Mandatory Annual Safety Education
Policy Statement
Culpeper Regional Hospital maintains that harassment of applicants and
employees based on race, color, sex, religion, national origin, age, genetic
information, marital status, military membership or veteran status or
disability, including sexual harassment (all as defined by applicable law) is
prohibited and will not be tolerated. The Hospital will not tolerate unlawful
harassment of any employee, patient, vendor, contractor or medical staff
member by anyone else including hospital managers, co-workers, patients,
visitors, vendors, contractors, or medical staff members. All forms of
unwelcome and potentially unlawful conduct should be reported
immediately to the Vice President Human Resources or the Vice President
of their area. Unlawful harassment by managers or employees will be
grounds for prompt, appropriate disciplinary action up to and including
Sexual Harassment
Sexual Harassment is defined as unwelcome sexual
advances, requests for sexual favors and other
verbal or physical conduct of a sexual nature when
submission is made a term or condition of
employment; employment decisions are based upon
submission to or rejection of the conduct; or the
conduct unreasonably interferes with an employee’s
work performance or creates an intimidating, hostile
or offensive work environment.
Sexual Harassment
Both men and women can be victims of sexual harassment
Quid Pro Quo – Latin for “something for something” describes a situation in which a supervisor conditions an
employment decision in exchange for sexual favors.
For example, it is quid pro quo sexual harassment for a boss to
offer a raise in exchange for sex.
Formal, courteous, respectful, pleasant and non-coercive
contacts between individuals that are acceptable to both are
not considered sexual harassment.
Hostile Work Environment
•Conduct that is pervasive enough to change the terms
and conditions of employment. Hostile work
environment harassment is a work environment that a
reasonable person would find offensive.
•For example: Unwelcome sexual attention, sexually
oriented conversation, displaying of graphic pictures or
jokes, which are clearly considered offensive.
Types of Sexual Harassment
• Gender Harassment
• Same Sex Harassment
• Sexual Orientation Harassment
• Transgender Harassment
Other Types of Harassment
Racial Harassment
• Ethnic slurs or jokes, offensive or
derogatory comments, or other verbal
or physical conduct based on an
employee’s race/color constitutes
harassment if that conduct creates an
intimidating, hostile or offensive work
Age Harassment
• The federal Age Discrimination in
Employment Act protects employees
from age discrimination and
• Age harassment can include agebased jokes or comments, offensive
cartoons, drawing, symbols, or
gestures, and other verbal and
physical conduct based on an
individual's age.
Disability Harassment
• The Americans with Disabilities Act prohibits discrimination
based on a person’s disability.
• Under this law, when a disabled worker is constantly
subjected to pervasive and severe harassment due to their
disability that creates a hostile work environment.
•Disabilities include mental impairments as well as physical.
•Offensive remarks regarding a person’s disability would be
considered harassment.
Religious Harassment
• Occurs when employees are required or coerced to
abandon, alter or adopt a religious practice as a condition
of employment or when an employee is subjected to
unwelcome statements or conduct that is based on religion
that is so severe that the employee finds the work
environment to be hostile or abusive.
• Antagonizing, ridiculing, mocking or making derogatory
comments about a person’s beliefs is considered religious
National Origin
• Discrimination or harassment due to a
person’s place of birth, ancestry, culture or
linguistic characteristics common to a
specific ethnic group.
• Harassing conduct might include slurs or
jokes about a particular ethnic group,
comments or questions about a person's
cultural habits, or physical acts of particular
significance to a certain ethnic group.
More Types of Harassment
• Harassment
based on someone’s filing a worker’s
compensation claim
•Harassment based on someone taking leave under
the Family Medical Leave Act
• Harassment based on a person’s political
•Harassment based on an employee’s status as a
• Harassment based on union membership or non
• Harassment based on complaints about safety violations
• Harassment that is a result of retaliation
Harassment can have a devastating effect on
victims and can undermine the morale of an
entire organization.
• All employees must assume an active role
in the prevention of any type of harassment.
• Treat everyone with respect.
• Set a good example.
• Examine your own behaviors, gestures and
• Pay attention to the response of others to
avoid unintentional offense.
• Be aware and conscious of engaging in
potential harassment behaviors.
• Discourage behaviors that negatively affect
your work, department or organization.
• Do not encourage harassers by smiling or
• Speak up - Let the harasser know you find
the behavior offensive.
• Report harassment to the appropriate
• It is important to prevent harassment in all
areas of our organization. Not only does it
conflict with our Core Values, it is illegal
under federal and state law.
Culpeper Regional Hospital’s Anti-Harassment policy prohibits any type of
harassment in the work place. All forms of unwelcome and potentially
unlawful conduct should be reported immediately to your director, the Vice
President of Human Resources or call the Hotline at
(877) 888-4806. All complaints of harassment are taken seriously and will
require a workplace investigation by Human Resources.
The Anti-Harassment policy #602.0 can be found online in Policy Manager..
In Closing
Culpeper Regional Hospital is committed to
maintaining a workplace free of harassment.
No employee will be retaliated against for
making a good faith complaint or assisting
with the investigation of a complaint.
Mandatory Annual Safety Education
Your Spine
• Consists of:
– 24 vertebrae
– Shock-absorbing discs
• 3 natural curves
– Cervical, thoracic, and
– Distribute weight evenly
– Maintain these curves for
good posture and body
6 B’s for Better Back Safety
• Be Prepared
– Test the load before lifting or moving it by trying to
move it with your foot
– Clear the path of transfer of any debris
– Ask for help if you are not sure you can perform
something safely on your own
• Bend Knees
– Bent knees protect the back by maintaining a neutral
– Lift with your legs and not your back
6 B’s for Better Back Safety
• Be Neutral
– Keep spine in a neutral position to protect the spinal
– Tighten the stomach muscles
• Base of Support Should be Wide
– Separate knees and feet about shoulder width apart
– Ease of balance
• Be Close
– Keep the patient/object close to your body, no
further away than elbows reach
– Raise the bed surface to you to keep spine neutral
6 B’s for Better Back Safety
• Be Mobile
– Move your feet, do not twist your spine
– Transfer your weight from one foot to the
other when moving a patient up in bed
Seated Activities
• Be Prepared
– Desktop should be
– Tasks requiring 75% or
more of your time should
be at elbows reach
– Tasks requiring less than
25% of your time should
be at shoulders reach
– Know when and how to
take micro-breaks,
stretching, etc.
• Be Close
– Computer monitor should
be at fingertips reach
directly in front of you
– Shoulders relaxed, elbows
at sides and bent to 90
degrees to reach the
keyboard tray
– Feet flat on the floor or
propped up on a footrest
Seated Activities
• Be Neutral
– Use your back
– Shoulders over your
hips and your head
over your shoulders
– Keep wrists neutral
• Be Mobile
– Pivot in the chair, no
spinal twisting
– Push around on the
wheels of the chair
rather than overreach
Sitting/Standing Postures
Standing Activities
• Be Prepared
– Tasks requiring 75%
or more of your time
need to be at elbows
– Tasks requiring 25%
or less of your time
need to be at
shoulders reach
• Bend Knees
– Do not stand with
your knees locked
backwards or straight
– Rest one foot up on a
stool, a footrest, or a
– Bent knees assist with
the neutral spine
Standing Activities
• Be Neutral
– Keep spine in a
neutral position
– Tighten stomach
muscles to assist with
keeping spinal curves
• Be Mobile
– Move your feet, do
not twist your body
– Stretch periodically,
forward, backward,
and side to side
• Base of Support
Should be Wide
– Better balance
– Able to get closer to
the task
• Be Close
– Less stress on your
• Common cause of back injury
• Two general rules
– Keep the load close
– Bend at the knees
Lifting Safely
• Analyze the load
• Place one foot out in
front of you
• Feet flat on the floor
• Knees slightly bent
• When lifting:
– Move both feet closer
to the load
– Bend at the hips
• Maintain neutral spine
• Move smoothly
Golfer’s Lift
• The golfer’s lift is a
way to lift a lightweight object from
the floor while still
maintaining good
body mechanics.
• You can hold on to a
solid object for
balance if needed.
Reaching Overhead
When performing a task involving reaching,
– Get close to the object using a stool or
– Bring the object close to you
when lifting
– Take frequent breaks if reaching
overhead for extended periods
of time
- Always maintain the 3 curves of
your back
Mechanical Lift Systems
Maxi Sky
Maxi Sky
Maxi Sky Lift
A Maxi Sky 600 is located in each patient room on
the Med/Surg, Step Down and ICU units. This
unit will accommodate up to a 600 lb person for
transfers. There is a Maxi Sky 1000 located on
Step Down that will accommodate up to 1000
lb. There are several size slings for these lifts,
all stored on the individual floors. Slings are
marked with the size and the type patient lift in
which they are to be used.
Tempo Lift
The Tempo Lift is located in the Storage
Room on Step Down. It is a portable
patient lift that can be used throughout
the hospital. The Tempo Lift has several
size slings that are stored with the unit.
Each is marked with the size and the type
of lift for which it is to be used. The
Tempo Lift is designed to lift a person
weighing up to 440lb.
Maxi Sky and Tempo Lifts
These units will: 1. Lift a patient from the
2. Lift a patient from bed to
chair/chair to bed
3. Lift a patient to scoot
them up in bed
4. Lift a patient to change
the bed linens
Patient Transfers
• Proper body
• Ask the patient to
• Get an assistant
• Mechanical lift
Other Patient Lift/Transfer
Hover Matt
Hover Jack
Pushing vs. Pulling
Push, don’t pull!!
Remain close to the load
Don’t lean forward
Use both arms and tighten
stomach muscles
• Keep elbows close to your body to help
maintain a better spine position
Protect your Back!
• Repetitive motion can cause an injury
over time.
• Being aware of your body mechanics
during everyday activity can
help prevent injury in the
Pressure Ulcer Prevention
Wound Care Education
What is a Pressure Ulcer?
Areas of damaged skin and tissue that
develop when sustained pressure
decreases circulation to vulnerable
parts of your body, especially the skin
over bony areas (buttocks, hips and
heels). Without adequate blood flow, the
affected tissue dies.
Pressure Ulcer Facts from JCAHO
An estimated 2.5 million patients are treated
for pressure ulcers in acute care facilities in
the United States each year.
 An estimated 60,000 patients die each year
from complications due to hospital-acquired
pressure ulcers.
 The estimated cost of managing a pressure
ulcer is as high as $70,000, and the total cost
for treatment of pressure ulcers in the United
States is estimated at $11 billion per year.
How does this impact CRH?
If a pressure ulcer develops or worsens in a
Hospital, the hospital can be held responsible
for all costs related to the pressure ulcers.
