Officer and Social Service Director
and Department Manager will investigate the report.

3. The investigation team will interview any person(s) with information of knowledge of the
incident. Appropriate
clinical records will be researched. Accurate notes will be taken during
each interview. The team will interview witnesses separately, in order to accurately assess
the information.

4. The facility may,

at its own discretion, involve the local police and/
or its own attorney to
assist with the investigation.

5. Before completion of the investigation, the CEO will be notified of the team’s conclusion
and recommendations.

If such an investigation involves an employee, on conclusion of the investigation, t
employee(s) will be notified of the results. The Decatur Health Systems Personnel Policy
Manual will be used to determine appropriate disciplinary actions.


1. In cases of suspected sexual abuse:

∙ Contact

your supervisor immediately. In the absence of your supervisor, report to the
nurse on duty.

∙ The nurse on duty will assess the resident/patient for possible injuries and document

∙ Provide the resident/patient with emotional s

∙ Do not disturb the area where sexual abuse is suspected to have occurred.

∙ The supervisor will contact the attending physician, responsible party, Chief Nursing
Officer and CEO immediately.

The CEO or designee will determine the need to contact the
police department.

∙ Do not attempt to bathe the resident/patient and do not douche the female

∙ Do not change the resident/patients clothing or linens so as not to di
sturb or lose

∙ Attempt to keep staff or potential witnesses from leaving the facility. If witnesses insist
on leaving, get names, addresses and phone numbers.

∙ Assist the resident/patient in preparation to be transported to the hospita
l or other
designation as instructed by law enforcement. Local authorities will direct further follow
and investigation as needed.

∙ Complete an Incident Report.

2. In cases of Resident /Patient Abuse:

∙ Remove aggressor from the situation
if the aggressor is still in the area in which the
incident occurred.

∙ Contact your supervisor immediately. In the absence of your supervisor, report to the
nurse on duty.

∙ The supervisor will contact the Chief Nursing Officer immediately; th
e CEO will be
contacted as needed.

∙ Provide medical attention, as indicated.

∙ Counsel the resident/patient involved to determine the cause of the behavior.

∙ Notify each resident/patient representative and attending physician.

∙ E
valuate the circumstances leading up to the incident.

∙ Complete an Incident Report; document the incident, findings and any corrective
measures taken in the resident/patient medical record.

∙ If any resident/patient is determined to be a dange
r to himself or others, contact the
attending physician immediately for alternative placement.

3. In cases of suspected physical abuse (other that of resident to resident):

∙ Contact your supervisor immediately. In the absence of your supervisor, re
port to the
nurse on duty.

∙ The supervisor will contact the Chief Nursing Officer and CEO immediately.

∙ The nurse will contact the:

a) Physician
if injury requires medical attention

b) Responsible party of each resident
/patient involved

c) Police department
as directed by the CEO/designee

· Follow physician’s orders or provide comfort and care. If police are involved, follow all

∙ Attempt to keep staff or potential witnesses from leav
ing the facility. If witnesses insist
on leaving get name, address and phone number.

∙ Complete the Incident Report.

∙ Local authorities will direct further follow
up and investigation as needed.

4. In cases of suspected misappropriation of r
esident/patient property:

∙ Contact your supervisor immediately. In the absence of your supervisor, report to the
nurse on duty.

∙ Two staff members may need to thoroughly search the resident/patient room, with
permission, and possibly search th
e entire facility.

∙ Complete Incident Report.

∙ The supervisor will contact the Chief Nursing Officer and the CEO/designee.

∙ The police department will be notified when directed to do so by the CEO.

5. In cases of suspected verbal abus

∙ Contact your supervisor immediately. In the absence of your supervisor, report to the
nurse on duty.

∙ The supervisor will contact the Chief Nursing Officer and /or CEO.

∙ Complete an Incident Report.

6. In cases of injury of unknown


∙ Contact your supervisor immediately. In the absence of your supervisor, report to the
nurse on duty.

∙ The supervisor is to contact the Chief Nursing Officer and/or CEO.

∙ Contact physician and responsible party.

∙ Provide

medical attention as directed.

∙ Complete an Incident Report.


During an investigation of alleged abuse the resident/patient will be protected from further
potential harm.


∙ During abuse investigations, resident/p
atients will be protected by the following measures:

a) Employees accused of participating in alleged abuse may be immediately reassigned
to duties that do not involve resident/patient contact or will be suspended without pay until
the findings of th
e investigation have been reviewed by the CEO.

b) If the alleged abuse involves a resident/patient’s family or visitor, such person(s)will not
be permitted to have unsupervised visits with the resident/patient until the findings has been
reviewed by
the CEO.


Decatur County Hospital/ Cedar Living Center will report all alleged violations and all
substantial incidents to the Kansas Department of Health and Environment and to all other
agencies as required.


1. Risk

Manager will notify the Kansas Department of Health and Environment at the earliest
possible convenience of the alleged incident via phone.

2. Upon the completion of the investigation a written report will be sent to the Kansas
Department of Health and E

3. Other regulatory agencies will be notified of their results as necessary and indicated by the
Kansas Department of Health and Environment.

4. The State nurse aide registry or licensing authority will be contacted at the time the facility
as any knowledge of any actions by a court of law
which would indicate an employee is
unfit for service.

5. The Performance Improvement Committee will analyze occurrence of incidents to
determine appropriate changes in policy and procedures or other inter
vention to prevent
further occurrences.

Residents involved in anything that is a reasonable suspicion of a crime and reportable to
the State of Kansas will also be reported to the local law enforcement officers during normal
daytime working hours in ac
cordance with Section 1150B of the Social Security Act. This
includes employee theft, employee battery or any illegal transactions, resident theft, resident
battery, or any suspicious deaths.

7. Family complaints of possible theft or battery should also be

reported to the local law
enforcement officers.

Reporting number: 1
Resident Issues

Kansas Department of Health and Environment

Patient Issues (ER, OP and IP)

Adult Protective Services

Oberlin Law


Glossary of Terms:


The willful infliction of injury, unreasonable confinement, deprivation, intimidation or
punishment with resulting physical harm, pain or mental anguish. This includes deprivation of
goods or
services that are necessary to attain or maintain physical, mental well
being. This
presumes that instances of abuse of all resident/patient (regardless of physical or mental
condition) cause harm, pain or mental anguish.


