3. What is Gaylord Hospital
Gaylord Specialty Healthcare is a not-for-
profit, long-term acute care hospital that
specializes in the care and treatment of
medically complex patients, rehabilitation and
sleep medicine.
Our mission is to preserve and enhance a
person’s health and function.
4. Our Vision and Our Values
is to promote patient • Clinical excellence,
compassion, integrity,
functionality through the respect and accountability
best clinical services, most are the values which guide
advanced and effective all of our actions.
treatment protocols, and • As an organization we will
excel in every aspect of our
documented outcomes for service delivery while
our patients. honoring the public trust.
As professionals we hold
ourselves accountable for
our actions.
5. I CARE Program
– an employee recognition award based on
nominations from patients, their family
members, hospital staff
– Awards are given quarterly at a breakfast event
– Quarterly recipients become eligible for the
Employee of the Year Award in May
– Underscores the importance of the Gaylord Values
among all employees each and every day
6. I is for INTEGRITY
C is for COMPASSION
A is for ACCOUNTABILITY
R is for RESPECT
E is for EXCELLENCE
7. What is an LTACH?
LTACH stands for:
Long-Term Acute Care Hospital.
As an LTACH, Gaylord Hospital is staffed and equipped
to handle the specific needs of acutely ill or
chronically disabled patients who require a hospital
level of care.
Gaylord Hospital is also able to treat those who need
rehabilitation for illnesses or injuries related to brain
injury, stroke, spinal cord injury, neurological
rehabilitation and orthopedics.
9. Service Lines
Gaylord consists of 3 Service Lines to manage
programming for our patients and referral
sources more efficiently:
– Inpatient Service Line
– Outpatient Service Line
– Sleep Medicine Service Line
10. Gaylord Locations
Trumbull
Wallingford Guilford
Glastonbury
North Haven
Main Campus Outpatient Centers Sleep Centers
Gaylord Hospital North Haven Glastonbury/Hartford
Gaylord Farm Road Wallingford Guilford
P.O. Box 400 North Haven
Wallingford, CT Trumbull
06492
11. Social Accountability
• Not-for-profit health care organizations must show
federal, state and local government that they fulfill their
mission of community service to meet their charitable tax-
exempt status.
• Gaylord does this through annual Social Accountability
reporting of programs and activities conducted by the hospital
and our employees:
– Education for health care professionals
– Community health education
– Counseling/support services
– Clinical research
– Participation in professional/community organizations
– Financial and volunteer contributions
– In-home services
12. GENERAL SAFETY
Gaylord Specialty Healthcare
strives to provide a safe environment and
to reduce risks for
patients, visitors, employees, volunteers
and students.
13. ELECTRICAL SAFETY
POLICIES
The Facilities Department must check ALL electrical
equipment before placing it into service.
YOUR RESPONSIBILITIES:
Remove damaged electrical equipment from service.
Report damaged electrical equipment to your supervisor.
Do not attempt to repair electrical equipment.
Do not bring in personal electrical equipment for your
use or for patient use.
14. EQUIPMENT MANAGEMENT
PROGRAM
Maintains a current inventory of all Hospital
equipment.
Provides periodic preventive
inspection, testing and maintenance.
Reports and investigates equipment
problems, failures, abuse and/or user error.
Monitors performance to identify trends and
implement improvements.
15. HAZARD COMMUNICATIONS
• OSHA established the HAZARD COMMUNICATIONS
STANDARD to protect employees who use
hazardous materials on the job.
• The standard states that companies who use or
produce hazardous materials must provide their
employees with information and training on the
proper use and handling of these materials.
• Your immediate Supervisor is responsible for
appropriate training and educational materials.
16. YOU HAVE
“A RIGHT TO KNOW”
You have a right to know about the
hazardous materials used in your
workplace and the potential effects of
these materials upon your health and
safety.
17. MSDS: MATERIAL SAFETY DATA
SHEETS
Manufacturer is required to
determine, record and distribute hazard
information for each product in the form of
the MSDS.
Gaylord Specialty Healthcare maintains a file
of all MSDS to which workers might
be exposed.
18. INFORMATION IN THE MSDS
YOUR RESPONSIBILITIES:
Product ID Know what hazardous
Hazardous ingredients chemicals are used in your
Physical data work area.
Fire and explosion hazard Know where MSDS sheets
data are located.
Health hazard data Know how to read an
Emergency and first aid MSDS sheet.
procedures
Reactivity data
Spill, leak and disposal
procedures Remember:
Personal protection MSDS Sheets are available
information on the Gaylord intranet.
19. BUILDING SECURITY
You must wear your ID badge at all times while
on duty.
Your badge is to be worn in a
conspicuous place between your
collar and your heart.
Your badge is to be worn with
the employee name and picture
visible.
20. SMOKING POLICY
• Gaylord Specialty Healthcare is a non-
smoking/tobacco-free facility.
• No smoking is permitted anywhere or by
anyone on hospital property.
21. KNOW THE CODES!
CODE RED: Fire emergency
CODE BLUE: Medical Emergency
CODE GREEN: Any situation which
interrupts our ability to
conduct business as
normal
22. KNOW THE CODES!
DR. STRONG: Help is needed when someone is a threat to
himself, others, or property.
SIGNAL 1: Help is needed to locate patient who is
unaccounted for.
SIGNAL 5: To inform staff when computer
networks are non-operational.
RAPID RESPONSE: To provide intervention
for a patient with acute change of condition.
FALLS RESPONSE: To provide assistance to a patient
who has fallen.
23. CODE LOCKDOWN
This code will be used to announce a situation of
potential extreme violence, up to and including an
armed intruder/active shooter.
The instinctive response is to flee – but the correct
response is to remain in place.
You must act and you must act quickly.
CEASE ALL TRAVEL THROUGHOUT THE HOSPITAL.
24. CODE LOCKDOWN
• Patient units: take all patients into a room, turn off the
lights, close the door.
• Therapy areas: patients are to remain with staff and to
seek refuge in offices or other low visibility areas. Close
and lock doors if possible, turn off lights.
• All other areas: remain in the area, taking refuge in closets
or offices. Lock doors, turn off lights.
• Seek whatever cover is available.
DO NOT CALL THE SWITCBOARD FOR INFORMATION.
DO NOT CALL THE MEDIA VIA PERSONAL CELL PHONE.
25. CODE LOCKDOWN
• Response time for Wallingford Police and/or State
Police is expected to be in the 7 -10 minute range.
• Listen for and follow all instructions from law
enforcement personnel.
• DRILLS will be held, as the only way to prepare for
this scenario is through education and training.
26. EMPLOYEE PARKING
The lots at the Jackson
Building are reserved for
patients, visitors and
medical staff.
Employees are to park only in
areas designated as employee
parking and to observe
restrictions for specified shifts.
27. NO PARKING!
DO NOT park in FIRE LANES or in front
of building entrances. YOU WILL BE
TOWED!
Use of handicapped-accessible parking
is restricted to those with State of CT
issued tags.