Insurance may also deny payment for the
entire inpatient stay.
 Therefore, it is each person’s responsibility to
thoroughly assess and document all
reddened and broken areas of a patient’s skin
upon admission and at regular intervals while
in our care.
How does this impact CRH?
It is everyone’s responsibility to
recognize signs of breakdown and know
how to implement an immediate course
of action.
 Hospital Acquired Pressure Ulcers lead
to decreased patient satisfaction,
increased patient health complications,
and increased legal actions.
How does this affect you?
Emergency Room – mattresses are
typically very thin; skin breakdown can
begin to occur in a matter of a few
hours; a thorough skin assessment
should be done with brief notations of
where current breakdown is located,
especially if the patient is there for more
than an hour and is at a higher risk for
How does this affect you?
ICU/StepDown/MedSurg – Patients may be
admitted with existing wounds. Immobility
and multiple other factors can lead to skin
breakdown if not closely monitored.
 FBC – Skin breakdown can begin to occur
within a few hours. If the patient has existing
medical problems that increase the risk of
breakdown, even a new mother can end up
with a pressure ulcer. Surgical patients are at
times admitted to this unit as overflow. Due
to decreased mobility, these patients are at a
higher risk of developing a pressure ulcer.
How does this affect you?
O.R. – Surgical patients who are under
anesthesia for extended periods often
have an increased risk of developing
pressure ulcers.
Diagnostic testing – Stretchers and
tables are typically very thin. 30 minutes
to an hour on these surfaces can be
enough to cause a Stage I pressure ulcer
in an at risk patient.
How does this affect you?
Dietary/Housekeeping – These
departments may enter the patient’s
room several times a day for various
reasons. If you notice the patient is in
the same position they were in the last
time you saw them, mention this to their
nurse; they may need nursing to assist
them in turning to a different position.
Pressure Ulcer Prevention
Leading cause of most pressure ulcers:
**Even though a patient may be on an air mattress
or placed on a total care bed with rotation settings,
the patient must still be repositioned at least every
2 hours.**
Pressure Ulcers
Risk Factors:
Inadequate nutrition
Sensory deficiency
Multiple co-morbidities
Circulatory abnormalities
Altered level of consciousness/mentation
Prior history of pressure ulcers
Chronic Disease states (Diabetes, CAD…)
Patient Positioning
Prevention of pressure ulcers is an
important aspect of care in any patient
at any age.
It is Culpeper Regional Hospital’s policy
to reposition patients at least every 2
Patient Positioning
Reasons for repositioning a patient:
– Prevent a pressure ulcer
– Provide comfort for the patient
Areas of Pressure
Main pressure points found on the body
– Sacrum
– Hips
– Shoulders
– Heels
– Elbows
– Ankles
– Back
– Back of the head
Causes of Pressure
Hospital equipment that may cause pressure
I.V. tubing
Wires (ECG and/or BP)
Foley tubing
S.C.D tubing
Casts, cervical collars
N.G. tube
Syringes and caps
Preventing Pressure Ulcers by
Frequent Rotation
Reposition the patient every 2 hours at
 A consistent rotation schedule for all patients
can help all staff know which position the
patient should be in, and can offer assistance
to ensure rotations are completed.
 Individualizing the rotation schedule may be
necessary for some patients (ie. A patient that
is unable to lie on one side due to pain from a
hip fx).
Nutrition and Wound
The Standard nutrition recommendation
for wound healing is a balanced diet
with adequate calories, proper
hydration, and rich in protein.
 Basic energy recommendations are 2535 Cal/Kg, depending on the severity of
illness and BMI.
– Goal: Provide adequate energy to
maintain or regain lost weight.
Nutrition and Wound
A Nutrition Consult would be
appropriate if the patient:
– Is not eating most of his/her meals
– Has other medical issues that affect eating
and/or nutrition
– Is diabetic and/or currently has a wound
 Remember
that prevention is
the best treatment for pressure
Striving for Competency
Across Cultures
Improving care and communications
Ethnic Diversity
Ethnic diversity includes a variety of religions,
races and cultures
More than one in four Americans are now either
Asian, Hispanic, or African-American descent
Certain areas of the country contain more
individuals of various cultures than others
Hispanics constitute 16.7% of the nation’s
population, making them the largest ethnic or race
minority currently in the U.S.
Diversity Today
U.S. census estimated Hispanic population in the
country as of July, 2011 = 52 million
Hispanic population in the U.S. during the 1990 census
(22.4 million) was less than half the current total
More than one of every two people added to the
nation’s population between July 2008 and July 2009
was Hispanic
Ethnic / Race Diversity Data
Virginia is one of 16 states with at least a half
million Hispanics residing*
For the first time, Asian immigration (36% of all
new immigrants) to the U.S. in 2010, surpassed
Hispanics (31% of all new immigrants)*
African Americans (multi race) total 13.6% of the
U.S.* population or 42 million people
*Courtesy of U.S. Census Bureau 2010 Statistics
2010 U.S Census Bureau Data
People Quick Facts:
White persons, percent (a)
Black persons, percent (a)
Asian persons, percent (a)
Native Hawaiian & Other Pacific Islander (a) 0.1%
Persons reporting two or more races, percent 2.5%
Persons of Hispanic /Latino Origin, percent (b) 8.9%
White persons not Hispanic, percent
(a)Includes persons reporting only 1 race
(b) Hispanics of any race, so also included in applicable race categories
US Census Bureau Projected
Populations for 2050
Projected Hispanic population is 132.8 or 30% of
total U.S. population
Projected African American population is 65.7
million or 15% of total U.S. population
Projected Asian American population is 37.6
million or 9.3% of total U.S. population
Defining Culture
Involves a total way of living
Includes values, beliefs, language, thought
process, behavioral norms and
communication styles
Guides decisions and actions of a population
through time
Individual’s foundation
Each culture promotes different ones
Americans value money, freedom,
independence, privacy, health, fitness and
Understanding values is the key to
understanding behaviors*
* Our behaviors reflect our values
Cultural Competency
Competency suggests adopting a set of
behaviors, practices, attitudes and practices
that allow effective care cross culturally
Developing cultural competency within an
organization begins with awareness, grows
with knowledge, and thrives with continued
learning and teaching
Achieving Cultural Competence
First you must recognize your own personal
culture and biases and become sensitive to
the culture of others
Next you must improve your knowledge
and understanding of other cultures
Finally you must apply what you have
learned in a caring and competent way
How Culturally Aware Are
Do you know what you don’t know?
Recognize Your Awareness
Some cultures believe:
Conversing with your hands in your pockets is impolite
Introductory social conversation is inappropriate
Patients should not ask questions of health professionals
because to do so challenges the professional’s authority
Illnesses originate magically and can be treated only with
voodoo medicine
Self-care is not important
Refusing pain relief is a means of atonement
Cultural & Language Barriers
Affect the Clinical Experience
Clinical experience is impacted by:
Religious customs and beliefs
Cultural beliefs, behavior patterns, and
View of mental health and acceptable practices
concerning recognition/treatment
Cultural & Language Barriers
Affect the Clinical Experience
Religious customs and beliefs impact:
Beliefs about blood, autopsy and amputation
Privacy and confidentiality expectations
Cause and treatment of disease
Dealing with death
Cultural & Language Barriers
Affect the Clinical Experience (cont.)
Beliefs, behavior patterns & communication impact:
Expectations concerning diagnosis, treatment and
symptom relief
Gender and family roles in decision making
Beliefs about body, health and diet
Reaction to pain
Cultural & Language Barriers
Affect the Clinical Experience (cont.)
Mental health practices impact:
Recognizing depression
Seeking treatment
Use of Counseling
Use of Psychiatry
Improving Care and
Communications Among the
Populations We Serve
Means for Improving Care
Become aware of your own values towards health
since they impact the way you assess a situation
Recognize own preferences & cultural biases
Seek to understand patients and their situations within
the context of their group & resources
Provide care that promotes respect for the other
person’s values, preferences and needs
Avoid stereotyping based on culture / religion
Increase own knowledge of customs, communication
patterns and differences in health beliefs
Communication Challenges
“Researchers in the Center for Health Policy Research
in the UC Irvine School of Medicine have found that
language barriers between patients and healthcare
providers result in longer hospital stays, more medical
errors and lower patient satisfaction”
Science Daily (Nov. 14, 2007)
Communication Challenges
Language barriers make it difficult for patients
to explain their symptoms and concerns
Language barriers can increase the risk of
Delays in seeking treatment can be due to
language barriers
Today, there are over 60 million Americans
who speak a primary language other than
English, and that will rapidly grow in coming
years. That's a big population that health care
providers committed to providing quality care
must not ignore!
Measures for Improving
Speak slowly, not loudly
Address person by formal name unless told
Don’t force a person to make eye contact
Face the person and use pictures to help
Use a trained interpreter whenever possible
Measures for Improving
Communications (cont.)
Be careful interpreting facial expressions and
the presence or absence of emotions such as
Use hand and arm gestures with caution since
they mean different things in different cultures
Keep what you want to say simple
Measures for Improving
Communications (cont.)
Rephrase and summarize often
Ask open ended questions and don’t interrupt
Use available resources, such as language
barrier help manuals, scripts, and CyraCom
translation phone services to get your message
CRH Communication Resources
CyraCom phone – enables you to access
interpreters 24 hours a day for interpreting over
170 languages
Scripts’ – print on demand education handouts
available in Spanish as well as English
Language Barrier Help Manuals – books with
pictures and English to Spanish translation of
frequently used health care words
CyraCom Phone Use
To place a call using ClearLink (patented dual hand
set phone):
Locate an analog phone outlet ( all patient rooms
at CRH have an analog phone jack)
Connect dual hand set phone to the analog phone
Follow the 1-2-3 instructions displayed on the
CyraCom phone to place your call
* See slide “Other Features” for what to do if
analog outlet is unavailable
CyraCom Conference Call
To conference a call:
Press ‘1’ when prompted if you would like to add
an additional person to the call
Follow the prompts to enter the added person’s
phone number
When the interpreter greets you, say you are
adding an additional person and supply the name
of the person you are calling along with purpose
of the call
CyraCom Conference Call (cont.)