Failure to provide go
ods and services necessary to avoid physical harm, mental anguish or
mental illness. Neglect occurs on an individual basis when a resident/patient does not
receive care in one or more areas.


To treat wrongly or badly contrary to facility
policy and compromise the resident/patient’s
physical or emotional integrity.

“Injury of Unknown Source”:

Injury of unknown origin or suspicious circumstances. This includes any injury which is not
clearly explained by a witness and corresponding event.
If source of injury is not clear, the
investigation must proceed.

“Serious Injury”:

Serious injuries are defined as an injury resulting in medical intervention/follow
up /treatment
which are beyond standing protocols and customary nursing.

“Verbal Abus

Any use of oral, written or gestured language that willfully includes disparaging and
derogatory terms to residents/patients or their families or within their hearing distance,
regardless of their age, ability to comprehend or disability.

“Sexual A

Includes, but is not limited to: sexual harassment, sexual coercion or sexual assault.

“Physical Abuse”:

Includes hitting, slapping, pinching and kicking. It also may include controlling behavior
through corporal punishment.

“Mental Abuse”:

udes, but is not limited to: humiliation, harassment, threats of punishment or deprivation,
calling and use of foul language toward and in regard to a resident/patient.

“Involuntary Seclusion”:

Defined as separation of a resident/patient from other
residents/patients or from his/her room
or confinement to his/her room (with or without roommates) against the resident’s/patient’s
will or the will of the resident’s/patient’s legal representative. Emergency or short term
monitored separation from other r
esident/patients will not be considered involuntary
seclusion and may be permitted if used for a limited period of time as a therapeutic
intervention to reduce agitation until professional staff can develop a plan of care to meet the
resident’s/patient’s n

“Misappropriation of Resident/Patient Property/Funds”:

The patterned or deliberate misplacement, exploitation or wrongful, temporary or permanent
use of a resident/patient’s belongings or money without the resident/patient’s consent.


fice of the Inspector General.

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Take the Abuse and Neglect Test



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What are Advance Directives?

They are legal documents that allow you to give directions for your future medical care. They
could be:

A Living Will and/or

A Durable Power of Attorney for Health Care Decis

The Patient Self
Determination Act passed by Congress became effective December 1,
1991. This act requires all facilities that receive Medicare and Medicaid funds such as
hospitals, nursing homes, home health agencies, hospices, and HMOs to inform p
atients and
residents about Living Will and Durable Power of Attorney for Health Care Decisions.

It’s your right to accept or refuse medical care. Advance Directives can protect this right if
you ever become mentally or physically unable to choose or com
municate your wishes due
to an injury or illness. Advance Directives are valuable tools. They can help YOU to protect
your right to make medical choices that can affect your life, YOUR FAMILY to avoid the
responsibility and stress of making difficult decis
ions; and YOUR PHYSICIAN by providing
guidelines for your care.

All patients have rights.

These rights include:


Your personal and medical information is confident. Medical records and communications
with your physician must be kept private.

Informed Consent

Your physician must clearly explain the advantages and risks of any procedures, tests, or
treatments. You must give your permission for such care. You have the right to refuse any

Information about your condition

You must be k
ept up to date about your medical condition, treatments, and chances for

Information about Advance Directives

Advance Directives must be explained in writing when you’re admitted if you wish to receive
the information.

Advance Directives help

protect your rights.

They can “speak” for you when you can’t make your wishes known due to:

∙ Irreversible brain damage or brain disease

∙ Coma or other unconscious states

∙ Terminal illness when death is expected within a short time

There are two types of Advance Directives:

Living Will
These written instructions explain your wishes for health care if you can’t
communicate as a result of a terminal condition or irreversible coma.

Durable Power of Attorney for Health Care Decisions

his is sometimes called a
“health care proxy.” This is a document that lets you name a person or two or three to make
medical decisions for you if you become unable to do so.

It’s a good idea to have both kinds, if possible.

Advance Directives can limit
prolonging measures when there’s little or no chance of
recovery. For example, Advance Directives may enable you to make your feelings known

∙ Surgery

∙ Cardiopulmonary Resuscitation (CPR)

used to restore stopped breathing and/or

∙ Antibiotics

∙ Dialysis

cleaning the patient’s blood when kidneys are no longer working

∙ Mechanical ventilator (respirator)

machines used to keep patients breathing

∙ Intravenous (IV) therapy

providing food, water, and/or
medication through a tube in a

∙ Feeding Tubes

food and water delivered through a tube in the nose, throat, or stomach

∙ Organ tissue or donation

∙ Pain relief and comfort care

What's Important to You?

Let your values be your guide

when creating Advance Directives. Consider what’s important
to you. Which of these statements express how you think you’d feel if you were near death?


for me to:

∙ Die without pain or suffering

∙ Prolong life, regardless of th
e chances for recovery

∙ Leave my family with good memories

∙ Have my religious beliefs respected

∙ Have others honor my decisions

∙ Not burden my family with difficult decisions

∙ Be with my loved ones at death

How to creat
e Advance Directives:

1. Check the laws in your state regarding Living Will and Durable Power of Attorney for
Health Care Decisions; you may consult with your attorney if you wish.

2. Put your wishes in writing and be as specific as possible. Forms are av
ailable at the

3. Sign and date your Advance Directives, and have them notarized.

4. Keep a card in your wallet, stating you have Advance Directives and where to find them.

5. Give your physician a copy to be kept as part of your medical recor
ds. Bring a copy to
your hospital as well. If you use a Durable Power of Attorney for Health Care Decisions, be
sure to give that person a copy.

6. Discuss your Advance Directives with your family and friends. Give copies to a relative or
friend who is li
kely to be notified in an emergency.

7. Review your Advance Directives. You can always change or even cancel Advance
Directives. Make sure to update copies you’ve given out.

What is a “do not resuscitate” (DNR) order?

A DNR order is a set of written ins
tructions from a physician telling health
care providers not
to perform CPR or related procedures.

