New Employee Orientation - OneSource Program - Implemented on March 4, 2007 - top

NORTHWEST COMMUNITY HOSPITAL

NEW EMPLOYEE ORIENTATION

This orientation manual is designed to ensure all contract/agency personnel receive an orientation prior to working at Northwest Community Hospital. All contract/agency employees are expected to read, acknowledge and adhere to the Policies and Procedures provided within the Northwest Community Hospital - New Employee Orientation. In addition, all contract/agency personnel will be provided an on-site, department specific orientation.

TABLE OF CONTENTS

NCH First Floor Plan - PDF - view map

WELCOME TO NORTHWEST COMMUNITY HEALTHCARE!

1Our Mission, Vision and Values - Return to Top

Our Mission

Our Vision

Values and Guiding Principles

2EMERGENCY CODES Return to Top

Emergency codes are used to signal employees of a potentially dangerous situation, which may require action to protect patients. These codes are announced on the Hospital's overhead paging system when appropriate. When the danger is past, an "all clear" will be announced.

Code Black - Severe Weather Watch or Warning: When a severe weather watch is declared, a "Code Black" will be announced. All drapes and blinds throughout the building should be closed.

Code Blue - Medical Emergency: A "Code Blue" is called for cardiopulmonary arrest or any kind of severe distress requiring immediate medical or technical assistance. "Code Blue" and the location will be announced, and a medical emergency response team will respond immediately. To report a "Code Blue" situation (an individual in need of emergency care) dial 3333 for locations in the:

Note: Anyone on any NCH property who becomes ill or injured will be given a medical screening exam without question. Under the law (Emergency Medical Treatment and Labor Act-EMTALA) NCH routinely provides medical screening exams in the Emergency Department, Labor and Delivery, and all the Treatment Centers regardless of race, color, creed, or ability to pay.

Code Green – Utility Failure: When a utility failure has occurred, the affected area will notify the Administrative Supervisor. The Administrative Supervisor will decide whether or not to call a “Code Green”. A utility failure includes loss of electricity, water, medical gases or telecommunications.

Communication methods are discussed in the telephone disaster plan that provides a back-up phone system with limited access. Twoway radios will be distributed as appropriate, and messengers utilized as needed.

Mr. Strong: A "Mr. Strong" announcement brings physical assistance from other departments to an area when needed to subdue or restrain a disturbed patient or visitor. "Mr. Strong" responders have been identified by their department heads and will report to the area indicated in the "Mr. Strong" announcement. To call for assistance, dial 3333.

Code Orange - Fire Alarm Out of Service: Periodically it is necessary to perform preventive maintenance on the fire alarm system, taking it out of service temporarily. This is signaled by the announcement of "Code Orange." Code Orange does not occur at the Treatment Centers.

Code Gray – Hostile Intruder: Code Gray will be called in the event of a hostile intruder. Remove all persons from the immediate area, otherwise stay in your department. If unable to leave area, seek shelter behind closed doors. Personal safety should guide all decisions.

Code Pink - Abducted Newborn or child: A "Code Pink" will be called (with the age of the child or baby) at the first suspicion that the baby or child cannot be accounted for. Security and the Maternal-Child / Pediatrics Services handle the first response to a “Code Pink”, but all employees should be alert to any suspicious activity.

Code Purple Alert - Evacuation Plan Preparation: A "Code Purple Alert" will be called to indicate the preparation stage for an evacuation of the building. At this point, a decision to evacuate has been made, and Hospital personnel should prepare to evacuate as outlined in their departmental plans.

Code Purple - Evacuation Plan: A "Code Purple" is called when an actual evacuation from the building will begin. Hospital personnel should perform duties or exit the building as indicated in their departmental plans. All personnel should check in at their department's designated meeting place upon exiting the building.

Code Red – Fire: The announcement of "Code Red" signals a fire in the Hospital. (See Fire Safety section for more information about responding to a fire.)

Code Triage - Levels One, Two, Three & Four: A Code Triage will be called along with its' level. When a "Code Triage" is called, Hospital personnel who are in the building will follow the directions outlined in their department-specific plans. Off duty personnel should come to the Hospital only when called; they should not call the Hospital. When the plan is activated, all normal, non-patient care activities not necessary to the support of the disaster program will be temporarily stopped; all patient care activities for existing Hospital patients will be reduced to absolutely essential activities. Reference Administrative Policies 45, 45a & 45b.