28. SLIPS, TRIPS AND FALLS
All workers are at risk of
dangerous slips, trips
and falls.
If you experience a slip/trip
or fall, you must report it to
your Supervisor who will
complete an Employee
Injury Report.
29. YOUR RESPONSIBILITIES
Wear proper footwear
Watch where you are walking
Keep work areas clean and orderly
Report or clean up spills immediately
Report hazards
31. Given the right conditions, fire can
happen anywhere …
In order for a fire to occur, the following are needed:
Fuel
Oxygen
Heat
A fire will break out whenever these
items come together in the right
amounts.
32. Fire Prevention Strategies at
Gaylord SPECIALTY HEALTHCARE
All new employees are required to attend New Employee
Orientation which includes an in-depth review of fire safety
issues and procedures.
Environmental rounds are performed regularly to identify
deficiencies, hazards, and unsafe practices.
Fire drills are conducted regularly to assess readiness for
response to a fire emergency.
33. Prevention is the best defense against
fire!
Gaylord Hospital is a Smoke Free, tobacco-product free
campus.
Smoking is prohibited anywhere on hospital grounds.
Remove damaged equipment from service.
Ask for training before using equipment.
34. R.A.C.E.
Rescue and/or assist in the rescue of
patients, visitors, staff.
Activate the nearest alarm; dial x3399 and
give the location of the fire.
Contain the fire by closing all doors.
Evacuate and/or Extinguish if you have been
trained in the use of a fire extinguisher.
35. Fire Response
DO keep a cool head
DO think before you act
DO wait for the “All Clear” Announcement
DO NOT shout, run or panic
DO NOT use elevators
DO NOT open fire/smoke doors
DO NOT block exits or stairwells
36. P.A.S.S.
Using a fire extinguisher
• Pull the pin on the extinguisher handle
• Aim the nozzle at the base of the fire
• Squeeze the handle to
discharge the retardant
• Sweep the base of the fire
with the retardant
37. Evacuation
The decision to evacuate is based on whether patients are in
danger. Evacuation in a healthcare facility is an action of “Last
Resort.”
Horizontal evacuation: movement is made horizontally
(connected floor to connected floor) beyond the fire doors to
the next smoke compartment.
Vertical evacuation: people are moved to a lower floor of the
hospital using stairwells.
38. Your Responsibilities
Know the location of
fire alarm pull stations
See Gaylord Hospital
Know the location of Policy 2-100.7
fire extinguishers for additional
information.
Know exit locations
Keep exits and smoke
and fire doors clear
Know your role in the
event of an
emergency
42. Purpose of Gaylord SPECIALTY HEALTHCARE’S Emergency
Management Plan
To attend promptly and efficiently to all
individuals requiring medical attention in an
emergency situation;
To provide maximum safety and to protect
patients, visitors, and staff from injury;
To respond quickly and appropriately to the
community’s disaster plan;
To protect property, facilities, and equipment.
43. Emergency Incident Command System
The Emergency Incident Command System
(EICS) is a management system designed to
assist hospitals in the management of minor
and major disasters. Specific personnel
responsibilities, clear reporting channels and
common nomenclature are detailed in the
plan.
44. CODE GREEN
Gaylord Hospital’s Emergency Operations Plan is
referred to as “Code Green.”
The plan will be activated based on authorization
of the Administrator-on-Call or designee, or after
hours by the Nursing Shift Coordinator.
45. WHAT IS A DISASTER?
A DISASTER OCCURS WHEN EVENTS:
• overload the capacity and/or ability of any
area of the hospital to provide care,
• cause significant disruption to normal hospital
operations, or
• arise in the community, leading to requests for
support from Gaylord Specialty Healthcare.
46. EVENTS THAT COULD TRIGGER
A CODE GREEN
Fires/explosions Natural gas leaks or
Floods/high winds chemical spills
Earthquakes Acts of terrorism
Hurricanes/other storms Civil disturbances
Loss of telephones Emergencies within the
organization
Loss of power
Loss of water Emergencies within the
community
47. PROCEDURES
A CONTROL CENTER will be established
in the Neubig Board Room.
A PERSONNEL POOL will be set up in the
Brooker Lecture Hall.
If additional staffing is necessary, the
Disaster Officer will activate Recall Rosters.
Evacuations may be deemed
necessary, depending on the nature of the
event and the extent of damage.
48. NOTIFICATION
When a Code Green is called, the switchboard
operator will announce: “Code Green”
three times in a row and every 5 minutes for
the first 15 minutes, and then every 15
minutes until the code is secured.
49. KNOW YOUR ROLE!
REVIEW POLICY 2-100.9 AND BE SURE
YOU KNOW YOUR ROLE IN THE EVENT OF
A CODE GREEN.
51. DID YOU KNOW?
Healthcare workers have the highest
incidence of back injuries.
Up to 80% of Americans will suffer
back pain at some point in their lives.
Back injuries cost American
companies 100 million lost workdays.
Nursing personnel lose an average of
750,000 workdays per year as a result
of back injury.
52. BACK PAIN CAN
BE PREVENTED!
Most back pain comes from soft
tissue injuries, including strains and
sprains of muscles, ligaments, and
tendons.
These injuries can be prevented by:
Good posture
Regular exercise
Use of lifting devices
Proper body mechanics
53. STRUCTURE OF THE SPINE
The vertebrae of the spine
are aligned to create four
natural curves:
an inward curve at the
neck
an outward curve at the
ribcage
an inward curve at the
low back
an outward curve at the
base of the spine
54. GOOD POSTURE
Aligns the curves of
the spine
Centers the
head, chest, and lower
body over one another
Balances the weight
of the body
55. REGULAR EXERCISE:
Can help you keep the muscles of your
back and stomach strong and flexible.
Can help you maintain a healthy
weight to avoid excessive stress and
strain on your back.
Be sure to include:
Cardiovascular conditioning
Stretching and strengthening
exercises
56. GOOD BODY MECHANICS
Size up the load – look it over; decide if
you can handle it or will need help.
Determine best lifting technique for the
height and location of the load.
Ask for help if you need it.
Inspect your intended path for obstacles
or other hazards.
Place your feet in a position that gives
you a wide, balanced base of support.
Tighten your stomach muscles prior to
performing a lift.
57. GOOD BODY MECHANICS
DON’T BEND
Use your legs, don’t bend at your waist. Let your
leg muscles do the work since they are stronger and
more durable.
DON’T REACH
Keep the load close to your body.
DON’T TWIST
Move your feet when you change directions; do not
twist your upper body while carrying the load.
58. USE PATIENT LIFTING EQUIPMENT
To limit manual lifting, motorized lifts
and assistive transfer devices are
available. These devices should be
used when a patient:
is not willing or able to transfer
is not able to maintain balance
while standing
is unpredictable, uncooperative,
or aggressive
59. IT’S UP TO YOU!
Know yourself
and know your
limits.
Know how to
move people IF YOU SUSPECT A
WORK-RELATED
and objects.
