Annual Mandatory Update
2009
Master Reference Guide
Audacious Goal
“To become the most trusted hospital in Los Angeles by 2012.”
Mission Statement
HollywoodPresbyterianMedicalCenter will provide
“Quality Care with Compassion and Respect”
Vision Statement
Hollywood Presbyterian Medical Center is a community teaching hospital serving the health care needs of all members of the population within it’s service area, and strives to distinguish itself as a leading healthcare provider, recognized for providing quality, cost effective and innovative care in a compassionate manner.
TABLE OF CONTENTS
Topic Page
HollywoodPresbyterianMedicalCenter: Compliance Program 3-6
Human Resources: Key Policies Review7-10
HIPAA 11
Fire & SafetyHospital Codes12 -14
Radiation Safety 15
Environment of Care / MSDS 16
Utility Safety 17
Medical Safety Device Act 18
Biohazard and Medical Waste18-19
Infection Control / TB20-24
Latex Allergies 25
Security and Personal Safety 26
Body Mechanics / Back Safety27-31
Cultural Diversity32-33
Population and Age Specific Care34-39
Team Building40-42
Customer Service43 - 45
Patient Rights 46
Bioethics Committee 47
Advance Directive47-49
Unapproved Abbreviations,Patient Safety-NPSG50-52
Risk Management 53
Performance Improvement54 - 55
HollywoodPresbyterianMedicalCenter
Compliance Program
PREAMBLE
It is the policy of Hollywood Presbyterian Medical Center that all services be provided and that all transactions and affairs be conducted at all times in accordance with applicable legal requirements; accreditation standards, professional and industry ethical standards and practices, and in conformance with the Medical Center’s Code of Conduct. This Compliance Program is intended to enhance existing MedicalCenter policies, procedures and practices. The Program applies to all MedicalCenter employees including the Senior Administration Team. It also applies to the Governing Board, its officers, managers, and employees, to the Medical Staff, allied professionals, to independent contractors and to volunteers. The program goals are to prevent misconduct, to monitor activities to detect misconduct if it occurs, to prevent future misconduct and/or wrong-doing, and to promote the MedicalCenter’s reputation as an ethical provider of health care services.
COMPLIANCE STANDARDS
Examples Of Non-Compliance Include But Are Not Limited To:
Examples of Violations of Stark & Anti-Kickback Laws: Provision of monetary payments or goods and services of any kind which are intended as an inducement for physicians or others to refer patients to the MedicalCenter. The use of gifts, discounts or waivers of co-payments or deductibles for the purpose of attracting patients to the Medical Center, financial arrangements between the hospital and physicians or other practitioners who refer patients to the Medical Center unless such relationships or arrangements qualify for recognized exceptions.
Examples of Coding/Billing Errors: Billing for services not provided or rendered. Billing for services that are not medically necessary. Billing for services not adequately documented. Up-coding. Billing in violation of other State or Federal program rules. Duplicate billing. Unbundling. Billing for discharge in lieu of transfer. Failure to refund credit balances.
Examples of False Claims Issues: Reporting incorrect information to, or information not in conformance with State and/or Federal government agencies, submission of false cost reports (reporting unallowable costs to State and/or governmental agencies).
Examples of Quality of Care Issues: Falsification of medical records. Premature discharge. Sub-standard care. Unnecessary re-admission. Malpractice. Negligence. Ignoring safety hazards. Patient abuse. Failure to maintain patient confidentiality. Violation of patients’ freedom of choice.
Examples of EMTALA Issues: Delaying treatment in the ED by inquiring about insurance or financial status. Failure to provide a medical screening exam by qualified medical personnel to all patients who present to the ED. Failure to provide stabilizing treatment when an emergency medical condition is determined to exist. Knowing failure to provide covered services/ necessary care to members of an HMO.
Examples of Scope of Practice Issues:Signing a form for a physician without the physician’s authorization, prescribing medication or treatments, performing any patient care services without proper privileges.
Examples of State/Federal/JCAHO Survey Issues: Falsification of medical records, improper or incomplete documentation of services rendered, missing policies and procedures, not following existing policies and procedures.
