East Jefferson General Hospital

Standing Out STANDING STRONG

Welcome!EJGHExperience

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OurServiceStatement

Providingcareandcomfortisourhighestmission...

Wepledgetoourguestsandeachother:

v Thefinestinpersonalservicev Courtesyandrespectv Asatisfyingexperience

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Senior Leadership

RubyBrewer,RN,MSN,MBASeniorVicePresidentChiefQualityOfficer/ChiefNurseOfficer

RaymondDeCorte,M.D.ChiefMedicalOfficer

JamesHritz,MPH,JDSeniorVicePresident

ComplianceandLegalServices

ValerieEngladeSeniorVicePresidentCommunityAffairs

RobHinyub,Jr.,JDVicePresidentLegalServices

GeraldPartonPresident/ChiefExecuDveOfficer

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•  HistoryofEastJeffersonGeneralHospital•  Mission,Vision,Values•  OurServiceStatement

•  InfecDonControl•  HIPAA•  HospitalStandards

Takeaways

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• OpenedonFebruary14,1971•  Louisiana’sfirstNurseMagnethospital• MemberoftheMDAndersonCancerNetwork• ACommunityHospital,butreceivesnotaxsupport

A Proud History

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Our Mission Statement

EastJeffersonGeneralHospital,community-owned,providesthehighestquality,compassionatehealthcaretothe

peopleweserve.

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EastJeffersonGeneralHospitalwillbetheregion'shealthcareleaderprovidingthe

highestqualitycarethroughinnovaKonandcollaboraKonwithourteammembers,

medicalstaff,andcommunity.

Our Value Statement

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• Quality• Integrity• CollaboraDon• ConDnualImprovement• Compassion• Stewardship

Our Values

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Wecommittoqualityineverythingthatwedo,throughachievementandinnovaKon,alwayscontribuKngtoexcellentcareandpaKentsaKsfacKon.

Quality

Weupholdthehigheststandardsofbehaviorencompassingfairness,trust,respect,andethicalpracKces.

Integrity

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Teamworkisthekeytooursuccess.Workingtogether,weensureeveryonebenefitsfromourcollecKvewisdom.

Collaboration

WeembraceandencouragecreaKvityandinnovaKon,aswellason-goingself-evaluaKonofourprocessesand

outcomes.

Continual Improvement

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Byourthoughts,words,anddeeds,wecreateandmaintainacaring,compassionateenvironment.

Compassion

WeareaccountabletomakewiseuseofKme,skills,andresources.

Stewardship

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Distinctions in Quality

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• CancerCare• CardiovascularCare• Pulmonology• StrokeCare-Neurosciences• WomanandChildServices• DiagnosDcImaging

EJGH Services

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“Thecareandwell-beingofourpaKentsshoulddriveeverydecisionwemake.”

•  PaDentSaDsfacDonSurveys–theopportunityforourpaDentstogiveusfeedbackandhelpusimprove

•  PaDentHandbook–orientpaDentsandfamilymemberstoourfacilityandsettheexpectaDonofexcellence

•  GuestServicesDepartment–assistwithpaDentandfamilyconcerns•  PaDentandFamilyAdvisoryCouncil–theVOICEofourpaDentsandfamilymembers

•  TeamMembersandPhysicians–weareanadvocateforthepaDentandtheirfamily

•  PaDentCenteredCare–creaDnganorganizaDonfocusedonpaDents

The Patient’s Perspective

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HCAHPS(HospitalConsumerAssessmentofHealthcareProvidersandSystems)

•  Federallymandatedsurveycreatesvalidcomparisonsacrosshospitalslocally,regionallyandnaDonally

•  AlladultinpaDentstays(exceptforpsych)areeligibletobesurveyed•  Hospitalsmustuseapprovedvendorsforthesesurveys–EJGHusesPressGaney,anaDonallyregardedhealthcareresearchprovider

•  Publiclyreportedathospitalcompare.gov•  Scoreseffectthehospital’sMedicarePayments–fundswithheldforpoorscores

Patient Satisfaction

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1.  CommunicaDonwithNurses2.  CommunicaDonwithDoctors3.  ResponsivenessofstafftopaDents’needs4.  ManagementofPain5.  CommunicaDonAboutMedicines6.  DischargeinformaDon7.  Environment–Cleanliness8.  Environment-Quietness9.  PaDents’overallraDngofthehospital10. Willingnesstorecommendhospital11. PostDischargeCare

HCAHPS Categories

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East Jefferson General Hospital, community-owned, provides the highest quality, compassionate healthcare to the people we serve.