To conference a call when an interpretation
session is already in progress:
Press ‘8’ to be prompted to enter the phone
number of the person you want added to the
Follow prompts
Cyracom Phone Accessories
Blue splitter is available for use when analog line
is not available
24 hour assistance service # 1-800-481-3289 is
available for help at any time
Directions attached to CyraLink phones provide
the service number along with ‘step by step’
instructions for placing/conferencing calls when
using the splitter
If planning a conference call, have available the
accessory equipment you will need
Using CyraCom Effectively
Know where the ClearLink phones are kept in your
work area (ClearLink Phones available on each
nursing unit and in patient care designated areas)
Use the language ID chart attached to the phone if
you need help with identifying a patient’s language
Obtain interpreter’s ID number for patient record
documentation purposes
Provide interpreter with brief explanation for the call
Using CyraCom Effectively
CRH currently spends $1900.00/month average for
phone based language translation services
You can help contain costs for this valuable service by
consistently doing the following:
Organize questions in advance:
• Identify what you need to say before calling
• Group questions and be specific
Be clear, brief, and simple with communications
Ask the interpreter to please ask the patient if he
has questions before ending the call
About scripts’
Scripts’ is an online accessed program offered
by Pritchett & Hull
Covers essential information about:
Wellness and prevention
Disease management
Lifestyle changes
Allows print on demand education handouts
for English and Spanish speaking patients
About Scripts’ (cont.)
Materials provided offer basic information that
is up to date and easy to read
Topics that have basic information on disease
process, management and complications
include: diabetes, congestive heart failure and
Accessing Scripts’
Log onto
In left lower corner of scripts’ page, click
on link titled ‘scripts print on demand’
Scripts’ page then will request you sign in
Click on sign in link and enter:
‘CRH’ for user name
‘nurse’ for the password
Accessing Scripts (cont.)
Choose ‘e folder’ link to find CRH specific
education materials routinely used by our
patient ed team
Locate the topic you want and click on it
Choose the language you want your hand- outs
in and click on the ‘handouts' tab
Check what handouts you want printed and the
order you want printed -then click print
Language Barrier Help Manuals
Several departments offer these manuals
Manuals offer pictures and language
instruction for health care providers
Manual types and design vary among
Ask your manager where to find your
department specific manual
In-house Interpreters
Restricted to identified employees – (current list
kept in nursing office)
Assist only to the level of their ability
Family and friends DO NOT qualify as
acceptable medical interpreters
CyraCom service should be used when a
qualified in house interpreter is not available
In-house Interpreters
Volunteer interpreters must be:
Fluent in the language they are asked to
Knowledgeable in the terminology and subject
matter being asked to translate
Accepted by the patient as a recipient and
translator of confidential information
Cultural Competence
As a patient centered organization, it is vital
that every employee become culturally
competent. For more resources and
information to help you become culturally
competent in the healthcare setting - visit:
Happy Learning!
Mandatory Annual Safety Education
Emergency Management
• The Four Phases of Emergency Mgmt.
– Mitigation activities refer to the actions an
organization undertakes in attempting to lessen the
severity and impact of a potential emergency.
– Preparedness activities are those actions that an
organization undertakes to build capacity and identify
resources that may be used if an emergency occurs.
– Response activities refer to those actions taken by
both management and staff when confronted by an
– Recovery strategies are the short and long term
actions directed at restoring essential services and
resuming normal operations.
Emergency Management
• National Incident Management System (NIMS)
– A consistent nationwide approach for Federal, State, tribal and
local governments to work effectively and efficiently together to
prepare for, prevent, respond to and recover from domestic
incidents, regardless of cause, size or complexity.
– Establishes standardized incident processes, protocols &
procedures to help agencies/organizations to work together
during any type of incident’.
– Applicable across jurisdictions & functions and provides a
flexible framework that facilitates all levels working together. It
requires that all domestic incidents use a common management
– CRH uses Hospital Incident Command System or HICS.
Emergency Management
• Emergency Operations Plan (EOP)
– The EOP was created and is revised to ensure predictable
behavior by the majority of staff during an emergency situation.
– It provides specific guidelines for staff to follow in an emergency
and is located in your Environment of Care Manual.
– It establishes a team of individuals who can assess damage and
make informed decisions about how to handle the immediate
situation while arranging for experts to deal with long-term
consequences of the incident. This group of individuals makes
up the structure of the Hospital Incident Command System or
– Emergency Management is the responsibility of all hospital staff.
If you are on shift during an emergency management exercise,
you are expected to participate as if it were a real event.
However, care of patients in-house remains top priority.
Critical Function Areas
• CRH uses the HICS response system.
The critical function areas of response
Resources & Assets
Safety & Security
Clinical Activities
Hospital Command Center (HCC)
• The activities of the Hospital Command Center (HCC)
are directed by the Incident Commander (IC).
• The IC has overall responsibility for all activities within
the HCC.
• The IC may appoint other Command Staff personnel to
assist as the situation and resources warrant. These
personnel may include: Public Information Officer (PIO),
Safety Officer, Liaison Officer and/or Medical Technical
• The HCC at CRH is located in the Administration area,
but may start out in the Nursing Office.
When the EOP has been activated, ONLY the PIO or
their designee may communicate with the media.
Command Staff Identification
All personnel assigned
to an incident command
role should wear
identification that
correctly communicates
their role.
Job Action Sheets
• Job Action Sheets (JAS) have been designed for each
command position and can provide “just in time”
training for hospital staff. They are located in the
Hospital Incident Command Cart.
• Some of the information provided on a Job Action Sheet
includes a radio identification title, purpose of the
position, to whom they report, and critical action
• These tasks are intended to “prompt” the incident
management team members to take needed actions
related to their roles and responsibilities.
HICS Communications Tool
If you hear an Alert of any level paged overhead, one
person from each department should log on to the HICS
Communications Tool in Outlook Web App. This is a
communication tool between the Hospital Command
Center and hospital departments.
Log-In Instructions for HICS Communication Tool
Go to Hospital web site at
Click on “Outlook Web App”
Use departmental or CRH generic login, i.e. CRHICS
All Passwords are set to MAYDAY (case-sensitive)
Emergency Management
• Alert Levels
Alert Level 1 – Informational/Preplan
Alert Level 2 – Response Needed
Alert Level 3 – More Resources Needed
Alert Level 4 – MAYDAY
Emergency Management
• Example of ALERT Levels in action:
– Alert Level 1 – the emergency department has been notified
that there has been a bus accident on Rt. 29. This would be in
incident in our community that may impact normal operations
of the hospital so we would Alert staff by an Alert Level 1.
– Alert Level 2 – the first patients begin arriving in the emergency
department all at once and we need an Operations Section
Chief and perhaps some other positions in the Command
System be filled to manage the current situation.
– Alert Level 3 – the media and concerned family members begin
to arrive at the hospital. We need to assign a Public
Information Officer (PIO) and may need support from the local
police department for crowd control
– Alert Level 4 – some of the passengers on the bus are covered
with diesel fuel and require decontamination. We would need
to set up our decon area and activate our decon team.
OSHA – Exposure Control Plan
The exposure control plan is the employer's written program that outlines
the protective measures an employer will take to eliminate or minimize
employee exposure to blood and OPIM (Other potentially infectious
• The three primary methods/mechanisms that reduce
exposure include:
– Personal Protective Equipment(PPE) (such as gloves, gowns and masks)
– Work Practices (The term, “Work Practice Controls” means controls that
reduce the likelihood of exposure by altering the manner in which a task is
performed {e.g., prohibiting recapping of needles by a two-handed technique})
– Engineering Controls (The term, "Engineering Controls," refers to
[controls (e.g., sharps disposal containers, self-sheathing needles, safer medical
devices, such as sharps with engineered sharps injury protections and needleless
systems) that isolate or remove the bloodborne pathogens hazard from the
Standard Precautions
Standard Precautions is OSHA's required method of control to protect
employees from exposure to all human blood and OPIM(Other Potentially
Infectious Materials means (1) The following human body fluids: semen, vaginal
secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal
fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly
contaminated with blood, and all body fluids in situations where it is difficult or
impossible to differentiate between body fluids; (2) Any unfixed tissue or organ
(other than intact skin) from a human (living or dead); and (3) HIV-containing cell or
tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other
solutions; and blood, organs, or other tissues from experimental animals infected
with HIV or HBV. The term, “Standard Precautions," refers to a concept of
bloodborne disease control which requires that all human blood and certain
human body fluids are treated as if known to be infectious for HIV, HBV,
and other bloodborne pathogens.
Employees are responsible to:
 -Know what tasks they perform that have potential for occupational exposure to
blood borne pathogens or tuberculosis prior to beginning work.
 -Plan and conduct all work activities according to hospital policies and procedures.
OSHA Respiratory Protection
Standard 1910.134(a)(1)
• In the control of those occupational diseases caused by
breathing air contaminated with harmful dusts, fogs,
fumes, mists, gases, smokes, sprays, or vapors, the
primary objective shall be to prevent atmospheric
contamination. This shall be accomplished as far as
feasible by accepted engineering control measures (for
example, enclosure or confinement of the operation,
general and local ventilation, and substitution of less
toxic materials). When effective engineering controls
are not feasible, or while they are being instituted,
appropriate respirators shall be used pursuant to this
OSHA Respiratory Protection
Standard 1910.134(a)(2)
• A respirator (N95 Mask) shall be provided to each
employee when such equipment is necessary to protect
the health of such employee. The employer shall provide
the respirators which are applicable and suitable for the
purpose intended. The employer shall be responsible for
the establishment and maintenance of a respiratory
protection program, which shall include the
requirements outlined in paragraph (c) of this section.
The program shall cover each employee required by this
section to use a respirator.
• Only wear the style of respirator that you have been fit
tested for!!
CRH Masks – Type is N95
• 3M 1870 Universal
• 3M 1860: Small/Regular
• PAPR (Powered Air Purifying Respirator)
Type is N100
Workers’ Compensation
• REPORT any accident, injury, illness or exposure must be
immediately to your supervisor.
• COMPLETE incident report using the on-line
• “Quality Care Control Reporting System,
• “Live Reporting System.”
• Fill out an incident report as soon as possible. Make sure you are
completing all the information on all of the screens. This gives
Employee Wellness a complete picture of the incident. Please make
sure your description of the incident is thorough: what happened,
how it happened, where it happened, what was hurt.
List witnesses and who was notified by name.
• Follow up with Employee Wellness as soon as or with in one
business day or your reported injury.
• CRH’s Workers Compensation insurance company will decide
whether the incident is accepted or denied.
• VA law states that YOU are responsible for the first 7 days out of
work – it’s on your time.
Workers’ Compensation
Employee Wellness Duties
 Review of the accident and resulting injury
 Offer CRH Workers’ Compensation Panel of
 If you choose to go to the ED and need a follow
up visit you MUST choose a physician from the
approved panel
 Employee Wellness does not approve or deny
services. We act as an agent to notify and
facilitate care with the CRH contracted WC
Workers’ Compensation
Employee Responsibilities
• Employee Responsibilities:
 Always report to supervisor**
 Determine if immediate medical attention is required – You may choose to be
evaluated in the ED (Note: NO ONE can make you seek medical attention or file a
workers’ compensation claim) Ask yourself this question: “If this happened at
home would you seek follow up treatment?”** It is your choice.