INJURY, CONTACT
Know when to YOUR SUPERVISOR
get help. IMMEDIATELY!
61. ERGONOMICS
The study of how human beings relate
to their work environment
The science of fitting the job to the
person, rather than making the person
fit the job.
Goals: increased
effectiveness, improved work
quality, greater health and safety, and
increased job satisfaction.
62. CUMULATIVE TRAUMA
DISORDERS
Cumulative trauma disorders are
musculoskeletal conditions that
develop gradually over a period
of time.
Do not typically result from a
instantaneous event.
Caused by repetitive wear
and tear on tendons,
muscles, related nerves and
bones.
63. POTENTIAL SYMPTOMS
Numbness or tingling in the arm or
hand
Weakened grip
Reduced range of motion
Swelling
Weak or painful
hands, arms, wrists, neck, shoulders,
back
64. INJURY PREVENTION
Change work area organization or layout
Change environment,
e.g. lighting
Reduce or avoid repetitive
motions
Reduce the amount of force needed to
perform the task
Reduce awkward movements, reaches,
or stretches
65. INJURY PREVENTION
Use tools that are
lighter, easier to grip
Keep wrists straight and
keep elbows at right angles
Use a chair with back
support, adjustable height
and arm rests
Use an appropriate foot
rest, if necessary
66. INJURY PREVENTION
Use padded wrist rests when typing
or using a computer mouse to
minimize contact pressure
Use a document holder placed at eye
level when typing
Use proper posture for standing,
sitting, and sleeping
Change jobs or tasks frequently
67. If you suspect a work-related
injury, contact your supervisor
immediately!
68. ERGONOMICS INFORMATION ON
SHAREPOINT
Go to the Intranet (Sharepoint)
Click on “Departments”
Click on “Human Resources”
On the left side, under “Documents” you will
find Ergonomic Resources.
69. ERGONOMIC REFERRAL PROCESS
1. Employee notifies Supervisor
2. Employee and Supervisor complete the Self-
Assessment Form.
3. If assessment reveals workstation complexity or
additional modifications, a request form is sent to
Human Resources to arrange an evaluation by the
Ergonomics team.
4. Evaluation is completed.
70. ERGONOMIC REFERRAL PROCESS
5. Recommendations of the Ergonomics Team are
given to the employee, the Supervisor and
Human Resources.
6. Equipment modifications and requisition of
recommended equipment must be made by
supervisor.
7. Follow up completed within 30 days to ensure
proper modifications and equipment use.
8. Human Resources sends 90 day follow-up as
above.
72. LEGAL DEFINITION
The law defines sexual
harassment as unwelcome
sexual advances, requests for
sexual favors, and other verbal
and physical conduct of a sexual
nature when:
73. LEGAL DEFINITION, cont.
Employment decisions such as hiring, firing,
work assignments, promotions or pay rises
depend upon the victim’s response, or
The conduct interferes with the victim’s job
performance, or
The conduct creates an intimidating, hostile
or offensive workplace.
74. UNWELCOME BEHAVIOR
Refers to any behavior which the recipient
does not invite or encourage or which the
recipient regards as undesirable or
offensive, such as obscene gestures or
sounds, persistent pressure for
dates, deliberate blocking of physical
movement, and/or the display of sexually
explicit or suggestive material.
75. TYPES OF
SEXUAL HARASSMENT
QUID PRO QUO
HOSTILE WORK ENVIRONMENT
76. QUID PRO QUO
Means “this for that”.
Usually involves supervisor & employee.
Supervisor makes unwanted sexual advances or
engages in unwelcome sexual behavior and states
or implies that the employee must accept in order:
to keep his/her job
to avoid transfer, demotion, or firing
to receive a raise or promotion
77. HOSTILE WORK ENVIRONMENT
Requires unwelcome verbal, physical, or
graphic conduct of a sexual nature which:
reasonably interferes with the
employee’s work performance, or
Creates an environment which is
intimidating, hostile, or offensive.
78. EFFECTS OF
SEXUAL HARASSMENT
Decreased productivity/morale.
Increased rates of employee turnover, transfer
and absenteeism.
Increased legal fees and other costs.
Increased rates of workers’ compensation and
unemployment claims.
Ruined lives, families, and careers.
79. THINGS YOU SHOULD KNOW ABOUT
SEXUAL HARASSMENT
Harassers may be respected, talented and well-liked.
Many who engage in offensive conduct stop when
asked to stop.
To be harassment, the behavior must be unwanted
or unwelcome.
Certain behaviors would be harassment to
some, but not to others. The courts ask “how would
it look to a reasonable person?”
80. EMPLOYEES’ RESPONSIBILITIES
If you think you have been sexually
harassed, REPORT IT.
If you observe sexual harassment, REPORT
IT.
If you are making suggestive comments or
behaving in ways that could make someone
uncomfortable, STOP IT.
81. YOU SHOULD KNOW THAT:
confidentiality at the time of reporting an
infraction is assured on a need-to-know
basis, and
retaliation against any employee for
complaining about harassment is
prohibited.
82. Gaylord Hospital is firmly
committed to providing an
environment that is free of any
form of sexual harassment.
84. Diversity is more than differences in
race, gender, ethnicity and age.
Diversity includes differences in:
Income Military experience
Education Personality
Sexual Orientation Learning Style
Religious Beliefs Working Style
Marital Status Language
Disability
85. Culture is more than differences in
patterns of daily living.
Culture includes differences in:
Language Religion
Customs Superstitions
Holidays Food
Art Music
Clothing
86. “The Melting Pot” and “The Salad Bowl”
The Melting Pot implied a
blending of many cultures
into one American culture.
Immigrants gave up traditions
and values to become
American.
87. “The Melting Pot” and “The Salad Bowl”
In the Salad Bowl,
the focus is on
retaining unique ethnic
and cultural values and
traditions.
88. Culturally Competent Healthcare
Culturally competent healthcare requires a
commitment from clinicians and other
caregivers to understand and be responsive
to the different health beliefs, practices
and needs of diverse patient populations.
89. Why is it so important?
• To improve quality of
care, outcomes, patient satisfaction, and
productivity.
• To meet legislative, regulatory and
accreditation mandates.
• To gain a competitive edge in the
marketplace, and decrease the likelihood of
liability/malpractice claims.
90. Characteristics of
Culturally Competent Healthcare
• Understanding different attitudes, values,
verbal cues, and body language.
• Respecting patients’ beliefs and values
• Interacting with patients in a culturally
appropriate and sensitive manner
91. Culture and Co-Workers
You may work with people from many
cultures. When staff members make an effort
to work well together:
• Job satisfaction
increases
• Patients receive
the best care
92. To learn more about other cultures:
• The Tremaine Library has a collection of books
which describe different cultures and their
perceptions of health and illness.
• The Tremaine Library website has links to
resources that describe the health
perspectives of a variety of populations.
