Required for medical students hoping to complete a rotation at Redmond Regional Medical Center

1. New Hire Orientation:
General Information
Our Mission Statement
Above all else, we are committed to the care and improvement of
human life. In recognition of this commitment, we will provide
exceptional healthcare to our expanding communities with
compassion and integrity pursuing excellence in all we do.
Helping, Healing, Giving HOPE.
· During the time you are completing this module, you may call 802-
3382 for any questions. Questions that you have at night or on the
weekends may be directed to the House Supervisor at 3037.
1

2. Vision Statement
As the Nationally recognized tertiary care provider of
the largest healthcare system in NW GA, Redmond will
support and engage our medical staff, expand and
modernize our facilities, grow our Primary Care,
Occupational Health, and EMS networks, and enhance
our community presence. We will promote staff
development and deliver exceptional patient care every
time. Our reputation for success will be recognized
through service line growth, increased market share,
exceptional clinical outcomes, and superior patient,
physician and employee satisfaction.
We are Redmond.
2

3. Values
 With
 Excellence
 Compassion
 Accountability
 Respect &
 Ethics...
 We are Redmond!
3

4. Ethics and Compliance
 Redmond and HCA have a comprehensive, values-based
Ethics and Compliance Program, which is a vital part of the
way we conduct ourselves. Because the Program rests on
our Mission and Values, it has easily become incorporated
into our daily activities and supports our tradition of caring
– for our patients, our communities, and our colleagues. We
strive to deliver healthcare compassionately and to act with
absolute integrity in the way we do our work and the way
we live our lives. All work must be done in an ethical and
legal manner. It is your responsibility and your obligation to
follow the code of conduct and maintain the highest
standards of ethics and compliance.
4

5. Ethics and Compliance
 If you have questions or encounter any situation which you
believe violates the provisions of the code of conduct or the
corporate integrity agreement, you should immediately
consult your supervisor, another member of the
management team, the Human Resources Director (Patsy
Adams ext 3023), the Ethics and Compliance Officer (Lori
Baker ext 3015), or the HCA Ethics Line (1-800-455-1996).
 Each employee and volunteer is required to attend one hour
of initial code of conduct training and a one hour annual
refresher training session. Leaders and individuals in key
jobs have additional annual education requirements.
5

6. Georgia False Claims Laws
 There is a federal False Claims Act, and there are also
Georgia laws that address fraud and abuse in the Georgia
Medicaid program.
 Any person or entity that knowingly submits a false or
fraudulent claim for payment of funds is liable for
significant penalties and fines.
 The False Claims Act has a “qui tam” or “whistleblower”
provision. This allows a private person with knowledge
of a false claim to bring a civil action on behalf of the US
Government. If the claim is successful, the whistleblower
may be awarded a percentage of the funds recovered.
 For additional information, please see the Georgia False
Claims Statutes Policy. 6

7. EMTALA
 The Emergency Medical Treatment and
Active Labor Act is commonly known as
the Patient Anti-Dumping Statute.
 This statute requires Medicare hospitals to
provide emergency services to all patients,
whether or not the patient can pay.
7

8. EMTALA
 When a patient comes to the emergency
department (emergency can be located on any
part of the hospital campus), the hospital must
screen for a medical emergency.
 If an emergency medical condition is found, the
hospital must provide stabilizing treatment.
 Patients with emergency medical conditions
may not be transferred out of the hospital for
economic reasons.
8

9. Medical Ethics:
End of Life Care
 Palliative Care
 The goal of palliative care is not to cure the
patient. The goal is to provide comfort.
 Understand the importance of addressing all
of the patient’s comfort needs near the end of
life. This includes psychosocial, spiritual,
and physical needs.
9

10. Medical Ethics:
End of Life Care
 End-of-Life Decisions
 Patients have the right to refuse life-sustaining
treatment.
 Respect this right and this decision.
 Withdrawing Life-Sustaining Treatment
 Withdrawing and withholding life-sustaining
treatment are ethically and legally equivalent.
Both are ethical and legal when the patient
has given informed consent.
10

11. Pet Partner
Animal Visitation Program
 Animal visitation is a short term intervention to help
improve the patient’s well being and reduce loneliness. Pets
provide opportunities for patients to display affection and
emotion, practice social skills, and have positive experiences.
The visit is determined by the patient’s needs at a particular
time. Pets used for animal assisted activity are not patient’s
pets. The adult dogs or cats brought to this facility will be
certified through Delta Society (www.deltasociety.org).
 Animal must be appropriately restrained with identification.
Identification will include a Redmond picture ID Badge
attached to the animal’s vest or collar.
 Pet Partner Volunteer will contact the charge nurse on the
floor of the patient on the day of the visit.
11

12. Pet Partner
Animal Visitation Program
 Staff Responsibility
 Ensures that patient meets criteria for an animal visit.
 Animals are restricted from food preparation service
areas, and other high risk areas including: any patient
with a decubitus, surgical patients, open wounds or
burns, open tracheotomy, immune-suppression, all
isolation precautions rooms, critical care area patients,
patients with tuberculosis, salmonella, campylobacter,
shigella, streptococcus A, MRSA, ringworms, giardia,
and amebiasesis are excluded from this program.
 In the event that a patient receives a bite or scratch, the
patient’s nurse will complete an occurrence form about
the incident. The nurse will notify the patient’s
physician and the Infection Prevention Director.
12

13. Teamwork: A cooperative effort by members of a
group trying to achieve a common goal.
To make teamwork happen…
Communication is a necessity.
Must have interaction with others even
when things are not going as planned.
Get Feedback from other staff members
and managers.
Share the responsibility.
13

14. Skills for Teamwork:
 Listening
 Questioning
 Respecting and supporting ideas
 Helping
 Sharing
 Participation
14

15. Teamwork
 People who work in a hospital situation know how to
manage high-stress situations, but frustrations can build.
Working as a team will reduce situations where a staff
member feels overwhelmed by his/her workload or the
temperament of an unpleasant staff member.
 Compassion and common courtesy are appropriate not
only when communicating with patients; they are also vital
in how you treat your coworkers.
 If everyone does his/her job in an efficient manner and is
aware of the needs of other staff members, he/she can
contribute to the overall morale.
 Remember Teamwork is used everyday in healthcare:
 Rapid Response
 Code Team Response
 STEMI or Stroke Alert
 Patient Hand-Off – SBAR Process
15

16. Ergonomic Safety
 Ergonomic Safety is adapting the equipment,
procedures and work areas to fit the person in order to
help prevent injuries and improve efficiency.
Musculoskeletal disorders (MSDs) affect muscles,
nerves, tendons, ligaments, joints ,or spinal discs.
Injuries can include strains, sprains, and repetitive
motion injuries.
 Signs and symptoms: pain, tingling, numbness,
swelling, stiffness, burning sensation, etc. May
experience decreased gripping strength, range of
motion, muscle function, or inability to do everyday
tasks. Risk factors: repetition, forceful exertions,
awkward postures, contact stress, and vibration.
Common MSDs: Carpal tunnel syndrome, rotator cuff
syndrome, trigger finger, tendonitis, herniated spinal
16

17. Ergonomic Safety
 Apply these tips to your job: Adjust chair height and
backrest (feet should be flat on the floor, knees level
with hips, and lower back supported). Sit an arm's
length away from the computer screen. Keep wrists
straight and elbows at right angles. Alternate tasks.
Use proper body mechanics when lifting, transferring,
etc. Avoid reaching and stretching overhead.
 You may recommend ways to reduce the chance of
developing musculoskeletal disorders to your
supervisor. Your work space may be evaluated for
ergonomic safety by notifying Employee Health at ext.
4968. Your departmental safety representative may
assist with body mechanic in-services. Report signs,
symptoms, illnesses ,and injuries to your supervisor,
complete an occurrence report, and obtain medical
treatment in Employee Health Services. 17

18. Ergonomic Tips
 The best way to avoid the discomfort of
MSDs is:
 Change body positions frequently/Set up work
stations to fit your body/Stretch every 45 minutes
to an hour/Perform stretches that are designed to
decrease discomfort for job specific tasks
Decrease Fatigue
Warm-up exercises
Interrupt sustained postures
Proper ergonomics
Appropriate work methods
Limited overtime
Increase Recovery
Physical fitness
Proper nutrition
Good sleeping postures
Ice after activities
Avoid smoking
Alternative job placement
18

19. Performance Improvement
(PI)
 Performance Improvement means simply doing
things a little bit better tomorrow than we did
them today. Redmond is accredited by The Joint
Commission which requires that we have an
improvement plan in place. To make our
improvement efforts as visible as possible,
Redmond uses a tool called FAST-PDCA to
document our improvement projects.
19

20. Performance Improvement
 High quality organizations make continuous efforts to improve
their services and products. Opportunities to “do things better”
exist in all departments of our hospital.
 Performance improvement occurs the fastest when every employee
asks themselves, "Is there a better way to do this?" or "Why are we
doing this at all?” You know when a process is broken because
you have to work with it every day. FAST-PDCA allows us to test
a new or better idea, fine tune it if needed, then implement it.
 Another way for patient care departments to improve their care
delivered is to implement evidence-based medicine that has
already been determined to be the best way, or best practice, to
deliver medical care. Healthcare delivery changes constantly due
to new innovation and continuing research. We have the
responsibility to know what constitutes best practice and to see that
it is implemented at Redmond. Please contact your manager or
quality department when you hear, see, or read of best practices
implemented at other facilities.
20

21. Performance Improvement
 Core Measures, which are a series of evidence-based best
practices, are an integral part of how we deliver patient care
at Redmond.
 They are not optional for a couple of reasons:
 They represent best care.
 How well we adhere to Core Measures is compared to every other
hospital in our region and state, as well as across the United States,
as an objective way for consumers to compare how well we deliver
care.
 Medical charts are audited continuously to determine our
adherence to the Core Measures.
 When we fail to adhere to them, an opportunity exists to
improve our processes. If you were involved in a missed
opportunity, the Quality Department will reach out to you to
help determine how to improve our care delivery.
 Nurses should commit to memory the next 8
slides on Core Measures, it’s that important!
21

