Student Orientation 2010
Mission Statement
Cartersville Medical Center is committed to treating
all of our patients with compassion, kindness, and
dignity. We will collaborate with our stakeholders to
continuously improve patient care, evaluate and
establish services beneficial to our community, and
position our hospital as the preferred health care
provider and a desirable business partner.
Welcome to
Cartersville Medical Center
An Overview of
Cartersville Medical Center
960 Joe Frank Harris
Parkway
Cartersville, GA 30120
(770) 382-1530
Hospital opened September 1, 1985
112 Total Beds
14 Intensive Care
88 Med/Surg
10 OB/Maternity beds
18 Beds in the Emergency Department
8 Operating Rooms
6,402 Admissions
1,031 Births
Volume (FY 2009)
48,514 ER Visits
67,376 Outpatient Visits
Personnel
750 Employees
160 Physicians
9,280 Surgeries
Cartersville Medical Center
Executive Management Team
Keith Sandlin, Chief Executive Officer
Lori Rakes, Chief Operating Officer
Benny McDonald, Chief Financial Officer
Miriam Eide, Chief Nursing Officer
Rebecca Battle, Associate Administrator
Vision
At Cartersville Medical Center, building on a
foundation of strong physician and community
support, we will continue providing top-quality,
patient-centered health care and remain the
preeminent hospital in Bartow County.
Customer Service and HCAHPS
Walking the Talk
HCAHPS
Objectives

Increase awareness of HCAHPS and its impact on
facility

Discuss how patient loyalty impacts satisfaction

Apply HCAHPS initiatives in your work setting to
help “move the bar” on current results
What is HCAHPS?

Hospital Consumer Assessment of Healthcare
Providers and Systems

The nation’s first standardized, publicly reported
survey of patients’ perspectives of hospital care.
Cliff Notes: It’s what our patients think about us after
they leave our hospital.
Why is HCAHPS Important?
The HCAHPS survey asks patients who have stayed at
our hospital (inpatients) 27 questions, including 18 items
about key aspects of their hospital experience.
These are broken down into the following domains:
 Communication with nurses and doctors
 The responsiveness of hospital staff
 Cleanliness and quietness of hospital environment
 Pain management
 Communication about medicine
 Discharge information
 Overall rating of the hospital
 And recommendation of the hospital
Caring Behaviors
It’s all about the things we do
Our collective acts of all hospital staff have important
consequences for patients, and directly affect their
perceptions of the quality of care they received.
I
C
A
R
E
Introduce yourself; explain your role
Call the patient by his/her preferred name
Appropriate touch
Review care with patient daily or purpose
of visit, sitting at eye-level with patient
Each day compliment another
caregiver/co-worker to the patient
T.E.A.M.
T- Together
 E- Excellence and
 A- Attitude
 M- Matters

“… Cartersville Medical Center is committed to
treating all our patients with compassion, kindness,
and dignity.”
Customer Service
and
HCAHPS continued
Welcome to
The Multi-Language Workplace
Learning Objectives
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Describe the impact of the multi-language workplace on
our facility
Identify your responsibility to respect different cultures
in our organization and patient base
Identify your responsibility in ensuring that we do not
exclude others just because English is not their first
language
Describe how to apply a commonsense approach for
addressing situations in which language might tend to
exclude others
Identify other ways in which our behaviors might
exclude others and strategies for demonstrating
respectful, inclusive behaviors
Core Concepts and Definitions
Respect
Showing appreciation and regard
for the rights, values, and beliefs of
others
Culture
A system of shared beliefs, values,
customs, and behaviors
Diversity
The similarities and differences
among all groups that make up
HCA
Core Concepts and Definitions
Continued
Cultural Diversity
The differences and unique
characteristics of the various
groups that make up our business
environment
Workforce Diversity
The differences that are created by
HCA’s own structure and culture
Cultural Competence
Having the knowledge and ability
to recognize and respond
appropriately to our similarities and
differences and use that
knowledge and understanding to
make better decisions
Ethics and Compliance
Cartersville and HCA have a comprehensive, values
based Ethics and Compliance Program, which is a vital
part of the way we conduct ourselves. Because the
Program rests on our Mission and Values, it has easily
become incorporated into our daily activities and
supports our tradition of caring – for our patients, our
communities, and our colleagues. We strive to deliver
healthcare compassionately and to act with absolute
integrity in the way we do our work and the way we
live our lives. All work must be done in an ethical and
legal manner. It is your responsibility and your
obligation to follow the code of conduct and maintain
the highest standards of ethics and compliance.
Ethics and Compliance
Continued

If you have questions or encounter any situation which you
believe violates the provisions of the code of conduct or the
corporate integrity agreement, you should immediately
consult your supervisor, another member of the management
team, the VP of HR(Robbie Tatum ext 1141), the Ethics and
Compliance Officers (Benny McDonald ext 1134 and
Rebecca Battle ext 2206), or the HCA Ethics Line (1-800-4551996).

Each employee and volunteer is required to attend two hours
of initial code of conduct training and a one hour annual
refresher training session. Leaders and individuals in key
jobs have additional annual education requirements.
Georgia False Claims Laws
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There is a federal False Claims Act, and there are also
Georgia laws that address fraud and abuse in the Georgia
Medicaid program.
Any person or entity that knowingly submits a false or
fraudulent claim for payment of funds is liable for significant
penalties and fines.
The False Claims Act has a “qui tam” or “whistleblower”
provision. This allows a private person with knowledge of a
false claim to bring a civil action on behalf of the US
Government. If the claim is successful, the whistleblower
may be awarded a percentage of the funds recovered.
For additional information please see the Georgia False
Claims Statutes Policy.
Infection Prevention

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Our goal is to identify and reduce risks of healthcare
associated infections in patients, visitors, and healthcare
workers.
Hand washing is the single most effective way to prevent the
spread of infection. Routine hand washing involves a rigorous
rubbing together of well lathered hands for 15-20 seconds
followed by a thorough rinsing under running water. Must use
soap and water if hands are visibly soiled.
Hand hygiene with an alcohol based product is acceptable as
long as the hands are not visibly soiled. (Always wash hands
with soap and water if the patient you are caring for has C.
Difficile).
IC Champions monitor hand washing in our facility. The use
of gloves does not eliminate the need for good hand washing.
Hand Hygiene

Wash hands at least in the following situations:
◦ Before donning sterile gloves when inserting a central
intravascular catheter
◦ Before inserting indwelling urinary catheters, peripheral
vascular catheters, or other invasive devices that do not
require a surgical procedure
◦ After contact with a patient’s intact skin (e.g. when taking a
pulse or blood pressure, and lifting a patient)
◦ After contact with body fluids or excretions, mucous
membranes, non-intact skin, and wound dressings
◦ If moving from a contaminated body site to a clean body
site during patient care
◦ After contact with inanimate objects (including medical
equipment) in the immediate vicinity of the patient
◦ After removing gloves
◦ Before eating and after using the restroom
Hand Hygiene Compliance

A comprehensive hand hygiene program involving
the patient.