 Complete incident report (immediately or by the end of your shift)
 Call Employee Wellness at time of injury or within 24 hours**
 Complete Urine Drug screen – IF seen by a physician post incident
 Provide Employee Wellness with regular updates after each physician visit**
 Contact your WC representative for approvals of services as needed and regular
updates on your progress
 Request and return a completed “Return to Work” form when you are ready to
come back to work, either full duty or transitional duty**
 Contact Employee Wellness if you have any questions or concerns**
 Follow the directions, treatments and limitations set by your physician**
**The above guidelines apply to all injuries, illnesses or exposures, whether on the job
or off the job
Employee Wellness
• ReadySet is the ON-LINE Employee Health Portal used
to complete annual wellness tasks. It is accessed at
• This software will be used by all employees, and
contract staff.
• “Tasks” are assigned in the “My Health Portal”. These
must be completed prior your annual appointment or to
receive a PPD or Immunization. Contact us if you need
assistance using the ReadySet system.
• Annual wellness evaluations are done annually during
YOUR HIRE month – you must complete both fit
testing (if applicable) and your TB screen or skin test by
the last day in your hire month.
• Auxiliary/Chaplains are due annually in May
Employee Wellness
Routine Office hours are Monday-Friday 8:00 am – 4:30 pm.
• Annual Wellness visits are routinely scheduled on the
1st , 2nd and 3rd Tuesdays and the 2nd Monday of each
• Annual Wellness visits are done by appointment only.
Please call the office to schedule an appointment.
• You may contact us at 540-829-5743.
Safe Working Practices
• CRH strives to provide a workplace free
from hazards. Those hazards can also
pertain to employees returning to work.
It is expected that the employee follow up
with Employee Wellness prior to any
return to work after an injury or illness.
• Employee Wellness clearance is needed
for the use of: removable splints, casts,
walking boots, crutches, walkers, canes or
any assistive devices, etc…while at work.
Safe Patient Handling (SPH)
• Safe patient movement and handling benefits patients.
The potential for patient (falls or skin tears) and staff
(strains/sprains) injury as a consequence of manual
handling is reduced by using assistive equipment and
devices. Equipment and devices provide a more secure
process for lifting, transferring or repositioning patients.
Patients are afforded a safe means to progress through
their care, have less anxiety, are more comfortable, and
maintain their dignity and privacy. Assistive patient
handling equipment can be selected to match a patients
ability to assist in his or her own movement, thereby
promoting patient autonomy and rehabilitation.
SPH cont…..
Safe patient movement and handling benefits healthcare workers.
Patient handling tasks are recognized as the PRIMARY cause for
musculoskeletal disorders among healthcare workers.
CRH patient handling equipment:
Tempo Lift: floor model can handle patients up to 440#’s;
MaxiSky: overhead lift system, can handle patients up to 600#’s;
Slip Sheets: new draw sheet with slippery texture that allows less
friction when repositioning patient
HoverMat: blow up mattress with NO weight limit for lateral transfers
HoverJack: blow up mattress’ (3) that can lift a patient off the floor to
bed height.
The National Institute for Safety recommends a 35 lb. maximum
weigh limit for use in handling tasks.
Injury Prevention & Other Benefits of Safe Lifting:
o Caregiver injury prevention
o Improved clinical outcomes for patients
o Greater patient protection, safety & comfort
o Workers’ Compensation and related cost savings
• Employees are NOT to enter any construction
area, at any time. This is for your safety.
Please know that construction dirt, dust, smoke, or noxious fumes may be
released into the air during construction, and can enter the ventilation
system and lower the entire facilities air quality. Some safety items you may
encounter while construction is being done:
Hepa filters – clean the air,
Sticky mats – at entrances and exits to construction areas (clean the shoes of workers so
they do not track debris around the hospital),
Closed off areas – allow construction to continue with minimum amount of disturbance
to patients and staff.
If you have any concerns regarding construction safety or health related
issues – you may contact:
Facilities Department x4336, Infection Control x4385, Employee Wellness
Misconceptions about the flu…
Q: Can a flu shot give you the flu?
A: No, a flu shot cannot cause flu illness. The influenza viruses contained in a flu shot
are inactivated (killed), which means they cannot cause infection. Flu vaccine
manufacturers kill the viruses used in the vaccine during the process of making
vaccine, and batches of flu vaccine are tested to make sure they are safe.
Q: Why do some people not feel well after getting the seasonal flu shot?
A: The most common side effect of seasonal flu shots in adults has been soreness at the
spot where the shot was given, which usually lasts less than two days. The soreness
is often caused by a person’s immune system making protective antibodies to the
killed viruses in the vaccine. These antibodies are what allow the body to fight
against flu. The needle stick may also cause some soreness at the injection site.
According to the Advisory Committee on Immunization Practices (ACIP), rare
symptoms include fever, muscle pain, and feelings of discomfort or weakness. If
these problems occur, they are very uncommon and usually begin soon after the
shot and last 1-2 days.
Q: What about people who get a seasonal flu vaccine and still get sick with flu-like
A: There are several reasons why someone might get flu-like symptoms even after they have been
vaccinated against seasonal flu.
1. People may be exposed to one of the influenza viruses in the vaccine shortly before getting
vaccinated or during the two-week period that it takes the body to gain protection after getting
vaccinated. This exposure may result in a person becoming ill with flu before protection from
the vaccine takes effect.
2. People may become ill from non-flu viruses that circulate during the flu season, which can also
cause flu-like symptoms (such as rhinovirus). Flu vaccine will not protect people from respiratory
illness that is not caused by flu viruses.
3. A person may be exposed to an influenza virus that is very different from the viruses included in
the vaccine. The ability of a flu vaccine to protect a person depends largely on the similarity or
"match" between the viruses or virus in the vaccine and those in circulation. There are many
different influenza viruses.
Unfortunately, some people can remain unprotected from flu despite getting the vaccine. This is
more likely to occur among people that have weakened immune systems or the elderly.
However, even among these people, a flu vaccine can still help prevent complications.
Seasonal influenza vaccine provides the best protection available from seasonal flu—even when the
vaccine does not exactly match circulating seasonal flu strains, and even when the person getting
the vaccine has a weakened immune system. Vaccination can lessen illness severity and is
particularly important for people at high risk for serious flu-related complications and close
contacts of high-risk people. Children younger than 6 months old are the pediatric group at
highest risk of influenza complications, but they are too young to get a flu vaccine. The best way
to protect young children is to make sure members of their household and their caregivers are
Q: Is it too late to get vaccinated ?
A: No. Vaccination can still be beneficial as long as influenza viruses are circulating.
CDC recommends that providers begin to offer influenza vaccination as soon as
vaccine becomes available in the fall, but if you have not been vaccinated by
Thanksgiving (or the end of November), it can still be protective to get vaccinated in
December or later. Influenza is unpredictable and seasons can vary. Seasonal
influenza disease usually peaks in January or February most years, but disease can
occur as late as May.
Q: Is the "stomach flu" really the flu?
A: No. Many people use the term "stomach flu" to describe illnesses with nausea,
vomiting or diarrhea. These symptoms can be caused by many different viruses,
bacteria or even parasites. While vomiting, diarrhea, and being nauseous or "sick to
your stomach" can sometimes be related to the flu – more commonly in children
than adults – these problems are rarely the main symptoms of influenza. The flu is a
respiratory disease and not a stomach or intestinal disease.
Q: What are the symptoms of the flu?
A: The flu can cause mild to severe illness, and at times can lead to death. The flu is
different from a cold. The flu usually comes on suddenly and you can spread the virus
one day prior to symptoms starting. Flu symptoms include:
• A 100oF or higher fever or feeling feverish (not everyone with the flu has a fever)
• A cough and/or sore throat
• A runny or stuffy nose
• Headaches and/or body aches
• Chills and Fatigue
• Nausea, vomiting, and/or diarrhea (most common in children)
Employee Drug-Free
Workplace Education
• Working Partners for an Alcohol- and
Drug-Free Workplace
• Provided by the Office of the Assistant Secretary for Policy
U.S. Department of Labor
Overview of Drug-Free
• Accomplishes two major things:
• Sends a clear message that alcohol and
drug use in the workplace is prohibited
• Encourages employees who have problems
with alcohol and other drugs to voluntarily
seek help
The Drug-Free Workplace exists to:
• Protect the health and safety of all employees,
customers and the public
• Safeguard employer assets from theft and
• Protect trade secrets
• Maintain product quality and company integrity
and reputation
• Comply with the Drug-Free Workplace Act of
1988 or any other applicable laws
Impact of Substance Abuse in
the Workplace
Employee Health – People who abuse alcohol or other drugs tend to
neglect nutrition, sleep and other basic health needs. Substance abuse
depresses the immune system. Its impact on the workplace includes higher
use of health benefits; increased use of sick time and higher absenteeism
and tardiness.
Productivity – Employees who are substance abusers can be physically
and mentally impaired while on the job. Substance abuse interferes with
job satisfaction and the motivation to do a good job. It’s impact on the
workplace includes reduced output; increased errors; lower quality of
work and reduced customer satisfaction.
Decision Making – Individuals who abuse alcohol and/or other drugs
often make poor decisions and have a distorted perception of their ability.
Here, substance abuse’s impact on the workplace includes reduced
innovation; reduced creativity; less competitiveness; and poor decisions,
both daily and strategic.
Impact of Substance Abuse in
the Workplace
Safety – Common effects of substance abuse include impaired vision, hearing and
muscle coordination and low levels of attention, alertness and mental acuity. Its
impact on the workplace includes increased accidents; and more workers’
compensation claims.
Employee Morale – The presence of an employee with drug and/or alcohol
problems creates a strain on relationships between coworkers. Organizations that
appear to condone substance abuse create the impression that they don’t care.
Impact on the workplace includes higher turnover; lower quality; and reduced team
Security – Employees with drug and/or alcohol problems often have financial
difficulties, and employees who use illegal drugs may be engaging in illegal activities in
the workplace. In this area, substance abuse’s impact on the workplace can include
theft and law enforcement involvement.
Finally, substance abuse impacts Organizational Image and Community
Relations – Accidents, lawsuits and other incidents stemming from employee
substance abuse problems may receive media attention and hurt an organization’s
reputation in the community. The impact on the workplace includes reduced trust
and confidence; and reduced ability to attract high-quality employees.