Advance Directives do not replace DNR orders.

Help and information are available. If you need help in preparing Advance Directives, or
you’d like more info
rmation, contact:

A lawyer

Hospitals, hospices, home health agencies, and long term care facilities

Your state Attorney General’s office

Choice in Dying (1

Go Home

the Advance Directives Test



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Paid Time Off

Paid Time Off (PTO) provides benefit eligible employees with paid time off to use for
personal reasons, the occasional sick day, vacations, bereavement, holidays and any
unscheduled work absence of 15 minutes or more. Therefore, time away from work for the
reasons requires that you use PTO if available. PTO must be used for all scheduled work
hours unless you are on management requested leave. PTO is also a means for you to
accumulate time to use during the waiting period for Short Term Disability (STD) b
Employees may use available PTO as an income source before or after the full pay period of
STD is exhausted, but will not be allowed to draw both STD and PTO at the same time. All
employees are required to take at least one consecutive week off ea
ch year using PTO.

PTO is earned for each hour worked by an eligible employee. PTO is calculated on a
percentage of each hour worked, based on the length of service of each individual employee.
PTO hours may be used after the first six months of employme
nt. Use of PTO requires your
supervisor's approval. No more than 80 hours of PTO can be carried over into the next year.
You will not be paid for PTO that is not used and is in excess of the 80 hours that may be
carried over. If you have more than 80 hours

PTO accumulated as your anniversary date
approaches, you may choose to cash out some of the PTO hours. In the month prior to your
anniversary date a PTO cash out form must be filled out. This form may be obtained from the
front office. Full time employees

may cash out up to a maximum of 40 PTO hours per year.
Part time workers may cash out up to a maximum of 20 PTO hours per year.

Short Term Disability

Short Term Disability is provided to the employee by Decatur Health Systems at no extra
cost. This ben
efit is for maternity leave, or when an employee has been injured or sick and
cannot work. There is a seven
day waiting period for STD. After the 7th day the employee
will be reimbursed at 60% of his/her normal wage up to $500.00 per pay period. An
e may elect to take time off through PTO or through STD, but not both at the same
time. To apply for Short
Term Disability the employee should pick up the paperwork in the
Business Office. Claim form sections for the employee, the employer and the physicia
n need
to be completed. After everything is filled out, return the form to the business office and the
paperwork will be sent in. Benefit checks will be mailed to the hospital and the Business
Office Manager, Natasha Weishapl, will
send the checks to the e
mployee’s home
. If there
are any changes in disability status the employee should notify


Freedom Claims Management Medical Insurance

All full time
and part time
employees are eligible to apply for medical insurance coverage
under Fr
eedom Claims Management. If a newly hired employee is eligible for benefits he/she
may apply for Medical insurance immediately on the hire date, but coverage is subject to a
day waiting period to take effect.

If an employee has a change of status and
needs to change the medical benefit, no 90 day
waiting period is required if the employee has been employed for 3 months. Changes in
medical coverage will take effect on the first of the month following the status change.

The open enrollment period for Freedom Claims Management Medical Insurance is some
time during March for an effective date of April 1st.

AFLAC Insurance

The employee may choose to enroll in AFLAC’s many benefits. A new hire employee is
eligible after a
day waiting period. All other employees may make changes at open
enrollment, which is some time during March, or if a qualifying event occurs in which
changes can be made.


Employees may enroll in the 401K plan on the first enrollment date after
reaching one year of
service. The employer will contribute to the plan on a tier level basis depending on years of
service. Enrollment dates for the 401k are quarterly. During these times employees may
change the amount of their contributions.

Checking I
n and Out on the Soft Time Clocks

Soft Time Clocks are posted at

locations throughout the facility. They are located
in the
Family Practice Clinic,
at the CLC nurses desk, the front office, in the small dining room
beside the kitchen area, and in

room next to the nursery

in the hospital. Employees may
select any of these locations to check in or out.

Check In Procedure:

Check in with the last four digits of your social security number using either the mouse or the
keypad. Select "Enter". The fi
rst screen will ask you to select which department you are
checking in or whether you have been called in. You will then be asked to verify by selecting
Continue for the next two screens. When you are checked in, the following screen will verify
you are no
w checked in.

Check Out Procedure:

Check out with the last four digits of your social security number using either the mouse or
the keypad. Select "Enter". The first screen will ask you whether you are checking out. Select
the Continue button, and the n
ext screen will verify that you are checked out.

Reviewing Your Punch History:

You may check the time you have worked by reviewing your Punch History. This can be
done at any time, whether you are checked in or out. Enter the last four digits of your s
security number and select the Review button. A page appears which shows your work
history for the past month. A different color background designates each 2
week pay period.
When you are finished viewing your Punch History, select the HOME button an
d you will
return to the main screen.


At the end of each pay period the following changes need to be written on the Time
Correction Forms which are found by the Soft Time Clocks:

Corrections to the time posted on the Soft Time Clocks

Hours for On
Call Pay

Reimbursement for Education Time

Request for PTO hours

Paycheck Distribution

Employees who elect to have their paycheck direct deposited in their bank account will have
their advice statements available from their Department Manage
r on the Friday before the
pay date. The money is also direct deposited into their bank account on Friday.

Employees who elect to receive a regular paycheck will have them mailed out on payday
Mondays. If Monday is a holiday, the check will be mailed out

on the following Tuesday.

Go Home

Take the Benefits Test




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Focus on Customer Needs

Customer focus is the cornerstone of a business’s success. Customer focus or
service is everyone’s job. Your customers may be external to the organization or
they may be internal.
Customer focus includes
but goes beyond
service. It means listening to customers; identifying, meeting, and exceeding their
needs; and anticipating their future needs. It means aligning what you do and
how you do it with what the customers need.

Listen Actively

Personally take time to ask customers, “How are you doing?” Actively listen to
what they say. Communicate these findings to the appropriate people in your

If you hear it, you own it, which means you need to inform the app
ropriate person
to handle the issue at hand.

Identify With Your Customer

Look “outside in” not “inside out”

look at things from your customer’s viewpoint.

Treat your internal customers with the same care and respect as you treat your
external customer

External customers purchase your products and services and internal customers
are your employees and co

Who is a customer?

