Catholic Health
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Welcome to the first part of your orientation
to Catholic Health.
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Please review the following slides. If you
have questions regarding the material please
bring them up when you attend you in class
general orientation session.
Catholic Health
Corporate Compliance
Anne Mason
Compliance &
Privacy Officer
Principles of
Corporate Compliance
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Promotes Ethical, Professional, and Legal conduct
“Doing what is right”
Defines Responsibility/Accountability
Supports CHS Standards
Assurance of Quality Care
Catholic Health System
Standards
Attain Compliance by:
• Embracing our Mission and Values
• Adherence to Policy and Procedures
Found in Compliance 360
• Maintaining High Standards of
Business and Ethical Conduct
Important Keys to CHS
Corporate Compliance
Standards of Conduct
Deal openly and honestly with others
Maintain high standards of conduct in accordance to the CHS
mission, directives of the Catholic Church, and applicable
federal, state and local laws and regulations
Conflict of Interest
We have a responsibility to act on the best interests of Catholic
Health. We need to avoid situations that lead to actual or
perceived conflicts of interest
Documentation and Billing
Must be accurate and complete
Catholic Health System
Standards of Conduct
Associate Compliance Guidebook
provides information on the Standards of Conduct
and is available on CHS website
An observation of failure to follow Standard of
Conduct, Policy or Procedures, or observation of
an error requires reporting.
Associates can face disciplinary action and even
termination for failure to report such events.
Catholic Health System
Standards of Conduct
All associates are expected to follow standards for:
• Legal and Regulatory Compliance
• Business Ethics
• Conflict of Interest
• Appropriate Use of Resources
• Confidentiality
• Professional Conduct
• Responsibility
And follow the Code of Ethics
Gifts and other Free items
• Associates may NOT accept any cash gifts or cash
equivalent gifts (gift cards) from any person or
business conducting or seeking to conduct business
with CHS
• Prior to receiving work related
gifts,
social or entertainment events,
or free meals
associates must consult with their supervisor.
See CHS Policy for further information
Conflict of Interest
If working on behalf of CHS do your actions or activities result in
personal gain or advantage, potential adverse effect for
CHS, or the potential to interfere with professional
judgment, objectivity or ethical responsibilities?
Potential Conflicts of Interest Relationships
include financial relationship for yourself or your immediate family
member or secondary employment
– Consultant
– Speakers’ bureau
– Advisory Panel
– Administrative positions with Pharm or DME
– Third party payor
– Other entities doing business with CHS
All potential Conflicts of Interest must be reported
Insufficient or Inaccurate
Documentation
It is fraudulent to either document services that were not
performed or to submit claims for services without
appropriately documenting those services.
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Missing clinical notes (dates, signatures, orders, care
or service rendered) or test results
Incomplete, or illegible documents
Improper billing and coding
can be interpreted as fraud or abuse and lead to a
false claim with the government resulting in penalties.
Reimbursement can only be sought for services or items that
have been provided and appropriately documented.
If it’s not documented, it’s not done
False Claims Act
Governs Fraud, Waste & Abuse
It is a crime to knowingly make a false record, file, or
submit a false claim with the government for
payment
A false claim can include billing for service that:
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was not provided or documented
not ordered by a physician
was of substandard quality
Improperly coded or billed
It is also unlawful to improperly retain overpayments
Allows for Qui Tam Relator –notification to government with protection
(Whistleblower provision)
Medicare Conditions of
Participation
Government Sanctions
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Individuals or entities can be excluded from
participation in Medicare and Medicaid programs.
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CHS must not submit any claims to Medicare
and/or Medicaid in which a sanctioned individual
or entity provided care or services.
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If sanctioned, the person must provide notification
immediately to the Compliance Officer.
