1. Department of Education and Professional Development
Student Orientation
Department of Education and Professional Development

2. Our Mission
To deliver high quality healthcare emphasizing excellence and compassion consistent with the healing ministry of Jesus Christ.

3. Hendrick Medical Center Principles of Performance
Attitude
Appearance
Cheerfulness
Commitment to Coworkers
Communication
Privacy
Customer Waiting
Respect and Equal Treatment
Safety Awareness
Sense of Ownership
Sense of Mission
Quality

4. Professional Appearance in the Workplace
Artificial nails, nail polish, exposed cleavage, and piercings other than studded earrings are not acceptable.
Hair color must be close to natural color.
No tattoos may be exposed.

5. Professionalism
Cell Phones and Text Messaging - are unacceptable in any patient care area or where visible by family and visitors
Verbal and Nonverbal Communication – remember to be polite and that body language can say a lot before ever opening your mouth

6. All Students Must Follow HMC policies and procedures.
Arrive on time and notify unit staff of their presence.
Be in appropriate uniform with appropriate identification with school identification badge worn on the upper third of the body.

7. Problems? Notify faculty as soon as there is a problem.
In the absence of faculty notify nurse manager or Department of Education.
Be specific---note date, time, name of those involved and occurrence. Name is very important!

8. Health Insurance Portability and Accountability Act
HIPAA
Health Insurance Portability and Accountability Act

9. The Minimum Necessary Rule
A key requirement of HIPAA is that you should use, share, or ask for only the minimum necessary amount of PHI to do your job.
For example, someone that works in Food and Nutrition, does not need to know how a patient broke their leg.
Avoid sharing the entire medical record of a patient by sharing only the relevant information for the other person to do their job.
Just because you have the ability to see the information does not mean you are permitted to look at all data for any reason.

10. Exceptions to the Minimum Necessary Rule
The rule does not apply to sharing a patient’s information with themselves.
Does not apply when a healthcare provider , such as a doctor, uses the information for treatment
If the doctor is directly involved in the patient’s care, then they can be allowed access to the patient’s entire medical record
Does not apply when sharing the information is required by law

11. Example
A heart specialist is treating a patient for heart problems. The doctor wants the person’s entire medical record . Does this situation allow you to share the entire medical record with the doctor or to only supply information about the heart condition?
Since the provider or doctor is accessing the information for treatment, we are allowed to give the doctor access to the entire medical record.

12. Case Study #2
A hospital employee was at home one evening reading the status updates her friends had posted on Facebook. She notices that one of her co-workers from the hospital posted the following:
“Had a busy day at work today. A 23 year old guy was brought in with massive head injuries. He was high on PCP and fell out a window.”
(Q.) Was this posting permissible?
No, the post contains several elements of protected health information (PHI).
(Q.) But no name was posted – how can this be PHI?
There is enough information that someone could identify who the patient was. Someone could have known that their neighbor fell out of a window and fits the above description. Now they know that he was “high on PCP” when the accident occurred.

13. Key Points to Remember Curiosity is not a valid reason to access data.
Although this gives an excellent overview of how HIPAA relates to the disclosure of a person’s medical records, or Protected Health Information (PHI), here at Hendrick only certain employees with certain job responsibilities are allowed to disclose this PHI.
Unless you have been told by your supervisor that you have this responsibility, and have been trained on how this is to be done at Hendrick, it is your responsibility to leave the release of information (verbal or otherwise) to those trained in this area.

14. Protected Health Information (PHI)
Individually Identifiable Health Information that is stored and/or transmitted verbally, electronically, or on paper.

15. Protected Health Information (PHI)
Patient’s Name
Street, City, State, Zip and County Code
Names of relatives and employers
Date of Birth
Phone & fax #s
addresses
Web URL
IP address
Social Security number
Medical Record #
Health Plan Beneficiary Number
Certificate/license number
Vehicle serial number
Finger or voice prints
Photographic images
Account number

16. Protected Health Information (PHI)
HMC may disclose personal medical information for:
Treatment
Payment
Health care operations

17. Protected Health Information
Patients may file a complaint with Hendrick’s Privacy Officer if they believe their privacy rights or confidentiality rights have been violated.