93. Diversity
Different
Individuals
Valuing
Each other
Regardless of
Skin,
Intellect,
Talent, or
Years
95. There are many forms of
maltreatment
• Physical abuse • Financial abuse
• Physical neglect • Financial neglect
• Self-neglect • Psychological
• Sexual abuse abuse
• Psychological
neglect
96. What to look for
• Recurring marks or bruises on the body
• Contradictory or implausible stories
regarding injuries
• Sudden or increasing isolation from
others
• Constant presence of caregiver
97. What to look for
• Patient is not willing or is not permitted
to speak for him/herself
• Resentment, denial, withdrawal, or
anger when questioned about obvious
facts, including medical treatment
• Compromised nutritional status, either
overeating or malnourished
98. Screening
Conduct
screening for
abuse and/or
neglect in
PRIVATE!
The following people SHOULD NOT
be present:
the primary caregiver
any other possible abuser
99. If the patient denies abuse
• Respect his or her right not to disclose
• Inform the patient of your ongoing support
and availability
• Offer information about resources that are
available
• Reassess the patient at appropriate
intervals
100. Legal issues
The State of Connecticut mandates
the reporting of suspected physical
or sexual abuse or neglect.
101. Mandated Reporters
Certain individuals are required to report cases of
suspected abuse or neglect involving children, the
elderly, or clients of the Department of
Developmental Services.
Mandated reporters include:
Physicians Nurses
Pharmacists Social workers
Therapists Psychologists
Clergy Physician assistants
102. Reporting vs. Confidentiality
Reporting requirements can provide an ethical
conflict for healthcare providers. The patient
may not want the provider to make a report.
In this case:
• explain that the law may require you to
report, and
• work to keep a positive relationship with
the patient.
103. How to report
For individuals under the age of 18 years,
contact:
Department of Children and Families
1-800-842-2288
For individuals 60 years of age and older,
contact:
Protective Services for the Elderly
1-888-385-4225
104. Reporting
For all DDS clients, regardless of age, contact:
Office for the Protection and Advocacy for
Persons with Disabilities at: 1-800-842-
7303
There are no reporting requirements for
disabled or non-disabled adult victims of
abuse between the ages of 18 and 59 years.
See Social Services Department for
assistance.
107. Words that Work
Not just words – it’s an attitude
Planned communication
Positive body language
Pleasant facial expression
NOT mechanical or robotic
NOT just for clinical staff
109. Step One: REASSURE
Many of our customers are experiencing high
stress levels as a result of their situation. It is our
responsibility to reduce their stress and make
them feel that they are in good hands.
Project a professional image; smile
Offer an appropriate greeting; introduce
yourself
Seek and maintain eye contact
Offer reassurances about Gaylord and the staff.
110. Step Two: EXPLAIN
Most people will be patient and understanding
if they know what to expect.
oExplain in clear and understandable terms
what is going on, why there is a delay or what
they should expect to happen next.
oSpeak clearly and at a level that is easy to
understand.
oMake eye contact and maintain it.
111. Step Three: LISTEN
Some people will question why they need to do
something or why they have to wait. We must remain
calm and patient , especially when the customer
becomes challenging.
oListen carefully for questions and concerns
oEmpathize with feelings
oBe sure you understand what the person is telling you;
ask clarifying questions
112. Step Four: ANSWER
Be positive and calm. Your answer needs to be
non-threatening. Remember, we are trying to
reassure the customer and explain what he/she
should expect.
oSummarize using the customer’s words
oCheck for understanding
113. Step Five: TAKE ACTION
Do what you said you were going to do.
o If there is a change in the process, stop and
explain.
o Keep your customer informed.
114. Step Six: EXPRESS APPRECIATION
Now is the time to sincerely thank the
customer for coming to Gaylord. If you are
handing off the customer to another employee,
it is appropriate to thank both parties.
Also, provide information about the next
person the customer will see.
o “Is there anything else I can do for you before
I leave? I have time.”
o “This is John. He will take good care of you.”
116. The Patients’ Bill of Rights has 3 goals:
• Strengthen consumer confidence that
the health care system is fair and
responsive to consumer needs;
• Reaffirm the importance of a strong
relationship between patients and
health care providers;
• Reaffirm the critical role consumers
play in safeguarding their own health.
117. PATIENTS HAVE A RIGHT TO:
INFORMATION
Patients have a right to accurate and
easily understood information about their
health plan, health care
professionals, and health care facilities.
If the patient speaks another language, or
has a mental or physical
disability, assistance must be provided in
order for the patient to make informed
health care decisions.
118. PATIENTS HAVE A RIGHT TO:
BE A FULL PARTNER IN
HEALTH CARE DECISIONS
Patients have a right to know their
treatment options and to participate in
decisions about their care.
Parents, guardians, family members or
other individuals can be named as a
surrogate to represent the patient when
the patient is unable to make his/her
own decisions.
119. PATIENTS HAVE A RIGHT TO:
RESPECT AND NONDISCRIMINATION
Patients have a right to respectful and
nondiscriminatory care from their
doctors, health plan
representatives, and other health care
providers.
120. PATIENTS HAVE A RIGHT TO:
CONFIDENTIALITY OF
HEALTH INFORMATION
Patients have a right to speak in
confidence with health care providers
and to have their health care
information protected. Patients also
have the right to review and copy their
own medical record and to request that
the physician change the record if it is
not accurate.
121. PATIENTS HAVE A RIGHT TO:
SPEEDY COMPLAINT RESOLUTION
Patients have a right to a fair, fast and
objective review of any complaint
he/she has against doctors, the
hospital or other health care personnel.
122. PATIENTS HAVE A RESPONSIBILITY
TO:
Collaborate with health care providers
in order to achieve the best possible
health care and treatment outcomes.
123. PATIENTS HAVE A RESPONSIBILITY
TO:
PROVIDE ADVANCE DIRECTIVES
Patients have a responsibility for
ensuring that the health care institution
has a copy of his/her written advance
directive if one has been written.
124. PATIENTS HAVE A RESPONSIBILITY
TO:
SEEK INFORMATION
Patients have a responsibility to ask for
information about their health status or
treatment if they do not understand the
information or instruction provided.
126. • 52 million people in the U.S. speak a
language other than English at home.
• 95 million people in the U.S. have literacy
levels below that required to understand
basic written health information, such as
how to take medication.
127. Limited English Proficient
An individual who does not speak English as
their primary language or who has a limited
ability to read, speak, write or understand
English is considered to be Limited English
Proficient (LEP).
Federal law requires all federally
funded health care providers to provide
meaningful health care access to LEP persons.
128. Our Policy
• LEP or deaf/hard of hearing patients will have
services provided to them during the delivery
of all significant healthcare services.
• Services will be provided within a reasonable
time and at no cost to them.
• The provision of interpretation services
extends to surrogate decision-makers.
129. Identification of Need for
Interpretation Services
Begins before Admission
Documented in the EMR
Patient or surrogate decision-maker
will be asked:
“Do you speak another language at
home?”
“How well do you speak English?”
“In what language do you prefer to
receive your medical services and your
written materials?”