3HAZARDOUS MATERIALS  - Return to Top

Northwest Community Healthcare is required to comply with the Hazard Communication Standard (HCS) set by federal OSHA regulations. All hazardous materials must be clearly labeled with the following information: the identity of the material, the manufacturer's name and address, and any health hazard or physical hazard.

Each employee, who works with or may be exposed to hazardous materials, either regularly or occasionally, will receive special training on the hazardous properties and safe use of those materials. Additional training will be provided each time a new hazardous material is introduced into the work area. The training will include symptoms of overexposure to hazardous materials, procedures to protect against hazards under both normal and emergency conditions, and first aid procedures where appropriate.

  1. OSHA (Occupational Safety Health Act) mandates that employees have a "right to know" about workplace hazards.
    1. Employee Health Service maintains logs and records related to occupational health issues and they are available upon request.
  2. OSHA Written Hazard Communication Standard involves the following:
    1. Written program and plan.
      1. Centrally located in Facility Support.
      2. Departmental plan covers chemicals in each department.
      3. Employee training
    2. Employee training about hazardous materials includes:
      1. The NCH Hazardous Materials policy is available online in the Administrative Policies and Procedures section under “Contents”.
      2. Department specific orientation for chemicals in your area, Check with your Supervisor/Manager for specific:
    3. Presence of chemicals
    4. Accidental release of chemicals
    5. Emergency procedures
    6. Health and safety concerns
    7. Material Safety Data Sheet (MSDS)
  3. MSDS - Material Safety Data (Call 1-800-451-8346):
    1. Chemical information sheets are prepared and provided by manufacturer on request.
    2. Contact the 3E Company when a spill occurs. Have available the product name, product number, manufacturer name, and UPC code. The 3E Company phone number is listed on all phones with a yellow sticker.

4FIRE SAFETY  - Return to Top

Northwest Community Healthcare has a detailed and comprehensive fire safety plan. The basic elements of the plan are fire prevention, protection of patients if fire threatens confinement of the fire to the area in which it starts, and avoidance of panic. Fire prevention is the responsibility of all employees. Employees should be alert for fire hazards, such as a collection of unnecessary papers or other combustible materials. Stairwell doors should be kept closed; self-closing doors are not to be wedged open. Corridors and exits should be kept clear of all obstructions. Each employee should note the locations of fire alarm boxes and fire extinguishers.

They should learn which type of fire extinguisher to use on certain types of fires and be familiar with the operation of the extinguishers. All employees are expected to know the basic fire safety rules and to act on them if a fire is discovered in their work area. Remember "RACE" & “PASS”:

The fire brigade will assume control. Fires of any kind must be reported immediately. If the fire is in another area, all employees should report back to their assigned work areas promptly.

How to Remember the Right Fire Extinguisher for the Type of Fire

Some tips that can help protect both employees and patients:

Smoke is the single greatest cause of fire fatalities. When smoke is detected, stay low and cover your nose and mouth with a damp cloth. Remember that even ambulatory patients may be incapacitated by smoke. Don't try to ventilate the smoke-filled area until the fire is located and under control. Ventilation may provide fresh oxygen to the fire and turn a small fire into a large one.

5INFECTION CONTROL - Return to Top

The organization has an infection control program designed to protect patients, employees, volunteers, and visitors. The goal of this program is to prevent hospital acquired infection.

Information about NCH’s Infection Control program can be found in the Infection Control Manual, which is located online under Infection Control and Employee Health.

The Infection Control Practitioner is available to answer questions at ext. 4370 or pager 5047 or the Administrative Supervisor at ext. 7933 or pager 0050.

Standard Precautions

Standard Precautions are to be used when caring for all patients regardless of presumed infection status with the use of Personal Protective Equipment (PPE). The type of PPE used is dependent upon the likelihood of contact with blood/body fluids. (See the Blood and Body Fluid Exposure List.)