Someone who receives:

Your information

Your product or

Your service.

What is customer service?

The customer’s pe
rception of how well needs and wants are met, meeting or
exceeding the customer’s expectations or providing continuous improvement of
our services.


Quality customer service is an integral part of our jobs.

ied customers are essential to our success.

Quality customer service is learned, not inherited.

Why do we provide quality service?

~Customers expect it.

~Competition demands it.

~It is a key to the success of the business.

Whether you

are a custodian, a physician, or a healthcare worker, you have
customers who want:

Reassurance that they matter to you

To enjoy the experience of contact with you

The Hostess Role

Assess the environment

Welcome guests

Take care of their needs

owledge them when they are leaving

Give Out Plenty of Free Stuff!

A smile and a friendly hello don't cost us anything, in fact they add to our value!
Pass out plenty of this "Free Stuff."

Handling Complaints

Listen carefully

Be understanding


Identify the problem

Determine a solution

Thank them






On the Phone

Communication is measured 16% by the words you use and 84% by the tone of
the voice.

Five Basic Needs of Our Customers

*Need for personal attention

*Need to feel comfortable and relaxed

*Need to belong

*Need to feel important

*Need to be recognized


Our organization is known for going above and beyond the call of

duty to care for
patients, residents and customers’ needs. Providing quality care is so important.
However, this cannot be accomplished if we provide inadequate customer

RULE # 1:



ake your choice now. The difference between professional and non
professional health
care providers is a matter of sensitivity, sincerity and selling skills. All of which can be


Treat people as you would like to be tr
eated. Be responsible for your own attitude and

The pay off for good customer service is to work in a pleasant environment where stress is

What is a Customer?

A customer is the most important person in any business.

A customer is not

dependent on us. We are dependent on them.

A customer is not an interruption of our work. They are the purpose of it.

A customer does us a favor when they come in. We aren’t doing them a favor
by waiting on them.

A customer is part of our business


an outsider.

A customer is not just money in the cash register. They are human beings with
feelings, like our own.

A customer is a person who comes to us with their needs and their wants. It is
our job to fill them.

A customer deserves the most courteo
us attention we can give them. They are the
blood of this and every business. They pay our salary.

Without them we would have to close our doors.
Don’t ever forget it.

Go Home

Take the Customer SatisfactionTest


Disaster Preparedness

Go Home

Definition of Disaster Preparedness

Disaster preparedness is the facility’s master plan for saving lives when disaster strikes.
The plan enables the facility personnel to respond quickly and effectively, provide first
aid to minimize loss of life, and treat the injured and care for existing
patient load.

What is a medical disaster?

A medical disaster is a sudden event that overloads a health care facility’s ability to
deliver emergency services.

Potential disasters are:

Natural Disasters





ational Emergencies

Terrorist attacks


asualty Disasters



Building collapse

Hazardous chemical spills

Transportation accidents

Power losses

Fuel shortages and water shortages

Mass food poisonings

Medical disasters are classified into two types:

External Disasters

These require a healthcare facility to admit and treat many casualties, but doesn’t damage
the facility itself or threaten personnel, patients, or residents.

Internal Disasters

se cause (or threaten to cause) injury or damage to the healthcare facility and its
patients, residents and staff. Examples are:


Water shortages

Fuel shortages

Loss of power

Bomb threats

The Disaster Plan

The Disaster Plan addresses both

internal and external disasters. It covers:

Admission of casualties

Securing the facility

Traffic control

Communicating with the public and families



Loss of Utilities

Bomb Threat

Snow Storm


Before Disaster Strikes, Be Pr

Know the plan for responding to internal and external disasters.

Know your role and responsibilities in the plan.

Practice via drills

Monthly fire drills

Annual tornado drills

Annual disaster drills


Code “Triage”

Disaster Plan Activation

Code “Red”


Code “Orange”

Hazardous Materials Release

Code “Blue”

Cardiac Arrest

Code “Black”

Bomb Threat

Code “Pink”

Infant Abduction

Code “Grey”

Resident or Patient Missing

Inclement Weather Alerts:

Code “Torn
ado Watch”

Weather Conditions Such That Tornadoes Could Form

Code “Tornado Warning”

A Tornado Has Been Sighted in the Area: Take Cover

Response To Discovery Of Fire

Employee Responsibility In Case Of Fire

All employees

need to respond appropriately upon discovery of a fire.

Any individual discovering a fire must remain calm and do the following:



Rescue any person that is in immediate danger.



Announce alarm. Call out "Code Red
location" and pull the nearest F
ire alarm station if
alarm is not already activated.



Confine the fire.



Extinguish the fire if reasonable. Evacuate as needed, following the Evacuation Plan for
your department. Evacuation Plans are in a red binder located in each department.
Be s
you know where this information is and acquaint yourself with it so you will be
prepared in case of an emergency.

Work as a team. You and/or others must do all of the above within the first 30 seconds of


Remain ca
lm, do not run or panic.

Smoke kills. Stop the spread of smoke, stay low and crawl below smoke level.


. If closed doors are touchable, open slowly.

Place a wet towel at the base of the door where the fire is located.

If clothing ca
tches on fire, smother flame by rolling in blanket.

Smother small fires with a pillow, towel or blanket.

Never leave an extinguished fire unattended. Stay until fire department arrives.

Apply extinguishing agent even after the flames are extinguished.

ire Drills and Fire Alarm System Testing

DHS Policy on Fire Drills

Fire drills and testing of the fire alarm system will be conducted monthly, on alternating shifts.

Procedure for Fire Drills

Fire drills will be conducted in a manner to simulate an actua
l fire situation, conducted
simultaneously in both units and will activate the fire alarm system during each drill. If the fire
alarm system is not activated during a drill (i.e.: patient/resident convenience between 9pm
and 6am), the fire alarm system wil
l be tested within 24 hours of the silent drill. The drill will
be documented on an approved form by the person conducting the drill.

1. Prior to initiating the drill, dispatch must be notified by the person conducting the drill that a
drill is being con

2. A red and white flag is used to indicate location of the fire. Different locations are used to
gain a variety of possible fire situations.