130. Specific Situations for Interpretation
Services
• Obtaining medical history • Obtaining informed consent
• Explaining diagnosis and • Providing medication
treatment plan information
• Discussing mental health • Explaining discharge
issues instructions
• Explaining changes in • Discussing issues at patient
condition conference
• Discussing Advance Directive
• Explaining tests and
procedures • Discussing end of life
decisions
• Explaining patient rights and
responsibilities • Obtaining financial and
insurance information
131. Use of Family Members
or Staff as Interpreters
Staff must be
Family members or certified as language
other individuals interpreters.
accompanying the Non-certified staff
patient may be used may be used to
to interpret NON- interpret NON-
MEDICAL MEDICAL
information only. information only.
132. Interpretation Telephones
Telephones are located
on all Nursing
Units, Inpatient
Therapy, Medical
Services, Outpatient
Therapy in Wallingford
and North Haven, and all
Sleep Medicine locations.
133. Interpretation Services
• Directions on use of interpretation
phones are attached to each device.
• Clinicians can also direct dial CyraCom
for assistance. The number is on the
device.
• TTY phones are available for hearing
impaired patients or surrogate
decision-makers.
• Face-to-face interpreters will be used in
special circumstances.
136. INFECTION PREVENTION AND
CONTROL PROGRAM
The goal of the Infection
Prevention and Control Program is
to improve patient care practices
and thus preserve and enhance a
person’s health and function by
preventing the acquisition of
hospital-acquired infections.
137. PROGRAM COMPONENTS
Infection prevention and control
strategies
Surveillance in patients and personnel
Communication and reporting
Education
Employee Health Program
Environment and Community controls
139. WASH YOUR HANDS:
Before and after patient contact
After removing gloves and other
Personal Protective Equipment (PPE)
After using the rest room or any
personal grooming
After coughing/sneezing/blowing nose
Before preparing, serving, eating food
When arriving at work and before
leaving work
140. HANDWASHING TECHNIQUES
Use water and plenty of soap
Work up a good lather
Scrub well; pay attention to
nails, between fingers, and up to your
wrists
Lather for AT LEAST 15 seconds
Rinse well; let the water run off your
fingers
Dry your hands well; use paper towels to
turn off the faucet and open the door
141. AN ALTERNATIVE TO SOAP
AND WATER: ALCOHOL RUBS
Use when handwashing is called for
EXCEPT when hands are visibly soiled
or when the patient has C Difficile.
Hand rubs: offer good protection, are
convenient to use, and less drying to
the skin than repeated soap and water
washing.
Apply enough to cover the surfaces of
both hands and rub hands until dry.
Do not rinse.
142. FINGERNAIL POLICY
The following applies to all staff who
have direct patient contact, as well as
staff who handle, prepare or process
patient items.
Artificial nails are prohibited.
Fingernails may not exceed ¼ inch
from the tip of the finger.
Nail polish must be intact.
143. LATEX ALLERGY
Definition: a sensitized response to
latex, a natural rubber product.
Transmission: latex antigen can be
transmitted by air or by contact
with latex rubber products.
Reaction: can range from dermatitis
to anaphylaxis (shock).
Signs and symptoms:
rash, redness, hives, difficulty
breathing.
145. TUBERCULOSIS
TB is a disease Symptoms
caused by
bacteria; the Productive, persi
lungs are stent cough
affected. Bloody sputum or
TB Spreads phlegm
through the air Fever
after an infected
person Weight loss
speaks, coughs, s Night sweats
neezes, or sings. Loss of appetite
146. UNIVERSAL/STANDARD
PRECAUTIONS
Standard Precautions are work
practices that help prevent the
spread of infectious diseases.
Standard Precautions help protect
patients and every member of the
health care team.
Standard Precautions can help prevent
illness and can help save lives –
including your own!
147. UNIVERSAL/STANDARD
PRECAUTIONS
TREAT ALL BODY FLUIDS AS
POTENTIALLY INFECTIOUS AT
ALL TIMES.
Universal Precautions stress that all body
fluids should be assumed to be infectious
for bloodborne diseases. The greatest
risks are from HIV, Hepatitis B, and
Hepatitis C.
148. COVER YOUR COUGH
ALWAYS COVER YOUR
COUGH OR SNEEZE.
USE TISSUE OR SLEEVE
TO COVER.
CLEAN YOUR HANDS
AFTER COUGHING OR
SNEEZING.
IF YOU ARE ILL – STAY
HOME!
149. BLOODBORNE PATHOGENS
Bloodborne pathogens are
microorganisms present in human
blood that can cause disease in
humans.
Bloodborne pathogens can enter the
body if infected blood or other
potentially infectious material
touches a body opening or break in
the skin.
151. PROTECT YOURSELF!
Get vaccinated! Hepatitis B vaccine
is available to employees free of
charge.
Do not eat, drink, apply
cosmetics, or handle contact lenses
in areas where exposure is likely.
Do not store food, beverages, or
personal items in refrigerators or
places where potentially infectious
material is stored.
152. PROTECT YOURSELF!
Practice proper hand hygiene.
Prevent injuries from sharps.
Practice proper handling of
contaminated materials.
Use Personal Protective
Equipment (PPE) if blood or
potentially infectious material
exposure is anticipated.
153. PERSONAL PROTECTIVE
EQUIPMENT [PPE]
PPE should be appropriate for the
type of procedure being performed
and the type of exposure anticipated.
GLOVES are to be worn when there
is potential for contact with
blood, potentially infectious
material or items/surfaces
contaminated with these materials.
154. PERSONAL PROTECTIVE
EQUIPMENT [PPE]
EYE & MOUTH GOWNS are to
SHIELDS are to be worn when
be used if there there is the
is a risk of potential for
spraying or splashing of
splashing body blood or body
fluids. fluids.
155. PERSONAL PROTECTIVE
EQUIPMENT [PPE]
POCKET MASK or BARRIER
VENTILATORY MASK is to be
worn when giving CPR.
156. SHARPS
Take precautions to prevent injuries
caused by needles, scalpels and other
sharp instruments or devices.
Get help before using sharps around
confused or uncooperative patients.
Utilize safety engineered mechanisms.
Needles should NOT be
recapped, removed from disposable
syringes, or manipulated by hand.
157. SHARPS
Sharps must be properly disposed of
in a marked container as soon as you
have finished with them.
Do not put a used sharp down and
never throw sharps in the trash.
Never overfill a sharps
container. Containers
should be replaced
at ¾ full.
159. BLOOD & BODY FLUID
EXPOSURES
Can be a needle stick/puncture
wound, mucous membrane exposure
(splash), contact with open chapped
skin, or a bite.
GIVE YOURSELF FIRST AID
IMMEDIATELY. WASH EXPOSED SKIN
WITH SOAP AND WATER OR FLUSH EYES
UNDER RUNNING WATER.
AFTER FIRST AID, NOTIFY YOUR
SUPERVISOR IMMEDIATELY.