Signs and Symptoms of
Substance Abuse
Emotional effects of substance abuse:
Behavioral effects of substance abuse:
Slow reaction time
Impaired coordination
Slowed or slurred speech
Excessive talking
Inability to sit still
Limited attention span
Poor motivation or lack of energy
Physical effects of substance abuse:
Weight loss
Smell of alcohol
Specific Drugs of Abuse
• Alcohol
• Depressants
• Marijuana
• Hallucinogens
• Inhalants
• Narcotics
• Cocaine
• Stimulants
• Designer Drugs
All drugs, including alcohol, chemically alter the mind and body. As a result, use of
drugs and/or alcohol can impair motor skills, hinder judgment, distort perception,
decrease reaction time and interfere with other skills necessary to do a job safely and
Assistance is available
• Difficulty performing on the job can sometimes be caused by
unrecognized personal problems - including addiction to
alcohol and other drugs
• Help is available
• Although a supervisor may suspect that an employee’s
performance is poor because of personal problems, it is up to
the employee to decide whether or not that is the case
• It is an employee’s responsibility to decide whether or not to
seek help
• Addiction is treatable and reversible
• An employee’s decision to seek help is a private one and will
not be made public
CRH Substance Abuse Policy
• Located online in Policy Manager
– Policy# 627.0
– EAP and Employee Wellness are here to help you
– Confidentiality is assured
– If you have any questions, please contact HR,
Employee Wellness or your direct supervisor.
Mandatory Annual Safety Education
The Fire Triangle
• The three “sides” of the fire triangle are a fuel source,
an air (oxygen source), and heat (ignition source).
• For any fire to occur, all three components of the fire
triangle must interact. For example, if a patient is having
facial surgery and receiving supplementary oxygen
(oxygen source) at the same time that an active
electrode (ignition source) is being used, and if the
active electrode tip accidentally touches the patient’s
drape (fuel source), they could ignite in the oxygenenriched environment and a fire could occur.
Fire Safety
R = rescue
A = alarm/Announce
C = contain
E = extinguish
Rescue anyone in immediate danger. Sound the fire alarm through the
nearest pull station and announcing the fire location overhead. Announce
overhead by dialing 777 from any hospital phone and repeating Code Red
+ Location three times. If there is more than one staff member in the
area of origin, designate one staff member to pull the alarm while the
other announces the fire overhead. All corridors should be cleared
and doors should be closed to contain fire.
If you are away from the fire’s point of origin and hear the fire alarms
sound, you should remain in your current location until the Code Red is
canceled. Do not breach fire doors while the fire alarm is activated.
Fire Extinguishers
– Pull the pins between the handles of the
– Aim the nozzle at the base of the fire
– Squeeze the handles together
– Sweep from side to side
“Fire First Responders” at CRH include staff
members from Facilities Management, Security
and Housekeeping. Members from these
departments are trained to respond to the site
of the fire with an extinguisher.
Fire Drills
CRH is required to complete a fire drill at least once per shift per quarter.
During fire drill we evaluate that staff know when and how to sound the fire
alarms, when and how to transmit to off-site fire responders, how to contain
smoke and fire, how to transfer patients to areas of refuge (as necessary); how
to use the fire extinguisher, and how to prepare for building evacuation.
After any activation of the fire alarm, each department should fill out a
“departmental fire drill critique” and send to Facilities Management. This
allows us to get feedback from all areas of the hospital even if they aren’t
directly observed by the fire drill team. This document is attached to the
Code Red plan in your Emergency Preparedness & Response Guide in Policy
• In a fire situation, you may be called on to help evacuate patients, patient
information, and medical equipment. In most cases, this will involve moving to
another compartment in our facility, but in extreme cases we may need to
evacuate the entire building to another location.
• If an evacuation order has been given, use the pillow system for tagging the
rooms already evacuated to avoid unnecessary backtracking.
Mandatory Annual Safety Education
Regulated Medical Waste
Cultures and stocks
Pathological waste
Human blood and blood products
Sharps, including needles, scalpels, blades, lab slides
Isolation waste
Blood or drainage-soaked dressing
Disposable items that could release blood or other potentially infectious materials if
Laboratory waste
IV tubing with visible blood
Regular Waste
Disposable gloves
Slightly soiled dressings
Glass products
Our Laundry Department does have the capability to launder blood soaked linens. Do not
put in red bag containers
Do not dispose of regular trash in red bag containers. Red bag trash cost 10x more to
dispose of than regular trash.
Label Elements
Global Harmonization requires that labels follow strict guidelines and
include the following elements:
Product Identifier - This is how the chemical is identified, which could
be chemical name, code or batch number. This is determined by the
manufacturer, importer, or distributor.
Signal Word - The signal word will either be “Danger” or “Warning” to
reflect the hazard class of the chemical. Danger will reflect more severe
hazards; warning will reflect the less severe hazards.
Hazard Statements - These statements describe the nature of the
Precautionary Statements - This is a phrase that will describe
recommended measures to minimize or prevent adverse effects resulting
from chemical exposure.
Pictograms - There are eight pictograms that identify chemical hazards.
They are pictured on next slide
Safety Data Sheet (SDS)
All Safety Data Sheets (SDS) will consist of these 16 sections:
Section 1, Identification (Product)
Section 2, Hazard(s) Identification
Section 3, Composition/Information on Ingredients
Section 4, First-Aid Measures
Section 5, Fire-Fighting Measures
Section 6, Accidental Release Measures
Section 7, Handling and Storage
Section 8, Exposure Controls/Personal Protection
Section 9, Physical and Chemical Properties
Section 10, Stability and Reactivity
Section 11, Toxicological Information
Section 12, Ecological Information*
Section 13, Disposal Considerations*
Section 14, Transport Information*
Section 15, Regulatory Information*
Section 16, Other Information... includes the date of preparation or last revision.
* Denotes optional information
What should you know specific
to your department?
When PPE is necessary for job tasks
What PPE is necessary for job tasks
Where PPE is located
How to properly don, doff, adjust, and wear PPE
Limitations of PPE
Care, maintenance, useful life and disposal of PPE
Chemicals should be stored with like hazards and no higher
than eye level.
If you have any questions about required PPE in your
department, ask your director or supervisor
Hazmat Spills
– Don’t clean up a spill of any hazardous material unless you have
the training and equipment to do so.
– Alert others in the area of the hazmat spill. Alert the Facilities
Management Department, x8840, Employee Wellness, x4102
and Safety Officer, x4164.
– If possible, keep the area ventilated.
– If possible, try to contain the spill with absorbent materials until
the spill responders arrive.
– If possible, get a copy of the Safety Data Sheet (SDS) to assist
the responders.
– Turn off all ignition and heat sources if possible.
• Two Ways to Get a Copy of an SDS
– 3E Company Fax-On-Demand 800-451-8346
• Use this method if you have had an exposure or spill. 3E
Company has Safety Specialist/Toxicologist on staff who can
help you with initial first aid information and clean-up
– 3E Company On-line
• Go to Log In is CRH and the Password
is MSDS. After you are signed in, you can search for the
product by name, hit enter, and you will have a chance to
view/print a copy of the SDS.
Culpeper Regional Hospital
Infection Prevention & Control
Tina Myers, RN, BA
Shirley Ann Bayne, RN, BSN, MSHA
What is the role of Infection
Prevention & Control (IP&C)?
• Assess, analyze, and eliminate the risks of hospital acquired
infections (HAIs)
• Conduct surveillance activities
• Monitor trends in anti-microbial resistance
• Educate clinical staff about strategies to prevent infection
• Participate in performance improvement and patient safety
• Ensure that evidence based infection prevention practices
are used
• Identify and manage infectious outbreaks
• Monitor the effectiveness of the IPC program
• Communicate with staff & leadership
Infection Prevention & Control
Works to Break the Chain of
The single MOST important
measure in preventing infections!
Our expected hand hygiene
compliance is 100%
Proper hand hygiene means
that you wash your hands or
use hand sanitizer every time
you enter and exit a patient’s
room and after every patient
Standard Precautions
• Previously called Universal Precautions
• Assumes blood and body fluid of ANY
patient could be infectious.
• Recommends personal protective
equipment (PPE) and other infection
control practices to prevent transmission of
• PPE use should be determined based on the
type of clinical interaction occurring
between the HCW and patient.
Personal Protective
Equipment (PPE)
Goggles/Face Shields
PPE Storage Cart or Caddy
YOU are responsible for using the correct
size of PPE
• YOU are responsible for wearing PPE at
the appropriate times
When to use PPE…..
Wear GLOVES when there is a likelihood of
Body fluids, secretions, excretions (such as emptying a foley bag
or drawing blood)
Mucus membranes
Any non-intact skin or wounds
Wear a GOWN during:
Patient care activities when anticipating contact of clothing or exposed skin
– blood/body fluids
– secretions
– excretions
When to use PPE…..
Mask , goggles and/or a face shield – Use
during patient care activities
• that generate splashes or sprays of
body fluids
• when patients are coughing
Order to Don PPE
Order to Remove PPE
Wash Hands
Wash Hands
• Droplet
• Airborne
Used for infectious
organisms that can
be spread by direct
OR indirect contact.
PPE Required
• Must wear gloves and
gown, except when in the
“safe zone”.
• Organisms can “hitch” a
ride on clothes, hands,
medical equipment and
transfer to the next
Safe Zone for
Contact Isolation
The safe zone is the area located in the vestibule of a patient care room
in which isolation PPE is not required for contact isolation as long as a
staff member remains in this area and does not touch any part of the
walls, curtain, or other objects in the room. Staff members are still
expected to perform hand hygiene.
• Can be spread by large
particle droplets.
• Requires close contact,
usually within 3-6 feet of
patient for transmission.
PPE Required
• Surgical mask
• Gloves, if handling
• Pathogens that can be
transmitted via the airborne
• Remains in environment for
extended period of time.
PPE Required
• N95 respirator or PAPR prior to
entering room.
• Patient must be in negative
pressure room with door
Why should we be concerned?
Patient safety:
• Prevent the transmission of organisms within the
• The Joint Commissions 2010 National Patient Safety
Goal 07.03.01: Implement evidence-based practices to
prevent Healthcare Associated Infections (HAIs)
• Due to multi-drug resistant organisms (MDROs) in
acute care hospitals.
• Difficult to treat
• Treatment can encourage colonization of other MDROs
• Increase length of stay
• Implicated in many Healthcare Associated Infections
National Patient Safety Goal to identify those with
MDRO and to prevent HAI
Monitoring Negative
 Air flow indicator devices are available on all
negative pressure rooms for continuous
 Report any malfunctions to Facilities
 Periodic checks are required to maintain the
desired negative pressure and the optimal
operation of monitoring devices.