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PaKent-CenteredCareModel

EveryJobGeneratesHarmony

EJGH Patient Experience

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Itisourhopethatthroughourefforts,patients,familymembers,andvisitorswillhaveapositiveexperience.ThegoalforeverypatientatEastJeffersonGeneral

Hospitalisexcellence.

Focus on Service Excellence

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• AIDET:5FundamentalsofPaDentCommunicaDon– Acknowledge– Introduce– DuraDon– ExplanaDon– ThankYou

Exceptional Patient Experience

UseAIDET…EveryDay

EveryEncounter

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Exceptional Patient Experience

• “Goodmorning/a>ernoon,_______(PaBent’sname)”A–Greetpeoplewithasmileandusetheirname.UseSirorMa’amifyoudonothaveopportunitytolearnname.

• “Mynameis_____andIworkintransport.Iamheretobringyoutoyourprocedure.”

I–Introduceyourself–Whoyouareandhowyouaregoingtohelpthem.

• “Itwilltake_____minutestoreachyourdesBnaBon.”D–KeepintouchtoeasewaiDngDme.Includewhereyouareinstatusofprocedure.

• “Iwilltransportyouvia______(gurney/wheelchair).Onceyouhavecompletedyourprocedure,Iwilltakeyoubacktoyourroom.”

E–Explainprocedure/process.Whotocontactiftheyneedassistance.

• “______(PaBent’sname),thankyouforyourpaBenceandforchoosingEastJefferson.LetmeknowifIcanassistyouinanyotherway.”

T–ThankthepaDent.FosteraitudeofgraDtude.

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• ParkingislocatedintheEsplanadeGarageonthe3rdfloorandup.

•  IDBadgesaretobewornatallDmesandabovethewaist.

Hospital Policies

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• Uniformsshouldbeinwrinklefreeandingoodrepair

• Haircolorshouldbefromnature(Blue,purple,pink,etc.notallowed)

• TaloosshouldbecoveredatallDmes• Piercingsareonlyallowedinearlobes

– Limit2perear

Hospital Policies

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Infection Control & Hand Hygiene

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• Patient Quality •  Improved Care • Patient Expectations • National Patient Safety Goals • Comparison to National Benchmarks •  Increased Cost

Why Infection Control?

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Cornerstones of Infection Control

•  Hand Hygiene –  Alcohol Foams –  Soap & Water – No Artificial Nails –  Appropriate Glove Usage – Hand Hygiene Champion

Program –  Two-Hands-Up Reminder

Symbol

•  Containment –  Environmental Cleaning –

Who Cleans What –  Infectious Waste

•  Isolation –  Standard Precautions –  4 Types of Isolation –

Airborne, Droplet, Contact, Enteric

–  Isolation Rooms/Caddies

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Cornerstones of Infection Control

•  Hand Hygiene –  Alcohol Foams –  Soap & Water – No Artificial Nails –  Appropriate Glove Usage – Hand Hygiene Champion

Program – Champion Oath –  Two-Hands-Up Reminder

Symbol

•  Containment –  Environmental Cleaning –

Who Cleans What –  Infectious Waste

•  Standard Universal Precautions •  Isolation Precautions

–  5 Types of Isolation – Airborne, Droplet, Contact, Enteric & Strict Isolation

–  Isolation Rooms/Caddies

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Corporate Compliance

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Standards of Conduct Major Sections

Introduction

1. Quality of Care

2. Privacy, Security and Confidentiality of Information

3. Compliance with Laws and Regulations

4. Safeguarding Property & Interest

5. Maintaining a Safe Healthcare Environment

6. Proper Consideration of Human Resources

7. Billing and Coding Outlined in the EJGH Experience Handbook on page 6

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Confidential Ethics and Compliance Hotline

TheEJGHEthicsCommileeprovidesnon-bindingadvisoryopinionstoassistinmanagingethicalissuesconcerningpaDentcare.The

commileereviewscasesbyrequestofphysicians,paDents,familymembersorsurrogateorhospitalstaffmembers.