Providing
High Quality Services
and Upholding Patient’s Rights
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Follow CHS Policies and Procedures
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Offer Language Assistance Services
to those in need
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Ensure patient privacy and confidentiality
is maintained (HIPAA and HITECH regulations)
Catholic Health
Compliance Policies
Compliance Policies and Procedures are available
on Compliance 360 (or in an on-site reference manual)
and apply to all CHS associates
Additional compliance policies are also applicable to:
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Home Care
Clinical Laboratory
Physician Practices
Nursing Facilities
Coding & Billing
Home Health Agency
PACE Program
Language Assistance
Program
• Ensures that limited English proficiency,
or hearing impaired persons utilizing
CHS services are able to understand
and communicate with CHS associates
and physicians
• Provided FREE of charge to the patient
Language Assistance Program Policy is found in
Compliance 360
Language Assistance
Program
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Mandatory service by law
Family may NOT routinely interpret
Offered upon initial contact AND every
time medical information is provided
Documentation is vital to compliance
See Policy for additional information
HIPAA/ HITECH
HEALTH
INSURANCE
PORTABILITY
ACCOUNTABILITY
ACT
and HITECH
Health Information Technology for
Economic and Clinical Health Act
Privacy and Security Policies are in Compliance 360
What is Protected by HIPAA?
Individually identifiable health information
Also known as
Protected Health Information (PHI)
Transmitted or maintained in any
form or medium
Protected Health
Information (PHI)
 Names
 Full face photos
 Medical Record Number
 Health plan Number
 Account Numbers
 Certificate/License Numbers
 Vehicle identifiers
 E-mail and web addresses
 Biometric Identifiers
 Geographic subdivisions
smaller than a state
 All elements of dates
related to birth date,
admission, discharge, or
date of death, ages over 89
 Telephone and fax numbers
 Social Security Number
Any other unique identifying data
What Information Can
Providers Share?
for:
Treatment, Payment or
Health Care Operations
• Only access portions of PHI necessary to carry out
your duties or to fulfill request
• Disclose minimum necessary for your job function
based on need for the information
• If unable to obtain patient consent, may use
professional judgment to share information with a
patient’s family and friends
HIPAA Safeguards
• Be aware of surroundings
– Be conscious of who is in the immediate area when
discussing sensitive patient information or at your computer
terminal
• Secure area when not attended
– Close out of computer screens containing PHI before leaving
the area
– Close medical records/chart when not in use
– Do not allow other associates to utilize your ID and
password
– Don’t leave papers with PHI in plain view
– Report theft or loss of computer devices immediately
Additional
HIPAA Safeguards
• Telephones
- Be careful with phone
call pertaining to patient
information
• Fax machines and Scanners
- Pick up faxed or printed PHI immediately
- Use fax cover sheet, verify # & receipt
- Scan PHI only to CHS e-mail accounts
• E-mail
- Make sure to encrypt if being sent outside CHS
- Careful forwarding and replying
• Mail
- Double check name/address and
material prior to sending
Sending e-mail with
Sensitive Information
All e-mails sent to a CHS web address are encrypted
and therefore secure.
Each e-mail sent outside the CHS system,
will need to be encrypted if it contains sensitive
information.
For instructions on a sending external encrypted
email type “encryption” in the search box of
Compliance 360.
UNAUTHORIZED ACCESSING AND
DISCLOSURE OF PATIENT
INFORMATION
Curiosity can be a normal human trait
– However accessing health information on yourself,
family members, friends, co-workers, persons of
public interest or any others that you are not involved in the
care of or …
– Disclosing PHI inappropriately
are...VIOLATIONS of HIPAA
Individuals do NOT have the right
to look up their own health records
Your computer use can be monitored
Other Catholic Health
Compliance Concerns
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Lack of integrity
Ethical concerns
Theft or misuse of services
Improper Political Activity
Breech of Corporate Confidentiality
Improper use of Proprietary Info.
Environmental Health and Safety Issues
Dishonest Communication (spoken or documents)
Improper Business Arrangements
Failure to follow Record Retention policy
Receipt of incentives for patient referrals
The Associate Guidebook or your supervisor can provide additional info.