 Facilities Management is responsible for
monitoring and will be logged weekly.
System in place to monitor positive/negative
pressure rooms. Ping Pong balls should be:
• Positive Pressure – outside room;
• Negative Pressure – inside room
Transporting a Contact
Isolation Patient
Assisting staff should perform hand hygiene and
wear gown and gloves.
Via bed:
• Wipe handrails and head/foot boards of bed.
• Patient should have clean top sheet placed
over bed.
• Patient should wash his/her hands upon
entry/exit to the room.
Via wheelchair:
• Clean gown should be placed on patient.
• Place clean top sheet over patient.
Transporting a Droplet
Isolation Patient
• Patient wears surgical mask if
leaving room for diagnostic tests.
• Mask should NOT be removed
until patient returns to his/her
• If mask must be removed from
patient, then HCW MUST wear
surgical mask.
Transporting an Airborne
Isolation Patient
• Visitors wear surgical mask.
• Patient wears surgical mask if
leaving his/her room for diagnostic
tests and must not remove it.
• HCW should NOT wear a mask
when transporting the patient.
Multi Drug Resistant
These highly resistant organisms require special
attention and Contact Isolation in healthcare facilities.
Methicillin (oxacillin) Resistant Staphylococcus aureus
Vancomycin Intermediate Staphylococcus aureus
Vancomycin Resistant Staphylococcus aureus
Vancomycin Resistant Enterococcus
Clostridium difficile – MUST wash hands w/ soap
& water for 15 seconds.
Carbapenem-resistant klebsiella pneumoniae
Transmission of MDROs can occur through
direct or indirect contact
• Direct: contact with contaminated body fluid
• Indirect: contact with contaminated surfaces
(linen, siderails, bedside tables etc…)
• Controlling transmission of MDRO’s involves all
departments and medical staff – thorough
cleaning of all surfaces in patient rooms and
multi-use items (stethoscopes, BP cuffs)
• Proper hand hygiene must be performed by all!
CDC guidelines to reduce
 Surveillance
 Measurement of Interventions
 Infection Control
 Hand Hygiene
 Consistent use of Standard precautions for all
 Contact isolation for all those colonized/infected
with MDRO-additional as indicated
 Proper use of PPE by all staff
 Environmental and Patient Care Equipment Cleaning
Environmental and Patient
Equipment Cleaning
• Before patient care use
• After patient care use
• All high touch areas such as side rail, call
bell, telephone, overbed table, equipment
handles, datascope, pulse oximeter,
accucheck, and baby scales
Infection vs. Colonization
• Infected means the organism is present and
patients show specific signs or symptoms of
bacterial invasion of a specific organ, such as the
lung in pneumonia.
• Colonized means the organism is present and
patients show no signs or symptoms, but still
could spread the MDRO from person to
• While the greatest concern is for patients
infected with an MDRO, other patients may
simply be colonized with these bacteria but are
still capable of spreading it to others.
Hospital Acquired
Infections/Conditions (HAIs/HACs)
• Healthcare-associated infections are estimated
to occur in 5% of all hospitalizations in the
United States.
• Healthcare-associated infections result in longer
length of stay, mortality and healthcare costs.
• In 2002, an estimated 1.7 million healthcareassociated infections occurred in the United
States, resulting in 99,000 deaths.
• In March 2009, the CDC released a report
estimating overall annual direct medical costs of
healthcare-associated infections that ranged
from $28-45 billion.
Monitoring HAIs
CRH monitors the following HAIs:
• Central Line Bloodstream Infection {CLABSI},
• Ventilator Acquired Pneumonia {VAP},
• Catheter Associated Urinary Tract Infections
• Clostridium difficile
• Surgical Site Infections {SSIs}
• MRSA infections
is a member of the Infection
Prevention & Control Team!
Infection Prevention = Patient Safety
Mandatory Annual Safety Education
 See It – Be on the lookout for unsafe situations
and recognize Red Flags that warn of potential
 Say It – Communicate what you see to your
team members – make sure you tell the people who
can make the needed changes
 Fix It – Take action – don’t stop until the issue
is resolved
If you have a concern about something that poses an immediate
threat to a patient’s safety you should:
by taking immediate action to prevent patient harm
If you are aware of any unusual incident that has harmed a
patient or that could harm a patient:
1. Notify a supervisor, manager or administrator on call
2. Complete an incident report in the rL Solution system
3. Phone the Patient Safety Officer at 829-8825
When you need to be sure to get a response when
immediate action is needed (to “Stop the Line”, you
can use an assertive statement.
Use this model:
Get Attention – Call the person by name
Express Concern – Use an “I” statement – I’m
concerned, I’m uncomfortable
State the Problem – Be brief, clear and objective
Propose a Solution – Use a “we” or “let’s”
statement – “We should stop and double
check this,” “Let’s get some help”
The following are important members of your team as an
employee at Culpeper Regional Hospital and a healthcare
People in your department
People in departments who you work with most days
People in departments who you don’t work with often
Members of the Medical Staff
Board of Trustee Members
Members of the Auxiliary (Pink Ladies)
And the most important member of the team…
And the most important member of the team…
…Our patients
and their families
How do we include our patients as members of the
Communicate with Them
 Listen to what they have to say
 Ask them what they need
 Ask them if they understand
 Let them know what to expect
 Tell them what you are doing while you are in
their room
 Include them in the discussion about their plan
of care
 Listen as much as you talk!
Communication failure
Lack of effective training
Memory lapse
Poorly designed equipment
Exhaustion, fatigue
Failure to follow policy
Poor communication or
failure to communicate with
members of the healthcare
team (including our patients
and their families) is the
number one cause of
medical errors that harm
To improve patient safety, CMS (Centers for
Medicare & Medicaid Services) along with most
insurance companies will not pay the hospital for
“never events” when they occur in the hospital.
Some of the Never Events are:
Air embolisms
Blood incompatibility for transfusions
Catheter-related urinary track infections (CAUTI)
Patient fall with an injury
Object left in following surgery
Pressure ulcer (Stage 3 or 4)
Central Line Associated Bloodstream Infection (CLABSI)
Deep Vein Thrombosis (DVT)
You can find information about the quality
of care delivered by the hospital on these
On these websites you will find information
in regards to patient satisfaction, patient
safety, and quality of care for certain
Excellent websites to learn more about healthcare
quality and patient safety
 (Institute for Healthcare Improvement (Agency for Healthcare Research
and Quality (National Patient Safety Foundation (National Quality Forum) (The Joint Commission)
• Suicide is the 10th leading cause of death in the US
• Nearly 4% of the adult population report thinking
about committing suicide in the past year
• Nearly 16% of high school students report thinking
about suicide in the past year
• Females are more likely to think about suicide
• Males are more likely to act on thoughts of suicide
• Suicide affects everyone!
But some groups are at higher risk than others:
• Men are about 4 times more likely than women to die from
• However, 3 times more women than men report attempting
• Suicide rates are high among middle aged and older adults, as
well as teens
Several factors can put a person at risk for attempting or committing
suicide. But, having these risk factors does not always mean that
suicide will occur.
Risk factors for suicide include:
• Previous suicide attempt(s)
• History of depression or other mental illness
• Alcohol or drug abuse
• Family history of suicide or violence
• Physical illness
• Feeling alone or hopeless
• Major life change like job loss or relationship loss
These are some of the warning signs to look for:
• Talking about wanting to die or to kill themselves.
• Looking for a way to kill themselves, such as searching online or
buying a gun
• Talking about feeling hopeless or having no reason to live.
• Talking about feeling trapped or in unbearable pain.
• Talking about being a burden to others.
• Increasing the use of alcohol or drugs.
• Acting anxious or agitated.
• Sleeping too little or too much.
• Withdrawing or isolating themselves.
• Showing rage or talking about revenge.
• Displaying extreme mood swings
The risk of suicide is greater if a behavior is new or has increased
and if it seems related to a painful event, loss, or change.
If you or someone you know exhibits any of these signs, seek help
as soon as possible
Where to get help:
• National Suicide Hotline at 1-800-273-TALK (8255).
• If they are a hospital patient, ask the doctor to call the
Community Service Board (CSB)
• If they are not a hospital patient, get them to the Emergency
• If the risk seems immediate, call 911
• Ask the doctor to consult CSB
• If you’re not involved in the patient’s care, you may
choose to speak with the nurse caring for the patient
• If CSB has already seen the patient and you’re still
concerned, they can be called to send another case
worker to talk to the patient
When you’re concerned about someone’s risk for
hurting themselves, always take the time to find
someone who can help.
There are some things that help people who are thinking of suicide
choose not to act on their thoughts:
• Treatment for mental and substance use disorders
• Restricted access to highly lethal means of suicide
• Strong connections to family and community support
• Support through ongoing medical and mental health care
• Help with skills in problem solving, conflict resolution and handling
problems in a non-violent way
• Support from a religious leader or faith community
Mandatory Annual Safety Education
Radiation Awareness:
 Radiation
awareness and safety is
everyone's business.
 A common misconception some people
have is that you can only be exposed to
sources of ionizing radiation in the Medical
Imaging department.
 Actually, you may be exposed to sources of
ionizing radiation throughout the hospital.
Radiation Awareness:
Radiation is the transmission of energy in
the form of electromagnetic waves or fast
moving particles. There are two forms:
Ionizing Radiation: Radiant energy that causes an
ionization of an atom , removal or addition of an
electron. *Sun, nuclear weapons, radon gas, x-rays, gamma rays, alpha and beta particles.
 Non-Ionizing Radiation: Radiant energy that only
causes an excitation of an atom. *Microwaves, cell phones.
Common Areas Where
Employees May Be Exposed
To Radiation:
 Medical
Imaging Department
 Operating Room
 Emergency Department
 Cafeteria/Coffee Shop
 Hospital Lobby and Waiting Rooms
 Halls and Elevators
Sources of Ionizing Radiation:
X-ray exams which are being performed portably
in the ED, OR, or in Inpatient rooms.
 C-Arm fluoroscopy procedures performed in the
Operating Room.
 Any patient who has had a nuclear medicine
procedure, in which they received an
administration of radioactive pharmaceutical.
These individuals are still radioactive long after
they leave the medical imaging department.
Radiation Safety Key Concept:
ALARA is an acronym for the radiation
safety philosophy in which one tries to
reduce their radiation exposures by keeping
them “As Low As Reasonably Achievable”.
You can achieve this goal by employing the
techniques outlined in the Golden Rule of
radiation protection.