22. CORE MEASURES:
Myocardial Infarction
• Beta blocker at discharge or document a reason if with-held
• Document LVSD or Ejection Fraction (EF)
• ACEI or ARB for EF<40% or document a reason if
with-held
• ASA for chest pain/or MI on arrival and discharge or
document reason if with-held
• PCI within 90minutes for STEMI or LBBB
• LDL within 24hrs of admit
• LDL >100 discharged on statin or document a reason if
with-held
22

23. CORE MEASURES:
Congestive Heart Failure
 Document LVSD or EF
 ACEI or ARB for EF<40% or document a
reason if with-held
 Discharge instructions must include:
 Activity & Diet & Follow-up visit
 Worsening symptoms
 Weight monitoring
 List medications as found on Med Reconciliation
Form
23

24. CORE MEASURES:
Pneumonia
 Blood cultures before antibiotics
 1st antibiotic in ED within 6 hrs of arrival
 Flu vaccine given – October–March (Must be
current season – Remember to document)
 Appropriate antibiotic selection
24

25. CORE MEASURES:
Surgical Care (SCIP)
 Prophylactic antibiotic 1 hour prior to incision (2 hours for
vancomycin)
 Appropriate antibiotic
 D/C antibiotic within 24hr (48 for CABG) after surgery end
time or document reason for continuing antibiotic
 Clip hair only/never shave
(continued)
25

26. CORE MEASURES
Surgical Care (SCIP) (continued)
 Continue beta blockers (never stop abruptly and document
received the day before surgery and/or the day of surgery as
well as POD 1 or POD2!)
 VTE (clot) prevention within 24 hours before surgery to 24
hours after surgery
 Cardiac surgery (CABG, Valve, most CT pts) patients with
controlled postoperative blood glucose (less than or equal to
180 mg/dl) in the timeframe of 18 – 24 hours after Anesthesia
End Time.
 D/C foley by POD#2 or document reason
26

27. CORE MEASURES
Venous Thromboembolism (VTE)
 NEW CORE MEASURE FOR 2013!
 Documentation required for:
 VTE prophylaxis for ALL inpatients OR
 “Patient at low risk for VTE, no prophylaxis
needed”
 If VTE prophylaxis is not built in to an order
set, there is a new universal order set for VTE
prophylaxis
27

28. CORE MEASURES
Immunization Measure
 UNIVERSAL MEASURE for all patients
 Pneumonia vaccine status:
 vaccines must be given, refused, or medically
contraindicated due to allergy or current active
chemotherapy
 Influenza vaccine status:
 Oct 1-March 31 – If received prior to admission, it
must have been for the current flu season
28

29. CORE MEASURE
Stroke Core Measure
 Venous Thromboembolism Prophylaxis
 by the end of hospital Day 2
 Antithrombotic Therapy:
 for ischemic stroke patients by end of
hospital Day 2
 Discharged on statin medication
 Assessment for Rehabilitation
 Stroke Education
29

30. Opportunities for Improvement
 If you want to learn more about Performance
Improvement or feel you have a better way of
doing things at Redmond, please see your
manager or Stephanie Jones, Nursing
Administrator for Outcomes and Metrics
(located in the Lower Level near Human
Resources at extension 3155).
 Thank you for all you do!
30

31. 2014 Hospital
National Patient Safety Goals
 The purpose of the National Patient
Safety Goals is to improve patient safety.
The Goals focus on problems in health
care safety and how to solve them.
31

32. Identify Patients Correctly
 Use at least two ways to identify patients. We
use the patient’s name and date of birth. This is
done to make sure that each patient gets the
medicine and treatment meant for them.
 Ask the patient who they are and their date of
birth. Verify with the arm band.
 Make sure that the correct patient gets the
correct blood type when they get a blood
transfusion.
 Follow BCTA process exactly.
 Match the identifiers on the armband to the order.
32

33. Labeling Specimens
 Label containers and specimens in the
presence of the patient
 Perform the Final Check by saying out
loud the last 3 digits from the specimen
label account number and the last three
digits of the patient’s account number on
the patient’s arm band
33

34. Improve Staff Communication
 Get important test results to the right staff
person on time.
 Critical results from lab, radiology, or
cardiology must be reported quickly, a
maximum of 30 – 45 minutes to
physicians. Time can be a factor when
addressing these issues for patient health.
34

35. Use Medicines Safely
 Label medicines in syringes, cups and basins.
 Take extra care with patients who take medicines to
thin their blood. Educate the family and the patient.
 Record and pass along correct information about a
patient’s medicines. Find out what medicines the
patient is taking. Compare those medicines to new
medicines given to the patient. Make sure the
patient knows which medicines to take when they
are at home. Tell the patient it is important to bring
their up-to-date list of medicines every time they
visit a doctor.
35

36. Prevent Infection
 Use the hand cleaning guidelines from the Centers
for Disease Control and Prevention or the World
Health Organization.
 Use proven guidelines to prevent infections that are
difficult to treat.
 Use proven guidelines to prevent infection of the
blood from central lines.
 Use proven guidelines to prevent infection after
surgery.
 Use proven guidelines to prevent infections of the
urinary tract that are caused by catheters.
36

37. Prevent Mistakes in Surgery
 Make sure that the correct surgery is done on the
correct patient and at the correct place on the
patient’s body.
 The physician mark’s the correct place on the
patient’s body where the surgery is to be done.
 Time out performed with the team before the
surgery to make sure that a mistake is not being
made.
 Nurses complete the pre-surgery checklist prior to
surgery to make sure the patient is ready to go.
37

38. New Goal for 2014
 Use clinical alarms safely.
 This has been established as a priority.
38

39. Identify Patient Safety Risks
 Find out which patients are at risk for
committing suicide, or are abused or
neglected.
 Keep the patient safe and notify the
physician.
 Make sure these patients are referred for
appropriate care and are kept safe in our
hospital.
39

40. I-Privilege  If you are un-sure if a physician is
credentialed to perform a service here at
RRMC you can use I-Privilege to look
up his/her credentials.
 From our home page click on the I-Privilege
link in the right hand column
 Then on the left of the screen that is
pulled up click on I-Privilege again
 Then use our COID -31052 for your
User ID and Password
40

41. Guidance Document: Tubing and Line
Safety using I-TRACE
Behavioral expectations
I: Illuminate the patient care area whenever invasive medical lines and tubes are
manipulated (initiated, accessed, maintained, or discontinued).
T: Perform hand hygiene. Touch the line or tube and trace it from the insertion point on
the patient back to the point of origin.
R: Perform a cognitive review.
· What is the purpose/expected outcome of the line/tube intervention about to
occur? Visualize the actions planned; take time to ensure the planned actions will
deliver the expected outcome.
· Has a 2 point patient identification been carried out?
· Has BCMA been utilized to the fullest extent possible for the intervention about to
occur (e.g. medications; TPN)?
A: Act if any mismatch between the planned activity and desired outcome is discovered,
either through BCMA alerts, independent double checks, or a cognitive review.
C: Clarify and correct. Concerns expressed by primary caregivers, colleagues, patients, or
family member are valid and sufficient reasons to seek clarification before proceeding with
a task involving lines and tubes. Correct any discrepancies before proceeding with the
intervention.
E: Expect to use the ITRACE process: each time a line or tube is accessed, manipulated, or
discontinued and when care is handed-off to another clinician or care team.
41

42. Do Not Use
Abbreviations, Acronyms, and Symbols
Abbreviation Preferred Term
U Unit
IU International Unit
Q.D. & Q.O.D. daily & every other day
Trailing zero (X.0 mg)
Lack of leading zero (.X mg)
X mg
0.X mg
MS, MS04, & MgSO4 morphine sulfate or
magnesium sulfate
μg Mcg
T.I.W. 3 times weekly
c.c. Ml
ii, etc. (apothecary symbols) 2 or two 42

43. Rapid Response Team
 The purpose of the Rapid Response Team is to provide
critical decision making and intervention at the first
sign of patient decline; to prevent arrest situations,
and save patient lives. The utilization of a Rapid
Response Team will bring critical care expertise to the
patient bedside before a crisis situation results in a
cardiac/pulmonary arrest.
 The call is initiated by dialing (706) 233-5625 and
entering the patient’s three digit room number.
 Hospital staff or patient's family/visitors may initiate.
43

44. Rapid Response Team
 The role of the Rapid Response Team
(RRT) will be to:
 Assess the patient and the situation.
 Assist with stabilizing and transporting, if needed,
to a higher level of care.
 Assist with organizing information to be
communicated to the patient’s physician using the
SBAR tool.
 Educate and support the nursing staff.
 The RRT does not “replace” calling the primary
physician – but supplements, organizes, and
expedites information to the physician.
 Family members and visitors may also call the
RRT.
44

45. FALL RISK
 Nursing staff will assess the patient for safety/fall risk at
the time of admission, and as indicated by the unit
assessment/ reassessment policy and with each change
in condition: Identify problem as potential for injury
related to fall risk on the care plan/problem list.
 Safety rounds (with a purpose) are completed and
documented Q 1 hour until 10pm, then Q 2 hours
through 7am and also PRN.
PLEASE EXPLAIN that you are there to
assist the patient to the bathroom, not
just ask if they have to use the bathroom.
45

46. FALL RISK
Fall Reduction Activities
 Place a yellow sign at the head of the bed.
 Place a yellow bracelet on the patient.
 Place yellow socks on the patient.
 Place fall risk magnetic stickers on the patient’s doorframe.
 Educate the patient and family about the risk of falling and to
call for help. Show them where the call light is located.
 See if family members can stay when patients do not follow
instructions. If they are not able, outside resources may be
hired by the family.
 Frequently round for pain, potty, proximity of patient needs,
and position.
 Use a low bed if you feel it would be a good tool to avoid a
fall.
46

47. Hand-off Communication Process
 The hand-off communication process for
Redmond is based on the SBAR
communication format.
 SBAR stands for
 S – Situation
 B – Background
 A – Assessment
 R – Recommendation
47

48. Hand-off Communication Process
 The tools used in the hand-off process
include:
 Direct face-to-face communication.
 Phone report.
 Reports printed from Meditech - SBARD.
 Communication is a factor in more than 90%
of Sentinel Events reported to the Joint
Commission.
48