Signs have been placed in patient rooms “It’s OK to
Ask”. Patients have a right to ask if you washed
your hands before you take care of them
Goal for Hand Hygiene is 100%
Artificial Nails

Artificial Nails, extenders, wraps, tips, etc. can not
be worn by employees providing any services to a
patient in accordance with the Center for Disease
Control (CDC) guidelines.

Chipped nail polish should be immediately
removed. Nails should be well-kept in appearance.
Ways Surgical Staff Help Prevent
Surgical Site Infections
All healthcare workers wash hands before and
after contact with patient
 Appropriate skin prep
 Clip hair instead of shaving hair
 Antibiotics are given in timely manner for
appropriate duration
 Surgical team wears mask, cap, gown and
gloves during surgery
 Monitor for signs and symptoms of infection
 Control of blood sugar
 Surgical hand scrubs before procedure

Ways Cartersville Staff Help Prevent
Blood Stream Infections

Wash hands prior to inserting line

Wash hands prior to touching line or giving
medication through line

Follow bundle best practices for line insertion:
◦ Special skin prep, wear gown, mask, gloves, and
cap when inserting line, remove line when no
longer needed, choose safe site for insertion,
evaluate necessity of line daily.
Ways Cartersville Staff Help Prevent the
Transmission of Multi-Drug resistant organisms
like MRSA,VRE, and C Difficile
Hand washing before and after contact
 Use contact precautions when caring for patient
with history of these conditions (wear gown and
gloves on entry to room)
 Special room assignments
 Screen patients at high risk when they are admitted
 Patient Education
 Carefully clean hospital equipment

Ways Cartersville Staff Help Prevent Urinary Tract
Infections caused by a Foley Catheter
Hand washing prior to inserting foley catheter
 Catheters are inserted only when necessary and
removed when no longer needed
 Only properly trained staff insert catheters
 Sterile technique used while inserting foley
 Skin prep prior to insertion
 The foley bag is kept below the level of the bladder
to prevent urine back flow
 The foley bag is emptied regularly

Ways Cartersville Staff Help Prevent
Ventilator Associated Pneumonia
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Hand hygiene prior to care
Mouth care every two hours
Follow the bundle best practices:
◦ Head of bed up 30 degrees unless contraindicated
◦ Evaluate daily need of ventilator
◦ Peptic Ulcer Disease Prophylaxis
◦ Deep Venous Thrombosis Prophylaxis
Personal Protective Equipment
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Personal Protective Equipment (PPE) is provided at no
cost to the associate
Worn when there is a chance of contact with blood or
other potentially infectious body material (OPIM).
PPEs include, but are not limited to: gloves, gowns,
goggles, pocket masks, and shoe coverings. PPEs are
available in each department.
Wear gloves when it can be reasonably anticipated that
there may be hand contact with blood or OPIM and
when handling and touching contaminated items or
surfaces. Replace them if torn or punctured or if their
ability to function as a barrier is compromised.
Gloves must be removed before leaving the room.
Hands must be washed after glove removal.
Personal Protective Equipment
Continued

Wear appropriate face and eye protection when
splashes, sprays, splatters, or droplets of blood or
OPIM may pose a hazard to the eye, nose, or mouth.

Remove immediately, or as soon as feasible, any
garment contaminated by blood or OPIM.

PPEs may be disposed of in the regular trash unless
contaminated with blood or other OPIM, if contaminated
they must be disposed of in red biohazard bags.

Each department has a list of tasks and what PPE is
recommended or mandatory to wear while performing
those tasks. Ask your leader about this list.
Standard Precautions

Standard Precautions apply to all blood or body fluid which
is considered potentially infectious. Very important to wear
appropriate PPE when dealing with blood or body fluids.

By using standard precautions you will substantially
reduce your risk of infection with a blood borne pathogen.

In addition to standard precautions, there are three types
of transmission based precautions (isolation precautions)
used for patients with documented or suspected
transmissible pathogens that require more than standard
precautions.
Isolation Precautions

Airborne (wear N 95 Mask)

Droplet (wear regular mask)

Contact (wear gown, gloves, sometimes mask)
◦ Add sign “Wash hands with soap and water if
patient has C difficile”
Contact Precautions
◦ Used in addition to standard precautions
◦ Bacteria transmitted by direct patient contact or
by indirect contact by touching environmental
surfaces.
◦ Isolation gowns and gloves must be worn and
sometimes a mask.
◦ Private room for patient or placed with patient
with the same bacteria.
◦ Patients should wear an isolation gown and wash
hands before leaving the room.
◦ Environmental services should be notified on
patient discharge to terminal clean room.
Airborne Precautions
◦ Used in addition to standard precautions for illnesses
transmitted by airborne droplets.
◦ Patient is placed in a negative air flow room.
◦ If patient must leave room, they are given a mask to
wear.
◦ Staff must be fit tested for an N 95 mask before
entering this type of isolation room. Staff members
who have not been fit tested may not go in this room.
◦ Visitors are taught by the nurse how to wear the
mask.
◦ Persons not immune to measles or varicella (chicken
pox or disseminated varicella) should not enter the
room of patients with these illnesses.
Droplet Precautions
◦ Used in addition to standard precautions for
illnesses transmitted by large droplets.
◦ A regular mask is worn in this room.
◦ Patient must be placed in a private room.
◦ If the patient needs to leave the room, they are
given a mask to wear.
◦ For patients with suspected H1N1, wear N 95
mask for aerosol generating activities (enhanced
droplet precautions)
Examples of Multi-Drug Resistant
Organisms (MDRO’s)
1.
Methicillin-Resistant StaphAureus (MRSA)
◦ Staph aureus are bacteria commonly found on the skin of healthy people.
◦ MRSA can be present without causing disease. When there is no associated
disease, we call their presence colonization. If MRSA is causing disease such as
fever or pneumonia, we call it infection.
◦ MRSA is spread by contact (direct contact with the pt or indirect contact with their
environment) thus contact precautions are implemented (gown and gloves)
◦ Good hand washing is the best prevention for the spread of MRSA.
2. Clostridium Difficile
◦ Causes severe diarrhea
◦ Can be spread by contact with patient or environment
◦ Contact precautions upon entry to room
◦ Good hand washing with soap and water
3. VRE
◦ High risk patients are screened on admission
◦ Most patients are colonized with VRE which means it is colonized (not bothering
them)
◦ Contact precautions upon entry to room
For all MDRO’s
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Use disposable equipment, such a B/P cuffs as much as possible.
Any equipment taken in to the room must be disinfected prior to
removing it from the room.
Education is given to patient/visitors by the nurse. The visitor may
decide for themselves whether or not to wear a gown or gloves.
If the visitor will be visiting other patients during this visit, they must
wear a gown and gloves
Notify receiving department that the patient is on contact
precautions.
If possible, schedule procedures when there are fewer patients in
the area.
The patient should wear an isolation gown and wash hands prior to
transport.
Have the area where the patient has been terminally cleaned by
Environmental Services
Screening for MRSA
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Certain high risk populations are screened for MRSA on
admission by having a nasal swab screening completed.
If they have MRSA in their nose, they are placed on
contact precautions to reduce the risk of MRSA to others.
You may have noticed more patients on isolation
precautions because of this process.
Patients who already have MRSA on admission to our
facility have Community Acquired MRSA. This is different
from MRSA acquired in a healthcare setting.
Usually it is a skin infection or MRSA colonization in the
nose.
Community MRSA is increasing throughout the US.
Tuberculosis (TB) Update
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Spread from person-to-person through the air droplets from
someone who has TB
Symptoms of TB include: greater than three weeks of cough,
unexplained fever, weight loss, and night sweats.
Infection is usually detected by a positive PPD skin test and
an abnormal chest x-ray.
Patients suspected of having active tuberculosis are placed
on airborne precautions in a private room with negative air
flow. The door must remain closed at all times except when
entering and exiting the room
A person can also have the TB germ which is dormant (not
active TB). This person has a positive skin test but they are
not ill.
They cannot spread the bacteria to others, however they do
have an increased risk of eventually acquiring active TB.
Tuberculosis (TB) Update
Continued