Radiation Safety Key Concept:
The “Golden Rule” of radiation protection is
Time, Distance and Shielding.
Time: Do not linger around an area of potential
radiation exposure any longer than you need to in
order to accomplish the task at hand.
 Distance: Maintain the greatest distance you can
between you and the source of radiation at all
times. At least 6ft from a patient having a x-ray.
 Shielding: Use appropriate shielding techniques to
reduce the amount radiation you receive.
Radiation Safety Measures:
Shielding Techniques:
Staff wear personal
protective equipment;
such as, lead aprons, lead
lined gloves, and even
lead eyewear to protect
Radiation Safety Measures:
Shielding Techniques:
Structural shielding built
into the exam room helps
to reduce staff exposures.
Mobile barrier shields can
be utilized in areas that do
not have fixed shielding to
reduce staff exposures.
Lead curtains fixed to
exam tables help shield.
Radiation Safety Measures:
Signs or placards are displayed
in areas where radioactive
materials are used and stored or
where x-ray procedures are
performed. They alert and warn
individuals of a possible
radiation exposure.
While in medical imaging, you
can do your part to reduce unnecessary radiation exposures
by knocking before entering an
exam room.
Radiation Protection Program:
Culpeper Regional Hospital is required by state and federal
regulations to administer and maintain a radiation safety
The Radiation Safety Officer(RSO) is typically responsible
for managing this program in order to make sure all
aspects of the program are being observed.
Dr. David Weber is our RSO here at CRH. You can
contact him by calling the nuclear medicine department at
ext. 4151 or by calling the medical imaging department at
ext(s). 4144/4145 after normal business hours.
Radiation Protection Program:
As part of the radiation protection program, the RSO
checks to make sure that the occupational radiation dose
for individual employees does not exceed 10% of the
maximal allowable adult dose limit/year as defined by the
NRC and the State of Virginia.
Medical Imaging and OR staff wear Film Badges and/or
TLD devices to record and measure their individual
occupational radiation exposures.
Radiation Protection Program:
In addition to the RSO, our medical health physicist from
Krueger-Gilbert Health Physics, Inc., assists in evaluating
and maintaining our radiation safety program.
The medical physicist comes to CRH at least once every
year to survey our imaging equipment, check our film
badge reports and evaluate our records. He does this to
ensure that everything is functioning properly and safely
within specified limits.
Mandatory Annual Safety Education
MRI Safety
Major Objectives for MRI Safety
Magnet Safety Considerations
MRI Site Access Restriction
MRI Safety Education
Magnet Safety
The Magnet is ALWAYS ON – and maintains the
potential for serious injury or death
When the magnet needs an emergency shutdown – it
will be quenched. The cost to restore the system after a
quench is over $50,000
All devices about to enter Zone 3 – must be positively
identified and/or tested to at least partially assess for
ferromagnetic concern / MR safety.
Patients with cardiac pacemakers can NEVER enter
Zones 3 or 4 and can NEVER have an MRI.
All external devices must be positively labeled as “MR
Safe” prior to being permitted to enter into Zone 4
Magnet Safety
No “codes”/resuscitative efforts should be run
in Zone 4
– Patient should be stabilized and removed
from the magnet room as soon as possible
and moved to Zone 2 – where emergency
personnel will be safe to perform the
necessary measures
MRI Accidents
An off-duty police officer who was a
patient - misunderstood the instructions
given by the Technologist and brought
his handgun into the magnet room. The
handgun became a projectile – struck the
magnet bore and despite two safety
mechanisms being engaged – the
handgun discharged – narrowly missing
the officer.
MRI Accidents
A firefighter in Germany responding to a
hospital fire, ran through an MRI room
with an oxygen tank strapped to his
back. He became sucked into the magnet
bore, fracturing his skull. As he tried to
free himself – the magnetic field took the
oxygen tank further into the magnet –
folding him in half and collapsing both
lungs. The magnet was quenched and he
was freed from the magnet and survived
his injuries.
MRI Accidents
A 6 year old boy who had just recovered from the
successful removal of an astrocytoma (brain tumor) was
having a pre-discharge MRI. The child was being sedated
for the scan – and during the procedure the
Anesthesiologist notice the wall oxygen was reading
empty. He tells this to the two Technologist who leave the
control room and the entrance to the magnet room - to
exchange the tank for the wall oxygen. The
Anesthesiologist becomes inpatient and begins to yell for
oxygen. A Nurse passing by hears the Physician call for
an order and brings an oxygen tank to the door of the
magnet room- where she is met by the Anesthesiologist.
He brings the tank into the room and as he approaches
the bore – the tank flies out of his hands – strikes the
child in the head and becomes lodged in the bore against
the child's head. The child dies several hours later from
these head injuries.
Four MRI Related Safety Zones
Zone 1: Public Access
Zone 2: Unscreened MRI patients and
Zone 3: Restricted Access / Badge Access
to MRI Control Room
Zone 4: The Magnet Room Itself
Site Access Restrictions
for Zone 3
Inside the MRI control room
The area around the MRI scanner
wherein free access by unrestricted nonMRI personnel and/or equipment can
result in serious injury or death
Non-MRI Personnel are ***NEVER*** to
unaccompanied access to Zone 3
Site Access Restrictions for Zone 4
Inside the magnet room -wherein free access
by unrestricted non-MRI personnel and/or
equipment can result in serious injury or
Non-MRI Personnel are ***NEVER*** to be
permitted unrestricted / unaccompanied
access to Zone 4
Site Access Restrictions for Zone 4
Before anyone (staff, patient, visitor) can
enter the magnet room, a screening form
must be completed and reviewed by an
MRI Technologist
Before entering the magnet room, (staff,
patient, visitor) must remove from their
person any watches, pagers, wallets,
pens, pencils, hair/money clips, jewelry,
keys, coins and any other items that
could become a projectile in the
presence of the magnetic field.
MRI Safety Education
All Hospital Staff and anyone with the potential need to be
in the MRI Scan Room area need to be trained in MRI safety
MRI Personnel receive extensive training in MRI safety
This training includes:
– The hazards of the magnet environment
– Patient heating issues
– Contrast agent safety
Any questions about MRI safety issues should be directed
to the MRI Technologists.
Mandatory Annual Safety Education
Safety Management
Every hospital has inherent safety risks associated
with providing care to patients and performing
daily activities. Some common safety risks of
which all employees should be aware are:
Back injuries
Exposure to radiation or other hazardous materials
Combative patients
Workplace violence
Slip, trip and fall hazards
Bloodborne pathogens
Property Damage
Safety Management
There are a number of ways our organization
identifies, minimizes and eliminates safety risks.
Some of these actions include the following:
Safety policies and procedures
Incident reporting systems
Proactive risk assessments and EOC tours
Data collection
Engineering controls
Safety Management
You are the eyes and ears of the hospitals efforts
to keep everyone safe! Should you witness a
safety incident, or if you are aware of conditions
or practices that create safety risks, you should
always report them to your department
director or the Hospital Safety Officer, Mark
Utz. You will NEVER be penalized for reporting
a safety concern.
Safety Management
Sometimes a risk or hazard can be fixed
immediately – for example, if a chair is blocking
an exit or there is a wet spot on the floor.
When possible, fix safety problems to prevent
immediate risks to patients, staff and visitors.
However, incidents should still be reported
because they may be symptoms of a bigger
problem. For example, the chair blocking an
exit can easily be moved, but it may indicate
furniture overcrowding or an inappropriate
room layout.
Safety Management
To further identify and address safety hazards in
the environment, CRH conducts regular
environmental tours or EOC Tours. These help
us determine the presence of unsafe conditions
and whether our current processes for
managing safety risks are being practiced
correctly and efficiently. EOC tours are
completed in patient care areas twice a year.
Safety Management
Data that is obtained during EOC tours is analyzed
and reported to the EOC Committee. Any
problematic findings are acted upon, and
appropriate feedback regarding problem
correction is provided to those affected.
Security Management
• Objectives Security Management
– To prevent security-related incidents
– To respond to and properly manage security
incidents that do occur.
– To provide general services that support the
achievement of CRH’s mission.
– To create an environment in which staff, visitors, and
individuals served perceive that they are interacting
in a safe and secure setting.
Expectations of all CRH staff:
– Report suspicious activity relative to visitors, other staff, or
– Report any security issues that make you feel uncomfortable.
– Use only assigned parking areas. Refer to light blue shaded
areas on Parking Map
– Appropriately wear/display CRH employee identification badge.
– Properly store and secure facility and personal property.
– Never loan or duplicate CRH-issued keys.
– Comply with all CRH Policies and Procedures.
– Work in cooperation with CRH Security Officers to ensure the
safety of your work area.
Identifying Staff, Patients and
• CRH staff members are identified by CRH color picture
badges that are worn above the waist. The badge must
be in plain view. This ID serves to verify personnel
identity, as well as to indicate staff status.
• Your ID badge is electronically equipped to
activate various security access control devices
in the facility.
• Patients in our facility are identified by
wristband. Staff members and patients can
recognize visitors by a lack of arm band or staff
ID badge.
Responsibilities of the Security
Patrolling the facility on foot.
Monitoring access to the building.
Locking and unlocking doors.
Issuing the proper identification badges to visitors, outpatients,
students, contractors, vendors and employees.
Securing valuables/property.
Monitoring/Reviewing security camera footage.
Ensuring the safety & welfare of staff from physical abuse by
patients, visitors or colleagues.
Responding to all security incidents and emergencies.
Workplace Violence
– The National Institute for Occupational
Safety & Health defines workplace violence as
– “any physical assault, threatening behavior,
or verbal abuse occurring in the workplace.”
Issues Contributing to Workplace
– Non-treatment issues contributing to Healthcare
Proliferation of guns and other weapons.
Gang activity.
Abusive domestic and personal relationships.
The influence of chemical abuse.
The opportunity for property crimes.
– Treatment issues contributing to Healthcare Violence
Frustration with inadequate resources.
Unrealistic expectations (often in relation to behavioral health)
Overcrowded care delivery environments.
Unreasonably long wait times for care.
Lack of perceived care giver respect
Lack of communication.
Types of Workplace Violence (WV)
– Spontaneous events: these are unpredictable and
represent 15% of all workplace violence events.
– Situational events: these are preceded by warning
signs. These type of events represent 85% of all
workplace violence events. The Security
Department offers Crisis Prevention
Intervention (CPI) class to train staff on how to
recognize and de-escalate potentially violent
situation. This class is educational and fun with many
hands-on activities. Sign up today - Mox Library.
