Holland Hospital
Orientation for students, contractors
and temporary employees
Welcome!
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Mission
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Vision
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Our Core Values
– To continually improve the health of the communities we serve in
the spirit of hope, compassion, respect and dignity.
– In partnership with our medical staff, to be the pre-eminent standalone hospital in West Michigan as measured by benchmark
customer service, business growth, financial performance and
medical quality.
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Customer Service – “Be There”
Commitment – “Choose Your Attitude”
Communication – “Make Their Day”
Creativity – “Play”
2
Introduction
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This presentation is intended to familiarize
you with procedures and expectations
while you are at Holland Hospital.
The presentation will offer reading material
on HIPAA, Infection Control and Needle
Stick Safety.
3
Instructions
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•
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Immediately following the slides for HIPAA and Infection
Control, a quiz will be given. Please complete the quiz and
then print completed quiz (please print only the quiz pages).
Complete the Non-Employee Workforce Form and NonEmployee Service Provider Acknowledgement Form on
slides at the end of this presentation and then print each.
Call Human Resources at (616) 394-3780 to schedule a time
to meet prior to starting your assignment at Holland Hospital.
Please remember all required documentation for your
appointment in Human Resources. Without it you may NOT
begin your assignment. A checklist is provided at the end of
this presentation to ensure you have all required paperwork.
4
HIPAA Training
Self-Study Module
5
HIPPA
Directions:
• Review the slide presentation.
• Complete the HIPAA quiz.
• Sign the HIPAA quiz. Be sure to print
and sign your name; include the date and
your department.
Thank you!
6
The HIPAA Privacy Rule
What You Need to Know
7
HIPAA
What are the possible repercussions to the
patient, to you, and to the hospital if
confidentiality is broken?
8
What is HIPAA?
HIPAA stands for Health Insurance Portability
and Accountability Act, passed in 1996. It’s a
federal law imposed on all health care
organizations such as:
– Hospitals, physician offices, home health
agencies, nursing homes and other providers.
– HMOs, private health plans and public payers
such as Medicare and Medicaid.
9
HIPAA Components
Portability and Accountability
• Its original goal was to make it easier for people to
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move from one health insurance plan to another as
they changed jobs or became unemployed.
This means they would be able to move their
medical records and information more easily and to
get the care they needed.
The next component of HIPAA is Administrative Simplification. What does
this mean?
10
HIPAA Components
Another component is Administrative
Simplification, intended to do the following:
– Standardize formats, codes and IDs for the
electronic transmission of health information.
– Protect the security of electronic health data.
– Protect the privacy of all health information.
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HIPAA Components
Administrative Simplification
• Before computerized records, it would have been
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difficult to remove many records and make use of this
information.
Today, with e-mail and electronic storage of
information, thousands of records can be sent
virtually anywhere in just a few minutes via a
computer.
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HIPAA Components
Imagine you wanted to identify patients who
had an expensive medical condition in order
to discriminate against them. It would take
countless hours to use paper records, but with a
computer and standardized records, it’s simple to
sort out patients who have expensive illnesses and
potentially use that information to hurt their chances
at getting jobs or insurance.
13
HIPAA Privacy Rule
•
•
HIPAA is the first federal law protecting patients’ privacy and
it gives patients certain rights to view their own medical
records and restrict who sees their health records.
Key concepts to remember:
– HIPAA punishes individuals and organizations that fail to
keep patient information confidential.
– HIPAA gives patients federal rights to gain access.
So what could happen if a patient’s
privacy is violated?
14
Penalties for Breaking HIPAA
Privacy Rules
• Criminal penalties: Maximum of 10 years in jail
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and a $250,000 fine for serious offenses.
Civil penalties: Maximum fine of $25,000 per
violation.
Facility sanctions:
See HR Policy 15.5.1.2. – “Confidential Information”
located on Holland Hospital’s internal website.
(Could result in suspension or termination.)