Rationale

  1. Infectious agents as HIV, HBV, and HCV can be present in the blood and risky body fluid of people who appear to be perfectly healthy.
  2. Routine screening every patient for a potentially infectious disease would be impossible to do.

Hand washing – is the most effective infection control procedure and must be performed at the following times including but not limited to:

Hand hygiene can also be accomplished effectively with the use of alcohol-based hand rubs. Dispensers are located throughout all patient care areas.

Personal Protective Equipment (PPE) that may be needed:

Gloves
Wear gloves (clean, nonsterile gloves are adequate) when touching blood, body fluids, secretions, excretions, and contaminated items. Put on clean gloves just before touching mucous membranes and nonintact skin. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environments.
NOTE: gloves must be changed between patients.

Face Protection such as Masks, Goggles, Glasses
Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions.

Gowns
Wear a gown (a clean, nonsterile gown is adequate) to protect skin and to prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. Remove a soiled gown as promptly as possible, and wash hands to avoid transfer of microorganisms to other patients or environments

Needles and Other Sharp Instruments
Must be disposed of in a puncture resistant container. Needles must not be bent, broken, or recapped using two hands.

At a minimum an Assistive Ventilatory Device must be used when performing CPR.

Laboratory Specimens must be transported in a specimen bag.

Blood and Body Fluid Exposure List - RISKY

Infection Control Exposure

Report all exposures* regardless of your antibody status to Hepatitis B or previous vaccination with Hepatitis B vaccine.

  1. An *Exposure is sustained if an employee suffers:
    1. A laceration or puncture with a sharp instrument that is contaminated with blood/body fluid
    2. A human bite
    3. Blood/body fluid contamination of an open wound
    4. Oral ingestion of blood/risky body fluids
    5. Mucous membrane or conjunctival contact with the blood or risky body fluids of another person.
  2. Immediately wash the affected area with soap and water. Obtain the name of the exposure source (the patient) and report the exposure to your Supervisor and then proceed immediately to the Hospital's Employee Health Service (EHS) or Emergency Dept. if EHS is closed.
  3. When reporting to Employee Health Services (EHS) or the Emergency Department (ED), the employee must bring the Needle Stick/Body Fluid Exposure Report Form with them.

Transmission Based Precautions

If your patient is in isolation, you must use correct proper infection control procedures for that disease. These will be reported to you.

The three types of Transmission Based precautions are:

Respiratory Protection - Preventing the Spread of TB

Special controls at Northwest Community Healthcare help prevent the transmission of TB.

  1. Administrative
    1. Special policies and procedures located in each department.
    2. Education programs for staff.
    3. Documentation of care and record keeping.
    4. Criteria for early identification of persons with possible TB.
    5. Special signage - "Airborne Precautions"
  2. Engineering Controls - Negative Air Rooms - There are two rooms with special air flow (negative pressure rooms) on 4 North, one on 4S, 6 in ICU, one on 5N, one on 6N and one in the Emergency Room. Endoscopy, Surgical Prep Area (SPA) and Post Anesthesia Care Unit (PACU) also have negative pressure rooms. Patients with TB or those who meet the criteria for suspected TB will be placed in these rooms. The negative pressure system should be turned on and Engineering Service should be notified that negative pressure has been activated. It is very important to always keep the room doors closed for the airflow to work properly.
  3. Protective Equipment - "N95 Respirators" - This is a special mask that filters the TB droplet nuclei from the air. In order to use this respirator you need to be properly fit-tested, given a medical evaluation, education and training on proper usage. You MUST wear a N95 respirator if you enter a negative pressure room in which a person with known or suspected TB is being isolated, if you perform cough-inducing or aerosol-generating procedures on such persons, or you are in a setting where administrative or engineering controls are not likely to protect you from inhaling infectious airborne droplet nuclei. The only exception applies to visitors who are at NCH to see a patient who is in Airborne Precautions. Visitors will use a N95 respirator per instruction of unit nursing staff when entering the room of a patient in Airborne Precautions.

6RADIATION SAFETY Return to Top

Radiation Areas at Northwest Community Healthcare

Basic Principles of Radiation Protection:

Individuals may keep their occupational exposure to radiation As Low As Reasonable Achievable (ALARA) by following the three basic principles:

It is recommended that individuals efficiently use the time spent in the patient's room, maintain maximum distance from the radioactive source, and make use of any shielding devices provided. These are the common practices for keeping the radiation exposures received to a minimum.