3. The person finding the flag will respond according to the
“Fire Response Procedure (R
. Observ
er calls Dispatch and informs them that a fire drill is to be conducted.
Observer announces drill after fire alarm has been activated.

4. All others respond according to the department specific guidelines outlined in the
“Response to a Fire Emergency” pro

5. Supervisors evaluate staff response and educate as needed. Fire drill participation forms
are kept at the Nurses Stations and are to be signed by all participants and delivered to the
Plant Operations Supervisor when completed.

6. Person condu
cting drill will announce
“all clear”

over the intercom at the end of drill. At
the completion of the drill, dispatch is notified that the drill has been completed and verifies
that the monitoring party has responded.

Fire Prevention
Employee Responsibili

DHS Policy on Employee Responsibility in Fire Prevention:

All employees shall observe good fire prevention and life safety practices.

Fire Prevention Procedure

1. Always keep areas near fire doors clear.

2. Maintain clear and unobstructed hallways a
nd exits. When using carts in hallways place
carts on odd numbered room sides only to maintain an unobstructed exit path.

3. Dispose of trash and rubbish properly.

4. Report any known electrical, fire or life safety hazards

to your supervisor or the mai
ntenance department.

5. Enforce and obey established smoking rules.

6. Know the location and proper use of fire extinguishers; pull stations and oxygen shut off
valves in assigned work area.

7. Report, immediately, any suspicious sounds, smoke, or smell

to your supervisor or the
Maintenance Department.

All facility fire extinguishers are
ABC multipurpose dry chemical

and can be used on

types of fires.

Using an Extinguisher:


Pull the pin between the two handles.


Aim nozzle at the base of

the fire.


Squeeze handles together.


Sweep from side to side.

Always, extinguish the fire with your back to an exit door, in case you have to leave the area.
If safe, you should remain at fire location until the fire department arrives.

Go Home

Take the Disaster Preparedness Test



Go Home


Some of the things we use around our workplace can be classified as hazardous substances.
Generally, we’re talking about chemicals used in different procedures throughout the facility.
Hazardous substances include everyday things like cleaners, radiation,
noise levels, ergonomics,
etc. Here are some simple guidelines to follow regarding general hazardous material safety:

1. If there is anything you don’t understand about the chemical hazards associated with your job,
be sure to ask!!

2. Be sure you know

where the company’s written hazard communication plan is stored.

3. Be sure you have received appropriate hazard communication training before working with
potentially dangerous substances.

4. Understand how to read chemical labels and review them bef
ore using any chemical.

5. Never use a substance in an unlabeled or unauthorized container.

6. Wear appropriate protective equipment when working

with hazardous substances.

7. Make sure you know where material safety data sheets (MSDSs) are located
and how to read

8. Always follow proper procedure when handling hazardous substances.

9. Store chemicals in closed containers and in accordance with instructions on the label.

10. Wash thoroughly after using a hazardous substance.

11. Clean a
ny tools, clothing or equipment that have been exposed to a hazardous substance.

12. Be sure you understand potential emergencies that could arise with chemicals you use at


According to OSHA regulations, you have a right to know about t
he hazardous
substances you work with. Taking advantage of this right is your responsibility. Please participate
in all hazard communication training; read and follow all instructions on chemical labels and
material safety data sheets (MSDSs); and if you a
re unsure about something,
ASK !!!!!


More than 10,000 people die from on
job accidents every year

and a worker is injured every
18 seconds.

Your company does much to protect you from accidents

from special training and protect
to providing printed information for you to read.

But there’s one key to safety only YOU can control: YOUR OWN SAFETY ATTITUDE.

Use Your Safety Sense

Carelessness is the main cause of accidents. People get careless about safety for severa

∙ Complacency

going on “automatic pilot” because you’ve done the job so often

∙ Emotions

being angry or upset by something that happened at home, an argument with
someone else at work, etc.

∙ Fatigue

too little rest or too many hours on the j

∙ Not appreciating risks

not enough training, not wearing protective equipment, or not paying
enough attention when you are being trained

∙ Reckless or know
all attitude

thinking that safety isn’t important or doesn’t apply to you.

The bottom lin
e: Don’t allow these factors to set you up for a painful accident.
Take safety

all the time!!!!!

Plan Your Job for Safety

Before you start any job, use the following safety checklist:

Look around for anything that could go wrong.

Eliminate t
he risks before you start.

Check and read labels and MSDSs.

Use the correct protective clothing and equipment.

Remove from the workspace anything you could trip over or that creates a hazard

sources, reactive chemicals, combustibles, etc.

Be sure equipment is in good working order. If it’s not,

Don’t eat or smoke in the work areas.

Use proper ventilation if it’s called for.

Respect electricity and power equipment. Turn off equipment when it’s n
ot in use.

Use the right tool or equipment for the job. For instance, don’t use a pile of boxes instead of a

Follow all job procedures. Don’t do a job if you’re not sure how.

Have a buddy around if you’re assigned to a hazardous task such as wo
rking in a confined

Keep focused on what you’re doing.

The most important rule: When it comes to safety, there are no dumb questions!!



The Occupational Safety and Health Administration (OSHA) created the Hazard Commu
Standard (HazCom) to protect you, the employee. You have the RIGHT TO KNOW about the
potential hazards you face on the job, and how to protect yourself from those potential hazards.

Your employer is required to provide you with the information,

training and equipment you
need to protect yourself and others when working with the potential hazards in your work area.

You, the employee, are required to use your RIGHT TO KNOW training to stay safe and
healthy on the job. Our HAZARDOUS MATERIAL


It is the responsibility of the Department Manager to see that all their employees have
received the in
service on the employee's RIGHT TO KNOW.

Chemicals make your work easier and more effective and they save lives. YET
, used carelessly
in ignorance or with poor judgment these same powerful tools become destructive.


A chemical can be a physical hazard,
a health hazard or both.

A physical hazard can cause a dangerous situation such as a fire or an explosion.

A health hazard can damage your health when a chemical is inhaled, eaten, or splashed on
your skin or into your eyes.

Acute health hazards hurt
you rapidly, after short
term exposure, i.e. Poisoning, chemical
burns or rash.