15
Penalties for Breaking HIPAA
Privacy Rules
• For instance:
– Knowingly releasing patient information in violation
of HIPAA can result in a one-year jail sentence
and $50,000 fine.
– Gaining access to health information under false
pretenses can result in a five-year jail sentence
and $100,000 fine.
– Releasing patient information with harmful intent
or selling the information can lead to a ten-year jail
sentence and $250,000 fine.
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Penalties for Breaking HIPAA
Privacy Rules
Civil:
Civil penalties are fines up to $100 for
each violation of the law per person, up to
a limit of $25,000 for each identical
requirement.
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Section VII: Employment Realities
Holland Hospital Standards of Conduct:
I understand that Holland Hospital employees are expected to conduct their duties in
a manner that meets the highest legal and ethical standards. I agree that I will comply
with all applicable laws, regulations, programs requirements and standards of ethical
conduct as described in the HH Standards of Conduct. I also certify that I will report
any known or suspected violations of these Standards of Conduct to the Corporate
Compliance Officer immediately and without concern for retaliation or retribution for
doing so.
Confidentiality:
I am aware that authorization to access computer systems at Holland Hospital also
allows me access to confidential information. I certify that I understand that it is my
responsibility to keep in strict confidence all information I encounter and will not
discuss, disclose or disseminate such information to unauthorized persons. I
specifically understand that information regarding patients, employees and individuals
affiliated with Holland Hospital is not to be accessed by individuals who do not have a
need to know this information. I recognize that unauthorized release of confidential
information may make me subject to civil action under the provision of state and
federal codes and regulations governing the confidentiality of patient specific health
care information. In addition, any such breach of confidentiality will be reported to
licensing and professional organizations as appropriate.
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Myths about HIPAA
When the privacy rule was released, many people
worried that hospitals would have to take extreme
measures to make sure no one overheard any
Protected Health Information (PHI). The
Department of Health and Human Services has
released statements assuring the health care
industry that such actions are not necessary.
Let’s take a closer look at some of these myths.
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Myths about HIPAA
Myth: Hospitals cannot put patient names
outside their doors or use white boards.
White boards and patient nameplates are acceptable
as long as a patient’s health information isn’t in plain
view for someone passing by. Problems arise when
patients’ names are linked to their conditions. If
patients’ names are listed next to their condition on a
white board, the board must be kept away from view.
20
Myths about HIPAA
Myth: Doctors and nurses can go to jail for
honest mistakes.
There are certainly serious penalties – including jail times and
huge fines – for health care workers who intentionally violate
patient privacy by selling information to a marketing company or
purposely looking up information about patients they're not
treating. However, mistakes such as accidentally grabbing the
wrong file will not result in serious sanctions.
Now let’s look at what information is considered confidential
information.
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What is Confidential?
It’s not just one piece of Protected Health
Information (PHI) by itself; it’s two or more
pieces of information that might identify a
person and their health information – a key
concept to remember.
What are acceptable uses of confidential information?
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Acceptable Uses of Confidential
Information
Health care providers are permitted to share and
disclose Protected Health Information (PHI):
- For treatment, payment and health care
operations – a key concept to remember
- For other reasons if they obtain permission
from the patient
23
Treatment, Payment and Health
Care Operations
Health Care Operations: Physicians and
quality control directors review confidential
information to make sure patients are getting good
care.
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. This is termed as the
“Minimum Necessary Requirement.”
Let’s review what this KEY phrase means to you.
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The Minimum Necessary Requirement
HIPAA calls on health care workers to use the
minimum amount of patient information they need
to do their jobs efficiently and effectively – a key
concept to remember.
Ask yourself:
- Do I need this information to do my job and provide good
patient care?
- What is the least amount of information I need to do my
job?
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Do You Need to Know?
•
•
Coders and billers need to look at certain
portions of records to code and bill
correctly.
Housekeeping staff do not need to look at
patient records at all.
If it’s not for treatment, payment, or health care
operations, patient authorization is necessary to use or
disclose Protected Health Information.