49. Patient rights
 Patients and healthcare workers need to understand patient rights and
responsibilities to ensure that quality care is provided and that the patient
can participate fully in their treatment and care.
 How are patients informed of their rights?
 Patient Hand Book
 Patient Bill of Rights
 Signage in all areas of the hospital.
 Patients have a right to an advocate to stay with them during their
hospitalization as long as it does not infringe upon other patient’s rights
or interfere with clinical care or pose risk.
 Patients must be asked about what language they prefer to receive their
healthcare information. The hospital is responsible to provide information
in the requested language.
 A patient or an advocate who is participating in their care must have the
opportunity to use a competent translator in the preferred language. If a
patient or family member refuses to utilize the provided interpreter, a
waiver must be signed.
49

50. Patient rights
 What is your role in patient rights?
 Every patient who does not speak English as their
primary language, is deaf, hard of hearing, and/or blind,
is entitled to an interpreter free of charge.
 There are forms in “Forms on Line” that are REQUIRED
to be completed for each patient whether or not they
chose to use the interpreter. Please see policies RI-05,
RI-06 and RI-07.
 This form should be placed on the patient chart after it
has been signed and has a date and time.
Our patients will be thankful that they are are able to
understand what is happening to them while they are in
our care.
50

51. Patient rights
Please also remember -
All patients also have the right to:
Refuse or accept treatment
Formulate Advance Directives
Informed participation in deipcisions involving their health care
The right to know who is resonsible for authorizing and performing
procedures or treatment
The right to have his/her own physician notified
promptly of his/her admission to the hospital
51

52. Patient rights
 Everyone is involved in protecting the rights of patients.
For example, the right to confidentiality means not
telling your friends or relatives when someone you
know has been a patient.
 We provide privacy for patients by always knocking
before entering a patient or procedure room.
 Patients have a right to a secure environment. Know
how to respond during a disaster or fire.
 Patients are informed of their right to establish advance
directives or to change their current advance directive
status.
 Patients also have a right to file a grievance. You can
assist with the investigation and response by
contacting Risk Management at ext. 3950 or
Administration at ext. 4100 should you have a question.
52

53. Patient rights
 Where can you find a list of
patient rights?
 In facility Policy RI-04 Rights and
Responsibilities of Patients, the Patient
Handbook, posted beside the elevator in
the front lobby and at outpatient services,
and on Redmond’s Intranet site.
53

54. Patient rights
 Access the Ethics Committee and the Ethic Resolution Process.
Phone: 706-802-3037.
 Any concerns over patient safety may be reported to the Joint
Commission. Phone: 800-994-6610.
 Access the grievance process. Express complaints or concerns
regarding care or services, including discharge.
 Facility contact: 706-802-3950
Independent Agency:
Office of Regulatory Health
2 Peachtree Street N.W., Suite 200
Atlanta, Georgia 30329
Telephone: 1-404- 657-5726
Peer Review Organizations:
Georgia Medical Foundation [Medicare]
57 Executive Park South, Suite 200
Atlanta, Georgia 30329
Telephones: 1-800-282-2614
1-404-982-0411
Humana Military Healthcare
Services, Inc [Champus]
931 South Semoran Blvd., Suite 218
Winter Park, Florida 32702
Telephone: 1-800-658-1405
54

55. Translation Services
When information involving healthcare is
discussed with a patient, the patient is
entitled to be able to speak and hear in a
language they consider their primary
language.
Language Services Associates will provide
interpretation services for all patients or
their family members or those assisting
with making medical decisions with or for
the patient in most any language.

56.  The process is simple – no matter what
language is required. Just contact:
LANGUAGE SERVICES ASSOCIATES
Dial: 1.877.274.9745
Access Code 1808319#
(have the special telephones available when
you call)

57.  Please explain to the patient and
family that this service is FREE of
charge!
 Document the use of service or the
denial of service.

58.  If you are in an area where you are not able to
use the telephone or the laptop, we do have
Interpreters available.
 Please check with your Director for additional
information. (This information should also be
available on a pink sign located in your area).

59. We also have Hearing Impaired translation
available from the Georgia Relay Center
for Speech and Hearing Impaired.
This agency provides a conference-type
telephone call for interpretation. It
requires a special telephone located at the
Switchboard.

60. There are forms that should be signed and placed in
the chart if the patient refuses our interpreting
services and/or if they want to use a family
member instead of an interpreter.
These are located in the Accommodation policies
under RI-05 (Limited English), RI-06 (Deaf) and
RI-07 (Blind).
If you are unable to locate these, check with your Director of call EXT. 3950.

61. ADVANCED DIRECTIVES
 Advance Directives include Living Will and Durable Power of
Attorney (DPOA) for Health Care.
 Living Will only applies to terminal conditions.
 DPOA for Health Care allows a person to name an agent to
speak on the person’s behalf, when the person cannot speak for
their self.
 Inside the hospital, the attending physician must be present
when the patient names an agent. An agent can speak for the
patient concerning any condition.
 Patients should be asked at the time of admission if they
have an advance directive. If the patient has a copy, obtain
a copy for the chart BY CONTACTING HIM.
 Patients should initial and date a copy of the directive(s)
and the hospital staff should place it inside the current
medical record.
 Social Services can assist by answering general questions and
providing blank forms.
61

62. Pain Management
 Four major goals of pain management
 Reduce the incidence and severity of patients' acute
postoperative or posttraumatic pain.
 Educate patients about the need to communicate
unrelieved pain, so they can receive prompt evaluation and
effective treatment.
 Enhance patient comfort and satisfaction.
 Contribute to fewer postoperative complications and in
some cases, shorter stays after surgical procedures.
 Effective pain management has additional benefits for
the patient ,e.g., earlier mobilization, shortened hospital
stay, and reduced costs.
62

63. Unanticipated Adverse Events and How to
Report
Occurrence Reporting
 An occurrence is an event that is unusual, significant or
notable.
 Categories include: Patient, Non-Patient (visitor, MD,
volunteer, student, facility, equipment) or Employee
Examples include: Near Miss, Fall, Medication, Treatment
and/or Testing, Adverse Effect, Equipment, Property,
Assault (abuse or harassment), Error, Failure to follow
policies & procedures, Failure to follow MD’s orders,
User/Operator error, Defective or malfunctioning
products, Incorrect action/activity, Inappropriate
action/activity, Omission, Delay, Complications, Loss or
theft of personal belongings, or Auto events with facility
vehicles.
 Occurrences should be documented in Meditech during
the working shift or def initely within 24 hours. The
department manager or house supervisor should be
notified at the time of the event. Please notify the Risk
Manager of all serious and potentially legal situations. 63

64. Occurrence Reporting
 Meditech Reporting
 Log onto Meditech - Select 500
Occurrence Reporting - Select Facility -
Select Category - (If patient) At prompt
type A# then the account number - (If Non-
Patient or Employee) Type N into the first
field to create a new report (For employee
type in last name and press the look-up key)
- If no previous Occurrence report exists for
this patient , you will receive a message “No
available notifications for this patient.
Create a new one? “ Answer Y (Yes) -
Answer all questions in field - Input will be
by free text or pull down menu selection -
Enter all the information you know or can
obtain. 64

65. Occurrence Reporting
 Look-up key (F9 ) displays a pull down menu.
 Previous field key (F6) allows you to backup.
 The enter key allows you to move forward one field.
 Magic or file key (F12):
This key will provide the menu for selection.
You MUST FILE to save your work.
 Exit key (F11):
Caution exit does not save your work.
 Text fields require typing from keyboard.
 An occurrence report is a confidential facility report that
should not be referenced in documentation on the
patient’s record.
 If you have any difficulties, please don’t hesitate to contact
RISK MANAGEMENT at 3950.
65

66. Sentinel events
 A sentinel event is an event which results in
unanticipated death or major permanent
loss of function, not related to the natural
course of the patient’s illness or underlying
condition. Also, suicide; infant abduction or
discharge to the wrong family; rape;
hemolytic transfusion reaction involving
administration of blood or blood products
having a major blood group
incompatibility; a health-care associated
infection; and surgery on the wrong patient
or wrong body part are all sentinel events.
Please secure all information and items
related to the event. If you have any
questions, contact Risk Management at ext.
66

67. Reportable Events
 State (Georgia) Reportable Events:
 The following type events should be reported to
the State of Georgia Office of Regulatory Services:
 1. Any unanticipated patient death not related to the
natural course of the patient’s illness or underlying
condition;
 2. Any surgery on the wrong patient or the wrong
body part of the patient;
 3. Any rape of a patient which occurs in the hospital.
 We report all deaths where the patient has been
in restraints within the previous 24 hours to CMS
or if a restraint was implicated in the cause of
death
 Report to the appropriate department leader and
Risk Management at 3950 or Regulatory
Compliance at 3038 in the event that any of the
above situations occur . The situation is reviewed
and reported to the Office of Regulatory Services
within 24 hours of knowledge that the event
67

68. Suspected Impairment of Licensed
Independent Practitioner
 All healthcare workers including physicians and
nurses should be competent and able to carry out
their patient care responsibilities free of any
impairment(s) that adversely affect their judgment
or clinical performance.
 A licensed independent practitioner (LIP) is defined
as any individual permitted by law and the hospital
to provide care, treatment, and services without
direction or supervision (e.g., doctor).
68

69. Identification of an Impaired LIP
 An impaired LIP is defined as one who is
unable to provide care, treatment, or
services with reasonable skill and safety to
patients because of a physical or mental
illness, including deterioration through the
aging process, loss of motor skill,
excessive use or abuse of drugs including
alcohol.
69

70. Signs and Symptoms of
Impairment
 Signs and symptoms of potential impairment
include, but are not limited to:
 Personality changes/mood swings
 Loss of efficiency and reliability
 Increasing personal and professional isolation
 Inappropriate anger, resentments
 Abusive language, demeaning others
 Physical deterioration
 Memory loss
 Increase in tardiness, absenteeism, illness
 Lack of empathy towards others
70

71. Reporting a LIP Suspected of
Impairment
 If any individual in the hospital has a
reasonable suspicion that a LIP (or any
other healthcare workers) may be impaired
and this impairment may adversely affect
patient care and safety, take immediate
action by notifying your supervisor, and
following the appropriate Chain of
Command listed in policy LD 05.
71

72. Environment of Care
 Defective Equipment
 Defective equipment should be reported to
BIOMEDICAL Services via Meditech or at Ext. 4962
if equipment removal constitutes an emergency.
Equipment will be tagged. Tag will say “danger
defective equipment”.
 Security Related Incidents
 Any incident requiring Security assistance (i.e.
theft or suspicious activity), contact security by
dialing 0 and asking PBX to page a member of
Security.
 Please refer to the Environment of Care section of the
policy manual for in-depth information on these
topics.
72