18. NEVER Take a photo of a patient.
Send information regarding a patient on unsecured cell phones or .
Access electronic medical record information on unassigned patients.
Discuss patient information

19. NEVER
Post information on the Internet, including Facebook and Twitter.
Access (look at or open) records of unassigned patients.

20. Publicity Codes
Hendrick will release specified patient information regarding patients who occupy a bed based upon each patient’s publicity code.
Publicity Code 2: Acknowledge their presence; Release room umber/telephone number of the patient to callers/visitors.
Publicity Code 4: Patients may choose this publicity code if they do not want Hendrick personnel to acknowledge that they are in the hospital.
Publicity Code 5: Assigned by a Security Department officer:
For patients under custodial arrest by a law enforcement agency
For inmates from state or local jails and/or state or federal prisons
For crime victims whose assailant is still at large
For victims of child abuse or sexual assault

21. HIPAA Violations Licensure issues Internal Discipline Bad Press
State -Federal Penalty
Civil Penalties
Criminal Penalties
State Law
Exclusion from Medicare Reimbursement
Licensure issues
Internal Discipline
Bad Press
Future Implications

22. Lack of Trust Quality of care is compromised
Conditions may go undetected, patients may not trust to give full disclosure.

23. Parking All Students/Faculty - Lot 1
Citations Sent To School Administrators
Students/Faculty receiving a citation may be removed from the clinical setting.

24. Map

25. 2016 Joint Commission
Patient Safety Goals

26. 2016 Hospital National Patient Safety Goals
NPSG , Prevent Infection
Comply with either the current CDC or WHO hand hygiene guidelines.
NPSG , Prevent Infection
Implement evidence-based practices to prevent health-care associated infections due to multidrug-resistant organisms in acute care hospitals.
NPSG , Identify Patient Safety Risks
Identify patients at risk for suicide.
Applies to psychiatric hospitals
In general hospitals, applies to those patients being treated for emotional/behavioral disorders.

27. Infection Prevention
High risk populations, such as the elderly, have weakened immune systems, which make them more susceptible to infection.
Quality infection control techniques will protect residents, visitors, other employees, yourself, and your family.

28. Transmission of Infection
Contact - direct contact with infection
Direct - touching the source of the infection
Indirect - touching contaminated objects
Droplet - secretions produced by coughing/sneezing or talking that come in contact with eyes, nose, or mouth of an individual
Airborne – respiratory particles produced by coughing/sneezing, talking, laughing, exhaling and inhaled by another individual

29. How Can I Prevent Infection?
Do not share or borrow personal supplies between patients.
Keep your work environment and equipment clean.
Perform procedures correctly and appropriately—shortcuts are unacceptible.

30. Preventing Infection
Hand washing is the most important measure of infection prevention.

31. Alcohol Hand Rub
HMC utilizes the alcohol based hand rub Avagard which is available in all patient rooms and exam rooms. The use of Avagard is recommended:
Before direct patient contact and prior to applying gloves (sterile/clean)
When moving from contaminated to clean body site
After contact with objects within patient vicinity
After contact with patient’s intact skin or body fluids, if hands not visibly soiled
After removing gloves

32. Hand Washing Hand washing is necessary:
When your hands are visibly dirty or contaminated.
Before eating and after using the restroom.
Wash hands after potential contamination with body fluid whether gloves are worn or not.

33. Transmission-Based Precautions
Color-coded signs are placed outside of rooms indicating the specific precaution to enforce. Visitors must report to the nurses station prior to entering.

34. Contact Isolation Wash hands before entering and leaving patient room.
Wear gloves and gown when in room at all times. Remove prior to leaving room.
Use disposable equipment. Clean and disinfect shared equipment.
Wash hands before entering and after leaving.