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Authorization
Facilities must obtain authorization from
patients before using or sharing their Protected
Health Information (PHI) for reasons other than
treatment, payment or health care operations
Reasons include:
- Research
- Marketing
- Some types of fundraising
- Attorney
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Authorization
It’s important that patients understand how they can
protect their own health information and how
providers protect their information. That’s why the
HIPAA rule requires health care providers to post
notices telling patients how their information will
usually be used.
Let’s take a look at some common sense ways that you
can protect patients’ privacy.
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Protect Patient Privacy
Don’t leave patient records lying
around.
It would be easy for a patient or other staff
member to look at the papers openly lying on a
desk or counter.
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Protect Patient Privacy
Do close curtains and speak softly when
discussing treatments in semi-private
rooms.
Be aware of who is around when you’re discussing
patient care, and use common sense to protect
confidentiality by taking simple steps such as
lowering your voice or moving to a more secluded
area of a room.
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Protect Patient Privacy
Do log off the computer when you’re
finished.
When using any computer system that contains
Protected Health Information, log off when you are
finished. Do not leave the information visible on an
unattended computer monitor.
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Rules for Faxing Patient Information
When sending a fax:
• Always use a fax cover sheet.
• Call intended recipient before sending the fax.
•
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That way, they will be ready for the fax.
Double check the fax number before sending it.
It’s critical when faxing PHI that we do everything
we can to ensure that the fax is going to the right
person.
If ever in question, ask the manager for
assistance.
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Rules for Using Computers
Keep your passwords a secret. Although computers
have greatly improved the efficiency of health care
delivery, they have also increased the risk that
large amounts of private information could be sent
to the wrong person, computer or website with one
keystroke.
– For instance, a Midwestern university mistakenly posted
children’s psychiatric records on a public website.
– Another example, a hospital accidentally revealed the
names of organ donors to the recipients in a computergenerated letter.
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Rules for Using Computers
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Do not log into the system using someone
else’s password or computer key.
Passwords should never be given out, and
they should not be written down.
Passwords and other security features are
put in place to protect patient information.
If you share passwords, you may be held
responsible for another worker’s
inappropriate use of records.
34
Rules for Using E-Mail
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Do not open attached files from unknown
sources; this may open the door for
viruses and hackers.
Do not use work e-mail for personal
matters.
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Rules for Using E-Mail
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Double check the address line of the
message before you send it to make sure
it’s going to the right person.
Do not use e-mail to send patient’s
Protected Health Information (PHI). Only
use the internal mail system provided by
the Protected Health Information program.
36
Patient Rights
Patients have the right to:
– View and keep a copy of the facility’s Notice of
Privacy Practices (this notice will be made
available at the time of registration).
– Request restrictions on disclosures of PHI for
treatment, payment and health care operations.
– Receive an accounting of disclosures not for
treatment, payment or health care operations.
37
Patient Rights
Patients have the right to:
– Inspect and copy their own health information.
– Request amendments to information in their
medical record.
– Request preferred method of contact.
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Patient Rights:
Notice of Privacy Practices
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This notice will be posted in main patient
areas, off-site locations and on Holland
Hospital’s internal website.
It will be offered to all patients at the time
of registration and will be available to any
individual who requests one from Patient
Relations.
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Patient Rights: Request for
Restrictions on Disclosures
Patients must agree to let facilities use PHI for
treatment, payment and health care operations, but
patients can request that they limit the use.
For example, a patient knows a lot of Holland Hospital’s staff
personally. He/she may request that his/her record not be
chosen for quality review, or could ask that we do not use or
disclose information about a previous surgery.
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Patient Rights: Viewing and
Copying Information
Patients have the right to view and copy their
Protected Health Information (PHI). This
may include information stored on computer
(e.g., their medical and business records).
Patients may contact Medical Records for a
copy.
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Patient Rights: Requests for
Amendments
Patients may think the information contained
in their medical record is incomplete or
inaccurate and may request an amendment
for as long as the information is kept by or
for the hospital.