73. Eye Wash Stations
 Know where they are located
 Do not block access to the station
 Flush eyes for 15 minutes unless MSDS indicates
different flush time for the substance involved in the
exposure
 Water should be temperate (not too hot or cold)
 Weekly checks and flushes must be performed for
each eye wash station
 Eye wash stations must be available everywhere
corrosive materials are used or stored
73

74. Eye Wash Station Locations
 Employee Heath
 Outpatient
 Emergency Department
 Outpatient Oncology
 Lab
 Pharmacy
 Radiology
 Cardiology
 BioMed
 Maintenance – Boiler Room
 Environmental Services –
Equipment Room
74

75. O2 Tank Storage
 Cylinders are designated as full or empty by the description
below:
 Unopened or Unused Cylinders = Full
 Used Cylinders = Empty
 Cylinders that are unopened/Unused or Full should be
properly secured in the green racks/Full
 Cylinders that have been used or have been opened should be
properly secured in the red racks/Empty. Even if gas remains
in the cylinder. Cylinders of compressed gas should be stored
in designated areas.
 All freestanding cylinders, whether empty or full should be
properly secured.
 Freestanding cylinders should never be secured to portable or
moveable equipment that is not designed for their use.
 Cylinders should never be placed on a stretcher.
 A patient should never be asked to hold an e-cylinder for
transport.
75

76. Hazardous Material and
Waste
Read Container Labels—Before handling any chemical container, always read the label.
Warnings may be in words, pictures, or symbols.
Consult the Material Safety Data Sheet (MSDS)– A MSDS gives more detailed
information on a chemical and its hazards. It also gives you specific precautions for
protecting yourself from dangerous exposure. Your department should have a
notebook with a list of the chemicals used in your area.
Use Proper Handling Techniques– Always wear proper personal protective equipment.
Dispose of Chemicals Properly– Carry and store chemicals only in approved, properly
labeled, safety containers. Never dispose of chemicals in containers used for ordinary
waste. Never pour them down sewers or drains. Always consult the MSDS sheet for
approved method of disposal.
Contact Mike Stewart in the Lab at ext. 3117 or 4050
if you have questions.
76

77. FIRE SAFETY
 Make good housekeeping part of your work routine.
 Keep passageways and exits clear.
 Don’t let furniture or equipment block stairways, halls, or
exits.
 Keep floors clear of waste and spills.
 Make sure exit paths and doors are well-lit and clearly
marked.
 Know your area.
 Where are the fire pull stations and extinguishers
 Know how to extinguish
 Cover and smother
 Be careful to not fan the flames
77

78. FIRE SAFETY
 Check fire doors.
 Make sure nothing is blocking them.
 Never wedge or prop them open.
 Dispose of trash safely.
 Put waste in approved containers.
Keep these away from heat
sources.
 Put flammable substances in
approved metal cans or containers.
78

79. FIRE SAFETY
 Prevention is the best defense
against fires.
 To prevent fires related to electrical
malfunction remove damaged or
faulty equipment from service and
submit malfunctioning equipment
for repair.
 To prevent fires related to
equipment misuse do not use any
piece of equipment you have not
been trained to use. 79

80. FIRE SAFETY
It's easy to use a fire extinguisher if you can remember the acronym
PASS, which stands for Pull, Aim, Squeeze, and Sweep.
 Pull the pin.
This will allow you to discharge the
extinguisher.
 Aim at the base of the fire.
If you aim at the flames (which is frequently
the temptation), the extinguishing agent will
fly right through and do no good. You want to
hit the fuel.
 Squeeze the top handle or lever.
This depresses a button that releases the
pressurized extinguishing agent in the
extinguisher.
 Sweep from side to side
until the fire is completely out. Start using the
extinguisher from a safe distance away, then
move forward. Once the fire is out, keep an
eye on the area in case it re-ignites.
80

81. IF YOU DISCOVER A FIRE –
REMEMBER:
 RACE
 R - RESCUE anyone
in immediate danger
 A - Activate the
ALARM
 C – CONFINE or
CONTAIN the fire
(close the door)
 E - EXTINGUISH
small controllable
fires/or EVACUATE
81

82. All Foam and Gel Hand Cleaners
 Foam and gel hand cleaners are becoming very popular for hand
cleaning in the healthcare environment. For them to be effective,
they must contain more than 60% alcohol. That makes the hand
cleaners FLAMMABLE. It is not unsafe to use the hand cleaners,
but you should be aware of the following information each time the
hand cleaner is being used:
 After applying the gel or foam, the alcohol on the hands should be
allowed to evaporate for 30 seconds.
 The solution on your hands is flammable until the alcohol evaporates.
 If a flame or spark is near your hands before the alcohol evaporates, a
fire could occur. There have been reports of healthcare workers whose
hands caught on fire from a spark or from static electricity after using
an alcohol based hand cleaner.
 Alcohol burns very clean and the flame is almost clear.
82

83. Prepare Your Family
 Visit www.ready.gov to find resources to prepare your family:
 Prepare yourself by building an emergency preparedness kit
 Made sure your family is educated on where to find information regarding the kit and what to do
 Make sure your preparations and supplies will cover your family for 72-96 hours
 Make sure you think about the following when preparing your kit
 Pets
 Special needs children or adults
 Seniors
 Infants & young children
 Teach your family you may be required to work
 Have a safe place for them to stay
 If you have needs for child care in order to work, let us know
 If you have other obligations which may prevent you from reporting to work, make sure
you manage is aware ahead of time so they won’t surprised. These include:
 Military obligations
 DMAT, other volunteer organizations
75

84. How would Redmond handle an emergency event?
 Redmond utilizes the Hospital Emergency Incident Command System (HEICS)which
provides us with proven and predictable command structure designed to handle any event.
 HEICS provides us with:
 Proven Incident Command System structure (ICS) for healthcare use
 Predictable chain of management
 Flexible organizational chart which allows for scalable responses
 Prioritized response checklists
 Defines position responsibilities
 Improves documentation for improved accountability and cost recovery
 This Incident Command structure can be utilized for any event allowing Redmond to be
prepared to manage “all hazards”.
 Redmond has policies in place and uses drills to help improve our response.
 When you hear a code announced do not call PBX to get details or find out what you should
do (they are only responsible for knowing their role).
 Don’t wait for an event to learn your role! Speak with your manager during orientation to
find out what the response is specific to your department.
76

85. Emergency, someone call FOR HELP!!!
 Question: What do you do in the hospital when you need
help in a hurry?
 Answer: Call extension 4000. The switchboard will
answer your call immediately.
 This extension should be used the same as if you needed
“911”. It is designed for emergency situations, not just to
get through to the switchboard in a hurry. For example,
this line could be used for a Code Blue or if a visitor was
seriously hurt.
 NEVER use this phone line for anything other than
emergencies!
85

86. EMERGENCY PREPAREDNESS
CODES
 Code Triage - Provides guidelines for
operations in the event of an emergency - this
is a multi-step code which will be shown on
separate slide
 Code 900 - Show of force
 Code 1000 - Visitor, associate, family member
needs assistance
 Code Manpower – Lifting assistance
 Tornado Watch or Warning – has been issued
for Floyd County
86

87. EMERGENCY PREPAREDNESS CODES
(cont’d)
 Code Red—Fire
 Code Gray—Bomb Threat
 Code Blue—Adult Cardiopulmonary Arrest
 Code Blue PEDS — Pediatric
Cardiopulmonary Arrest
 Code Pink – Pediatric Abduction
 Code White – Adult Patient Elopement
 Code Green— Hostage Situation
 Code Orange—Hazardous Material Event
 Code Silver —Active Shooter
 Code Black - Structural damage to facility
87

88. Code Triage
Code Triage is announced when an event occurs which may exceed our
resources. The different stages (standby, activate, and stand-down) allow the
facility to determine our response based on the event.
Code Triage
 Standby: An event has occurred – HEICS structure in implemented.
Based on the information provided from the field, the Incident
Commander and other leaders determine if we can meet the demands of
the event or go into our disaster plan implementation. For staff during
this phase:
 Develop a plan within the department – your manager can assist
 Call your immediate family to assure they are okay
 Activate: Initiate the disaster plan – activate your department response
 Stand-down: Begin recovery and return to normal operations
Routine updates regarding the event and response will be
disseminated from the Command Center.
Know your role!
88

89. Code Manpower
 Associate should call for assistance when lifting the patient places either the
associate or the patients at risk of injury.
 When lifting for a routine procedure, call the House Supervisor and allow her
to arrange for staff to come and assist if at all possible to have an organized
response.
 If the need for assistance is due to a fall, try to get the attention of someone at
the nurse’s station to call the PBX operation and announce Code Manpower
and the location.
 All available associates should respond immediately to assist. After assessing
the patient, the nurse caring for the patient, the Charge Nurse and a Physical
Therapist will determine the best plan for lifting patient to prevent injury to the
patient or themselves.
 Any patient requiring placement on a backboard for safety or treatment, staff
should call EMS at 4911 and request a unit to respond to assist.
89

90. Code Gray
 If a bomb threat is called in:
 If you get the call, notify the switchboard at ext. 4000
 Try to get as much information from the caller as
possible and try to keep them on the line while 911 is
notified by PBX. Be prepared to give detailed
information regarding the call to Law Enforcement
officials.
 If you hear Code Gray announced:
 Look for packages or people that should not be in your area
– if someone or something looks suspicious – be sure to get
as much detail as possible to share with law enforcement.
 Stay in your area and try to keep others from leaving the
area
 Take direction from Incident Command or law enforcement
 Only if there is a legitimate reason would we evacuate
90

91. Code Blue & Code Blue PALS
 Code Blue
 Adult cardiac or respiratory event.
 Don’t forget the Rapid Response Team (Call for
the Rapid Response Team when you feel a
patient’s clinical status is in decline and you may
prevent a Code Blue).
 Know how to call a code and where your supplies
are located.
 Code Blue PALS
 Pediatric cardiac or respiratory event.
 ED Nurse will respond to assist with running the
code. 91