Warning Signs of WV
– Pacing with a display of
being tense and angry
– Flushed face, twitching
face or lips, and shallow
– Darting or jerking eye
movements, rapid looking
– Making threats
– Demanding unnecessary
services or attention
– Making unwarranted
claims of entitlement
– Challenging authority,
invading personal space
– Making statements about
losing control (veiled
– Acting chronically
– Escalating loudness, often
with profanity
– Using overly aggressive
actions and language,
possibly due to
intoxication or drug abuse
WV De-Escalation Techniques
Stand at an angle to the disturbed
person, which is less
threatening than directly facing
Do not invade personal space;
stay at least 4’ from the
Do not maintain a rigid stance or
cause the individual to feel
Do not touch the individual
unless it is necessary to
manage extreme behavior
Move and speak clearly, calmly,
and confidently
Break eye contact with the
individual to reduce the
suggestion of aggression or
Show that your are listening to
the individual and respect
his/her feelings
Indicate that you want to help
resolve the situation and do
not make any promises you
can’t enforce
Clarify communication and ask
for specific responses.
Don’t get caught up in
challenges. Comment only on
the person’s behavior
Take all threats seriously
Staff involvement in Security
– Make an effort to remember conversations you may have
overheard before or during the incident
– Obtain identity information from persons who may otherwise
leave the area before security can interview them
– Memorize the physical description of perpetrators or others
who may have fled the scene
– Be alert for unusual behavior that may occur before security
responders arrive or while they are occupied managing the
– Reassure and support care recipients and other staff
– Maintain an appropriate level of confidentiality regarding details
of the incident
– Write down everything while it’s still fresh in your mind
Compliance, Risk & Regulatory
Patricia Sautel Slater, CPHRM, CHC CSHA
Compliance, Risk & Regulatory Officer
Health Care Oversight
Culpeper Regional
Doing the Right Thing
Compliance issues include
 Patient safety & quality issues
 Adhering to licensing and accreditation requirements
(Department of Health, The Joint Commission)
 Meeting all Medicare Conditions of Participation
 Correcting survey deficiencies
 Fraud & Abuse laws (Stark, Anti-Kickback, False
 Privacy & Security (HIPAA, HITECH)
 OSHA and Worker’s Compensation
 Employment Matters (ADA, FMLA, etc.)
Improper or fraudulent billing is the No. 1 compliance issue
Office of Inspector General
Submissions of accurate claims and information.
Self-referral and anti-kickback statutes.
Payments to reduce or limit services.
The Emergency Medical Treatment and Labor Act
Substandard care.
Relationships with federal health care program
HIPAA privacy and security rules.
Billing Medicare or Medicaid substantially in excess of usual
Self Referral
False Claims
Health Insurance Portability &
Accountability Act (HIPAA)
Federal law to protect patient privacy, confidentiality &
access to patient health information
 Access to patient information must be legitimate &
 CRH enforces compliance with training, policies &
 Privacy Officer for CRH is Patricia Sautel Slater
 Auditing of access is done through monthly audits
 Violations are subject to penalties & fines. Reporting
to the Department of Health for licensed staff.
Civil Penalties
Criminal Penalties
• Civil Monetary
• Treble Damages
• Discretionary
• Corporate Integrity
• Fines
• Prison Time
• Mandatory Exclusion
Implementing written policies, procedures, and standards
of conduct.
Designating a compliance officer and compliance
Conducting effective training and education.
Developing effective lines of communication.
Enforcing standards through well publicized disciplinary
Conducting internal monitoring and auditing.
Responding promptly to detected offenses and developing
corrective action.
Code of
Policies & Procedures
 Compliance Program
 Conflicts of Interest
 Disciplinary Action
 Document Retention
 Fair Treatment of Hospital
 Intellectual Property
 Impermissible Patient
 Kickbacks
 Occupational Safety
Patient Care
Patient Confidentiality
Patient Transfers
Relationships with Patients
Submission of Accurate
Healthcare Claims
 Tax Exempt Status
 Truth, Accuracy and
Completeness in Business
 Unfair Competition
Board of Trustees
Oversight Committee
Compliance Officer
“ The
Culpeper Regional Hospital
Compliance Program remains a top
priority for the Board of Trustees. Our
goals of quality care and patient safety will
be significantly enhanced by a strong
compliance program. The Board will
continue to support the efforts of our
compliance team.”
Thomas Reynolds, MD, Board Chair
Subcommittee of the Board of Trustees
Mechanism for direct Board involvement
Reviews the work of the Compliance
Committee and advises full Board on
Ensures the Board is aware of significant
compliance issues
In her role as Compliance
Officer, Ms. Slater is responsible
for ongoing development and
execution of the Compliance
The Compliance Officer is
supported in her duties by the
Compliance Committee and she
reports to the CEO and the
Patricia Sautel Slater,
Duties and Responsibilities:
 Oversees, monitors and modifies the
Compliance Program
 Reports to CEO and Board (Culpeper Class)
 Investigates suspected compliance violations
 Provides compliance training and education
 Etc.
Authority to review documents and information
necessary to carry out duties.
Assists Compliance Officer with development,
implementation & operation of Compliance Program
Meets regularly
Duties and Responsibilities
Assists in identifying legal duties and risks.
Assists in development and revision of policies .
Develops annual audit plan.
Monitors internal controls.
Develops strategies for detecting compliance violations.
Assists with reviews, audits, investigations, etc.
Reporting: Each employee is required, as a
condition of employment, to report any
practice that the employee believes does or
may violate the law, the Code of Conduct or
any Compliance Program policies or
Non-Retaliation: Persons reporting
compliance issues in good faith will not be
subject to retaliation or reprisal.
Compliance Officer: 829-5703 (internal x5703)
Compliance Hotline: 1-877-888-4806
Email: [email protected]
In person or in writing to Director, Supervisor
or Compliance Officer
Reports are kept confidential to the greatest
extent possible.
Persons filing reports are provided with
feedback regarding investigation,
substantiation/non-substantiation, and followup action taken.
If reported anonymously, must call back to
request feedback.
RL Solutions Reporting System
 Risk Management has responsibilities for overseeing the Incident Reporting
System (RL Solutions).
 Incident reports should be completed at the time of detection of the incident
(no later than 24 hours).
 Some examples of unexpected events include but are not limited to:
medication events, adverse drug events, patient/visitor falls, equipment
failure, property damage, injury related, diagnosis related, and treatment
related events.
 An incident report is not used to retaliate against an employee or used for
disciplinary purposes.
 An incident report is a confidential document that is not part of the patient’s
medical record.
 The appropriate director will research the reported incident and follow-up
 Any Hospital employee, medical staff member,
contractor or volunteer who violates the Code of
Conduct, Compliance Program policies or
procedure or any relevant law will be subject to
disciplinary action.
 All individuals who fail to comply will receive
consistent and appropriate discipline, regardless
of position.
 The Hospital will impose disciplinary action
equally to all executives, managers, supervisors,
and employees.
Abuse, Neglect & Domestic
 Virginia law requires reporting abuse & neglect
 Adult Abuse – 60 years or older or an adult who is
mentally incapacitated
 Child Abuse – 12 years and younger
• Mandated reporting if diagnosed with sexually transmitted
• Minor who has had sexual relations with adult (rape)
reportable to police
 Protection from immunity
Americans with Disability Act
Service Animals
Under the Americans with Disabilities Act (ADA), organizations that provide services to the public, such as
hospitals, must allow service animals (i.e. dogs that are trained to do work or perform tasks for an individual
with a disability) to accompany people with disabilities in all areas of the facility where the public is normally
allowed to go. Individuals with service animals cannot be isolated or treated less favorably than other patients.
You must accept an individual’s assurance that the dog is a service animal. The law prohibits asking
questions about the individual’s disability or for documentation regarding the service animal’s training. Staff
may ask two questions: (1) is the dog a service animal required because of a disability, and (2) what work or
task has the dog been trained to perform. Staff cannot ask about the person’s disability, require medical
documentation, require a special identification card or training documentation for the dog, or ask that
the dog demonstrate its ability to perform the work or task.
We cannot request that the service animal be removed from the premises unless: (1) the dog is out of control
and the handler does not take effective action to control it or (2) the dog is not housebroken. When there is a
legitimate reason to ask that a service animal be removed, staff must offer the person with the disability the
opportunity to stay and receive services without the animal’s presence. Prior to refusing access or
services please contact the Nursing Supervisor or Administrator on Call.
Honoring disabled individuals’ rights is of upmost importance to Culpeper Regional Hospital. Should you
have any questions regarding the ADA requirements or your responsibilities, please contact Patricia Slater at
The hospital is accredited by The Joint Commission which is known
as having the “gold standard” in quality of care and patient & staff
 Survey’s occur every 18 – 39 months after a previous full survey.
These survey’s are unannounced.
 Ongoing readiness is essential in patient and staff safety.
Everyone has a role in regulatory readiness!
 Patients and staff are informed on how to get answers to
questions about the safety and quality of care they receive
through the “Speak Up” brochure (see next slide). This is posted
in each patient treatment room and area. In addition all new
employees and medical staff receive this information.
Speak Up
Everyone has a role in making health care safe. That includes doctors, health care executives, nurses and
many health care technicians. Health care organizations all across the country are working to make health
care safe. As a patient, you can make your care safer by being an active, involved and informed member of
your health care team.
Speak up if you have questions or concerns, and if you don't understand, ask again. It's your body and you
have a right to know.
Pay attention to the care you are receiving. Make sure you're getting the right treatments and medications
by the right health care professionals. Don't assume anything.
Educate yourself about your diagnosis, the medical tests you are undergoing, and your treatment plan.
Ask a trusted family member or friend to be your advocate.
Know what medications you take and why you take them. Medication errors are the most common health
care errors.
Use a hospital, clinic, surgery center, or other type of health care organization that has undergone a rigorous
on-site evaluation against established state-of-the-art quality and safety standards, such as that provided by
Joint Commission.
Participate in all decisions about your treatment. You are the center of the health care team.If you have
questions about the safety or quality of the care you receive, please speak with your doctor or your nurse
about your concerns. You may also ask to speak with the charge nurse or nursing supervisor.
If you feel that your concerns are not addressed, please contact Hospital Administration (540) 829-4300.
If these concerns cannot be resolved, you may contact:
The Joint Commission Office of Monitoring at (800) 994-6610 or email [email protected]
Risk Management Program Goals
and Objectives
Risk Management has responsibilities for:
 Minimizing losses to the organization overall by proactively
identifying, analyzing, preventing, and controlling potential
clinical, business, and operational risks.
 Facilitating compliance with regulatory, legal, and
accrediting agency requirements (e.g., Joint Commission
and Centers for Medicare and Medicaid Services).
 Protecting human and intangible resources (e.g.,