Radiation Safety Information:

For additional information, or in case of an emergency, contact the Radiation Oncology Department at extension 6560 (Monday-Friday, 8am-4pm) and/or the Radiation Safety Officer at extension 6594. The Nursing Supervisor has a call list of the Radiation Oncologists and the Radiation Safety Officer for other times.

7CORPORATE COMPLIANCE - Return to Top

Doing Right Things Right!

What is “Ethical Conduct” – Doing the Right Thing

What is “Regulatory Compliance” – Doing the Thing Right

Corporate Compliance means:

The purpose of a Compliance program:

What resources provide guidance:

Patient safety concerns may be directed to the JCAHO’s Office of Quality Monitoring.

Individuals may call (800) 994-6610 regarding any questions. Complaints will not be taken over the phone.

What is ‘your’ personal obligation?

8CODE OF CONDUCT -  Return to Top

Dear Colleague and Fellow Employee,

For over four decades, Northwest Community Healthcare (“NCH”) has provided quality, compassionate healthcare services to the people of the northwest community. As an important part of this mission, we integrate ethical conduct standards and regulatory compliance into our approach to healthcare delivery and business management. The attached Code of Conduct is being provided to you to as a helpful resource that supports our care giving mission and the business integrity of NCH.

The purpose of the Code of Conduct (“Code”) is to provide guidance to ensure that our work is done in an ethical and legal manner. It emphasizes some of the most important laws and policies that we are expected to know and comply with as healthcare providers. It also identifies resources that can help answer questions about appropriate conduct in the work place. Please review it thoroughly.  Adherence to its spirit, as well as its specific provisions, is critical to our future.

If you have questions regarding this Code or become aware of any situation or behavior that you believe violates any provisions of this Code or other policies, you should immediately consult your supervisor, a Leadership Team member, or the NCH Compliance Director. You may also call the NCH Compliance Line at 1-888-203-2523. You have my personal assurance there will be no retaliation for asking questions or raising concerns about the Code or for reporting possible improper conduct.

Each of you plays an important role in creating a culture within NCH that supports the Values and Guiding Principles that are essential to achieving our mission. As a healthcare team, we are dedicated to excellence as a basic performance standard. Therefore, we expect all of our employee’s actions to reflect the high standards set forth in this Code.

In your daily work experiences, if you encounter a situation or are considering a course of action that you are not sure is the right thing to do, please don’t struggle alone. Instead, discuss the situation with any of the resources referenced above. We trust you as a valuable member of our healthcare team and ask you to assist us in supporting the underlying values and guiding principles, which are critical to achieving our mission.

Sincerely,

Bruce K. Crowther
President and Chief Executive Officer

Purpose of NCH Code of Conduct

The purpose of this Code of Conduct is to support our care giving mission within a framework of corporate integrity, honesty and compliance with applicable rules and regulations. These obligations apply to our relationships with patients, physicians, third-party payers, subcontractors, independent contractors, vendors, consultants, and one another.

The Code is an important part of our Compliance Program. The Board of Directors has adopted this Code to ensure that NCH has a formal compliance function and established standards of conduct to guide the staff in carrying out their duties and responsibilities. A current copy of the Code is maintained for reference in the Health Resource Library and in departmental copies of the Administrative

Policy Manual.

Your Personal Accountability - Who Should Read This?

Getting Help and Reporting Issues
NCH recognizes that each department is subject to ever-changing rules that create uncertainty about the correct way to perform our job or handle work situations. To obtain guidance on an ethics or compliance issue or to report a suspected violation, several options are available. Human Resources encourage the resolution of issues and concerns within the area whenever possible and as is appropriate under the circumstances. It is an expected good practice, to raise concerns with the manager first. In any event, if you are unsure of whether your own actions (or another’s) are compliant with the law or our policies, please follow the process below:

  1. Ask Your Director or Manager - Ethical or legal questions should be taken promptly to your Department Director or Manager. They can help you sort through work issues and assist with taking appropriate action. Keep asking until you get an answer that makes sense. If you are not comfortable discussing the issue with your Director or Manager, or the answer they provided, then take the next step in the process.
  2. Ask The Compliance Director - The Compliance Director is a valuable resource to employees seeking help with understanding internal policies and regulatory compliance issues. The Compliance Director helps alert and coach employees about how to keep our behavior and work practices in line with the law. Employees are encouraged to contact the Compliance Director to clarify questions or report concerns about ethical or legal work problems. The Compliance Director will involve other resources as needed, such as Human Resources for personnel related issues, Security for safety related issues, or Legal Counsel for regulatory issues such as Medicare fraud and abuse. For ethical issues involving patient care, you may contact the Chairman of the Ethics Committee. If you are not comfortable with contacting these resources, then take the next step.
  3. Call The Confidential Compliance Line - NCH has established an external Compliance Line that enables anonymous reporting of suspected misconduct. This line is answered by an outside service specializing in these types of calls. The benefits of this line are:
  4. Reporting Retaliation - If you suspect you or another employee is being retaliated against for reporting suspected misconduct, immediately contact the Compliance Director or call the Compliance Line. NCH protects to the fullest extent permitted by law the identity of employees who contact key resources with questions and concerns. NCH does not allow retaliation against any employee who in good faith raises a concern, asks a question, or reports suspected misconduct. If a suspected problem turns out to be unfounded but was reported in good faith, the reporting employee will not suffer harm for bringing it to the attention of NCH.
  5. Reporting False Information - Any NCH employee who deliberately makes a false accusation with the purpose of harming another employee will be subject to discipline. The consequences of such conduct will be determined in accordance with NCH disciplinary procedures. Legal action may be taken if appropriate.

Leadership Responsibilities

The Board of Director’s responsibility is to implement an effective Compliance Program, to assure that corporate information and reporting system is properly maintained, and to insure NCH’s compliance with all state and federal laws. To achieve this goal, the Finance Committee of the Board has been delegated the responsibility to oversee the compliance activities of the organization and to ensure that the Compliance Program is effective in preventing, detecting and correcting compliance problems. While employees are obligated to follow the Code, the Board expects all levels of management to set the example of “ethical corporate citizenship”.

The Compliance Working Committee is composed of department directors from across the organization. It meets regularly to carry out the day-to-day operations of the Compliance Program ensuring that audits are conducted and work plans developed to address potential risk areas for NCH. Directors and managers are responsible for ensuring that their teams have sufficient information to comply with applicable laws, regulations, and policies, as well as the resources to resolve ethical dilemmas. We expect those with supervisory responsibility to exercise their compliance responsibility in a manner that is kind, sensitive, thoughtful, and respectful. We expect each supervisor to create an environment where all team members feel free to raise concerns and propose ideas. Managers and directors are also responsible for understanding the Code and explaining it to their staff, and for monitoring staff work performance to minimize instances of Code violations or business misconduct. By helping to raise employee awareness about compliance issues and initiatives, managers and directors help create a culture within NCH, which promotes adherence to this Code and the Compliance Program.

Our Fundamental Commitments

The Board of Directors and Management make the following commitments:

Guidance on Employee Behavior
Many regulations that employees are expected to comply with are based on common sense notions of right and wrong such as those against stealing, cheating, and lying. These need no technical explanation. Others, however, are more technical in nature and require explanation about how they may affect your duties.

Patient Relations
NCH treats all patients with respect and dignity and provides care that is medically necessary and appropriate. NCH makes no distinction in the admission, transfer or discharge of patients or in the care it provides based on race, color, religion, sex, or national origin. Clinical care is based on patient needs, not on a patient’s ability to pay or organization economics. Upon admission, NCH will issue each patient a written statement of patient rights. This statement includes the rights of the patient to make decisions regarding medical care and conforms to Federal and Illinois law.