3 Steps for Reporting
CH Compliance Concerns
Immediate supervisor or appropriate department
Higher level manager
Compliance Officer
Compliance Line 1-888-200-5380 available 24/7
Confidential and Anonymous (if desired)
Report behavior issues, HR policy violations,
and union contract matters to Human Resources
Catholic Health
Non-Retaliation Policy
• Protects associates from adverse action when
they do the right thing and report a genuine
concern
• Reckless or intentional false accusations by
CHS associates are prohibited
• Reporting the possible violation does not
protect the constituent from the consequences
of their own violation or misconduct
Associates have a duty to report
HIPAA/Compliance concerns
Catholic Health
Associate’s Responsibility
• Upholding CHS Mission and Values,
Adhering to Code of Conduct,
Policies & Procedures, and the Law
• Completing education and employment requirements
• Constant Monitoring for Concerns
• Duty to Report Concerns
and Support Non-retaliation
• During an Investigation
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be truthful
preserve documentation or records relevant to ongoing
investigations
Possible Consequences
for Non-Compliance
For the Associate and CHS Managers/Supervisors/Administrators
• Fines and Prison sentences
• Corrective Action
includes termination of employment for violations or
failure to report concerns
For Catholic Health System
• Exclusion from government funded
insurance programs (Medicare/Medicaid)
• Fines
Things to Remember
• Adhere to CHS code of conduct,
policies & procedures, and other standards
• Duty to report Compliance/HIPAA concerns
as soon as aware of situation
• Do the right thing
apply ethical decision making
• If uncertain…
Always Seek Knowledge (A.S.K.)
Use Associate Booklet as reference
on CHS website
CHS Contacts
Compliance/HIPAA Privacy Officer
Anne Mason 821-4469
CHS HIPAA Hotline
862-1790
HIPAA Security Analyst
Sally O’Brien 862-1938
Corporate Compliance Hotline
1-888-200-5380 (available 24/7)
All reports are confidential
New York State Patient Bill Of
Rights
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19 Bill of Rights
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They are posted in all
patient care areas
They are available in
Spanish as well as English
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If they don’t understand their rights,
someone needs to explain them
Receive treatment without discrimination
Receive considerate and respectful care in
a clean safe environment free from
unnecessary restraints
Receive needed emergency care
Know the names and positions of people
caring for them, and refuse their treatment
Know who the MD is who is in charge of
your hospital care
A non smoking room
Receive complete information about their
diagnosis, treatment and progress
Receive all information for informed
consent
Receive all information to give informed
consent regarding do not resuscitate
Refuse treatment and be informed of effect
Refuse to take part in research
Privacy in the hospital and confidentiality
of all information and records of your care
Participate in decision making about their
care, including discharge
Review of their medical record
Receive an itemized bill with explanation
of charges
Complain without fear of reprisal
Authorize family members to visit
Make known your wished regarding
anatomical gifts
Catholic Health
RISK
MANAGEMENT
What is “Risk Management”?
Risk Management is the
systematic review of events
that present a potential for
harm and could result in
loss for the system.
FOUR ELEMENTS OF
RISK MANAGEMENT
Risk Identification
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Review Occurrence Reports
Review Patient/Visitor Complaints
Participate in Root Cause Analysis
Review concerns expressed by CHS
staff
FOUR ELEMENTS OF
RISK MANAGEMENT
Loss Prevention
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Educational Programs through
CHS University
Department specific inservices
FOUR ELEMENTS OF
RISK MANAGEMENT
Claims Management
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Investigating & reporting occurrences and
claims made to insurance carriers
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Assist with discovery requests for lawsuits
Claims Management
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Assist with Summons & Complaints
and Subpoenas
**NOTIFY RISK MANAGEMENT
IMMEDIATELY
UPON RECEIPT OF A
SUMMONS OR SUBPOENA
Claims Management
Within CHS, a process server is to be
directed to Administration of the facility in
order to serve a Summons or a Subpoena.
(HIM may accept subpoenas for hospital
records)
***INDIVIDUAL DEPARTMENTS
SHOULD NOT ACCEPT,
EVEN IF IT IS FOR SOMEONE IN THE
DEPT
FOUR ELEMENTS OF
RISK MANAGEMENT
Risk Financing
Obtaining & maintaining appropriate insurance
coverage:
HPL
(Healthcare Professional Liability)
 GL (General Liability)
 D&O (Directors & Officers)
 Property & Casualty
 Auto
 Crime
Fiduciary (Finance)
OCCURRENCE
REPORTING
An occurrence is an event that was
unplanned, unexpected and unrelated
to the natural course of a patient’s
disease process or routine care and
treatment.