160. TRANSMISSION BASED
PRECAUTIONS
ALL PRECAUTIONS ARE
IN ADDITION TO
STANDARD PRECAUTIONS –
FOR ALL PATIENTS.
161. AIRBORNE PRECAUTIONS
Examples: Tuberculosis, Chickenpox, Measles
Use when there are organisms that remain suspended
in the air and can be dispersed by air currents within
a room or over a long distance.
Transfer suspected patient to negative-pressure
room ( M115, M215 and L102 or Exam Room 9 in
Outpatient) Keep door closed.
N95 respirators or PAPR Hoods must be applied prior
to entering room.
Fit testing of N95 mask is required
Pt must wear a surgical mask if leaving the room.
162. CONTACT PRECAUTIONS
Examples: MRSA, VRE, ESBL shingles,
scabies, impetigo
Use when there are organisms that are
transmitted by direct contact with patient.
Gowns and gloves are to be used for direct
contact with the patient, the environment or
equipment.
Masks are to be used if within 3 feet of the
patient if the infected site is respiratory.
163. DROPLET PRECAUTIONS
Examples:
Influenza, Pertussis, Mumps
Use for organisms transmitted by
droplets generated during
coughing, sneezing, or talking.
Masks are indicted if within 3 feet.
Gowns and gloves are indicated if
touching infected materials or if
soiling is likely.
Patient must wear a mask if leaving
room.
164. ENTERIC PRECAUTIONS
Use for patients with C Difficile Diarrhea.
Gloves and gowns are to be used when in
contact with the patient or the patient’s
environment.
Alcohol-based hygiene products are not
effective against C Difficile spores. Utilize
soap and water only.
Therapy warded until diarrhea free x48hrs.
Disinfect equipment with hospital approved
bleach solution.
165. Protective Environment Precautions
Examples: bone marrow
transplant, chemotherapy
Use when patient has an absolute
neutraphil count is below 500
Thoroughly wash hands before
entering patient’s room
Wear a surgical mask if you are
experiencing a respiratory infection.
Patient should wear a surgical mask
when leaving the room if determined
by their physician.
166. EMPLOYEE HEALTH
Pre-employment 2-step PPD skin test
and annual PPD for all employees and
volunteers
Employee Education
Vaccination program: Hepatitis
B, Chicken Pox, Measles, German
Measles, Mumps and Flu.
Employee exposure reporting and
follow-up.
167. For your information:
The Infection Control,
Isolation and Employee
Health Manual is available
on the Gaylord Intranet
under “Infection Control.”
168. QUESTIONS?
If you have questions about any of
the Infection Prevention
Information presented
here, contact:
Susan Paxton RN CIC
Director of Infection Prevention
Brooker 108, x3278
203-412-2475 beeper
170. INFLUENZA
• Influenza is a serious respiratory disease that kills an
average of 36,000 persons and hospitalizes more than
200,000 persons in the United States each year.
• Influenza is PREVENTABLE.
• Influenza vaccination is recommended for all
healthcare workers to prevent influenza disease and
it’s complications , including death.
• The influenza virus can be spread from asymptomatic
carriers.
171. Flu Symptoms
• Fever
• Chills
• Cough
• Sore throat
• Headache, body aches, fatigue
• Diarrhea and vomiting in some cases.
• Symptoms may be mild or severe
172. How is the Influenza Virus Spread?
• Spread is mainly
through coughing
and sneezing.
• People may become
infected by touching
something with flu
virus on it and then
touching their mouth
and nose.
173. Who is at risk?
Anyone who has contact with an infected
person may be exposed.
174. PREVENTION
• Get vaccinated!
• Wash your hands often and well
• Cover coughs and sneezes
• Eat well and get plenty of rest
• Avoid contact with sick individuals
• Frequently disinfect high touch items such as keyboards,
phones, doorknobs)
• Have tissue and Purell readily available
• Don’t share community food, drinks etc.
• Follow travel alerts
• If sick, stay home!
175. If you are sick….
• Stay home! Notify your supervisor that you are
experiencing flu symptoms. Your supervisor will report this
to Infection Prevention ext 3278.
• Employees are to remain out of work until fever free for 24
hours without the use of Motrin, Tylenol or medications
containing fever reducing ingredients, such as Theraflu.
• Call your doctor. Anti viral medication may be indicated.
• Avoid close contact with others and cover your cough.
• Rest, drink plenty of fluids.
• Warning! Do not give aspirin to children or teenagers who
have the flu. This can cause a rare but serious illness called
Reye’s syndrome.
176. Helpful Tips when caring for some one at
home with Influenza
• Social distancing: Avoid close contact (less than 6 ft)
with the sick person. Avoid being face to face with the
sick person.
• When holding small children who are sick, place their
chin on your shoulder so that they will not cough in
your face.
• Wash your hands after every contact with the ill
person or the ill person’s things.
• Reduce visitors and keep sick person in a room
separate from the common area of the house.
• If possible designate a bathroom for the ill person.
• Talk to your care giver about antiviral medication.
• Monitor yourself for signs and symptoms.
177. Protect Our Patients
• Please do your part
• Vaccinate yourself and your family
• It’s the right thing to do!
• Joint Commission targets a 75% Health Care
worker’s vaccination compliance rate this year
• A signed declination is required for all employees
who refuse vaccination, as well as a documented
reason why
• FYI: Mandatory vaccination has been passed in some
states (NY and West Virginia)
• More to come as the season evolves….
179. Risk Management
Risk Management is a proactive approach to
improve safety and reduce risk for
patients, visitors, and employees.
Key steps:
• Identify the risk
• Assess frequency/severity of the risk
• Reduce or eliminate the risk
180. Risk Management Tools
– Employee Injury Report Form
– Occurrence Forms
• Medication
• Falls
• Wound
• General/All Other Occurrences
These confidential forms are available on the
Gaylord Hospital Sharepoint site. Paper copies are
available in each department.
181. In the event of an employee, visitor or
patient occurrence
• Respond to the needs of the person
• Obtain a form and provide a brief, factual description
of the event
• Give the completed form to your supervisor
by the end of the shift during which the event
occurred
• Do not make copies of the form
• Do not note in patient’s chart that an occurrence
report has been written
• For employee occurrences, obtain care, notify your
supervisor and have him/her complete a form
182. Who to Contact
• In the case of serious events, contact
your supervisor and the Outcomes
Management Director
• Share information with only those who
need to know
• Maintain confidentiality
183. If a patient/family member has
questions/concerns about care
• Try to answer the question/concern yourself or if
not possible, contact
your supervisor or the responsible director
• Inform the patient about the Patient Advocate at
Ext. 3000
• (Only when unsuccessful in responding to the concern)
• Provide contact information for the CT Department
of Public Health or The Joint Commission as
appropriate
184. PERFORMANCE IMPROVEMENT
• Performance Improvement is a process for
improving organizational performance.
• The overall goal is the provision of safe, high
quality, sustainable health services.
• Gaylord Hospital is committed to the process
of Performance Improvement to help us
achieve our mission.