92. Code Pink
Represents a Pediatric Abduction
 Can be a patient or visitor
Patient Care Coordinator for the area in which the event occurred:
 Call ext. 4000
 Give gender and age
 Building must be locked down
 Each department has a response
PBX will announce: Code Pink b or g and age
Try to detain, but do not put yourself in harm’s way
 Get a good description of person, vehicle, tag, etc.
Make sure unoccupied rooms and areas are checked
No one with bags should be allowed to leave the building without the bag
being checked.
If someone has an infant or child with them, do not allow them to leave the
building without checking the identify of the infant or child in comparison to
the missing child.
92

93. Code White
 Patient Elopement/patient can’t be located:
 Patient Care Coordinator
 Call ext. 4000
 Give gender and age and clothing description
 Building must be locked down
 Each department has a response
 PBX will announce: Code White m or f and age
 Make sure unoccupied rooms and areas are checked
 Plant Operations should check outside the building.
 Contact EMS at 4911 to assist with searching the
public area around the hospital
93

94. Code Green
 Hostage situation is occurring
 Lock down your area
 Do not try to negotiate
 Police should be alerted to enter in an area
distant from the hostage situation
94

95. Code Silver “Active Shooter”
WHEN AN ACTIVE SHOOTER IS IN YOUR
VICINITY
QUICKLY DETERMINE THE MOST REASONABLE WAY TO PROTECT YOUR
OWN LIFE. VISITORS AND PATIENTS ARE LIKELY TO FOLLOW THE LEAD
OF EMPLOYEES AND MANAGERS DURING AN ACTIVE SHOOTER
SITUATION.
EVACUATE
 Have an escape route and plan in mind
 Leave your belongings behind
 Keep your hands visible
 Your goal is to keep yourself safe so that you can care for others
HIDE OUT
 Hide in an area out of the active shooter’s view
 Block entry to your hiding place and lock the doors
 Turn off all lights, computers and put phones on silent to prevent drawing attention to where
you are
TAKE ACTION
 As a last resort and only when your life is in imminent danger
 Attempt to incapacitate the active shooter
 Act with physical aggression and throw items at the active shooter
CALL 911 WHEN IT IS SAFE TO DO SO 95

96. Code Silver “Active Shooter” (con’t)
HOW TO RESPOND WHEN LAW ENFORCEMENT ARRIVES ON THE
SCENE
HOW YOU SHOULD REACT WHEN LAW ENFORCEMENT
ARRIVES:
 Remain calm, and follow officers’ instructions
 Avoid pointing, screaming and/or yelling
 Immediately raise hands and spread fingers
 Keep hands visible at all times
 Do not stop to ask officers for help or direction when evacuating, just proceed
in the direction from which officers are entering the premises
 Avoid making quick movements toward officers such as attempting to hold on
to them for safety
96

97. Code Silver “Active Shooter” (con’t)
RECOGNIZING SIGNS OF POTENTIAL WORKPLACE VIOLENCE
AN ACTIVE SHOOTER MAY BE A CURRENT OR FORMER
EMPLOYEE. ALERT YOUR HUMAN RESOURCES
DEPARTMENT IF YOU BELIEVE AN EMPLOYEE EXHIBITS
POTENTIALLY VIOLENT BEHAVIOR.
INDICATORS OF POTENTIALLY VIOLENT BEHAVIOR MAY
INCLUDE ONE OR MORE OF THE FOLLOWING:
 Increased use of alcohol and/or illegal drugs
 Unexplained increase in absenteeism, and/or vague physical complaints
 Depression/Withdrawal
 Increased severe mood swings, and noticeably unstable or emotional
responses
 Increasingly talks of problems at home
 Increase in unsolicited comments about violence, firearms, and other
dangerous weapons and violent crimes
97

98. Code Orange
Represents a Hazardous Material Event
Haz Mat Team will respond. Decon is in ED or outside and only associates
trained in handling hazardous material should be in the area
Don’t forget your PPE’s as you are receiving patients
If someone who has been contaminated walks in – don’t touch them – take
them back out the way they came to prevent further contamination. The area
in which they entered is now considered unsafe and foot traffic will be limited
and rerouted.
Stay uphill and upwind if the event is outside.
98

99. Code Black
There is a structural damage to the building as a result from either a natural or man-made
event.
 Associates will call operator at extension 4000 to report the damage give as much information
as possible.
 PBX will notify the Administrator on Call and a Code Triage will be announced to implement
the Incident Command structure.
 Admin rep, Security, Maintenance, Plant Engineer, and EMS will respond to area if safe.
 No associate should attempt to enter unstable area for rescue unless trained to respond,
wearing appropriate PPE, and has recovery assistance.
 Further response will determined based on information given to the Incident Commander
regarding the severity of damage. If required, a Code Triage Activate will be announced and
the facility will implement the disaster plan to manage the incident.
99

100. Code 900
If you or someone else is in a situation in which you are threatened verbally
or physically
Try to get someone’s attention and have them call PBX at ext. 4000. Code 900
will then be announced overhead
All males respond – this represents a show of force and may help deescalate the
event
Avoid making physical contact with the agitated person
There are staff who have been trained in managing this type of incident and will
direct others how to respond once they arrive
If needed, the Law Enforcement Officer in the ED will respond.
DO NOT USE THIS CODE FOR LIFTING HELP!!
100

101. Code 1000
 A visitor, family member, or staff member becomes
acutely ill or is injured
 Stay with person and have someone call ext. 4000 to
report the incident
 Make sure to give PBX Operator what happened and
where the person requiring help is located.
 A staff member should try to stay with them at all
times
 ED Nurse, House Supervisor will respond as will EMS if
they are in the building
 Call EMS if they aren’t in the building at ext 4911 if
“packaging” is required to safely transport to the ED
 ALWAYS offer the individual the opportunity to be taken
to the ED for treatment
101

102. Tornado Warning
Tornado warnings are announced by PBX when the National
Weather Services issues to warning for Floyd County. This way both
staff and visitors will be aware of the severe weather potential.
 The announcement will be, “Attention, Attention, Attention.
Floyd County is currently under a tornado warning”.
 If a Tornado Warning has been reported in our area
 Close patient doors and drapes
 Get everyone out of halls and away from glass
 Discourage visitors from leaving
 Turn beds to inside walls
 Clear area of anything that can become a projectile
 Instruct family members & ambulatory patients to go into the
bathrooms and cover themselves
 Assure that ambulatory patients can access their shoes in the event
they need to leave the building.
102

103. Inclement Weather
When the facility is made aware of a potential for weather that
makes travel difficult or unsafe, plans will be made to have
appropriate coverage to continue essential operations.
Each leader will review staffing and supplies for the anticipated
period
Employees are expected to report to duty. Administration or
Managers will notify staff if there is a need to come in early to
arrive before weather system hits
Make sure to pack clothing, medicines, personal items, foods,
etc for 24-72 hours
We will provide housing either on campus or with a local
vendor to allow staff to be available as needed
Make sure to have plans for family, family members with
special needs and pets for 96 hrs.
If you drive make sure you have supplies and a way to
communicate if stranded
103

104. Inclement Weather… cont
 Transportation may be provided through EMS
Department
 Call 706-291-0298 ext 4911 to arrange for
transportation
 Transportation Officer will assign a pickup time
 Be prepared to leave 30 minutes before the time
 If you live on a hill or in a valley, find a flat
area where you can shelter until pickup
 Please if you drive, know a couple of ways to get to
your destination and also make sure you know how
to drive on icy roads
104

105. Evacuation
Many types of events could require either partial or full evacuation of our facility.
The goal is to move patients and staff from an unsafe area to a safe area.
During evacuation, move patients in this order
 Ambulatory first
 Sickest last
Horizontal Evacuation
 Room to Room, Wing to Wing
Vertical Evacuation
 Floor to floor
Full Scale
 Triage and transport area will be established
 In general this will be the area across the tracks in the parking lot for most
inpatients
 In lower ED parking lot for ED, OP and Radiology patients
Make sure you account for all patients – a designee from each area will need to
run a census report in order for us to accomplish this
105

106. Organ Donation
 Timely referrals of potential organ donors
is critical.
 Healthcare professionals are required to
identify and refer patients who meet clinical
triggers to the Donation Referral Line at
(800) 882-7177.
 Timely referrals preserve the option of
donation for families of medically suitable
patients.
 A representative from LifeLink our organ
procurement agency is the only one who can
approach a family about donations. 106

107. Heart Disease Remains #1 Cause of Death in the U.S.
107

108. Heart Attack Facts
Each year, approximately 1.2 million Americans
suffer a heart attack, and nearly one-third of these
individuals die…many before they reach the
hospital.
About every 26 seconds an American will suffer a
coronary event, and about every minute someone
will die from one.
Hundreds of thousands of Heart Attack victims
survive, but are left with a damaged heart.
108

109. Heart Attack Facts
A heart attack occurs, in most cases, when
a blood vessel supplying the heart muscle
becomes completely blocked. The vessel has
become narrowed by a slow buildup of fatty
deposits made mostly of cholesterol. These may
crack open, forming a clot.
Blocked artery
(before treatment)
When a clot occurs in this narrowed
vessel, it completely blocks the supply of
blood to the heart muscle. That part of
the muscle will begin to die if the
individual does not seek immediate
medical attention.
Same blocked artery
(with restored flow after
treatment) 109

110. Heart Attack Facts
The best way to stop the heart attack process is to
detect the symptoms early, before damage to the
heart muscle occurs.
It is critical for those who experience any chest
discomfort or heart attack symptoms to call 9-1-1
and quickly get to the Emergency Department.
It is just not the heart attack itself that kills; it is also
the time wasted when one is trying to decide whether
or not to go to the hospital.
110

111. Time Wasted =
Muscle Lost!!
Delays in time result in loss of
heart muscle.
It is important to note that 85% of muscle damage
takes place within the first hour. This is often referred
to as the “golden hour.” It is within this timeframe
that the blocked heart vessel needs to be opened.
Complete destruction of the muscle being supplied by
the blocked vessel continues over a six-hour period.
111

112. Time
Wasted….Why?!
People often dismiss heart attack warning signs, such as
chest pain, thinking they merely have heartburn or a
pulled muscle. The unfortunate conclusion is that
many people wait too long before getting help.
Because every minute counts when having a heart
attack, it seems that getting to the ED as quickly as
possible would be everyone’s first choice.
Unfortunately, more than 50 percent of all patients
experiencing chest pain walk into the ED rather than
calling 911.
112