Upon hire, associates are required to have a PPD skin unless they
have ever had a positive skin test.

CMC is a low risk facility for TB. This means we do not have to have
annual skin testing except in histology, microbiology and the
bronchoscopy department

Associates with active tuberculosis will be placed on a work furlough
until cleared by the health department as no longer being a risk of
transmission to others and healthy enough themselves to perform
the tasks of their occupation.

Special masks (N 95) are worn by healthcare personnel when
entering the room.

Contact Employee Health Services if your facial structure changes
or your mask does not fit for any reason, or if you have problems
wearing the mask. Personnel should fit check the mask before
entering the patient’s room. The mask must be discarded if it
becomes soiled or at the end of your shift. Masks are stored in the
ante room.
How would the hospital handle an
influx of infectious patients?

If a large number of infectious patients suddenly
presented to the hospital, we would activate our
emergency preparedness plan.

This plan addresses staffing, supplies, and other
issues that might occur as a result of the increased
patient load.
Blood Borne Pathogens
A copy of our plan is available to any associate.
 The plan explains the processes we have in place to
minimize exposures, and what we do if there is an
exposure to a blood borne pathogen.
 The following fluids are considered to be potentially
infectious: blood, semen, vaginal secretions,
cerebrospinal fluid, synovial fluid, pleural fluid,
peritoneal fluid, pericardial fluid, amniotic fluid, or any
other fluid that is visibly contaminated with blood and all
body fluid where it is difficult or impossible to
differentiate, saliva in dental settings, tissue and organs
that are not fixed other than intact skin (from any human
living or dead), HIV containing cell or tissue cultures or
organs, and tissue from experimental animals infected
with blood borne pathogens.

What is Hepatitis B (HBV)?
◦ Hepatitis B is a serious liver disease.
◦ Symptoms include jaundice, fatigue, fever, nausea and
abdominal pain.
◦ It can be transmitted by contact with infected blood and
body fluids.
◦ HBV is much easier to transmit than HIV and lives on
surfaces for longer periods of time.
◦ You can help protect yourself from acquiring Hepatitis B if
you practice infection control guidelines and get
vaccinated.
◦ The Hepatitis B vaccination is given free of charge to
associates. Generally people have few side effects from
the vaccine. If you previously declined the vaccination, you
may notify Employee Health Services if you choose to
begin this series.
What is Hepatitis C (HCT)?
◦ Hepatitis C is a disease that attacks the liver.
◦ It is transmitted by contact with an infected
person’s blood or blood products which enters
the body of a person who is not infected.
◦ HCV infection often occurs without symptoms or
with mild symptoms. The symptoms are very
similar to those of Hepatitis B.
◦ There is no vaccine that offers protection from
Hepatitis C.
What is HIV?
◦ Human Immunodeficiency Virus (HIV) is the virus that
causes the disease Acquired Immune Deficiency
Syndrome (AIDS).
◦ HIV damages the immune system and makes a
person with AIDS more likely to get serious infections
and other diseases.
◦ To become infected with HIV, the virus must get into
your body and enter your bloodstream.
◦ Many people who are infected with HIV do not have
symptoms for years. Persons who are HIV infected
(with or without symptoms, diagnosed with AIDS, or
recently exposed with a negative HIV antibody test)
can spread HIV to others.
◦ It may be transmitted by contact with an infected
person’s blood or body fluids which enter the body of
a person that is not infected.
How to Reduce Transmission of
Blood Borne Pathogens
Observe engineering controls; needle-less systems,
safety devices, sharps disposal containers, biohazard
waste containers, needle boxes at appropriate height.
 Observe work practices; never recap needles, perform
hand hygiene, use appropriate PPEs, do not bend or
break needles, do not eat or drink in areas where there
is potential for exposure, do not store food or drinks in a
refrigerator that is used to store blood or other
potentially infectious material (OPIM), use red
biohazard bags for disposal of infectious wastes.
 Know the job tasks in your department that may involve
exposure to blood or OPIM and wear appropriate PPEs.

What is an Exposure?

Contact with another person’s blood or OPIM such as in needle
sticks/sharps exposures, mucus membrane exposure, or exposure
to non intact skin.

If you are exposed to blood or OPIM, you should clean the skin
injury site with soap and water. If it is a mucous membrane
exposure, flush the area with water.

Inform your supervisor or the designated charge person and go to
Employee Health Services (may go to the Emergency Room during
other hours) to be evaluated.

Complete occurrence form.

You will receive risk information, be evaluated by the ER physician
or the Nurse Practitioner in Employee Health Services, be informed
of recommendations of treatment, and receive care.

You should follow up after your initial evaluation the next day with
Employee Health Services.

You will receive a written opinion for any future recommended follow
up in approximately 15 days.
Prevent Blood Borne Pathogen
Exposures
Use appropriate barriers such as gloves, eye
protection, or gowns when contact with blood is
expected.
 Wash your hands with soap and warm running
water as quickly as possible after contact with
blood or potentially infectious materials.
 Don’t eat, drink, smoke, apply cosmetics or lip
balm, or handle contact lenses in area with
possible exposure to bloodborne pathogens.
 Do not store food in refrigerators, freezers,
cabinets, shelves, or on countertops where blood
or other body fluids are present.