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Patient Rights: Patient Directory
When patients are at the hospital, they are put in the
directory so that visitors can inquire about them. Patients
may opt out of appearing in the directory. If they have opted
out, no information can be given to the visitor or caller. For
patients who do not opt out, staff can tell visitors or callers
who ask for the patient by name the following:
• The patient’s location in the facility.
• The patient’s general condition (e.g., stable, good,
fair).
At the time of registration, the patient will be given the option
to opt out of the directory.
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Patient Rights: Patient Directory
Don’t:
– Give out a patient’s location or condition without making sure
the patient is listed in the directory.
– Disclose patient information other than location and general
condition.
– Say anything about a patient who has opted out of the
directory, including confirming if the patient is here or not.
If the patient’s privacy is violated, you may direct the
patient to Patient Relations (394-3742). You may also call
Patient Relations if you know or suspect breaches of
confidentiality.
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Corporate Compliance
The main purpose of the program is to create a work culture that is
compliant with legal and ethical standards and a way for you to
anonymously report inappropriate activities (e.g., The Corporate
Compliance Hotline).
Standards are set by authorities such as the OSHA, CMS, Medicare,
Medicaid, Federal (e.g., HIPAA), state, local governments and Holland Hospital’s
own standards and policies (Standards of Conduct).
An important part of keeping the trust of our patients and our
community is to follow the laws and guidelines established by outside
agencies and our own organization.
Example: Maintaining patient confidentiality and reporting breaches
in confidentiality.
Compliance is the responsibility of ALL staff members, regardless
of their positions or job responsibilities.
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Key Concepts to Remember
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Minimum necessary – HIPAA calls on
health care workers to use the minimum
amount of patient information they need to
do their jobs efficiently and effectively
(e.g., for treatment, payment and/or health
care operations).
We have a legal and ethical obligation to
protect patient privacy and rights.
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Next Step
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Complete HIPAA quiz on next two slides.
Print off your completed quiz and take to
Human Resources (make sure to only print
the pages containing the quiz).
47
HIPAA Quiz
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The criminal penalties for improperly disclosing patient health information can be as high as fines of $250,000 and
prison sentences of up to 10 years.
True or False
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Confidentiality and privacy are important concepts in health care because:
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They help protect hospitals from lawsuits
They allow patients to feel comfortable sharing information with their doctors and care providers
They help establish trust with the organization
All the above
Which of the following are some common ways that employees protect patient privacy?
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Looking up your neighbors medical information because you are curious
Lowering voice when needed
Logging off the computer when not using
b&c
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Confidentiality protections cover not just patient’s health related information, such as the reason they are being
treated, but also information such as address, age, social security number and phone number.
True or False
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Any employee or physician who violates the hospital privacy policy is subject to punishments up to and including
firing or termination of work privileges.
True or False
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HIPAA Quiz
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If you suspect someone is violating Holland Hospital’s Confidentiality policy(s), you should:
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–
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Say nothing – it’s none of your business
Watch the individual involved until you have gathered solid evidence against him or her
Report your suspicions to your supervisor or call Holland Hospital’s anonymous Compliance Hotline (616) 494-4050 and complete an
Occurrence Report (orange form)
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Only employees who care for patients need to be concerned with protecting patient privacy and confidentiality.
True or False
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HIPAA gives patients certain rights to view their own medical records and restrict who sees their health records.
True or False
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What kind of personally identifiable health information is protected by HIPAA’s Privacy Rule?
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–
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Written
Electronic
Spoken
All the above
In addition to regulating your own behavior with regard to confidentiality, you are responsible for monitoring the behavior of others,
including physicians, co-workers, volunteers, visitors and patients.
True or False
Print Name:________________________________________Date:__________________________
Signature:__________________________________________Department:____________________
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Infection Control
Holland Hospital Infection Control
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Infection Control Objectives
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Protect our patients
Protect ourselves
Protect our coworkers
Protect our families
Protect our visitors
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Who and Where is Infection Control?