185. PERFORMANCE IMPROVEMENT
Performance Improvement is driven by the
mission, vision, values and strategic plan of
Gaylord Hospital.
Performance Improvement goals are
focused in 3 areas:
– Safety and Quality
– Patient Satisfaction
– Outcomes
186. PERFORMANCE IMPROVEMENT
Hospital Wide Patient Satisfaction
The gap between the height of the monthly bar and the red goal line represents the
difference between the performance we want (the goal) and the performance we
have achieved. We want that gap to be as small as possible. When it appears in
successive months, eg, March and April, we use a Performance Improvement Plan (PI
Plan) to close the gap.
187. GAYLORD’S PI PROGRAM
• Monitored by the Organizational
Excellence Committee
• Carried out collaboratively with a
hospital-wide approach
• Involves hospital staff at all levels
188. Gaylord’s PI Plan Methodology
FOCUS PDCA
Find an opportunity to Plan an intervention that
improve responds to the analysis
Organize the study and of the data
identify the team Do a pilot of the intervention
Clarify the knowledge of the Check the effect of the
process intervention
Understand the data Act on the results of the
Select an intervention based intervention
on the data
189. Examples of 2012 PI Monitors
All Service Lines
Likelihood of Recommending Gaylord
Patient Satisfaction with Gaylord
Inpatient
Number of Central Line Associated Blood Stream
Infections
Outpatient
Percent of patients reporting Improvement in
Function
Sleep
Percent of patients who Comply with CPAP
treatment
190. Why focus on PI?
• To improve quality of
care
• To enhance safety for
patients/staff
• To improve patient
satisfaction
• To save time and
money
192. OUR COMMITMENT
TO INFORMATION SECURITY
Gaylord is committed to
protecting information
and information
systems, maintained in
any medium, from
improper use, alteration
or disclosure, whether
accidental or deliberate.
193. WHAT IS INFORMATION SECURITY?
Information Security encompasses all of the
protections in place to ensure that Protected
Health Information [PHI] is:
kept confidential
not improperly altered or destroyed
readily available for those who are
authorized
What is PHI? PHI is
confidential, personal, identifiable health
information about individuals.
194. WHY IS INFORMATION
SECURITY NECESSARY?
Protecting patient information is an essential part of
quality health care.
Creating an environment where patients can trust us
to protect their private information is the
responsibility of every employee.
Information security policies and procedures are
required by The Joint Commission, HIPAA and other
state and federal laws and accreditation standards.
195. WHEN CAN WE SHARE PHI?
For Treatment of the patient
For Payment
For Healthcare Operations
With Business Associates: individual
or entity who performs a function on
behalf of Gaylord Hospital with whom
we share PHI.
196. E-MAIL
Not all of electronic mail sent outside of Gaylord is encrypted.
Encryption scrambles the data so that it cannot be read by anyone who
does not have the key to read it.
In an un-encrypted state, if someone intercepts the e-mail, it can easily
be read or hacked.
Do not send PHI outside of the Gaylord Hospital network.
Best Practice: Use the minimum necessary information at all times.
197. MINIMUM DISCLOSURE NECESSARY
An organization must make reasonable
efforts to disclose ONLY the amount of
health information needed to accomplish
the intended purpose.
The Medical Provider CAN disclose the
entire record to another health care
provider for treatment.
198. UNAUTHORIZED
HARDWARE/SOFTWARE
Do not install any hardware or software without the
approval of Gaylord’s IT Department
Certain software can disable your computer, threaten
our network, or contain malicious software or coding.
Digital cameras, jump drives and CD’s from home or
other outside sources may contain viruses malware or
spyware that may also do harm to our systems.
Please contact the IT Helpdesk at x2222 if you have
any questions about hardware and/or software.
199. USER IDs AND PASSWORDS
User ID’s and Passwords are the most effective
way to protect access to electronic PHI.
Properly manage your ID and password: do not
share your ID and/or password with anyone, and
never use anyone else’s ID or password.
Choose a strong ID and password, one that is
not easily guessed.
See Gaylord Hospital policy 2-200-48 for more
information on password management.
200. KEEP THIS IN MIND!
If you let someone else
use your personal ID or
password or use a
computer where you are
still signed in, you are
risking YOUR
REPUTATION, YOUR
PROFESSIONAL
CREDENTIALS AND YOUR
JOB!
201. IN THE EVENT OF VIOLATIONS
Violations of Information Security
policies will result in corrective
action, up to and including
termination of employment.
Policy violations that also violate
HIPAA could result in fines and prison
sentences.
202. WHO TO CONTACT?
Gerald Maroney, Chief Information
Officer
x 2120 or gmaroney@gaylord.org
Susan Hostage, Director of Outcomes
Management
x 2747 or shostage@gaylord.org
204. COMPLIANCE AT GAYLORD
HOSPITAL
Gaylord Hospital is committed to
conducting its business in an ethical and
lawful manner. We will comply with
both the letter and spirit of all applicable
laws, regulations, policies and procedures.
205. Gaylord Hospital’s
Compliance Program
Written standards of conduct (Code of Ethics
and Privacy/Security Statement)
A Compliance Officer and a Compliance
Committee
Training and education of employees
Written policies and procedures
Investigation/ corrective action for detected
problems/disciplinary action as appropriate
Ongoing monitoring and auditing to assess the
effectiveness of the program
206. Written Standards of
Conduct
The Code of Ethics provides guidance to
ensure that our work is done in an ethical and
legal manner. It contains standards of ethical
behavior for all staff in their professional
relationships with colleagues, patients, other
organizations, state and federal government
agencies, donors, the community and society
as a whole.
207. Examples of Organizations/Laws
Requiring Compliance
• The Joint Commission
• Commission on Accreditation of
Rehabilitation Facilities (CARF)
• American Academy of Sleep Medicine
• Centers for Medicare and Medicaid (CMS)
Conditions of Participation
• CT Department of Public Health Code
• Fraud and Abuse Laws
208. Examples of
Non-Compliance
Accessing patient information without a
business need to know
Documenting incorrectly
Billing for services or supplies not actually
provided
Sharing passwords
Failing to maintain patient confidentiality
and privacy
209. Fraud and Abuse
Gaylord Hospital will investigate all
allegations of fraud and/or abuse, take
necessary corrective actions after a
thorough investigation, and report
confirmed misconduct to the
appropriate parties.
210. Definitions of Fraud and Abuse
FRAUD: ABUSE:
an intentional deception provider practices that
or misrepresentation are inconsistent with
made with the sound business, fiscal or
knowledge that the medical practices, and
deception could result in result in unnecessary cost
some unauthorized to health programs, or in
benefit to him/herself or reimbursement for
some other person. services that are not
medically necessary.
211. Federal Deficit
Reduction Act
Requires development of policies and
education relating to false
claims, whistleblower protections, and
procedures for detecting and preventing fraud
and abuse.
False Claims Act: those who knowingly
submit, or cause another person or entity to
submit false claims are liable for damages plus
civil penalties.