What are sources of an
Occurrence?
Patient harm/potential for harm like
falls, med errors
 Visitor injury
 Patient related equipment
“failure”
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What are sources of an
Occurrence?
Security issues like elopement, crime,
altercations
 Lost or damaged property
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What is the purpose
of an Occurrence Report?
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Enhance the quality of patient care
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Assist in providing a safe environment
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Quick notice of potential liability
Who can complete
an Occurrence Report?
Any associate or physician who discovers,
witnesses or to whom an occurrence is reported,
is responsible for documenting the event
immediately by means of the Occurrence
Report. Anyone who requires assistance should
contact the department manager.
DO NOT MAKE COPIES OF AN
OCCURRENCE REPORT
What happens to the Occurrence
Report?
The completed Occurrence Report is
to be forwarded to
the Department Manager
Who will investigate the occurrence
and forward to either Quality &
Patient Safety Dept or Security as
indicated in the
Risk Management process
Risk Management Process
Patient and visitor safety are assessed from both
clinical and environmental perspectives
Notify Quality & Patient Safety of patient occurrences
 Notify Security of visitor or property occurrences
 Risk Management will be notified by QPS or Security
and will participate in evaluation of occurrence
 Risk Management will report occurrences to insurance
carrier in cases of potential liability
Risk Management will manage claim as indicated
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Documenting an Occurrence
in the medical record
•Date (MM/DD/YY) and time (military)
•State facts, be clear and concise
•Your own observations
•If event described to writer, use quotes or
“according to…”
•Do not place blame in the record
•DO NOT REFER TO
OCCURRENCE REPORT IN
THE MEDICAL RECORD
EMTALA REGULATIONS
EMTALA is the Emergency Medical Treatment
and Active Labor Act
(aka COBRA)
EMTALA provides a
Guideline for safely and
appropriately
transferring patients in
accordance with
Federal regulations.
EMTALA REGULATIONS
The law provides for a medical screening exam (MSE) to
all individuals seeking emergency services on hospital
property. Hospital property includes the driveway, parking
lot, lobby, waiting rooms and areas within 250 yards of the
facility.
If an emergency medical condition is found, it will be
stabilized within the hospital’s ability to do so, prior to the
patient’s transfer or discharge.
If a patient does not have an emergency medical condition,
EMTALA does not apply.
*** IMPORTANT: NEVER SUGGEST THAT
A PATIENT GO ELSEWHERE FOR
TREATMENT
IDENTITY THEFT
Fair and Accurate Credit Transactions
Act of 2003
or
“RED Flag Rules”
Hospitals that maintain covered accounts
must develop and implement written policies
and procedures to identify, detect, prevent,
and mitigate identity theft.
IDENTITY THEFT
“RED FLAGS”
•Alerts, Notifications, Warnings
•Presentation of Suspicious
information
•Suspicious Activity
•Notice from patient, law
enforcement, etc
**Patient Access, Health Information,
Finance, IT Depts primarily involved
IDENTITY THEFT
You can help reduce opportunities for
Identity Theft by keeping PHI confidential
and out of public view.
If you believe someone is presenting
suspicious documents or acting in a
suspicious manner, notify your supervisor
who will notify Risk Management
Catholic Health
RISK MANAGEMENT DEPARTMENT
Carol Ahrens, RN, BSN
Director, Risk Management
821-4462
Joanne Ricotta, RN, BSN
Risk Management Coordinator
821-4463
Linda McGavin
Risk Management Technical Assistant
821-4467
Valerie Pizarro
Legal Services Administrative Assistant
821-4468
Violence in the Workplace
What is Workplace Violence??
 NIOSH (National Institute for Occupational
Safety and Health) defines workplace
violence as violent acts (including physical
assaults and threats of assaults) directed
toward persons at work or on duty.
Types of Violent Acts
 Threats: Expressions of intent to cause harm,
including verbal threats, threatening body
language, and written threats.