• Infection Control is under the Quality Department
• Located at the 24th Street building
• Infection Control Medical Director: Dr. Shannon
Walko, D.O.
• Available on-site, Monday-Friday, 8:00 a.m.-4:30 p.m.
• Amy Lyons, RN, MS, CIC (ext. 4201)
• Available by pager 24/7
• 713-0804
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Infection Control Questions or
Concerns?
When you are at the hospital…
• Our policies are located on the hospital’s internal website. The
Infection Control section of the Hospital Policies and Procedures is
Chapter 16. This chapter includes:
• The Bloodborne Pathogen (BBP) Exposure Control Plan (16.3).
• Isolation Policies.
• If you do not have direct access to the internal website, please
contact your direct supervisor for assistance.
•
•
OR
Feel free to contact the Infection Control Coordinator (in person
8:00 a.m.-4:30 p.m., Monday-Friday, or by pager 24/7).
or
The Patient Care Coordinators (PCC) are available 3:00 p.m.-7:30
a.m. daily. The PCC pager number is 713-0777.
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History of the Final Standard
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•
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December 6, 1991 – Federal Register is
where the final standard was originally
published.
It was created due to complaints of federal
unions for their health care employees.
Michigan OSHA and Federal OSHA BBP
Standards are both available at any time
by contacting infection control coordinator.
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What are Bloodborne Pathogens?
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Human Immunodeficiency Virus (HIV)
Hepatitis B
Other bloodborne diseases include:
• Hepatitis C
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High Risk Fluids for Bloodborne
Pathogens
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Blood
Blood by-products
Unfixed tissue or organs
Semen
Vaginal secretion
Amniotic fluid
Cerebrospinal fluid
Peritoneal fluid
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Pleural fluid
Pericardial fluid
Synovial fluid
Saliva in dental procedures
Any body fluid visibly
contaminated with blood
• Any body fluids which are
difficult or impossible to
differentiate from body fluids
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Hepatitis B
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•
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Etiologic agent : Hepatitis B virus
Clinical Features: jaundice, fatigue,
abdominal pain, loss of appetite,
intermittent nausea, vomiting
Transmission: bloodborne, sexual and
perinatal
57
Hepatitis C
Hepatitis C is a liver disease caused by the
Hepatitis C virus (HCV) which is found in the
blood of persons who have this disease.
The infection is spread by contact with blood
of an infected person.
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How Serious is Hepatitis C?
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•
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Hepatitis C is unpredictable; it can be
serious for some and not for others.
Most people who get infected carry the
virus for the rest of their lives.
Complications from chronic Hepatitis C
can include cirrhosis, which can lead to
liver failure later in life.
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Risk Factors Associated with
the Transmission of HCV
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•
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Transfusion or transplant from infected donor
Injecting drug use
Hemodialysis (years on treatment)
Accidental injuries with needles and sharps
Sexual/household exposure to anti-HCV-positive
contact
Multiple sex partners
Birth to HCV-infected mother
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Hepatitis C Virus is NOT Spread by:
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Breast feeding
Sneezing
Hugging
Coughing
Sharing eating utensils or drinking glasses
Food or water
Casual contact
61
Human Immunodeficiency Virus (HIV)
•
•
•
AIDS is caused by the human immunodeficiency virus (HIV).
As of December 2001, Center for Disease Control has
received reports of 57 documented cases and 138 possible
cases of occupationally acquired HIV infection among health
care personnel in the United States since reporting began in
1985.
The average risk of HIV infection after a needle-stick injury or
cut exposure to HIV infected blood is 0.3% (1 in 300). Stated
another way, 99.7% of needle-stick/cut exposures do not
lead to infection.
Reference: Exposure to Blood from CDC published in July 2003
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HIV Transmission
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•
•
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Sexual
Perinatal
Blood to blood exposure
Blood to mucous membrane exposure
It is NOT spread by:
• Casual contact or through insect bites or
stings
63
Where is the Bloodborne Pathogen
Exposure Control Plan?