113. What You Need to Know
Know the frequent signs of a heart attack
 Chest discomfort. Most heart attacks involve discomfort in
the center of the chest. The discomfort lasts for more than a
few minutes or it may go away and come back. The
discomfort may feel like pressure, squeezing, fullness, or
pain.
 Discomfort in other areas of the upper body. This may
include pain or discomfort in one or both arms, the back,
neck, jaw, or stomach.
 Shortness of breath may occur with or before chest
discomfort.
 Other symptoms may include breaking out in a cold sweat,
nausea, or light-headedness. Treatments are most effective
when they occur in the early stages of chest pain.
113

114. What You Need to Know
Know that heart attacks are NOT just a man's problem! More women
in the United States die of heart disease each year than men. Women
often experience signs and symptoms that are different from men. Or
signs in women may go unnoticed altogether.
Heart Attack Signs/Symptoms in Women include:
 Unusual fatigue
 Upper abdominal pressure or discomfort
 Nausea or Vomiting
 Lower chest discomfort
 Dizziness
 Unusual shortness of breath
 Back pain
 Light-headedness, fainting, sweating,
 Pressure, fullness, squeezing pain in the center of the
chest, spreading to the neck, shoulder, jaw or arm
114

115. What You Need to Do
 Be able to recognize the early symptoms of a heart
attack. Educate others in early heart attack care.
 Be an advocate for the exceptional heart attack care
coordinated by Redmond EMS and Redmond Regional
Medical Center.
 Inform others that our 911 dispatchers and Emergency
Medical Services (EMS) are trained to recognize heart
attack symptoms. Our EMS units transmit EKG’s
directly to our ED from the scene so that by the time
the patient arrives, the ED, Cardiologist and Cath Lab
team are ready to assist.
115

116. What You Need to Do
Know the signs of a heart attack
Call 9-1-1 to get to the hospital
immediately if you are concerned
Know your risk factors
Be an advocate for your own health
Consider healthy lifestyle changes
Get off the couch- begin exercising
20 minutes per day, 4-6 days per week
Stay active physically, mentally and socially
Build social relationships through family, church,
even pets
Eliminate stress by finding a hobby
……and always……REMEMBER REDMOND………….
FOR COMPLETE HEART CARE!
116

117. We at Redmond take the
“Golden Hour” Seriously!
 The speed of opening the
blocked artery is measured in
door-to-balloon (D2B) time.
 The time starts when the
patient enters the hospital and
ends when the clot causing the
blockage is removed in the
Cardiac Cath Lab.
 The National goal for D2B
time is less than 90 minutes.
Redmond’s goal is 60
minutes!
 In 2013, Redmond’s
average D2B time was
53 minutes!
 Our focus in 2014 is to
targeting our population at
risk for MI and educating
them on risk factor
modification and calling
911, not driving to the
hospital.
We are Redmond! 117

118. And We Have the Awards to
prove it!
Redmond’s Chest Pain program is accredited by the Society of
Cardiovascular Patient Care and by The Joint Commission for
Cardiovascular and Disease Specific Heart Attack care.
The accreditation philosophy is based on process improvement. It
Encourages us to improve our quality by standardizing care processes
across departments, including EMS, provide outreach education, and
improve patient, physician, and staff education.
We promote EHAC (Early Heart Attack Care) which is a public
awareness campaign to educate the public about signs of an impending
heart attack AND that these signs and symptoms can occur days or
weeks before the actual event.
118

119. Heart Failure Facts
 Heart failure is the leading cause of morbidity (ill
health) and mortality (death) in the U.S.
 The most common reason for admission to the
hospital in the age group 65 years and older!
 1 in 5 people diagnosed with Heart failure die
within 5 years of diagnosis.
 Many people can lead full and enjoyable lives if
Heart Failure is managed with lifestyle changes,
education, diet, and medications.
119

120. What is Heart Failure?
 A condition resulting from the heart’s inability to
pump an adequate amount of blood to meet the
body’s needs.
 It can be sudden, but usually develops over time.
 Basically the heart can’t keep up with the body’s
workload.
It Does Not mean your heart is going to STOP beating
It Does mean the heart pump is weak.
120

121. What Causes Heart Failure?
Anything that can damage the heart can cause Heart Failure:
 High blood pressure.. Common cause
 CAD and Heart attack….Most common cause
 High cholesterol and arrhythmias
 Damage to heart valves
 Viruses, drugs, excessive alcohol
 Advancing age or congenital heart defects
 Heart muscle disease
 Etc.
121

122. When your heart is damaged
 At first the weakened heart tries to make up for it’s
inability to meet the needs of the body by:
 Enlarging to contract more strongly
 Beating faster (got to get that oxygen to the cells!)
 Blood pressure increasing to perfuse the organs
These temporary measures mask the problem of
heart failure, but they don’t solve it. Heart failure
continues and worsens until these substitute processes
no longer work, and you start seeing signs of heart
failure.
122

123. Warning signs of Heart Failure
 Shortness of breath
 Swelling in feet,
ankles, stomach
 Weight gain from
FLUID (not fat
weight)
 Fatigue, tiredness
 Increased heart rate
 Coughing when lying
down 123

124. Prevention of Heart Failure
 Lose weight (weight causes increased work)
 Stay active (exercise helps everything)
 Quit smoking (and avoid second hand smoke)
 Keep your BP under control
 Eat healthy (low fat …low SALT)…lower your
Cholesterol
 Limit alcohol (If you drink alcohol, do so in moderation.
This means no more than one or two drinks per day for
men and one drink per day for women)
 Control your Diabetes
 Routine MD checkups and immunizations
 If you have chest pain…get to the ER!!!
124

125. Treatment of Heart Failure
 Treat the underlying Cause (BP, CAD, etc.).
 Weigh daily… looking for fluid build up.
 Heart healthy 2 GM Sodium diet …no added salt.
 Limit fluid intake (less than 2 liters).
 Medications for heart failure and BP control….Be
compliant!
 Lifestyle changes…(weight loss, exercise, smoking,
etc.).
 Limit Stress.
 Know the signs of heart failure!
125

126. Redmond Regional Medical
Center
 Maintains Advanced Certification for the treatment
of Heart Failure with The Joint Commission.
 Has Gold Plus Achievement with American Heart
Association in the treatment of Heart Failure.
 We strive everyday to provided Evidence based care
for our patients with heart failure.
126

127. Facts About Stroke
3rd leading cause of death in the United States.
Risk increases with age, but people of any age
can have a stroke.
Leading cause of adult disability in the U.S.:
 Without treatment, 62% of people who have
a stroke will have moderate to severe
impairment.
127

128. What is a stroke?
Old Term: CVA or
Cerebrovascular
accident.
Bad term because stroke
is preventable and
treatable.
New Terms: Stroke,
TIA
It’s not an “accident.”
A stroke occurs when
something happens to
interrupt the steady
flow of blood to the
brain.
128

129. Three Types of Strokes
 Mini-Stroke or Transient Ischemic Attacks
(TIA) – brief episodes of stroke symptoms.
 Ischemic Stroke is caused by blood clot. The
clot blocks flow of blood to brain.
 Hemorrhagic Stroke is caused by bleeding.
Results from burst or leaking blood vessels in
the brain. 129

130. Stroke Symptoms: Remember
“FAST”
Only one
symptom
is
necessary
to indicate
stroke 130

131. FF == FFaaccee • Droops on
left or right
side
• Sudden
drooling
• Numbness
AAsskk ppeerrssoonn
ttoo ssmmiillee
• Look for difficulty
holding things or
putting on clothing
• Numbness
• One arm drifts down
or won’t go up
• May have trouble
walking
AA == AArrmmss
AAsskk ppeerrssoonn ttoo
rraaiissee bbootthh aarrmmss
131

132. SS == SSppeeeecchh • Slurred speech
• Doesn’t make
sense
• May not
understand what
other people are
saying
• Forgets how to
read or write
AAsskk ttoo
rreeppeeaatt
pphhrraassee
oorr nnaammee
oobbjjeecctt
• Time lost is
brain lost
• Save time
and brain
cells
• Go in an
ambulance
TT == TTiimmee
AAtt aannyy ssiiggnn,,
CCaallll 99--11--11
132

133. Stroke Prevention: Know your Risk
Factors and develop a lifestyle to
decrease you risk
 High Blood pressure
 Tobacco use
 Diabetes
 TIAs
 Carotid or other artery
disease
 Atrial Fibrillation or
other heart disease
 Certain blood disorders
 High blood cholesterol
 Physical inactivity and
obesity
 Excessive alcohol
intake
 Illegal drug use
 Increasing age
 Gender
 Heredity and Race
 Prior stroke 133

134. “Stroke Alert”
 EMS and Emergency Department play key role
in coordinating care of stroke patients admitted
to our hospital
 What if the patient is already here and starts
having signs and symptoms of a stroke????
Call our Rapid Response Team at:
706-233-5625
Redmond Regional Medical Center
is certified by The Joint Commission
as a Primary Stroke Center.
134

135. Sexual Harassment
 The following is prohibited:
 Unwelcome sexual advances, requests for sexual favors,
and all other verbal or physical conduct of a sexual or
otherwise offensive nature.
 Behavior that engenders a hostile or offensive work
environment will not be tolerated. These behaviors may
include but are not limited to: offensive comments, jokes,
innuendoes and other sexually-oriented or culturally
insensitive/inappropriate statements, printed material,
material distributed through electronic media or items
posted on walls or bulletin boards.
135

136. Sexual Harassment
 You should promptly report the incident to your
supervisor, who will investigate the matter and take
appropriate action, including reporting it to the Human
Resources Department.
 If you believe it would be inappropriate to discuss the
matter with your supervisor, you may bypass your
supervisor and report it directly to the Human Resources
Department which will undertake an investigation.
 Or you may call our Ethics and Compliance Officer,
Deborah Branton, at 3036 or the Ethics Line at 1/800-
455-1996. The complaint will be kept confidential to the
maximum extent possible.
136

137. VIOLENCE PREVENTION
 Violence can happen in any department or
area.
 Before violence strikes, there are usually
warning signs.
 These include:
 Making threats, talking about or carrying weapons
 Screaming, cursing, challenging authority
 Restlessness, pacing
 Violent gestures, such as pounding on a desk
 A loner, someone angry and depressed
137