Chronic health hazards harm you more slowly, after long
term exposure, i.e. Cancer, organ
damage, or allergies.

~Reactive chemicals can burn, explode, or release toxic vapors
, if exposed to certain other
chemicals or heat, air or water. (Mixing toilet bowl cleaner and bleach)

~Toxic chemicals cause illness or even death. (Asbestos, coal dust, weed killers, bug dope)

~Corrosive chemicals can burn the eyes or skin. (Lye, oven
cleaners) Consider what the
corrosive chemical from poison ivy does to your skin.

~Flammable chemicals catch fire easily. (Some paints)

~Some chemicals can explode or emit harmful radiation. (Gas containers, oxygen cylinders,
radiology procedures)

icals aren’t just liquids in a container. They may be solids, liquids, gases, vapors, fumes
and/or mists.

Below are some chemicals which appear in these different forms:


Car gas


Carbon monoxide

Welding fumes

Spray paints

What about
the fumes released when mixing toilet bowl cleaner and bleach?

Chemicals can enter your body by three routes:

Skin and eye contact



Swallowing hazardous chemicals (easy to do if you eat or smoke after handling chemicals without
hing first) can poison you or damage your internal organs.

How do we find out which products contain potentially hazardous chemicals?

Chemical manufacturers must determine the physical and health hazards of their products. This
information is passed on

to users of the chemical by container labels and material safety data
sheets. (MSDSs)

Manufacturers are not required to use a standard format for their warning labels or MSD sheets
but the labels and MSD sheets must contain the required information as s
et by the Hazard
Communications Standard.

Product Warning Labels

Warning labels on containers alert you to the dangers of the chemicals you are about to handle.

The label states:

The products chemical name

Any hazardous ingredients

Physical and h
ealth hazards

The name, address and emergency phone number of the company that manufactured or
imported the chemical

Important storage and handling instructions

Basic protective clothing, equipment and procedures that should be used to work safely with
the chemical might also be listed.


Each hazardous product has its own MATERIAL SAFETY DATA SHEET (MSDS).

Read it before you start any job where you will be using a product containing a chemical if you
have not been trained i
n the use of the product. You will learn:

What the chemical is

What its hazardous ingredients are

What its physical and chemical characteristics are

Why the chemical is hazardous

How to work safely with the chemical


Not all MSD Sheets have the same format BUT they do contain the following


~ The name of the chemical on the product container, its chemical name and any common
names, such as “formalin” for formaldehyde.

~ The manufacturer name, a
ddress, phone number, plus an emergency phone number you
can use to get immediate information on specific chemical hazards.


~ Any hazardous ingredients of a chemical

~ Safe exposure limits, such as Permissible Exposure Limits (PEL
s) and Threshold Limit
Values (TLVs)


~ Physical information to help you identify the chemical and its characteristics, such as
appearance, odor, boiling point, vapor pressure, vapor density, solubility in water, mel
point and evaporation rate.


~ Fire and explosion information

~ The chemical flash point, or temperature at which it ignites

~ What to put on the fire to extinguish it safely

~ Special fire fighting techniques and equipment

~ Any unusual fire or explosion hazards


~ Dangers from chemical reactions with the material

~ Conditions or other materials that can cause reactions with chemicals you are using.

~ Any dangerous substances that can be produced in relation wi
th other chemicals or in
atmospheric change.


~ Health hazards caused by the chemical itself

~ Symptoms of overexposure, both acute and chronic

~ Medical conditions that may be aggravated by exposure

~ How the chemical can enter your bod

~ Whether the chemical can cause cancer

~ First
aid and emergency procedures

sometimes listed separately at the beginning of the
form for quick reference


~ How to deal with spills and leaks

~ Clean
up techniques

~ Personal pr
otective equipment to be used during clean up

~ How to dispose of waste materials properly

Always notify your supervisor of a chemical spill immediately. Make sure you are
trained and wearing appropriate protective gear before you attempt clean up.


~ Special protection information on the MSDS includes any personal protective equipment
you will need to work safely with the chemical


~ Safety glasses and/or goggles

~ Protective clothing or suits

~ Gloves

~ Special boots or shoes

~ A respirator

For your safety use these protective items when you are required to.

Be sure to:

Follow the manuf
actures directions

Read the MSDS for warning information

Make sure the protective items fit snugly yet allows you to do your job

Make sure the protective items have no rips or tears

Check that all fasteners are secure

Remove protective items carefully

after the job to prevent contaminating yourself and the
surrounding area

Dispose of contaminated protective items according to facility procedures


Additional special precautions to follow when handling the chemical may include:

~ What you need to clean up a spill or extinguish a fire

~ Other health and safety information


A Color and Number coded label system has been d
eveloped by the National Fire Protection
Association (NFPA) and other organizations.

This system uses the following codes:


represent the KIND OF HAZARD

∙ Blue = Health Hazards

∙ Yellow = Reactivity

∙ Red = Flammability

White = Specific Hazard


show the “DEGREE” of HAZARD

∙ 0 = minimal hazard

∙ 1 = slight hazard

∙ 2 = moderate hazard

∙ 3 = serious hazard

∙ 4 = severe hazard

Hazard warning information such as organs of the body t
hat may be affected by the chemical
will usually be shown.

By law every chemical container must have a label attached to it. If you find a damaged,
incomplete or missing label, notify your supervisor immediately. It must be replaced. A new
container must
be labeled when a chemical is transferred to another container.

Labels are not required when you transfer a chemical from a labeled container to a portable
container if you plan to use that chemical immediately yourself. NEVER leave an unmarked

of a hazardous chemical unattended. NEVER assume that an unlabeled container
has contents that are harmless.
DO NOT SMELL, TASTE or TOUCH an unknown liquid.
Always read the label before you use a chemical. Read the MSD Sheet. Use the information
to work s
afely with the chemical.

Your safety training along with label and MSDS information can protect you and others when
working with chemicals.







Your facility provides you with

training programs and equipment to protect you. BUT it is up
to you to use this help to stay safe around chemicals you use in your work area. Get to know
the MSD Sheets for the chemicals you work with now

before a problem occurs.