The Exposure Control Plan is located on
the hospital’s internal website under
Chapter 16.
If you do not have direct access to the
hospital’s internal website, please contact
your direct supervisor for assistance.
64
What is Contained in the Exposure
Control Plan?
• Risk classification of all jobs within the
organization
• Types of personal protective equipment
are to be utilized and when
• Defines standard precautions
• Blood and body fluid exposure follow-up
• Biohazard signage or color coding
• Hand hygiene
65
Hepatitis B Vaccine – Did You Know?
• Three injection series: given first injection; one 30
•
•
•
days later and then five months following the
second injection.
90 percent will develop serum antibodies.
Antibody testing should occur six weeks to three
months following last injection.
If an employee of a health care facility that
requires Hep B chooses not to participate upon
employment, they must sign a formal declination
and may choose later to receive injections.
66
Regulated Waste
Medical waste was discovered on the Lake
Michigan shore in 1988 which led to the
enactment of the Medical Waste Regulatory
Act of 1990. This act controls the handling,
storage, treatment, transportation and
disposal of medical waste from its
generation to ultimate disposal.
67
Biohazard Labeling
68
Medical Waste Labeling
•
•
•
Warning labels are affixed to containers of
regulated waste, refrigerators and freezers
that contain blood body fluids and
containers that are used to store or
transport blood or body fluids.
Red bags or red containers may be
substituted for labels.
Laundry is NOT medical waste and is
never placed in a red bag.
69
What to Do in Case Of a Blood
or Body Fluid Spill
• Always wear the personal protective equipment
•
•
•
•
appropriate to the size of the spill.
Never pick up glass fragments by hand; always
use dustpan and broom or forceps, etc.
Absorb fluid with either absorbent towels or
powders.
Area must be disinfected with approved
disinfectants.
Housekeeping will assist during hours 0600 to
midnight. After hours, a spill kit located in the
housekeeping closets or soiled utility rooms.
70
Other Information…
• Personal protective equipment
• Available in clean storage rooms, isolation carts
• Goggles available in clean storage areas
• Disinfectant wipes available for reusable
equipment (stethoscopes, glucometers, etc.)
• Located on isolation carts and dirty utility rooms
71
Blood or Body Fluid Exposure
If you get a needlestick or blood or body fluid exposure:
• Wash area with soap and water (exception: eyes or
mouth – use only water).
• Notify the Infection Control Coordinator or Patient Care
Coordinator:
• Page either the Infection Control Coordinator
(713-0804) or Patient Care Coordinator afterhours (713-0777)
• Complete necessary paperwork (available through
Infection Control Coordinator/Patient Care Coordinator):
• Employee illness and injury report (ask
supervisor for report)
72
What Happens if You Have a
Bloodborne Pathogen Exposure?
•
•
If we know whose blood you were exposed to:
• Lab draws for HIV/Hepatitis B and C on that person (not
you).
• We notify you of their HIV results that day.
• The hepatitis labwork comes back within a week.
If we do not know the source of the blood:
• We will send you to either Med 1 or ED (after-hours)
immediately for care:
• You may be offered testing
• Determine risk
• Consultation on meds and treatment options
73
Our Isolation Procedures
• Standard Precautions
• Transmission-Based Precautions
•
•
•
•
•
Contact
Contact-PLUS
Droplet
Airborne
Neutropenic
* Not CDC based precaution
74
Standard Precautions Use on Every
Patient, Every Time
Standard precautions must be followed even
if transmission-based (the colored signs)
isolation is in place.
75
Our Transmission-Based
Isolation Signs
76
Contact Isolation
• Yellow sign
• Any contact with patient or objects that patients
•
may have contact will spread these organisms
Equipment:
• Gloves
• Gown
• Diseases:
• C.difficile
• Scabies
• Lice
77
Contact Plus
•
•
•
•
•
Green sign
(Not officially a Center for Disease Control
transmission-based precaution)
• Other health care facilities will not use this
term. Specific only to Holland Hospital.