 Physical assaults: Attacks ranging from slapping
and beating to rape, homicide, and use of
weapons such as firearms, bombs, or knives.
 Muggings: Aggravated assaults, usually conducted
by surprise and with intent to rob.
Who is Violent?
 Workplace violence in hospitals usually
results from patients and occasionally from
family members who feel frustrated,
vulnerable, and out of control.
When Does Violence occur?
 Violence takes place
– During times of high activity such as meal time
or visiting hours or patient transportation
– When service is denied
– When a patient is involuntarily admitted
– When limits are set regarding eating, drinking,
tobacco or alcohol use
Who is at Risk??
 Hospital personnel having direct contact
with patients and families are at increased
risk.
Case Reports
 An elderly patient verbally abused a nurse and
pulled her hair when she prevented him from
leaving the hospital to go home in the middle of
the night.
 An agitated psychotic patient attacked a nurse,
broke her arm, and scratched and bruised her.
 A disturbed family member whose father had died
in surgery walked into the E.D. and fired a
handgun, killing a nurse and an EMT and
wounding a physician.
Where May Violence Occur??
 Anywhere in the hospital but it is most
frequent in the following areas:
– Psychiatric wards
– Emergency rooms
– Waiting areas
– Geriatric units
What are the Effects of
Violence??
 Effects range in intensity and may include:
– Minor physical injuries
– Serious Physical injuries
– Temporary and permanent physical disabilities
– Psychological trauma
– Death
Effects of Violence
 Violence can have a negative effect on an
organization as reflected by:
– Low morale
– Increased job stress
– Increased worker turnover
– Reduced trust of management or co-workers
– Hostile working environment
Risk Factors
 Contact with violent people or those with history
of violence
 Contact with those under the influence of drugs
and/or alcohol
 Contact with people having psychotic diagnoses
 Contact while transporting patients
 Contact with people perceiving a long wait for
service
 Working alone
Safety Tips
 Watch for signals of impending violence:
– Verbally expressed anger and frustration
– Body language such as threatening gestures
– Signs of drug or alcohol use
– Presence of weapons
Be Alert
 Assess current demeanor when you enter a
room or begin to relate to a patient or visitor
 Be vigilant throughout the encounter
 Don’t isolate yourself with a potentially
violent person
 Keep an open path for exiting
Diffusing Anger
 Present a calm, caring attitude
 Don’t match the threats
 Avoid giving commands
 Acknowledge a person’s feelings
 Avoid behavior that may be interpreted as
aggressive
If potential for violence occurs
 Remove yourself from the situation
 Call security for HELP if needed
 Report any potential or actual violent
incidents to dept manager
Summary
 No universal strategy exists to prevent
violence
 All hospital workers should be alert and
cautious when interacting with patients and
visitors
 Staff need to be aware of polices and
procedures relating to violence prevention
‘The process of transforming CHS into an
organization with a superior ability to
deliver patient-centered, quality,
compassionate healthcare through
outstanding professionals and
innovative technology.’
Welcome to Equinox
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Equinox - Why?
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Individual Hospitals – “grew-up” with their
own process, culture, technology
Need for Electronic Health Record (EHR)
 Improve Quality
 Enhance Patient Safety
Equinox – How?
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Comprehensive effort to standardize and
improve processes
 Standardized Clinical Practices
New and innovative technology like Soarian
Welcome to Equinox

Equinox - When?
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Now! Process started in 2004 and is
ongoing
Strategic Alliance with Siemens Medical
Solutions – 10 year agreement
Drive toward “meaningful use” of EHR
Equinox – Who?

Everyone – directly and indirectly!
Welcome to Equinox

Examples of Equinox in Action:

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Soarian Clinical Technologies
Clinical Standardization Process
Financial Process Redesign
Mercy Hospital Emergency Center
Process – New triage/registration
 Culture – Patient-centered focus
 Technology – Computers at the bedside,
integrated wireless communication

Welcome to Equinox

Your Role…
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Stay informed
Ask questions
Identify ways to “do it better” always
with the patient in mind
Embrace change!
Welcome to Equinox
 Questions
- contact….
EQInfo@CHSBuffalo.org