NCH assures patients' involvement in all aspects of their care. Working together the attending physician and employees will provide patients with an explanation of care which may include diagnosis, treatment plan, right to refuse or accept care, care decision dilemma advice, advance directive options, and an explanation of the risks and benefits associated with available treatment options. Patients and their representatives will be accorded confidentiality, privacy, security and protective services, opportunity for resolution of complaints, and pastoral counseling. Additionally, NCH maintains processes for prompt resolution of patient grievances, which include informing patients of whom to contact regarding grievances and informing patients regarding the grievance resolution. (See Administrative Policies #104, Patient Rights and Responsibilities, #102, Patient Problem Resolution)

All patients are treated with dignity and respect, regardless of their financial situation. NCH has a Charity Care and Financial Assistance program for patients that re indigent, uninsured, or have limited financial resources, who require medically necessary  services. We provide financial counselors to answer patient’s billing and insurance questions or assist with payment issues. Financial counselors can be called at 847.618.4542. (See Charity Care and Financial Assistance, Administrative Policy # 152)

Emergency Treatment
NCH complies with the Emergency Medical Treatment and Active Labor Act by providing an emergency medical screening examination and stabilizing treatment to all patients, regardless of their ability to pay. In an emergency situation, financial and demographic information will be obtained only after the immediate medical needs of the patient are met. NCH does not admit or discharge patients based on their ability to pay. Anyone with an emergency medical condition is treated and admitted based on medical necessity. Patients will only be transferred to another treatment facility if the patient’s medical needs cannot be met at NCH and appropriate care is knowingly available at another facility. Unless the patient requests a transfer, patients may only be transferred after they have been stabilized and are formally accepted by the receiving facility.

Patient Information
Patients can expect that their privacy will be protected. NCH collects patient information for treatment, payment and business purposes. We realize the sensitive nature of this information and are committed to complying with the Privacy and Security standards outlined in the Health Insurance Portability and Accountability Act (“HIPAA”) when collecting, using or disclosing protected health information (“PHI”) Employees must not release or discuss our patient’s PHI with others unless the it is necessary to serve the patient or required by law. Releases or disclosures of PHI for purposes not related to treatment, payment, business operations, or as required by law are permissible only after obtaining the patient’s written authorization. (See Administrative Policy #87, Release of Patient Information) No NCH employee or physician has a right to access any patient’s PHI other than the amount that is minimally necessary to perform his or her job. (See Administrative Policy #137, Disclosing and Requesting only the Minimum Necessary amount of Protected Health Information)

Research
All patients asked to participate in an approved research project are given a full explanation of the goals and objectives of the project as well as the alternative services that might prove beneficial to them. They are also fully informed of potential discomforts and are given a full explanation of the risks, expected benefits, and alternatives. These patients are fully informed of the procedures to be followed, especially those that are experimental in nature. Refusal of a patient to participate in a research project will not compromise their access to services. Any individual applying for or performing research of any type is responsible for maintaining the highest ethical standards in any written or oral communications regarding the research project as well as following appropriate research guidelines set forth by the Institutional Review Board.

Physician Relationships
Any business arrangement with a physician must be structured to comply with legal requirements. Such arrangements must be in writing and approved by Legal Counsel. In negotiating and entering into business arrangements with physicians, NCH will adhere strictly to two primary rules:

  1. We do not pay for patient referrals. We accept referrals and admissions based solely on the patient’s clinical needs and the ability of the organization to render the needed services. Violation of this rule may have grave consequences for the organization and the individuals involved, including civil and criminal penalties, and possible exclusion from participation in federally funded healthcare programs.
  2. We do not accept payments for referrals that we make. No NCH employee or any other person acting on behalf of the organization is permitted to solicit or receive anything of value, directly or indirectly, in exchange for the referral of patients. Similarly, when making patient referrals to another healthcare provider, we do not take into account the volume or value of referrals that the provider has made (or may make) to us.

Billing Compliance
NCH will not knowingly submit billing data that is false, inaccurate or unsupported by proper medical documentation. The claim development process involves the cooperation of our referring physicians and the coordination of multiple departmental functions. NCH will insure the integrity of all billing claims by performing claim development functions that include, but are not limited to, the following:

NCH will be forthright in dealing with any billing inquiries. Requests for information will be answered to the best of our ability with complete, factual, and accurate information. Employees must cooperate with and be courteous to all government inspectors and provide them with the information to which they are entitled during an inspection. Employees must never conceal, destroy, or alter any documents, lie, or make misleading statements to a government representative. Employees may not cause another to fail to provide accurate information relating to a possible violation, nor obstruct, mislead, or delay the communication of information or records.