Good Housekeeping is Important

§ Keep your work area clean. Dust, debris, etc. can easily catch fire.

§ Keep aisles and stairs clear. Do NOT leave anything that could be tripped over.

§ Do NOT have
more than one file drawer open at a time.

§ Have enough light to see what you’re doing.

§ Make sure tools are clean and in good working order before you put them away.

§ Only smoke where permitted. Use deep ashtrays in any areas where smoking is permitt

§ Do NOT leave sharp edges sticking out.

§ Clean up spills promptly.

§ Dispose of trash, scrap, and other debris promptly. Use the proper containers.

§ Follow storage procedures to the letter. For instance, Do NOT store flammables near heat
or igni
tion sources.

Follow Your Common Sense


§ Treat safety as an important part of your job.

§ Keep asking yourself

what could go wrong here?

§ Keep your full attention on what you’re doing.

§ Know and follow your company’s safety rules.

§ Use requi
red protective clothing and equipment.

§ Remind other workers about safety procedures and equipment.

§ Pay attention during training programs and safety meetings.


§ Fool around or show off on the job.

§ Let anger, frustration, arguments, or pe
rsonal problems interfere with your work

§ Ignore a safety hazard.

§ Become overconfident with jobs you’ve done many times.

§ Use equipment such as conveyors or forklifts in ways they’re not intended.

§ Get pressured by others into ignoring safety proc

§ Take shortcuts on job procedures like machine guarding.

§ Assume safety is someone else’s job.

Develop a Safe Attitude

A safe attitude is

responsibility. And it’s the best thing you can have to prevent

When you think an accid
ent can’t possibly happen to you, you may become careless. And
that’s when accidents happen.
Develop a Safe Work Attitude.

Go Home

Take the Haz
Mat Test



Go Home

HIPAA Education


Why are privacy and confidentiality important?

No matter where you work in

the hospital, labs, radiology, nursing
homes, doctors’ offices, business units, IT, or right in a patient’s home, it is
important to understand what privacy and confidentiality mean.

Patients have the right to control who will see their protect
ed, identifiable health
information. This means that communications with or about patients involving
patient health information will be private and limited to those who need the
information for treatment, payment, and healthcare operations. Such
ations may involve verbal discussions, written communications, or
electronic communications. Only those people with an authorized need to know
will have access to the protected information.

Hospitals and healthcare organizations have always upheld strict

privacy and
confidentiality policies. Unless you are new to healthcare, this idea will be
familiar to you. However, the U.S. government strengthened the laws protecting
privacy and confidentiality in response to situations in which private medical
mation has ended up in the wrong hands.

In North Carolina, an employer fired a good employee shortly after learning that
the employee had tested positive for a genetic illness that could lead to lost work
time and increased insurance costs. In New
York, a congresswoman who had
battled depression found out her medical history was released to newspaper

Not surprisingly, cases of misuse of health information have also caused
lawsuits. A California woman sued a pharmacy that released her me
information to her husband, who used it to damage her reputation in a divorce.
In another divorce case, a woman threatened to use information about her
husband’s health status that she had obtained from his health records in custody
hearings, forcin
g him to settle in order to avoid public discussion of his health.

As the number of cases of misuse of health information rises, Congress has
taken action to ensure that hospitals and healthcare providers protect health
information privacy and confidentia

With the enactment of the Health Insurance Portability and Accountability Act of
1996, (HIPAA), a patient’s right to have his or her health information kept private
and secure became more than just an ethical obligation of physicians and

t became the law.

What is HIPAA?

HIPAA is a broad law dealing with a variety of issues. Its original goal was to
make it easier for people to move from one health insurance plan to another as
they change jobs or become unemployed. This also means they
must be able to
move their medical records and information easily, to get the care they need.

To make it easier for healthcare organizations to share medical information, the
law requires that common transactions

such as submitting a claim on the
s behalf

be in a standard format for all healthcare organizations and
payers. But as patient information becomes easier to transmit, it also becomes
easier for information leaks and abuses to happen. This is especially true as
more and more information i
s shared electronically through e
mail and the

Before computerized records, it would have been difficult to remove many
records and make use of the information. Today, with e
mail and electronic
storage of information, in just a few minutes at
a computer, thousands of records
can be sent virtually anywhere.

Imagine you wanted to identify patients who had an expensive medical condition
in order to discriminate against them. Using paper records, if you could get
them, the task would take countle
ss hours. But with a computer and
standardized records, it is simple to sort out patients who have expensive
illnesses and potentially use that information to hurt their chances at getting jobs
or insurance. Standardizing and computerizing patient health

information has
important benefits, but it also brings risks.

As a result, an important part of HIPAA focuses on patient privacy and
confidentiality. Under HIPAA privacy and information security sections, it is
illegal to release health information to i
nappropriate parties or to fail to
adequately protect health information from release.

Potential Consequences

The U.S. Department of Health and Humans Services (HHS) enforces HIPAA.
Breaking HIPAA privacy or security rules can mean either a civil or

Civil penalties are fines of up to $100 for each violation of the law per person, up
to a limit of $25,000 for each identical requirement of prohibition. For instance, if
a hospital released 100 patient records illegally, it could be fi
ned $100 for each
record, for a total of $10,000. If there are found to be multiple violations, these
fines could increase significantly.

Criminal penalties for wrongful disclosure can include not only large fines, but
also jail time. The criminal
penalties increase as the seriousness of the offense
increases. In other words, selling patient information is more serious than
accidentally letting it be released, so it brings stiffer penalties. These penalties
can be as high as a $250,000 fine or a p
rison sentence of 10 years. For

Knowingly releasing patient information in violation of HIPAA can result in a one
year jail sentence and a $50,000 fine.

Gaining access to health information under false pretenses can result in a five
year jail se
ntence and a $100,000 fine.

Releasing patient information with harmful intent or selling the information can
lead to a 10
year jail sentence and a $250,000 fine.

Your facility is committed to protecting patient privacy and confidentiality. When
you fail
to protect patient information and records by not following your
organization’s privacy and security policies, it reflects on your ability to perform
your job. To learn more about the consequences of violating patient privacy and
confidentiality, review o
ur facility’s privacy policy.