138. VIOLENCE PREVENTION
 You can help prevent violence by:
 Treating everyone with respect
 Checking the patient charts for history of
violence or aggression, alcohol or other
drug abuse
 Trusting your gut feelings
 Watch for warning signs
 Try to spot—and head off—trouble before
it turns to violence
 Staying calm if someone starts to lose
control
 Don’t let your escape path get blocked
138

139. VIOLENCE PREVENTION
 To reduce your risk for potential injury use
the following guidelines:
 Notify security at the first sign of a potentially violent
situation
 Communicate in a low, calm tone of voice
 Allow the person to voice their feelings
 It’s important to stay calm and maintain self-control
 Avoid defensive words or angry gestures
 Do not argue
 Do not turn your back on the person
 If possible, give the person what they demand
139

140. RECOGNIZING ABUSE, NEGLECT
And Exploitation
 Signs of Abuse
 History inconsistent with nature and extent of
injury
 Delay in seeking medical treatment
 Frequent Emergency Room visits
 Accident prone
 Discrepancy in patient’s and family’s story
 Bruises in various stages of healing
 History of previous trauma in patient or
sibling
140

141. The Definitions
 Abuse
 To treat in a harmful, injurious or offensive way
 Neglect
 To omit through indifference or carelessness
 Signs and symptoms include;
 Failure to thrive
 Poor hygiene
 Dehydration
 Malnutrition
 Poor social skills
 Exploitation
 To use for profit, to ask for money or materials
141

142. Reporting Abuse, Neglect or
Exploitation
 Nursing Interventions:
 Routinely screen during each patient encounter.
 Screen one-on-one in a private environment.
 Assess patient’s immediate safety.
 Listen with a non-judgmental attitude.
 Document in the medical record the following: abuse history
(subjective and objective), results of safety assessment, authorities
notified, family notified, treatment given, and any safety instructions
provided.
 The person suspecting the abuse should notify Social Services
during weekday hours and the House Supervisor at night and on
weekends to inform them of the situation. These resource persons
will assist with the notification of the authorities.
142

143. Reporting Abuse
 Reporting Responsibilities:
 Notify the MD.
 Notify DFACS or Adult Protective Services (APS) of the
possibility and the appropriate authorities.
 GA has general mandatory reporting laws. MUST report to
law enforcement the following: injuries resulting from general
violence and injuries inflicted by gun, firearm, knife, or other
sharp object.
 Resources: Department of Family and Children Services
(DFACS): 706-294-6500 / Police Dept: 911 / Battered
Woman/Domestic Violence Hotline: 1-800-334-2836 /
Prevent Child Abuse GA: 1-800-532-3208 /
Adult Protective Services: 1-888-774-0152
143

144. Population Served at RRMC
Demographic RRMC Population Served
White 84%
African American 12%
Hispanic 2%
0 - 19 Years Old 8%
20 - 44 Years Old 24%
45 - 65 Years Old 35%
Greater Than 65 Years Old 33%
144

145. Population Served at RRMC
Most Common Principal Diagnosis
 Coronary Artery
Disease
 Acute
Myocardial
Infarction
 Osteoarthritis
 Chest Pain
 Atrial
Fibrillation
 Renal Failure
 Pneumonia
 Congestive
Heart Failure
 Stroke
145

146. CULTURAL COMPETENCY
 Cultural competence means providing
medical care in a way that takes into
account each patient’s values, beliefs,
and practices.
 Culturally competent care promotes
health and healing.
146

147. CULTURAL COMPETENCY
 The healthcare provider must have an
understanding of the predominant cultures
that exist in the geographic area in which
s/he provides patient care. Because the
U.S. is so diverse, certain cultures may not
be seen in all areas of the country.
147

148. CULTURAL COMPETENCY
 A very important aspect of cultural competency
is the avoidance of stereotyping.
 We must not presume that all people of a
certain culture adhere to all aspects of their
culture. The healthcare provider must identify
which aspects are appropriate for each patient
during the admission process.
148

149. CULTURAL COMPETENCY
 Communication begins with identifying the
patient’s primary language.
 Patient must be offered an interpreter in their
preferred language free of charge. If family
interprets, a waiver must be signed.
 As a staff member, if you have any
cultural or religious preferences that
might impact on your delivery of
patient care please let your supervisor
know.
149

150. Cultural Competency
 To achieve the important goal of preventing, identifying and
resolving barriers maintain the following principles :
 Inclusiveness. Strive to prevent exclusion any of patient or
staff member.
 Respect is showing appreciation and regard for the rights,
values and beliefs of others.
 Respect. Foster an environment that maintains respect for
cultural differences between patients and staff members.
 Value. Appreciate and value cultural differences.
 Diversity is a state of being diverse; difference; unlikeness;
variety; multiformity.
 Service. Strive to provide accessible services to every patient.
 Understanding. Try to assess and identify the needs of the
culturally evolving patient population and incorporate those
needs into your programs and practices.
 Compliance. Adhere to all applicable federal and state laws
and regulations addressing limited English proficiency and
cultural competency. 150

151. Federal Privacy Rules
• HIPAA: Health Insurance Portability &
Accountability Act – Protected Health
Information (PHI) – established federal rules
for healthcare organizations & staff to protect
patient privacy
• HITECH: Health Information Technology for
Economic and Clinical Health Act – expanded
rules regarding breach notification to patients
and government
151

152. Patient Rights Regarding
Protected Health Information
• Right to Privacy
• Right to Access/Review
• Right to Opt Out of Directory (Census listing)
• Right to Request an Amendment
• Right to Request Privacy Restrictions
• Right to Confidential Communications
• Request an Accounting of Disclosures (who received information)
• HIPAA privacy standards require that facilities use and disclose only the
minimum amount of protected health information (PHI) necessary to
accomplish the intended purpose.
• Authorization for uses and disclosures of protected health information
(PHI) must be obtained for uses and disclosures outside of treatment,
payment and health care operations, unless otherwise permitted by law
• HITECH require Breach Notification to the patient and the Department of
Health and Human Services. The media must also be notified when
breaches involving more than 500 individuals in the same state or
jurisdiction occur. 152

153. Protected Health Information
 Once patient information is given as
identification, it is protected;
 Name, DOB, SSN, insurance # ID, address,
telephone number, etc.
 Diagnosis, treatment, personal information
 Paper/electronic medical record, images,
photographs, voice recordings, spoken word
153

154. Staff Responsibility
• Protect health information
– Don’t leave PHI in plain site (counters/monitors)
– Discard paper in shredding bin
– Ask patient permission before discussing PHI in front of
visitors
– Validate requestors authorization to information BEFORE
discussing or releasing
– Share only what is minimally necessary
– Refer privacy complaints/restriction requests to Facility
Privacy Officer
– Document /log disclosures to others outside organization
– Secure electronic media
– Encrypt confidential emails
154

155. Violations/Breaches
 Facility Privacy Officer to investigate
 (Jamie Ferrell, Extension 3095)
 Substantiated Breach Notification to:
 Patient
 Department of Health & Human Services
 Media, if more than 500 patients impacted
(example: loss of laptop with PHI on it)
155

156. Examples of Breaches
• Fax information to wrong number
• Discuss PHI with unauthorized person
• Throw PHI in the regular trash
• Leave PHI unattended in public area
• Write PHI on white board with patient ID in public
area
• Take a photo of a patient without permission
• Post PHI on Facebook or Twitter
• Access electronic medical record on family member
• Give patient another patient’s paperwork by mistake
156

157. Violations/Sanctions
Types of Violations:
 Negligent: Accidental, oversight, lack of
education or failure to follow acceptable
protocols
 Intentional: Deliberate action/inaction
Employee Sanctions:
 Re-education
 Disciplinary action up to termination
157

158. Civil & Criminal Penalties
• Facility AND/OR the staff member who breaches
PHI may face:
– Civil Penalties
– Criminal Penalties
IT ISN’T WORTH IT TO LOSE:
– Lose your job
– Lose your credibility
– Lose professional license
– Pay a financial fine
– Go to jail
158

159. Information Security
The Who, What, Where,
When, Why, and How of
protecting sensitive
information.
159

160. Session Goals
 Review Common Information Security Terminology
 Provide Key Contact Information - Who
 Explain Types of Information - What
 Provide Key Resources Information - Where
 Share When to Report Concerns or Incidents - When
 Describe Why You Should Care about Information Protection - Why
 Give Specific Tips on What You Can Do to Protect Information - How
160

161. Common Terminology
 Privacy - addresses the use and disclosure of individuals’ health
information as well as individuals‘ rights to understand and control how
their health information is used.
 Information Security – assures patients that the integrity, confidentiality,
and availability of their electronic protected health information (ePHI) is
protected as we collect, maintain, use, or transmit it.
 PHI – Protected Health Information
 ePHI – electronic Protected Health Information
 PII – Personal Identifiable Information
Look for the blue bubble for more definitions through out the presentation.
161

162. Contacts
 Angie Turner-Zone FISO contact information
 706-331-9724
 Angie.turner@hcahealthcare.com
 Service Desk
 888-821-2065
 Division and Facility Information Security Contacts:
o Director of Information Security Operations (DISO)-Monica Smith
o Facility Information Security Official (FISO)-Brad Treglown
 Atlas keyword DISO or FISO
 Division and Facility Privacy Contacts:
o Ethics and Compliance Officer (ECO)-Lori Baker
o Facility Privacy Officer (FPO): -Jamie Comer
 Atlas Keyword ECO or FPO
162

163. Types of Information
Information Security standards define sensitive data as data that includes one
or more of the following types of information:
Social Security numbers
Any government issued identification number
Account number in combination with any required security code, access
code, or password (e.g., a PIN) that would permit access to an individual's
financial account
Electronic Protected Health Information as defined by the HIPAA Security
Rule
Human Resources employee files
163

164. Challenge!
Which of the following is not PHI?
A. Medical record number
B. Finger prints
C. Shoe size
D. Photographic images
E. Fax number
164

165. Examples of Protected Health
Information (PHI)
 Name.
 Address including street, city,
county, zip code and equivalent
geocodes.
 Names of relatives.
 Name of employers.
 All elements of dates except
year (i.e. DOB, Admission,
Discharge, Expiration, etc.).
 Telephone numbers.
 Fax Numbers.
 Electronic e-mail addresses.
 Social Security Number.
 Medical record number.
 Health plan beneficiary
number.
 Account number.
 Certificate/license number.
 Any vehicle or other device
serial number.
 Web Universal Resource
Locator (URL).
 Internet Protocol (IP) address
number.
 Finger or voice prints.
 Photographic images.
 Any other unique identifying
number, characteristic, code. 165