Examples of HIPAA Privacy Issues: Release of patient information without the patient’s consent except as permitted in the MedicalCenter’s patient privacy policy. Violation or invasion of patient privacy. Failure to adequately protect electronic submission of PHI (protected health information) not in compliance with HIPAA regulation. Discussing patients in public areas.
Examples of HIPAA Security Issues: Identity theft, using another employee’s computer access ID and password. Unauthorized download or installation of unauthorized software.
Examples of Policies & Procedures Issues: Theft, giving false information, failure to report errors in payment of wages or benefits, alcohol or illegal drugs in the workplace, violation of health and safety rules, unlawful harassment, unauthorized use/display of a dangerous or deadly weapon, conflict of interest, solicitation.
NON-RETALIATION POLICY
MedicalCenter is committed to compliance with all laws and regulations that govern hospital and medical practices and strives to foster an environment in which all employees and others feel free to report possible instances of non-compliance. Accordingly, MedicalCenter adopts the following policy to protect employees and others from intimidation, threats, coercion, discrimination, or other retaliatory actions.
Employee: Obligation To Report. It is the responsibility of all MedicalCenter employees to report perceived misconduct including but not limited to actual or suspected violations of laws, regulations, policies and procedures, the Code of Employee Conduct, and compliance. Employees may report suspected or actual misconduct to their supervisor, manager, director, compliance officer, or they may use the confidential reporting mechanism through the MedicalCenter’s Compliance/Ethics
Hot-Line: 323-913-4520.
Management: Open-Door Policy. All management employees, including supervisors, managers, directors, and the compliance officer will be readily accessible so that employees, vendors, patients, physicians and visitors will be able to easily report problems and/or concerns.
Reports: Must Be Good Faith, Reasonable. This non-retaliation policy applies to all reports or expressions of opposition to the practice’s procedures that are held in good faith and that are expressed in a manner that is reasonable and that does not violate the law.
Policy: Will Not Retaliate.MedicalCenter will not retaliate through harassment, intimidation, denial of promotion or raises, or loss of employment, or business opportunities, or in any other manner against employees, individuals, and others for:
a. Exercising any right under, or participating in any process established by,
federal, state, or local law or regulations or MedicalCenter policies;
b. Making a good faith complaint with MedicalCenter, any third-party payer, or any state or federal regulatory or law enforcement agency, including the Office of Inspector General and the Department of Health and Human Services;
c.Testifying, assisting, or participating in an investigation, compliance review, proceeding, or hearing; or
d.Opposing in good faith any act, practice, or procedure that is unlawful by federal, state, or local law or regulation or that is improper according to MedicalCenter policies.
Violation of Non-Retaliation Policy: Subject to Discipline. Any MedicalCenter employee, agent, or medical staff member who violates this non-retaliation policy is subject to discipline, up to and including immediate termination of employment or staff membership.
OVERSIGHT RESPONSIBILITIES
Compliance Committee:
This Plan shall be implemented under the guidance and supervision of the Compliance Committee, as delegated by the Senior Administration Team. The Compliance Committee will be responsible for overseeing compliance efforts, including reviewing the effectiveness of medical center compliance with the Plan, recommending revisions to the Plan, receiving reports on compliance issues and monitoring follow-up and corrective action. In discharging its responsibilities, the Compliance Committee shall work closely with other appropriate Committees and departments, and will investigate potential compliance issues referred by other committees.
EDUCATION AND TRAINING
All MedicalCenter employees and non-employees such as agents, independent contractors, volunteers, medical staff and allied professional staff are required to participate in Compliance/Ethics education and training. The Compliance Officer will determine what materials will be used for education and training. A written record of attendance/participation will be made and retained by the Compliance Officer.
All new employees will receive, during new hire orientation, an introduction to the MedicalCenter’s Compliance Plan including the procedure for confidential reporting. The Human Resources Department will monitor compliance with this requirement and provide status reports to the Compliance Officer on a routine basis.