Ways to protect patient privacy

Whether they are in the hospital, physician’s office, lab, or other setting, patients
receiving medical care expect privacy. They expect to be physically separated
from str
angers and employees when the consult or interact with their doctors and
nurses, and they expect that their private health information will not be shared
with people who do not have a need to know.

Decatur Health Systems is committed to giving patients pr
ivacy. As you work
here, you will see many ways patient privacy is protected.

Patient care or discussion about patient care is kept private by closing doors or
drawing privacy curtains and conducting discussions so that others may not
overhear them. Pat
ient medical records are not left where others can see or gain
access to them. Laboratory, radiology, and other ancillary test results are kept

Privacy is essential to the mission of Decatur Health Systems, and it is important
to patients

many o
f whom will be uncomfortable in strange surroundings. As
you perform your job, you need to protect patient privacy.

When carrying out your job assignments and meeting deadlines, remember that
you don’t want to interfere with patient privacy or jeopardize

the confidentiality of
patient information in the process.

Much of this is common sense. Knock on a door and ask to enter before
entering a room. Keep patient records locked away and out of public areas. If
you find records unattended, return them to
the nursing supervisor.

If you need to page a patient, the page should not include information that can
allow others to identify the patient’s condition or reason for being there.

If visitors ask you for information about a patient, direct them to the c
harge nurse
for assistance rather than giving out patient names or locations yourself. Be sure
the patient has agreed to see visitors or has agreed that information about
his/her location can be released before you disclose any information.

Patients expe
ct privacy when they are receiving healthcare. It is up to everyone
to see that their expectations are met by both respecting their privacy and not
repeating any information that may detract from a patient’s privacy.

Consider what you would choose to do
in the following cases to protect patient

Case Scenario # 1:

You are called to work in a patient’s room to perform a routine job assignment.
You knock on the door and are invited in. You see that a nurse is in the room,
discussing the patient’
s condition or medication.

Q: What should you do? Should you ask if it’s OK to perform your job? Or

should you come back later?

A: If the task is critical to patient care, ask if you can interrupt. Otherwise explain
that you are there to perform a
routine job and will return in 15 to 20 minutes.
That protects the patient’s privacy by allowing them to conduct their discussions
without being overheard.

While some patients may say that it’s OK for you to remain in the room during a
consultation, reme
mber that patients might not feel comfortable sharing complete
information about symptoms while you are in the room. Some patients might not
feel comfortable asking you to leave. Some nurses might even forget that you
shouldn’t be in the room while they
are discussing treatment with a patient.

That’s why good privacy practices require that you tell them you will return later
to complete your work so that you don’t interfere with the patient’s care.

Case Scenario # 2:

You are working in the emergency d
epartment when you see that a neighbor has
just arrived for treatment after a car crash and you hear someone saying that he
will be taken to surgery soon. Your neighbor’s wife works in another part of the

Q: Should you notify the neighbor’s wi
fe that her husband has arrived in
the emergency department?

A: No. The correct course of action is for you to tell the nursing staff that you
know the patient and his wife, and let them know if they need to locate her, you
can help by providing informa

When patients are in the hospital, they have the right to decide who should know
they are there. Your neighbor has a right to privacy. Your neighbor may not
want to notify his family of his accident. If he is conscious, the emergency

staff will allow him to decide who should be notified of his presence
at the hospital.

If he is unconscious, the doctors and nurses will use their professional judgment
about whether to notify his wife and will decide whether you, as a friend, should
involved in any way. Leaving this decision to the emergency department staff
is essential.

If you are unsure about what to do when a situation arises, consult with your
supervisor or your privacy officer.

Which of the following situations describe
proper techniques for protecting a
patient’s privacy and confidentiality?

A doctor brings a patient into an unused room to discuss the patient’s medical

A doctor who is reviewing a patient’s record leaves the folder in the doctor’s
lounge to re
view later.

A doctor emails a physician colleague to consult about a patient’s condition. He
explains the condition but omits any identifying information regarding the patient.

If you selected #1 and #3, you are correct. In both these cases the patient’
privacy was protected.


What is confidential information?

When patient give information to their providers, they expect that only people
involved in their healthcare will see it. Confidential information includes patient
ity, address, age, Social Security number, and any other personal
information that patients are asked to provide. In addition, confidential
information includes the reason a person is sick or in the hospital, the treatments
and medications he or she may r
eceive, and other observations about his or her
condition or past health conditions.

How is patient information used?

The hospital collects this information so that it can take care of patients and
perform other related functions. However, the facility
and its workforce can use it
only in limited ways.

Obviously, doctors, nurses, therapists, dietitians, and other caregivers use
information about patients to determine what services they should receive. In
addition, the billing department uses confidenti
al information to bill patients or
their insurance companies for the services they receive. And, other physicians
and quality control directors review confidential information to make sure patients
are getting good care.

Other uses are, generally speak
ing, not allowed. It is helpful to ask yourself
before looking at any patient information:

Do I need this in order to do my job and provide good patient care?

What is the least amount of information I need to do my job?

This requirement to use or sha
re only the “minimum necessary” is covered in the
HIPAA privacy rule, section 164.502(b).

Who is authorized to see information?

All members of the workforce at a hospital contribute to the quality of care. But
that doesn’t mean everyone needs to see health information about patients.
Many employees have no access to patient information, whether in the computer
or on paper. That’s

because they don’t need to know the information. That’s an
important phrase to remember:
Need to know

If you do not need to know confidential patient information to do your job, you will
not be given access to it. That means that you should not look
at medical
records, either in the computer or on paper.

But there still will be occasions when you will have access to confidential
information. For example, if a patient is placed in an isolation room, you may
learn of why he or she is there, or you may

suspect you know why. This is
confidential information about a patient, and you should not share it with anyone

Another example of confidential information is the information about a patient’s
condition that you see written on whiteboards around
the hospital. The
information contained on these boards is used for giving care to patients. In
general, it is recorded in places where the public will not see it. But you may
work in areas where this information is visible. This information is confide
That means you should not use it or share it with anyone, including coworkers,
other patients, patient visitors, or anyone else who may ask you about it.