212. Reporting Violations
• Discuss the issue with your supervisor, or
• Contact the Compliance Officer Susan
Hostage, or
• Contact the Compliance Hotline.
• You may also refer to the Code of Ethics and
specific policies for additional guidance.
213. Compliance Hotline:
203-679-3537
The Compliance Hotline can be used to
report something you believe is, or may
be, a compliance violation.
You do not speak directly to anyone; you
simply leave a recorded message.
You do not have to identify yourself.
214. Consequences
For the hospital:
Monetary fines
Exclusion from federal healthcare
programs (Medicare or Medicaid)
Possible criminal penalties
For the individual employee:
Disciplinary action
Possible termination
215. Employees’
Responsibilities
Read compliance-related materials such as the
Code of Ethics
Know the type of conduct that is expected of
you and what is prohibited
Follow all policies and procedures that apply to
your job
Share concerns/questions you have regarding
potential compliance issues with your
supervisor.
216. Questions and/or Concerns??
Non-Retaliation Policy
No action will be taken against a staff member
for asking questions or raising concerns in good
faith about the Code of Ethics or for reporting
possible improper conduct.
All employees are strictly prohibited from
retaliating against anyone who reports a
violation or a concern.
218. WHAT IS HIPAA?
HIPAA is an acronym for the Health
Insurance Portability & Accountability Act
of 1996.
HIPAA consists of three separate parts:
1) Privacy, 2) Security, and 3) Electronic
Data Exchange
Privacy
Security
Electronic Data
Interchange
219. THREE AREAS OF PRIVACY
Use and disclosure of protected health
information (PHI)
Patient rights related to their PHI
Security of PHI
Administrative
Physical
220. WHAT IS PROTECTED HEALTH
INFORMATION?
Protected Health
Information, also known
as PHI: any individually
identifiable information
including demographic
information which is
collected from an
individual.
221. PHI
PHI is created, received, maintained or
transmitted by a healthcare provider.
Relates to the past, present or future physical
or mental health or conditions of an
individual and the provision of healthcare to
an individual.
PHI can be found in electronic, paper or oral
formats.
PHI either identifies the individual, or
contains information through which the
individual could be identified.
222. PHI INCLUDES THESE PATIENT
IDENTIFIERS:
• Names • Any dates related to
• Medical Record Numbers any individual (date of
• Social Security Numbers birth)
• Account Numbers • Telephone numbers
• Vehicle Identifiers/Serial • Fax numbers
numbers/License plate • Email addresses
numbers • Biometric identifiers
• Internet protocol including finger and
addresses voice prints
• Health plan numbers • Any other unique
• Full face photographic identifying
images and any number, characteristic
comparable images or code
223. WHAT DOES THE PRIVACY RULE
MEAN FOR PATIENTS?
• Enables patients to find out how their info
may be used.
• Enables patients to find out what disclosure
of their info has been made.
• Limits release of info to the minimum
reasonable needed for the purpose of the
disclosure.
• Gives patients right to examine and obtain
copy of their own health records and request
corrections.
224. WHEN CAN WE SHARE PHI?
For Treatment, Payment, and Healthcare
Operations (TPO)
A doctor may access the patient’s medical file to treat
a patient.
We may send PHI to an insurance company to pay a
hospital bill.
We may use PHI for operations such as quality
improvement, case management or training
programs.
225. Minimum Necessary
An organization must make reasonable
efforts to disclose ONLY the amount of
health information needed to
accomplish the intended purpose.
Medical provider CAN disclose entire
record to another health care provider
for treatment (referrals, etc.)
226. Minimum Necessary and Need to Know
• Only staff members who “need to know” a
patient’s PHI to perform their job should
access the information
• HIPAA requires healthcare workers to use or
share only the “minimum necessary”
information needed to perform their job
function.
227. Ask yourself the following questions before
accessing or viewing any patient information:
• Do I need this information to perform my
job?
• Do I have an immediate business need to
obtain this information?
• What is the least amount of information that
I need to perform my job?
228. HIPAA Compliance
Under HIPAA we are required to:
• Conduct random security audits to ensure that only
staff members who need to know PHI are accessing it.
• Ensure that only the minimum information necessary
to perform the job are being accessed.
• An employee who inappropriately accesses PHI is
subject to disciplinary action. Refer to Policy # 2-600-
B-23 Compliance Investigations and Associated
Disciplinary Action
229. Do your part to protect PHI…Clean It Up
Retrieve documents that contain PHI
immediately from printers and fax
machines.
Secure all files or documents with PHI
out of sight when you leave your
desk.
Minimize PHI and lock your computer
when leaving your workstation for
any reason.
Place all papers or documents that
contain PHI in appropriate shred-bin
for proper destruction.
230. THE SECURITY RULE
Ensures the confidentiality, integrity and access of all electronic
Protected Health Information which Gaylord
creates, receives, maintains, or transmits.
Safeguards electronic system use by providing employees
individual passwords that are not shared, and allowing access
to the systems based on job description.
Protects against any reasonably anticipated uses or disclosures
of information that is not permitted by educating staff and
performing routine and ongoing audits of system use and
access.
231. SECURITY ALSO APPLIES TO
Email
Social Networking
Handheld devices and laptops
Unauthorized hardware & software
232. SECURITY REMINDERS
• Select passwords that are hard to guess and
include alpha and numeric characters
• Do not share your password with anyone
• Do not send email containing PHI outside of the
Gaylord network (gaylord.org)
• Do not save PHI directly to your computer
• Do not remove PHI from the hospital
• Secure laptop and portable devices
233. THE HITECH ACT OF 2009
Expands the protection under HIPAA with
increased focus on Privacy & Security
Increased civil penalties and potential for
criminal penalties
Breach Notification – the mandatory
requirement to report the unauthorized
access of protected health information
234. THE BREACH RULE
A breach is the unauthorized
acquisition, access, use or disclosure of unsecured
PHI that compromises the security or privacy of
such information.
The hospital is required to provide notice to each
patient affected by a breach within 60 days of the
occurrence.
The hospital must submit an accounting of all
reportable breaches to the Department of Health
& Human Services each year.
**Not every HIPAA violation is a “reportable” breach but
should be reported to a compliance officer.
235. WHAT HAPPENS IF
…a Privacy or Security
policy is violated?
Organization-specific
sanctions
Right to file a
complaint
Civil and criminal
penalties
236. WHAT SHOULD YOU DO?
Follow all Confidentiality and HIPAA policies
2-300-06 Use and Disclosure of Protected
Health Information
2-800-07 Breach Notification Policy
2-800-20 Notice of Privacy Practices
2-800-02 Minimum Necessary for Use &
Disclosure of PHI
Additional Privacy & Security policies can be found on
SharePoint
Report all potential breaches immediately to the Privacy
Officer (Ext 3303), regardless of its significance.
When in doubt, contact the Privacy or Security Officer
Privacy Officer: Tracey Nolan ext. 3303
Security Officer: Gerry Maroney ext. 2120
Compliance Officer: Susan Hostage ext. 2747