Any contact with patient or objects that patients may
have contact will spread these organisms
Equipment needed:
• Gown and gloves
• Surgical mask if within three feet of the patient
Diseases:
• MRSA and VRE
78
Droplet
•
•
•
Orange sign
Equipment needed:
• Surgical mask within three feet of the
patient
Diseases:
• Influenza
• Pertussis
• Bacterial meningitis
79
Rules for the N-95 Respirator Mask
• Disposable
• Can be used up to 8 hours if not soiled or
misshapen for TB.
• Exception: use only once and replace during a
pandemic flu, SARS, etc.
• Store the mask
• Paper bag
• Label with your name on the bag or elastic
strap
80
Airborne Isolation
•
•
•
•
Red sign
Need a negative-pressure room
• Both doors (inner and outer) must remain closed.
• Bioengineering must inspect airflow daily when patient
present.
Equipment needed:
• N-95 respirator mask
Diseases:
• Tuberculosis
• SARS/Avian Flu
• Chicken Pox/Measles
81
Neutropenic Precautions
Neutropenia is a blood condition in which the patient white blood
cells are abnormally low. Patients with neutropenia are more
susceptible to bacterial infections.
•
Blue sign (does not state neutropenic since this is a
diagnosis).
•
A mask is required if you are going to be within three feet of
the patient.
•
Good hand hygiene!
82
Handwashing
•
•
•
•
Handwashing remains the cornerstone of all preventative
measures. Our policy Hand Hygiene is 16.3.3. (If you do not
have direct access to the hospital’s internal website, please contact your
direct supervisor for assistance.)
Our policy is Wash in … Wash out!
Handwashing with soap and water is ideal; however, in times
when these are not available waterless degermers are
acceptable.
– 10-15 seconds of scrubbing in order to be most effective.
– Lots of hand jewelry and very long nails can harbor
germs, puncture gloves and get in the way of good
handwashing.
Only Holland Hospital hand lotion may be used.
83
Handwashing – The #1 Way to
Maintain Infection Control
•
•
Soap and water:
• Visibly dirty, soiled (with or without gloves)
• “Feel” sticky, sweaty or dirty
• After using the restroom
• Before eating
Alcohol-based waterless hand sanitizer:
• Before/after contact with patients
• Before/after putting on gloves
• If moving from a contaminated body area to a clean area
• After touching dirty or contaminated environmental
surfaces
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For Questions or Concerns…
•
•
Please contact Infection Control at
494-4201 or pager 713-0804 (24/7).
After business hours or on weekends,
for in-person assistance the Patient
Care Coordinator (PCC) can assist
you.
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Next Step
•
Complete the Infection Control Quiz on
next four slides.
•
Print off your completed quiz and take to
Human Resources (make sure to only print
the pages containing the quiz).
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Infection Control Quiz
Circle the best answer
• TRUE FALSE Standard precautions apply to all patients with
•
•
•
•
any diagnosis.
TRUE FALSE Hand washing is not required between patient
contacts if you wear good quality gloves.
TRUE FALSE Hand hygiene is the most important defense
against the spread of infection.
TRUE FALSE Infection Control policies and procedures are
located on Holland Hospital’s internal website under Policies
and Procedures, Volume 16.0.
TRUE FALSE Patient care equipment can be a source of
infection for the patient and the staff.
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Infection Control Quiz (page 2)
• TRUE FALSE Report an exposure incident at least two days
•
•
•
•
after it happens.
TRUE FALSE If you don’t work directly with patients, you
don’t need to be concerned about infection control.
TRUE FALSE Report an exposure incident by sending an email message to Infection Control.
TRUE FALSE Contact precautions prevent the spread of
pathogens through physical contact.
TRUE FALSE Tuberculosis is a disease that requires airborne
precautions in a negative pressure room (a room with an anteroom).