Blood Borne Pathogen Exposure

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Report to Employee Health Services or the E.R. immediately
after a Bloodborne Pathogen Exposure. If you go the E.R.,
then follow-up with Employee Health Services as soon as the
office opens.
Following a bloodborne pathogen exposure, the risk of
infection may vary with factors such as these
 the pathogen involved
 the type of exposure
 the amount of blood involved in the exposure
 the amount of virus in the patient’s blood at the time of
exposure
The following factors were associated with an increased risk
of HIV seroconversion:
 deep injury (deep puncture wound)
 visible blood on source patient device causing injury
 procedure involving needle placed in a vein or artery of
source patient
 endstage AIDS in source patient
Questions OSHA might ask about
Blood Borne Pathogens
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What is standard precautions? All blood and body fluids are
treated as if potentially infectious by wearing appropriate PPE
when dealing with them.
What do you do when there is a blood spill? Wear PPE, locate
spill kit, follow directions, dispose of properly in red bag and
disinfect area where spill occurred.
What do you do with contaminated sharps and laundry? Used
sharps go in designated sharps containers made of hard
plastic that are puncture resistant, soiled linen goes in a blue
linen bag inside a soiled linen hamper and held inside the
soiled utility room.
Have you been offered the hepatitis B vaccination free of
charge? Yes by employee health services (all employees have
opportunity to receive the vaccine)
Where is the Blood borne pathogen plan? On the intranet
under IC policies, in the nursing office or can be obtained
through employee health services
Infection Control
Contact Information

If you have any questions about Infection
Prevention or Blood Borne Pathogens, you may
contact Infection Control ext 8194 (8:00 – 4:30
Monday through Friday)

If the Infection Control Department is not available,
contact your Department Leader or the Nursing
House Supervisor
What Can You Do To Prevent Sharps
Injuries?
Be Prepared
 Complete your Hepatitis B vaccine series and titer
in Employee Health Services free of charge.
 Organize your work area with appropriate sharps
disposal containers within reach.
 Receive training on how to use sharps safety
devices.
 Wear gloves if you expect to come in contact with
blood or body fluids.
What Can You Do To Prevent Sharps
Injuries?
Be Aware
 Keep the exposed sharp in view.

Be aware of people around you. Stop if you feel
rushed or distracted.

Focus on your task.

Avoid hand-passing sharps and use verbal alerts
when moving sharps.

Watch for sharps in linen, beds, on the floor, or in
waste containers.
What Can You Do To Prevent Sharps
Injuries?
Follow Policies
 Don’t recap needles.

Never use needles with the needleless IV system.

Be responsible for every device you use.

If you identify a sharps without a safety device,
discuss this with your supervisor and/or Employee
Health Services.
What Can You Do To Prevent Sharps
Injuries?
Dispose of Sharps with Care
 Don’t remove contaminated sharps with your
hands unless medically required (i.e. caps off used
needles, scalpel blades). If necessary, use a
mechanical device or forceps.

Always activate safety devices immediately after
using a sharp. Never remove safety devices.
Keep your hands behind the needle at all times.
What Can You Do To Prevent Sharps
Injuries?
Disposal of Sharps With Care
 Place all used sharps in biohazard containers, see
policy HIC-16.
 Securely close biohazard containers when ¾ full
and notify Environmental Services to change the
sharps container.
 Do Not overfill sharps containers.
 Do Not reach by hand into containers where
sharps are placed.
Additional Sharps Injury Prevention
for the OR
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Use a neutral zone when passing sharps
instruments. Pass sharps on a tray, not directly to
another individual. Use verbal alerts when moving
sharps.
When suturing, use blunt sutures for muscle and
fascia.
Stay focused on your task. Stop if you feel rushed
or distracted.
Use mechanical devices such as tongs to handle
contaminated reusable sharps. Do Not use your
hands.
Needle Stick/Sharps Injury

What is the risk of infection after exposure?

HBV
◦ Healthcare personnel who have received
hepatitis B vaccine and developed immunity to
the virus are at virtually no risk for infection.
◦ For a susceptible person, the risk from an
exposure can range from 6 – 30% and depends
on the status of the source individual.
Needle Stick/Sharps Injury

What is the risk of infection after exposure?

HCV
◦ The average risk for infection after a needle stick
exposure to HCV infected blood is approximately
1.8%.
◦ There is a small risk associated with exposure to
the eye, mucous membranes, or non-intact skin.
Needle Stick/Sharps Injury

What is the risk of infection after exposure?

HIV
◦ The average risk of infection after a needle stick
exposure is 0.3% (or about 1 in 300).
◦ The risk after exposure of the eye, nose, or
mouth is about 0.1% (1 in 1, 000).
◦ The risk after exposure to non-intact skin is less
than 0.1%.
Needle Stick/Sharps Injury

Treatment for the Exposure

HBV
◦ Hepatitis B vaccine for all healthcare personnel
who have a reasonable chance of exposure to
blood or body fluids.
◦ Hepatitis B immune globulin (HBIG) alone or in
combination with vaccine (if not previously
vaccinated or no immunity developed after
vaccination).
Needle Stick/Sharps Injury

Treatment for the Exposure

HCV
◦ There is no vaccine against hepatitis C and no
treatment after exposure that will prevent
infection.
◦ Following recommended control practices to
prevent percutaneous injuries is imperative.
Needle Stick/Sharps Injury
Treatment for the Exposure
 HIV
◦ There is no vaccine against HIV.
◦ Post-exposure prophylaxis (PEP) with retroviral
drugs is recommended for certain occupational
exposures that pose a risk of transmission of
HIV.
◦ PEP is not recommended for exposures with low
risk for transmission of HIV.
◦ PEP should be started as soon as possible after
exposure, preferably within 2 hours.

Latex Allergies

Latex allergies pose a serious problem for nurses, other health care
workers, and for 1% to 6% of the general population. Anaphylactic
reactions to latex can be fatal.

Health care workers’ exposure to latex has increased dramatically
since universal precautions against blood borne pathogens were
mandated in 1987. Latex can trigger three types of reactions: irritant
contact dermatitis, allergic contact dermatitis, and immediate
hypersensitivity.