Some Hospital Staff may receive specialized training as a result of the areas in which they work. This specialized training may focus on complex or high-risk areas. As new developments or concerns arise, the Compliance Officer may require additional training sessions for some or all Hospital Staff.
MONITORING AND AUDITING
Periodic compliance audits both internal and external will be conducted on a semi-annual basis, minimum. The purpose of such audits will be to assess medical center compliance with laws, regulations, standards, and policies and procedures. If an audit reveals potential non-compliant conduct, research, investigation and corrective action will take place. Results of all compliance audits will be reported to the CEO, CFO and the Compliance Committee to include Legal Counsel.
All contracts and other arrangements with physicians, outside laboratories, vendors, providers, referral sources and other agents will be reviewed by Legal Counsel and the CEO or his designee to ensure that they are in compliance with State and Federal regulations, laws, statues.
INVESTIGATION AND CORRECTIVE ACTION
Upon receipt of external audit results, a hotline report or other information suggesting a possible compliance issue, the Compliance Officer will record the information and confer with legal counsel before any investigation is undertaken. The Compliance Officer, in concert with legal counsel, will determine who should conduct the investigation. Investigations will commence in a timely manner.
Investigation activities will include, but are not limited to:
Interviews
Review of relevant documents
Review of applicable laws/regulations
Consultation with Legal Counsel.
Any issue for which a corrective action plan is implemented will be monitored and reviewed and will be included in all future audits. All pertinent information learned during investigations will be incorporated into Hospital Staff education and training so as to prevent recurrence of the non-compliant activity.
HUMAN RESOURSES KEY POLICIES REVIEW
- Child Abuse, Dependent Adult Abuse, and Elderly Abuse – Section 11166, Penal Code
Developmentally Disabled Abuse – Calif. Welfare and Institutional Code 15630
Both of these laws serve to protect the rights of those mentioned, specifically children, dependent adults, the elderly and the developmentally disabled. These codes require that any care custodian, health practitioner or employee of an adult or child protective services agency or local law enforcement agency who has knowledge of or observes either a child, a dependent adult, or elderly person in his/her (the employee’s) professional capacity, or within the scope of his/her employment who he/she knows or reasonably suspects that the patient has been a victim of physical abuse must report the abuse; He or she is required to report the known or suspected instance of physical abuse to the appropriate protective services agency or law enforcement agencyby telephone and in written form within 36 hours of receiving the information concerning the incident. “Dependent Adult” means any person residing in the state, between the ages of 18 and 64, who has physical or mental limitations which restricts his or her ability to carry out normal activities or to protect his or her rights.
- Use of Information & Technology Systems (HR P&P 514)
HPMC’s (HollywoodPresbyterianMedicalCenter) technology and information systems such as voice-mail, e-mail, computers, associated computer networks, software, the Internet and other related technologies are used for business purposes only. Hospital policy serves to inform employees that they must refrain from personal use of these systems, in addition they should be advised that all information stored in or transmitted through such systems, as well as the equipment itself is company property and to alert all employees of the privacy and confidentiality limitations inherent in the use of such company systems.As such, all messages or information created, sent, received or stored in the systems as well as all information and materials downloaded into HollywoodPresbyterianMedicalCenter systems are and remain the property of HollywoodPresbyterianMedicalCenter. Employees should not use a password, access a file, or retrieve any stored communication without authorization. To ensure compliance with this policy, computer and e-mail usage may be monitored.
HollywoodPresbyterianMedicalCenter strives to maintain a workplace free of harassment and sensitive to the diversity of its employees. Therefore, HollywoodPresbyterianMedicalCenter prohibits the use of voice-mail, computers and the e-mail and Internet systems in ways that are disruptive, offensive to others, or harmful to morale. Further, employees are expressly prohibited from abusing HollywoodPresbyterianMedicalCenter's information systems.