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Infection Control Quiz (page 3)
• TRUE FALSE A regular surgical mask can be worn when
•
•
•
•
entering a room of a known or suspected tuberculosis patient.
TRUE FALSE When a TB patient is cared for in a negative
pressure room, only the inner door of the ante-room needs to be
kept closed.
TRUE FALSE When a patient requires airborne, droplet, or
contact precautions, you don’t need to follow standard
precautions.
TRUE FALSE Lots of hand jewelry and very long nails can
harbor germs, puncture gloves and get in the way of good hand
washing.
TRUE FALSE Alcohol-based hand rubs can be used for hand
hygiene instead of soap and water hand washing, unless hands
are visibly soiled.
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Infection Control Quiz (page 4)
TRUE FALSE Infection Control is everyone’s shared responsibility.
Employee Signature:_____________________________
Date:________________
Print Name:______________________________________________
Department/Job Title:______________________________________
90
Once Slide Orientation is Complete
• Complete the Non-Employee Workforce Form
•
•
•
and Non-Employee Service Provider
Acknowledgement Form on the following slides.
Print both of the above documents.
Call Human Resources at (616) 394-3780 to
schedule a time to meet prior to starting your
assignment at Holland Hospital.
Please remember to return all required
documentation for your appointment to Human
Resources. Without it you may NOT begin your
assignment.
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Non-Employee Workforce Form
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Name:
Position:
Address:
Phone:
Licensure or certification type (if applicable):
Licensure or certification number (if applicable):
Department you will be working:
Reporting to:
Assignment start date:
Assignment end date:
Employer/school:
Employer/school contact:
Employer/school phone:
Please circle type of provider:
Student/Instructor
Contract-Clinical
Contract Non-Clinical
92
Non-Employee Service Provider
Acknowledgement Form
Confidentiality Statement
•
•
•
I realize that in the course of my work at Holland Hospital, I may be exposed to
confidential patient health information. I understand that I have no right or ownership
interest in any confidential information. Additionally, I will limit my exposure to
confidential patient health information and will treat this information, regardless of how
it was obtained, with utmost discretion.
I am required to conduct myself professionally and in strict compliance with applicable
laws including, but not limited to, the Health Insurance Portability and Accountability
Act of 1996 and Holland Hospital policies governing confidential information. I
understand that a breach in confidentiality may result in immediate discontinuation of
our agreement and/or legal action against me and/or the business I represent.
I recognize that unauthorized release of confidential information may make me
subject to civil action under the provisions of State and Federal codes and regulations
governing the confidentiality of patient-specific health care information. In addition,
any such breach of confidentiality will be reported to licensing and professional
organizations, as appropriate.
93
Non-Employee Service Provider
Acknowledgement Form
Acknowledgement
•
I have reviewed the Non-Employee Service Provider
Safety Information Sheet or the "What You Need to
Know" booklet and agree to comply with all Holland
Hospital policies and procedures.
• Service Provider Name (please print your
name)___________________________________________
• Department/Unit__________________________________
• Your signature___________________________________
• Last four digits of Social Security Number_________
Print this page and take to Human Resources.
94
IMPORTANT
Please take the following with you for your appointment in
Human Resources. You MUST have all required and
completed paperwork prior to starting at Holland Hospital.
– Non-Employee Workforce Form
– Non-Employee Service Provider Acknowledgement Form
– Completed HIPAA Quiz (print once completed)
– Completed Infection Control Quiz (print once completed)
– TB test results within one year
– Immunization records or records of Hepatitis History & Titer,
MMR Titer, Varicella Titer
– Current CPR for all clinical positions
– Other documentation may be required for certain positions
95
You Are Finished!!
Checklist to bring to Human Resources:
–
–
–
–
–
–
Current TB Test
Record of Immunizations
CPR (if applicable)
Current licensure/certification (if applicable)
Printed Non-Employee Workforce Form
Printed Non-Employee Service Provider
Acknowledgement Form
– Printed HIPAA Quiz
– Printed Infection Control Quiz
96