166. Resources
166

167. Am I in Compliance?
 What happens if I violate an IS policy or standard? See WS.SWB.03 - Sanctions
Process
 Am I using email appropriately? See IS.SEC.002 Information Security - Electronic
Communications
 What did I agree to when I signed a Confidentiality & Security Agreement? See
Confidentiality & Security Agreement (Atlas Keyword: CSA)
 Do I use USB drives appropriately? See COM.MH.02 - Information Handling
Procedures
 Do I encrypt emails containing sensitive data? See COM.EI.01 - Electronic
Transmissions
 Do I lock my workstation when I leave it unattended? See AC.UR.02 - Session
Security
 If my laptop or mobile phone was stolen, how quickly must I report it? See
IR.RISE.01 - Incident Reporting
 Do I know how to sanitize electronic media correctly? See COM.MH.01 - Media
Sanitization
 What is a business owner or CFO responsible for? See IS.SEC.009 Information
Security - Risk Acceptance and Accountability
 What are managers required to do? See WS.SWB.01 - Management Responsibilities167

168. Report Concerns or Incidents
To one of the following within 24 hours:
FISO
FPO
Service Desk
 888-821-1065, choose the Security option
An incident could include:
 Stolen/lost computer or portable device
(phone)
 Misdirected fax or email
 Virus alert on your computer
 Posting of PHI on a social media site
WHY?
WHY?
Reporting incidents or
concerns promptly allow
the appropriate personnel
to respond in a timely
manner in order to
manage risks to the
enterprise - even if the
incident is accidental.
Reporting incidents or
concerns promptly allow
the appropriate personnel
to respond in a timely
manner in order to
manage risks to the
enterprise - even if the
incident is accidental.
168

169. It’s Part of the Job
 It is the right thing to do.
 HCA’s mission says we are “committed to the care and
improvement of human life”. This includes taking care of our
patient’s information.
 We are legally bound to protect the confidentiality of our patients,
the company and its employees' information.
 At HCA, we take privacy and information security seriously.
• HIPAA - Health Insurance Portability and Accountability Act
• HITECH - Health Information Technology for Economic and Clinical Health Act
169

170. To Reduce the Risks
 Identity Theft
 Loss of Privacy
 Loss of Trust
 Costly Breach Notifications
 Malware like Viruses, Worms, Trojans, Spyware
 Cyberbullying
 Online Predators
• Breach Notification – Usually in the form of letters sent out to individuals whose
protected health information has been disclosed or compromised.
• Malware – malicious software
170

171. How Can I Protect Information?
Learn more about ten areas where you can
actively protect information.
1. Passwords
2. Workstation Security
3. Portable Device
Security
4. Malware Protection
5. Electronic
Communications
6. Phishing
7. Social Engineering
8. Social Media
9. Mobile Devices
10. Awareness
171

172. Passwords
 Your password is your key. Do not give your key to
any one else - ever!
HCA will never ask for your password
 Use different user names and different passwords
for work use and personal use.
 Create a strong password. Use a combination of
letters, number, special characters, upper and lower
case.
WHY?
WHY?
If someone uses your
password to access
unauthorized systems or
information, it is very
difficult to prove that you
were not the one to
access it. You could be
held liable.
If someone steals your
network password and
it’s the same as your
online banking password,
the bad guys can get lots
of information.
If someone uses your
password to access
unauthorized systems or
information, it is very
difficult to prove that you
were not the one to
access it. You could be
held liable.
If someone steals your
network password and
it’s the same as your
online banking password,
the bad guys can get lots
of information.
172

173. How Much Time Would it Take
To crack your
password…
The graph is from inetsolution.com
173

174. Creating Strong Passwords
“I love my dog Spot”
This example uses the first letter of each word
of a sentence. If Spot is 5 years old, it is easy to
remember the number "5" at the end of the
password.
Strong Password = ilmdSx5
or
Strong Password = Il0vemyD0gSp0t5!
Using the same phrase, here are examples of weak passwords:
Weak Password: mydog
or
Weak Password: Spot1
WHY?
WHY?
STRONG PASSWORDS
•IMPROVE PATIENT
SAFETY
•PROTECT YOU
•ARE UNIQUE
•IMPROVE
CONFIDENTIALITY
STRONG PASSWORDS
•IMPROVE PATIENT
SAFETY
•PROTECT YOU
•ARE UNIQUE
•IMPROVE
CONFIDENTIALITY
174

175. Workstation Security
• Lock or log off when you are done to activate the
screensaver
 Lock: Press CTRL-ALT-DELETE, select LOCK
 Lock: Windows logo key and “l”
 Log off: Select START, and Logoff.
• Log out of applications on shared workstations when
done
• To suspend a session in MEDITECH, press Shift F12 to
lock the patient record.
 Make sure no one is watching over your shoulder when
you enter information, PIN numbers, or passwords.
 If you feel someone is watching what you’re typing,
lock your screen immediately and ask that person if you
can help them.
WHY?
WHY?
Prevent
unauthorized
viewing of data on
your unattended
workstation.
Prevent
unauthorized
viewing of data on
your unattended
workstation.
175

176. Device Security
 Always keep portable equipment/devices with you
and in your sight or lock them up when not in use.
 If using or traveling with a company-owned laptop,
request a cable lock from your IT&S Department.
 If it is necessary to leave your laptop in your vehicle,
make sure that it is out of sight.
 If you require the use of a USB drive, ensure it is
encrypted.
• Don’t store sensitive data on a portable device unless
you need to for your job.
WHY?
WHY?
One lost or stolen
device could result
in a costly breach
notification. Even
if there isn’t a
breach, there is
also the cost to the
company to
replace the
hardware or
device.
One lost or stolen
device could result
in a costly breach
notification. Even
if there isn’t a
breach, there is
also the cost to the
company to
replace the
hardware or
device.
176

177. Malware Protection
 Be aware of phishing.
 Avoid pop-ups that advertise anti-virus or anti-spyware
programs.
 Don’t install unapproved software to your
device.
 Do not plug an unknown USB into your
computer.
 Connect back to the HCA network through the
VPN gateway if you use your HCA device away
from the office before using the internet.
 Avoid using your HCA device to visit internet
sites that are known for malware such as social
networking sites (My Space and Facebook),
coupon sites, etc.
WHY?
WHY?
Malware disrupts or
damages your computer’s
operation, gathers sensitive
or private information, or
gains access to private
computer systems.
Malware is mean.
Malware disrupts or
damages your computer’s
operation, gathers sensitive
or private information, or
gains access to private
computer systems.
Malware is mean.
177

178. Electronic Communications
Before you press the [SEND] button on an
email, Instant Message (IM), or Text, ask
yourself four questions:
1. Does it include sensitive data?
2. W here is it going (internal HCA
recipients or external)?
3. Is the recipient authorized to have that
data?
4. Is the data protected?
 Refer to Electronic Communication policy-
IS.SEC.002 for more information.
178

179. Email Encryption
 Add [Encrypt] anywhere in the Subject line
to encrypt the email and any attachments.
WHY?
WHY?
Email is like a
postcard. Encryption
is like the envelope.
Unless encrypted,
the contents can be
viewed during
transit which could
result in a costly
breach notification.
HCA requires
encryption of emails
containing sensitive
data.
Email is like a
postcard. Encryption
is like the envelope.
Unless encrypted,
the contents can be
viewed during
transit which could
result in a costly
breach notification.
HCA requires
encryption of emails
containing sensitive
data.
• Do not include any sensitive information in
the subject line.
• This encryption technique ONLY works if
you are emailing from your HCA supplied
email address. Messages to internal recipients
do not require you to enter [Encrypt].
• Any of the brackets work – [], (), {}, <>.
179

180. Other Email
Requirements
 DON’T use your personal email accounts
(e.g., Gmail or Yahoo) to conduct Company
business – use your Company email (e.g.
Outlook or MOX).
 DON’T forward company email to a personal
address.
 NEVER access another person's e-mail
(unless specifically authorized).
WHY?
WHY?
If sensitive
information is
transmitted using other
email systems, the data
is no longer protected
by the company’s
security controls and
the information could
be compromised
causing possible
damage to the
company reputation,
financial loss, and
liability to you.
If sensitive
information is
transmitted using other
email systems, the data
is no longer protected
by the company’s
security controls and
the information could
be compromised
causing possible
damage to the
company reputation,
financial loss, and
liability to you.
180

181. Know How to Catch a PHISH
WHY?
WHY?
Your identity
could be stolen.
Your credit could
be ruined. Your
computer could be
infected with a
virus. You could
cause someone
else’s identity to
be stolen.
Your identity
could be stolen.
Your credit could
be ruined. Your
computer could be
infected with a
virus. You could
cause someone
else’s identity to
be stolen.
Look for these clues in an
email:
P Personal Data Reference or Request
H Hyperlinks or Attachments
I Inaccurate Information
S Suspicious Sender
H Hurry Up and Respond
Phishing - unlawful attempt to obtain personally identifiable information (PII) about you
or others such as Social security numbers, Credit card numbers, Bank account
information; usually occurs via email
181

182. Verify or Report a PHISH
 Call the sender or the organization represented in the email or visit their
website (not using the link in the email) to see if they have reported any
phishing attempts.
 Send a separate email (not a reply) to the sender.
 Contact your local Help Desk, FISO (Atlas Keyword: FISO), or DISO
(Atlas Keyword: DISO).
 Learn more about Phishing and hyperlinks on Information Security’s
Atlas site. Keyword: Protect
182

183. Social Engineering
 Don’t share sensitive information with anyone
over the phone or in person even
 If they appear as “friendly”.
 If they seem in a hurry to get the
information.
 If they use an agitated tone or are very
pleasant depending on how you respond.
 Ask to see a badge.
 Wear your badge.
Social Engineering - an attempt to gather information
from you in order to gain access to systems and/or gain
confidential information; can occur in person, over the
phone, or electronically
WHY?
WHY?
Social
engineers
intend to get
information
from you
without you
knowing or
understanding
what they are
doing.
Social
engineers
intend to get
information
from you
without you
knowing or
understanding
what they are
doing.
183