Many medical devices contain latex that might trigger serious
systemic reactions by cutaneous (skin) exposure, (i.e. ECG
electrodes, masks, bandages, catheters, gloves, and tape.)
There are some diagnostic tests to determine if a person has an
allergy to latex. If a patient tells you they are allergic to latex, notify
Materials Management and they will provide a cart with latex-free
products. Need more information? Contact the Nursing House
Supervisor at ext. 6910. For associates with latex allergies, contact
Employee Health Services ext. 2129.
Cartersville Medical Center
Employee Health
Employee Health
Body Mechanics
Consider using
mechanical help when
possible
 Ask for help if needed
 Remember to push, not
pull
 Bend your knees
 Avoid twisting

Potential Hazard
Increased potential for employee
injury exists with awkward
postures with include:

Twisting while lifting

Bending over to lift

Lateral of side bending

Back hyperextension or flexion
Forces on the spine increase
When lifting, lowering or handling
objects with the back bent or
twisted. This occurs because the
muscles must handle your body
weight in addition to the weight of
the object being lifted.
This is unsafe lifting
back posture.
CMC is a Drug Free Workplace

CMC drug screens for the following:
◦ Pre-Placement drug screen
◦ Reasonable Suspicion drug screen
◦ Any time you have an injury at work you will have
to complete a post accident urine drug screen as
soon as possible prior to the end of your shift.
Ergonomic Safety


Ergonomic Safety is adapting the equipment, procedures and
work areas to fit the person in order to help prevent injuries
and improve efficiency. Musculoskeletal disorders (MSDs)
affect muscles, nerves, tendons, ligaments, joints or spinal
discs. Injuries can include strains, sprains, and repetitive
motion injuries.
Signs and symptoms: pain, tingling, numbness, swelling,
stiffness, burning sensation, etc. May experience decreased
gripping strength, range of motion, muscle function, or
inability to do everyday tasks. Risk factors: repetition, forceful
exertions, awkward postures, contact stress, and vibration.
Common MSDs: Carpal tunnel syndrome, rotator cuff
syndrome, trigger finger, tendonitis, herniated spinal disc, and
back pain.
Ergonomic Safety
Apply these tips to your job: Adjust chair height and
backrest (feet should be flat on the floor, knees level
with hips, and lower back supported). Sit an arm's
length away from the computer screen. Keep wrists
straight and elbows at right angles. Alternate tasks.
Use proper body mechanics when lifting, transferring,
etc. Avoid reaching and stretching overhead.
 You may recommend ways to reduce the chance of
developing musculoskeletal disorders to your
supervisor. Report signs, symptoms, illnesses ,and
injuries to your supervisor, complete an occurrence
report, and obtain medical treatment in Employee
Health Services.

12 Principles of Ergonomics
Keep everything in easy reach
 Work at proper heights
 Reduce excessive forces
 Work in good postures
 Reduce excessive repetition
 Minimize fatigue
 Minimize direct pressure
 Provide adjustability and change of position
 Provide clearance and access
 Maintain a comfortable environment
 Enhance clarity and understanding
 Improve work organization

Ergonomics: The “Do Nots”
Upper Extremity
◦ Shoulder
 Reaching over 90 degrees (vertical flexion)
 External rotation of greater than 45 degrees
◦ Elbow
 Avoid static hold time of flexion
 Lower Extremity
◦ Sitting position
 The hip, knee, and ankle should be placed at 90
degrees
 Body positions to avoid
 Deep knee bends
 Constant standing in hip and knee extension
 Walking with feet externally rotated

Ergonomics

Self Care
◦ Ice THEN heat
◦ Stretch regularly
◦ Use good posture
◦ Exercise!!!!!
◦ Work smart
◦ Play smart
Ergonomic Tips

The best way to avoid the discomfort of MSDs is:
◦ Change body positions frequently/Set up work
stations to fit your body/Stretch every 45 minutes to
an hour/Perform stretches that are designed to
decrease discomfort for job specific tasks
•Decrease
Fatigue
•Warm-up
exercises
•Interrupt sustained
postures
•Proper ergonomics
•Appropriate work
methods
•Limited overtime
•Increase
Recovery
•Physical
Fitness
•Proper nutrition
•Good sleeping
postures
•Ice after activities
•Avoid smoking
•Alternative job
placement
Performance Improvement
Continual Quality Improvement

What is PI?
◦ PI is a work philosophy that encourages every
employee to find new and better ways of doing
things. All accredited healthcare organizations
are required to have an improvement program.
Cartersville is accredited by The Joint
Commission.
Performance Improvement
Continual Quality Improvement
Excellent organizations make sustained and continuous
efforts to improve their care and services. Healthcare,
our business, is constantly changing; what made us
successful last year may no longer be appropriate.
Even if we think today's solution is perfect, tomorrow
will teach us that it wasn't perfect; it was just the best
that we could do at the time
 Even though a process may appear to work most of the
time, we are challenged to look at the process and ask
ourselves, "Is there a better way to do this?" or "Why
are we doing this?” Because we live in a rapidly
changing environment that is fast-paced and stressful,
change brings many opportunities to improve our care
and services.

Performance Improvement
Continual Quality Improvement

Key Points to Remember




Customers come first.
Every employee is important.
Communication is essential.
Tasks (processes) are streamlined whenever
possible.
 Ongoing improvement is crucial.
 Improvement should be maintained.
We want to improve everything we do! We owe
this to our ultimate customer ~ the patient.
Performance Improvement
Continual Quality Improvement

What does this mean to me?
◦ Management provides support and guidance, and
they bear ultimate responsibility, but the best
improvement ideas come from people who work
providing care and services for our customers.
Continually improving one’s own performance and
their own job processes are essential for producing
great patient outcomes. Within your department, you
have the responsibility to think about your “daily work
life” to determine if there are processes that can be
improved. At the department level, the organization
has determined that the Pillars of Excellence should
be continually improved. There are five pillars:
Service, Quality, People, Growth, and Finance.
Performance Improvement
Continual Quality Improvement

What does this mean to me?
◦ You can make suggestions for improvement to your
supervisor by expressing the idea and asking if an
improvement team could be organized to work on the
project. There is also an “Improvement Suggestion
Form” in your department’s PI Manual (or posted on
your department’s Communication Center); you can
fill out the form and turn in to your supervisor. If the
idea only relates to your job, your supervisor may ask
you to “just do it.” You may be asked to serve on an
improvement team or lead an improvement project;
you should accept this as an honor.
2010 National Patient Safety Goals
for Hospitals

The purpose of the National Patient Safety Goals is
to improve patient safety.