Examples of inappropriate use of the information systems include, but are not limited to, the following:
a)threatening or harassing other employees;
b)using obscene or abusive language;
c)creating, displaying or transmitting offensive or derogatory images messages or cartoons regarding sex, race, religion, color, national original, marital status, age over 40, physical or mental disability, medical condition or sexual orientation or which in any way violate Hollywood Presbyterian Medical Center's policy prohibiting employment discrimination and harassment in employment;
d)creating, displaying or transmitting "Junk mail" such as cartoons, gossip or "joke of the day" messages;
e)creating, displaying or transmitting "chain letters"; and
f)Soliciting or proselytizing others for commercial ventures or for religious, charitable or political causes. This includes "for sale" and "for rent" messages or any other personal notices.
Abuse of hospital Information and Technology systems is subject to disciplinary action up to and including termination.
3.Appearance and Hygiene (HR P&P 406)
All employees are requested to be aware and conscientious of their personal hygiene, neatness of attire and cleanliness of apparel. Strong odors or excessive use of perfumes or cologne are inappropriate. Good judgment, in most instances, should be sufficient to define appropriate dress and hygiene. General grooming standards must be followed and include but are not limited to neat, clean and well trimmed hair, facial hair, and nails. Employees must wear his/her employee badge on his/her upper front body.
Employees, who fail to follow personal appearance and hygiene guidelines, will be sent home and directed to return to work in proper form. Under such circumstances, employees will not be compensated for the time away from work.
4.Staff Rights (HR P&P 112)
Employees of HollywoodPresbyterianMedicalCenter may request not to participate in any aspect of patient care, including treatment, due to perceived conflict with your cultural values, ethics, or religious beliefs. The hospital will make every reasonable effort to accommodate requests not to participate in such procedures, so long as the accommodation of such request will not negatively affect the patient’s care, including treatment, and so long as there is an appropriate alternative method or methods of care delivery.
Some of the treatments or procedures performed at Hollywood Presbyterian Medical Centerwhich may conflict with a person’s cultural values, ethics or religious beliefs include, but are not limited to: withholding/withdrawal of food and/or hydration; withholding/withdrawal of life support systems; Withholding/withdrawal of life sustaining measure; Organ harvesting; Organ donation; Administration of blood components; Elective termination of pregnancy; Sterilization procedures; Experimental drug administration; and Experimental device research.
Procedure: Employees and Applicants for Employment at Hollywood Presbyterian Medical Centerwho believe that a particular aspect of patient care or treatment is in conflict with their cultural values, ethics, or religious beliefs, and who desire not to participate in that aspect of patient care or treatment, must submit a Request Not to Participate Form to their supervisor at the time of hire, or as soon as possible after being notified that they may be required to participate in specific patient care or treatment. The employee is informed that:
- The hospital will make every reasonable effort to accommodate this request not to participate.
- However, if adequate staffing cannot be found, or if this request cannot be granted without negatively affecting patient care, including treatment, the employee will be required to participate in such care and treatment.
HollywoodPresbyterianMedicalCenter is dedicated to providing safe quality care to our patients. If you are concerned about the safety or quality of care that is being provided we expect for you to bring your concerns forward to your immediate supervisor or manager. You should also be aware that:
- Any employee who has concerns about the safety or quality of care provided in the hospital may report these concerns to the Joint Commission.
- No disciplinary or retaliatory action will be taken if an employee reports safety or quality of care concerns to the Joint Commission.
5.Meal & Rest Periods (HR P&P 504)
Meal Periods:Under California wage and hour law, employees are entitled to one half (1/2) hour unpaid meal period when they work an eight (8) hour shift, or when they work fewer than eight hours, but more than five (5) hours. If an employee’s shift is completed at the end of six (6) hours, the meal period may be waived by mutual consent of the facility and the employee. Employees who work shifts equal to or in excess of ten (10) hours are entitled to two (2) half (1/2) hour unpaid meal periods, unless they have signed an appropriate meal waiver form for one of the two breaks.
Rest Periods:Under California wage and hour law, employees are entitled to one (1) ten (10) minute break for every four (4) hours worked. A break or rest period is defined as a ten (10) minute period scheduled as close to the middle of a four (4) hour period as possible. Employees are entitled to three (3) rest breaks when working twelve-hour shifts.