35. Contact Isolation

36. Droplet Precautions Door may remain open.
Wash hands before entering and after leaving room.
Mask required.
Wear gown & gloves when in direct contact with patient.
Dispose of gown, mask & gloves prior to leaving patient rooms.

37. Droplet Precautions

38. Airborne precautions Negative pressure room is required.
Keep door closed.
N-95 Mask must be worn before entering room. Students may NOT take care of patients in Airborne isolation.

39. Airborne Precautions

40. Common Infectious Conditions
Blood-borne diseases are caused by pathogens found in blood and body fluids.
Spread mainly by direct blood or sexual contact.
Ex: Hepatitis, HIV, Malaria
Standard precautions required.

41. Drug Resistant Organisms
Pathogens that cannot be killed with common antibiotics. They are transmitted by direct contact.
May be due to prolonged exposure to low levels of antibiotics.

42. Drug Resistant Organisms
Methicillin resistant staph aureus (MRSA) and vancomycin resistant enterococci (VRE) are commonly seen in health care facilities.
Use contact isolation precautions.

43. C-Diff Precautions
Wash hands with soap and water. Avagard is ineffective.
Initiate Contact Isolation

44. Hospital Safety

45. EMERGENCIES “2222” for ALL EMERGENCY ASSISTANCE Security “2911”
Any code
Security “2911”
Off campus Dial “911”
Explain Who? What? Where?

46. Fire Our main objective is patient care and safety.
Fires are extinguished by a defend in place method
evacuate horizontally then vertically
Attempt to contain the fire to a minimum, i.e. keeping all doors closed.
For safety purposes, we always try to have one compartment between us and the fire.

47. R.A.C.E. Rescue people in danger
Alarm, call 2222, notify the proper authorities
Contain the fire and the smoke
Evacuate or extinguish

48. Fire Extinguishers P.A.S.S Pull the pin Aim at the base of the fire
Squeeze the handle
Sweep across the fire

49. Fire Drills Performance and knowledge is evaluated during each drill
It is a team effort!
Drills are held quarterly and annually

50. Emergency Codes (x2222) Code 5 Code Blue Code 99 Code 32 Code Silver
Code Brown
Code Red
Code Green
Code Pink

51. Code 5 Drill Fire Drill The Operator will announce the wing and floor
Close all doors, windows, trash chutes and linen chutes; clear hallways of all equipment including crash carts

52. Code Blue
Cardiac Arrest = Life threatening event anywhere in the hospital
Code Blue Team will respond

53. Code 99
Cardiac Arrest in CCU

54. Stroke Certification Accreditation
We are a Stroke Accredited facility. You must know the signs and symptoms observed and report immediately if noticed.

55. (Facial drooping; Arm drifting; Slurred Speech; Time to call)
ATTENTION
If your patient is demonstrating any of the following Stroke signs and symptoms
Sudden numbness, weakness or loss of sensation of the face, arm or leg, especially one side of the body
Sudden confusion, trouble speaking, or understanding
Sudden trouble seeing in one or both eyes
Sudden trouble walking, severe dizziness, loss of balance, coordination, or unexplained fall
Sudden severe headache with no known cause
CALL Rapid Response Team FAST!!!!
(Facial drooping; Arm drifting; Slurred Speech; Time to call)

56. Code 32
Same as code blue, however it is for infants or children

57. Code Brown
Tornado or severe weather

58. Code Red Bomb threat Look for suspicious items Don’t touch or move
Report to your supervisor or security, call 2911

59. Code Green
Hazardous Material Spill Refer to SDS sheets

60. Code Pink Infant abduction
Monitor stair wells, halls or isolated areas.
Look for small bundles, packages, backpacks and listen for noises

61. Code Silver
Active shooter, barricaded subject, escaped prisoner, or hostage situation on HMC campus

62. Operation D Internal Disaster External Disaster Ex. Chemical spill
Ex. Terrorist threat

63. HMC is a smoke free campus