The Goals focus on problems in health care safety
and how to solve them.
2010 National Patient Safety Goals
for Hospitals

Improve the accuracy of patient identification
◦ Use at least two ways to identify patients. For
example, use the patient’s name and hospital
account number. This is done to make sure that
each patient gets the medicine and treatment
meant for them.
2010 National Patient Safety Goals
for Hospitals

Improve the effectiveness of communication among
caregivers
◦ Provide timely reporting of critical tests and critical
results
◦ Read back and verify spoken or phone orders to the
person who gave the order.
◦ Create a list of abbreviations and symbols that are
not to be used.
◦ Quickly get important test results to the right staff
person.
◦ Create steps for staff to follow when sending patients
to the next caregiver. The steps should help staff tell
about the patient’s care. Make sure there is time to
ask and answer questions.
2010 National Patient Safety Goals
for Hospitals

Improve the safety of using medications
◦ Create a list of medicines with names that look
alike or sound alike. Update the list every year.
◦ Label all medicines that are not already labeled.
For example, medicines in syringes, cups and
basins.
◦ Take extra care with patients who take medicines
to thin their blood.
2010 National Patient Safety Goals
for Hospitals

Reduce the risk of health care-associated infections
◦ Use the hand cleaning guidelines from the Centers
for Disease Control and Prevention.
◦ Report death or injury to patients from infections that
happen in hospitals.
◦ Use proven guidelines to prevent infections that are
difficult to treat, such as multidrug-resistant organism
infections.
◦ Use proven guidelines to prevent infection of the
blood, these infections may be associated with
central lines.
◦ Use safe practices to treat the part of the body where
surgery was done.
2010 National Patient Safety Goals
for Hospitals

Accurately and completely reconcile medications across the
continuum of care
◦ Find out what medicines each patient is taking. Make sure
that it is OK for the patient to take any new medicines with
their current medicines.
◦ Provide a list of the patient’s medicines to their next
caregiver or to their regular doctor before the patient goes
home.
◦ Provide a list of the patient’s medicines to the patient and
their family before they go home. Explain the list.
◦ Some patients may get medicine in small amounts or for a
short time. Make sure that it is OK for those patients to take
those medicines with their current medicines.
2010 National Patient Safety Goals
for Hospitals

Reduce the risk of patient harm resulting from falls
◦ Find out which patients are most likely to fall. For
example, is the patient taking any medicines that
might make them weak, dizzy or sleepy? Take
action to prevent falls for these patients.
2010 National Patient Safety Goals
for Hospitals

Prevent health care-associated pressure ulcers
◦ Initiate prevention methods to reduce
occurrences of pressure ulcers.

Identify patient safety risks
◦ Find out which patients are most likely to commit
suicide.
2010 National Patient Safety Goals
for Hospitals

Establish a universal protocol for preventing wrong
site, wrong procedure, and wrong person surgery
◦ Conduct a pre-procedure verification process.
Create steps for staff to follow so that all
documents needed for surgery are on hand
before surgery starts.
◦ Mark the part of the body where the surgery will
be done. Involve the patient in doing this.
◦ Conduce a time-out prior to beginning procedure.
Patient Rights

We believe that most patients want to understand and
participate in their care. Therefore, it is important that
each patient understand his or her rights and
responsibilities while at Cartersville. It is also necessary
as healthcare workers that we understand patient rights
and responsibilities to ensure that quality care is
provided.

How are patients informed of their rights?
◦ Upon admission, each patient is given a handbook,
which includes a list of patient rights and
responsibilities. This patient bill of rights tells a
patient and his or her family what they can expect of
caregivers and what caregivers expect of them.
Patient Rights

What is your role in patient rights?
◦ Everyone is involved in protecting the rights of patients, not
just those involved in direct patient care. For example, the
right to confidentiality means not telling your friends and/or
relatives when someone you know has been a patient.
Also, you provide privacy for patients by making sure you
always knock before entering a patient’s room or any room
where a patient might be having a procedure.
◦ Patients have a right to a secure environment, which
means you should know how to respond during a disaster
or fire in the building. Patients are informed of their right to
establish advance directives.
◦ Patients also have a right to file a grievance. You can assist
with the investigation and response by contacting Risk
Management (Clair Williams) at ext. 1004 or Administration
at ext. 8161 should you have a question.
Patient Rights

Where can you find a list of patient rights?
◦ In facility Policy HW362 Rights and
Responsibilities of Patients, the Patient
Handbook, posted beside the elevator in the front
lobby and at outpatient services and on
Cartersville’s Intranet site.
Patient Rights


Access the Ethics and Compliance Officers at
770-606-2206 or 770-387-8183
Access the grievance process. Express complaints
or concerns regarding care or services, including
discharge.
 Facility contact: 770-606-2206
 Corporate Ethics Line: 1-800-455-1996
Reportable Events

State (Georgia) Reportable Events:
◦ The following type events should be reported to the State of
Georgia Office of Regulatory Services:
 1. Any unanticipated patient death not related to the natural
course of the patient’s illness or underlying condition;
 2. Any surgery on the wrong patient or the wrong body part of
the patient;
 3. Any rape of a patient which occurs in the hospital.
◦ Cartersville Medical Center’s employees and the medical staff
should report to the appropriate department leader and Risk
Management at 1004 or Regulatory Compliance at 3038 in the
event that any of the above situations occur to a patient at
Cartersville. A multidisciplinary group will review the situation,
complete the State forms, and provide them to the Office of
Regulatory Services within 24 hours of knowledge that the event
meets one of the State definitions.
Recognizing Abuse and Neglect

Signs of Abuse
◦ History inconsistent with nature and extent of
injury
◦ Delay in seeking medical treatment
◦ Frequent Emergency Room visits
◦ Accident prone
◦ Discrepancy in patient’s and family’s story
◦ Bruises in various stages of healing
◦ History of previous trauma in patient or sibling
Recognizing Abuse and Neglect

Signs and Symptoms of Neglect
◦ Failure to thrive
◦ Poor hygiene
◦ Dehydration
◦ Malnutrition
◦ Poor social skills
Reporting Abuse


Nursing Interventions:
◦ Routinely screen during each patient encounter.
◦ Screen one-on-one in a private environment.
◦ Assess patient’s immediate safety.
◦ Listen with a non-judgmental attitude.
◦ Document in the medical record the following:
abuse history (subjective and objective), results of
safety assessment, authorities notified, family
notified, treatment given, and any safety
instructions provided.
The person suspecting the abuse should notify Social
Services during weekday hours and the House
Supervisor at night and on weekends to inform them
of the situation. These resource persons will assist
with the notification of the authorities.
Reporting Abuse


Reporting Responsibilities:
◦ Notify the MD.
◦ Notify DFACS or Adult Protective Services (APS)
of the possibility and the appropriate authorities.
◦ GA has general mandatory reporting laws. MUST
report to law enforcement the following: injuries
resulting from general violence and injuries
inflicted by gun, firearm, knife, or other sharp
object.
Resources: Department of Family and Children
Services (DFACS): (770) 720-3610
/ Police Dept: 911 / Battered Woman/Domestic
Violence Hotline: 1-800-334-2836 / Prevent Child
Abuse GA: 1-800-532-3208
Adult Protective Services: 1-888-774-0152
Occurrence Reporting

Completed in the Meditech Module

Initiated by the person with the most knowledge

Used for tracking, trending, mandatory reporting
and system Performance Improvement

Risk Assessment: Prevent/Limit harm to the patient

Non-Punitive “Just” Culture
Occurrence Reporting Facts

Never print report!

Never document in the record that an occurrence
report has been completed

Never write statements that point fingers
◦ “Just the facts Ma’am” Sgt. Joe Friday- Dragnet

Be factual, brief, and objective

Tell the end of the story if known
What should I report?