•CallsaretakenbyanindependentcompanywithoperatorstrainedinHotlineprotocol•Callsareneverrecordedortraced•CalleranonymityandconfidenDalitywillbeprotectedtothelimitofthelaw•EJGHhasapolicyofnon-retribuDonagainstanyonewhocallstheHotline•AllinformaDonisthoroughlyinvesDgated

TollFreeCall1-877-631-0016

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HIPAA q HIPAA"isanacronymfortheHealthInsurancePortability&AccountabilityActof1996,whichisafederallawaffecDngallparDcipantsinthecountry'shealthcaresystemandthatincludesEJGH.

q HIPAAPrivacyregulaDonswererequiredforcomplianceinAprilof2003toprotectpaDentconfidenDality.

q HIPAASecurityregulaDonswererequiredforcomplianceinAprilof2005.

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HIPAA Privacy & Security

HIPAAPrivacy&SecurityOfficer•RobHinyub–Legal&ComplianceDepartment

Responsibletoensure..

Policies&proceduresaredocumentedtoprotectconfidenDality,integrity,andavailabilityofinformaDonsystemsandePHI(electronicprotectedhealthinformaDon)

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HIPAA Privacy & Security

ThereisadirectrelaKonshipbetweenprivacyandsecurity:Privacyis‘what’willbeprotectedPHI(paDenthealthinformaDon)and‘why’weprotectPHISecurityis‘how’toprotectePHI(electronicpaDenthealthinformaDon)Procedurally,physically&technically

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EJGH Work Stations or Electronic Media

•PROTECTACCESS–Lockorlog-offworkstaDonwhenlerunalendedorwhenshiriscomplete.

–WhenacommonID/passwordisusedbyseveralmembersoftheworkforce(toshareadevice),logoutofapplicaDonsaccessingePHI(electronicpaDenthealthinformaDon)inaddiDontolockingtheworkstaDon.

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EJGH Work Stations or Electronic Media

•PHYSICALPROTECTION–Takereasonablepre-cauDonstophysicallyprotectePHIandbusinessconfidenDalinformaDon.

•posiDondisplayscreenssuchthattheycannotbereadilyviewedbyothers.•physicallylocatedevicestominimizetheriskofunauthorizedaccess.

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HIPAA Compliance

WhatYouShouldDoToBeHIPAASecurity/PrivacyCompliant

–DON'Taccessdataunlessitisrequiredtoperformyourjob–DOprotectdevices(posiDonscreens,passwords,physicallysecure).–DON’Tdownloadsorware(astheycouldhavevirusesthatinfectsystems&data).–DOrecognizehoaxe-mails&don'topene-mailoralachments.–DOhaveanD-virussorwareonalldevicesyouuse.–DOreportrisksandsecurityincidents.♦ReportHIPAAsecurityincidentsasquicklyaspossibletoTheHIPAASecurityofficerorthroughtheconfidenDalhotline.

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HIPAA Compliance

DisposalofDocumentsContainingConfidenKalInformaKon

q  Disposeofdocumentsinrecyclebinslocated

withinthedepartment.

q  Alwaysaskforassistanceifnotsurewheretodisposeproperly.

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HIPAA Security Violations

DisciplinaryacDons,uptoterminaDon,ifyouareaccessingoralempDngtoaccessePHI(electronicprotectedhealthinformaDon)whennotauthorizedorimproperdisclosure.

CompletetheNon-TeamMemberReceiptofUnderstandingForm

(Step4ofEJGHExperiencehomepage)

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Sexual Harassment

Sexualharassmentisagainstthelaw!–VerbalAbuse–Jokingorkiddingthatissexuallyorientedandconsideredunacceptableandoffensive

ForaddiDonalinformaDon,requestacopyofthepolicy

–Reportimmediately–AppropriateacDonwillbetaken

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The Joint Commission

•Isavoluntary,non-governmentalorganizaDonthatestablishesstandardsfortheoperaDonofhospitalsandnursinghomes.

•CompliancewithJointCommissionisrecognizedbytheissuanceofcerDficatesofaccreditaDon.

•AccreditaDonallowsMedicarereimbursement.

Visitsareunannounced!

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WateronfloorElevatormalfuncDonVisitorfallLostItemsThersVehicleAccidentsVandalismTripHazardsBurnedoutlightsDefecDvedoorsImproperLiringTechniques(BackSafety)

Safety Hazards, Incidents, or Accidents

ReportimmediatelytoSafety&Securityatextension4059

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Workplace Violence

Ifyouhearadirectorimpliedthreat,reporttosupervisorwhothencallsSecurityatextension4059Ifimminentdangertolife,call911,security,andthennoDfysupervisor

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Next Steps…

• PleasereporttoworkwiththeHIPAAagreementsignedanddated.

• Alsobringthecompletedquizwithyou.

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EastJeffersonGeneralHospital

great people… …doing great things!