Patient, visitor, and employee falls or injury
Sentinel Events
Medication events and near misses, ADRs*
Equipment and supply related events
Lost/damage to personal belongings
Adverse surgical/procedural outcomes
Behavioral issues◦ Against Medical Advice, Left Without Being Treated,
Refusal of treatment, Elopement
◦ Other events that may result in injury or potential
unfavorable outcome such as disruptive behavior
◦ Complaints regarding patient care or treatment
Occurrence Reporting

3 Types
◦ Patient: All patients
◦ Non Patient: Visitors, Contractors, Students,
Physicians
◦ Employee: CMC Employees
Completed ASAP prior to the end of your shift
 Discoverability and Admissibility
 Risk/Safety/Quality Connection

Environment of Care
Safety and Security
 Fire Safety
 Hazardous Materials
and Waste
 Medical Equipment
 Utilities
 Other Physical
Environment
Requirements

Safety and Security
EC.02.01.01, EC.02.01.03
 The hospital manages safety and security risks
 The hospital identifies safety and security risks
 Electrical Safety
 Incident/Accident and Near Miss Reporting
 Infection Control Precautions
 Storage (medical gas, supplies ETC.)

Your Role Includes…


Wearing Proper ID
Knowing the Location of Emergency Plans and
your role in them

How to Respond to and Document
Incidents/Accidents

Access Control

How to obtain an MSDS
Floors & Walking Surfaces
Dry, Level, Clear of Obstructions / Debris
 Well Lit
 Appropriate Mat Placement
 Condition of Carpet
 Walk to Center or Right
 Watch Intersections
 Keep hallways clear of clutter

Environment of Care
What is an MSDS?
Material Safety Data Sheets (MSDS)
The MSDS is used by
chemical manufacturers
and vendors to convey
hazard information to
users.
 MSDS’s should be
obtained when a
chemical is purchased.
 A chemical inventory list,
and MSDS, for each
chemical are required to
be maintained

Hazardous Materials Management





OSHA Hazard Communication Standard Right-toKnow (R2K)
Material Safety Data Sheets (MSDS’s)
Training and Labeling Requirements
Storage, Handling and Disposal of Hazardous
Materials
Jeff Barwick 770-382-8190
Kelly Proctor 770-387-8168
Cartersville Medical Center
Communication
Telephone use:
 Dial “0” for the PBX
operator
 Dial “9” for outside line
 Dial “66” for emergency
phone
 Departments located
outside the main
hospital building must
call 911 for
emergencies.

Medical Equipment
Avoid use of extension
cords
 If you don’t know how to
safely use equipment,
don’t.
 Make sure all electrical
equipment has been
inspected by the
biomed department
before use.
 Make sure all Medical
Equipment has a
current inspection
sticker

Hazardous Materials and Waste

Radiation Safety
◦ International radiation symbol
will be used near sources of
radiation
◦ Radiation used in x-rays is
known to cause harm at large
doses.
◦ If you work in an area where
x-rays are being performed,
you should wear all required
PPE
◦ The use of radioactive
material is overseen by the
Radiation Safety Officer and
the Radiation/Laser
Committee
◦ Frank Homiller – 678-7215580
Hazardous Materials and Waste

Biohazard Waste Standard Precautions
◦ Use gloves, masks, shoe
coverings, eye protection,
fluid resistant gowns when
appropriate.
◦ Sharps must be discarded
in sharps containers.
◦ Seal and discard
sharps containers
when ¾ full
Hazardous Materials and Waste

Biohazard Waste
◦ Biohazard waste that
cannot be disposed of
in the Municipal Waste
System must be
discarded in leak proof,
break resistant
containers
◦ Red Bags – What can
and cannot go in them
◦ Needle boxes – What
can and cannot go in
them
Utility Systems

Code White
◦ Utility system failure
◦ Power
◦ Water
◦ Communication
systems
◦ HVAC System
Utility Systems

Emergency Electrical
Power System
◦ provides electrical
power after the
hospital’s normal
electrical system has
failed or interrupted.
◦ Emergency power is
provided by generators
in 5-10 seconds.
◦ Only the red power
receptacles will work
under the emergency
power
Utility Systems

Heating, ventilation, air
conditioning systems
(HVAC)
◦
◦
◦
◦
◦
Cooling towers
Chillers
Boilers
Thermostats
P.I.U.’s
Utility Systems
◦ Water – In the event
the hospital looses its
main water supply,
Plant Operations will:
◦ The hospital will
follow the loss of
water plan
◦ Plant Operations will
activate the
emergency well
◦ Emergency water
supply
Utility Systems

Medical Gases
◦ Provides oxygen
◦ compressed breathing
air for patients
◦ specialty gas systems
in surgical suites
Know location of shut off
valves in your
department.
Only Plant Operations
and the fire
department can
authorized medical
gas shut off
Utility Systems

Communications includes:
◦ Telephone systems
◦ Beepers/pagers
◦ Nurse call systems
◦ PA system
◦ 2-way radios
◦ Cell phones
◦ Civil defense radio
◦ EMS communication
◦ Fire alarm systems
◦ Emergency
Preparedness
communication systems
Security

Security of the hospital
requires a cooperative
effort and is a
responsibility of each
employee.
◦ Wear ID badges at work
◦ Secure valuables and
belongings
◦ Be alert. Report any
suspicious activity
◦ Assure secured areas
stay that way
Environment of Care
Security- Code Gray
Security staff are
employees of the
hospital
 Security staff are
present 24/7
 In a security
emergency, dial “66”
and ask PBX operator
to page “Code Gray” to
your location
 If additional support is
needed, dial 911 and
ask for law enforcement
response.

Fire Safety
RACE Fire Response Plan
Remove
Anyone in immediate danger
Alarm
Pull closest alarm; Dial “7777”
Confine
Close doors and windows
Turn off air moving equipment
Extinguish
Use closest proper
extinguisher
Fire Extinguisher Basics

PULL the safety pin at the top
of the extinguisher

AIM the nozzle, horn or hose at
the base of the flames (from 68 feet away )

SQUEEZE or press the handle

SWEEP from side to side at the
base of the fire until it goes out
Fire Safety
Code Red


Using a fire
extinguisher:
P-A-S-S
◦ Pull the retaining pin
◦ Aim the fire
extinguisher at the
base of the fire
◦ Squeeze the handle to
release contents
◦ Sweep the nozzle
from side to side
Code Blue




Cardiopulmonary Arrest
(adult or child) – Code
Blue
Dial “66” and tell the
PBX operator to page
“Code Blue” to your
location
Code Blue response
team: Charge nurse
from ICU, ER, 2N, 2C,
PCU, respiratory
therapy, and the ED MD.
Other personnel will be
called if needed
Code Neonate




Cardiopulmonary Arrest
(neonate) – Code
Neonate
Dial “66” and tell the
PBX operator to page
“Code Neonate” to your
location
Code Neonate
response team: Charge
nurse from ER and 2C,
respiratory therapy, and
the ER MD.
Other personnel will be
called if needed
Code Pink






Infant/Child Abduction
All hospital staff on alert
Dial “66” to report
Secure all exits and
entrances
Advise leaving staff,
visitors, and contractors
Do not physically stop
anyone
Code Triage



External Disaster – Code
Triage:
Code Triage Standby:
employees will be notified
and called to hospital as
needed
Code Triage Activate:
employees will
immediately activate
disaster plan
Code Triage Standby



External Disaster –
Code Triage Standby
Dial “66” and have the
PBX operator page
“Code Triage Standby”
Evaluate department
situation and staff and
prepare for influx of
patients
Code Triage Activate



External Disaster –
Code Triage Activate
Dial “66” and have the
PBX operator page
“Code Triage Activate”
Prepare for immediate
influx of patients and
accept change of
assignments
Code Weather






Sighting of Tornado: Code
Weather
Notification by civil
defense radio, 911, or
weather channel.
Administration will notify
and ask PBX to page
“Code Weather”
Move visitors into internal
hallways or patient rooms.
Reassure and calm
patients
Updates will be
communicated by
Administration via PBX
Code Runner

Patient Elopement “flight risk” patient is
missing
◦ “Flight Risk” is defined
as any patient who is
assessed to be
confused, disoriented,
or demented and
mobile
◦ Dial “66” and tell the
PBX operator to call
Code Runner
Code Orange
Chemical or large
biohazard spill or
event.
 Dial “66” and ask
the PBX operator
to call Code
Orange
 Secure the area

Code Medic



Visitor or employee
injury or severe illness
Dial “66” and ask PBX
operator to page Code
Medic.
ED RN and security will
respond
Information Security
Cartersville Medical Center relies heavily on computers to meet its
operational, financial, and informational requirements. The
computer systems, related data files, and the derived information are
important assets of the company. Cartersville has established a
system of internal controls to safeguard these valuable assets by
processing information in a secure environment. As a Cartersville
employee, you are expected to share the responsibility for the
security, integrity, and confidentiality of this information.
 Policy Enforcement
Any employee who has knowledge of a violation of the IT & S Security
policy must immediately report the violation to his/her supervisor.
Anyone who violates the policy is subject to:
◦ Suspension
◦ Termination
◦ Civil and/or criminal prosecution
◦ Other Disciplinary action

Secure your workstation at all times!
Information Security
CMC standards and policies include information about:
◦ Individual accountability for the use of any computing
and network resources
◦ The authentication process to allow access to, and
use of, systems and networks
◦ Audit trails of sensitive security events
◦ A means to ensure the integrity of systems, networks,
and processes
◦ The design and implementation of security controls
with adequately met identified risks
◦ The controls necessary to interface Carterville
computer systems/networks with foreign computer
systems/networks
 Please refer to policies IS.SEC.001 – 005 for additional
information.
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Information Security
Workstation Security
◦ Protection of the workstation and its equipment is each
employee’s responsibility. Control your work area fully so that
ALL your equipment and information is kept secure.
 Secure Workstations
◦ When not in use, hard copy information is kept in a secure place
◦ Information on any screen or paper is shielded from casual public
view
◦ Terminals are not left active or unlocked and unattended
◦ Short (5-20 minutes) Screensaver “time-out” settings
◦ Company approved anti-virus software actively checks files and
documents
◦ Only company approved, licensed, and properly installed software
is used
◦ “Shareware” or downloaded Internet programs are not permitted
◦ User ID and Passwords are not written down and physically
displayed
◦ “Log Off” and “Shut Down” your PC before leaving work each day

Information Security
Electronic Communications
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Promote effective and efficient business communication
Use e-mail and the Internet in a productive manner
Transmit information only to individuals that are
authorized to see it
Do not bypass system security mechanisms
Do not automatically forward messages using mailbox
Do not access or distribute obscene, abusive, libelous,
or confidential information
Do not conduct any type of personal solicitation
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Maintain and enhance the hospital’s public image
*Do not use electronic communication for any purpose
which is illegal, against company policy, or contrary to
the company’s best interest
Information Security
Electronic Communications
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Send only relevant information to people who need
it
Do not use publicly accessible areas of the Internet
to transmit or display info
Use e-mail and the Internet for highly limited
personal use
Do not distribute chain letters
Rules to e-mail addresses outside hospital
Do not address another persons e-mail
Do not transmit unsecured patient identifiable or
other sensitive and offensive material
Information Security
Social Engineering
“Social Engineers” are individuals who attempt to gain
access to systems of confidential information through
the manipulation of others. Using a combination of
basic knowledge about a given business with some
personal information or details that the “victim” will
recognize, the Social Engineer converses with, wins the
trust of, and extracts information from an employee.
 To combat social engineering:
◦ Limit your conversations in public areas
◦ Be aware of your surroundings and who listens to
your conversations
◦ Identify as fully as possible anyone asking you for
information
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HIPAA & HIM-Health Information
Management
“Medical Records”
Kim Hicks, HIM Director, FPO, x 1413
Angel Shellhorse, HIM Supervisor, x 1106
Purpose
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Protect patient privacy, confidentiality, and security
of Protected Health Information (PHI) and provide
methods in which to accomplish the above.
Information protected under HIPAA includes oral,
written, and electronic communications.
HIPAA Privacy Policies
Policies can be located on Cartersville’s Intranet
1. Notice of Privacy Practices
2. Patient’s Right To Opt Out of Facility
Directory
3. Right to Request Confidential
Communications
4. Patient’s Right To Access
5. Patient’s Right To Amend
PHI (Protected Health Information)
Information is obtained on a “need to know” basis
 Follow appropriate access guidelines
 Employees only have access to what they need to
know to perform their job
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***Employees are not allowed to access their own
information
PHI, Continued
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Minimum necessary information is released to fulfill
the intended purpose
PHI must be disposed of properly in Re-cycle bins
Fines for HIPAA violations for facility start at
$10,000 up to $250,000 and/or
10 years imprisonment.
Practicing Privacy
1.
2.
3.
4.
Treat all information as if it were about you or
your family
Access only those systems you are officially
authorized to access
Use only your own User ID & Password to
access system(s)
Access only the information you need to do your
job
Practicing Privacy Continued
5.
6.
7.
8.
Only share sensitive & confidential information
with others that have a “need to know”
Refrain from discussing patient info in public
places
Create “hard to guess” passwords & never share
them
Log-off when finished
External Faxing Guidelines
Limit when possible
 Verify fax number
 Utilize preset numbers when applicable
 Locate fax machine in secure location
 Always use cover sheet with confidentiality
statement for transmittals
 Highly sensitive information should NEVER be
faxed (HIV status, abuse records, etc.)
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Thank you!!!