For coding questions, contact Health Information Management (Medical Records). For questions concerning billing issues, contact Patient Financial Services.

Cost Reports
A significant portion of the healthcare services that NCH provides involves reimbursement under government programs. These programs require the submission of certain annual operating cost data. Employees will comply with Federal and Illinois law relating to all cost reports. These laws and regulations define what costs are allowable and outline the appropriate methodologies to claim reimbursement for the cost of services provided to program beneficiaries. Given their complexity, all issues related to the completion and settlement of cost reports must be communicated through or coordinated with Corporate Finance.

Regulatory Compliance
NCH services may only be provided pursuant to specific federal, state, and local laws. Such laws and regulations may include subjects such as licensure requirements, pharmaceutical distribution, police intervention, access and consent to treatment, record retention and confidentiality, patient rights, terminal care decision-making, occupational safety, and Medicare and Medicaid regulations. All employees, physicians, and contract service providers should be knowledgeable about and ensure compliance with all such laws. Questions regarding specific regulations may be directed to the NCH legal counsel.

In order to ensure that NCH fully meets its regulatory obligations, employees will be informed about specific areas of potential compliance concern. The Department of Health and Human Services routinely notify healthcare providers of specific business practices that have created a compliance risk, this information shall be shared with affected employees to further awareness of the government’s regulations and concerns. NCH will be diligent in maintaining systems of internal control for purposes of ensuring regulatory compliance and will provide employees with the information and education they need to comply fully with applicable regulations.

Dealing with Accrediting Bodies
Employees and physicians will deal with all accrediting bodies in a direct, open and honest manner. No action should ever be taken in relationships with accrediting bodies that would mislead the accreditation organization or its survey teams. NCH will comply with required accreditation standards and follow the guidelines regarding such standards.

Business Information and Information Systems

Workplace Conduct and Employment Practices

Marketing Practices

Environmental Compliance
Immediately alert a manager of any situation involving the discharge of a hazardous substance, improper disposal of medical waste, or any situation that may be potentially damaging to the environment. It is NCH policy to comply with all environmental laws and regulations and operate each NCH facility with the necessary permits, approvals, and controls. Employees must diligently follow the proper procedures with respect to handling and disposal of hazardous waste, including medical waste.

Business Courtesies

Political Activities and Contributions

Because of its not-for-profit status, the law limits NCH’s participation in political activities. NCH funds or resources are not to be used to contribute to political campaigns or for gifts or payments to any political party or their affiliated organizations. NCH resources include the use of work time and telephones to solicit for a political cause or candidate and loaning property for use in the political campaign.

It is important to separate personal and corporate political activities in order to comply with the appropriate rules and regulations relating to lobbying or attempting to influence government officials. Employees may, of course, participate in the political process on personal time and at their own expense. In doing so, care should be taken to avoid giving the impression that such involvement is on behalf of or connected with NCH. Employees cannot seek to be reimbursed by NCH for any personal contributions for such purposes.

At times, NCH may ask employees to make personal contact with government officials or to write letters to present NCH’s position on specific issues. In addition, it is a part of the role of some management to interface on a regular basis with government officials. When making these communications on behalf of the organization, the spokesperson should be familiar with any regulatory constraints involved and observe them. Guidance is always available from the Compliance Director and Legal Counsel as necessary.

The Compliance Program

Questions & Answers
The Code is not intended to provide answers to every question that may arise concerning NCH policies. The following questions and answers are intended to increase an employee’s understanding of how the specific guidelines must be applied.

The Compliance Program

Ethical Behavior Generally

Accuracy, Retention, and Disposal of Documents

Business Courtesies

Conflicts of Interest

Patient Information

Personal Use of Organization Resources

Political Activities and Contributions

9HIPAA & CONFIDENTIALITY -  Return to Top

What is HIPAA?
HIPAA (The Health Insurance and Accountability Act of 1996) is a federal law imposed on all healthcare organizations including doctor’s offices, hospitals, and long-term care facilities. Effective April, 2003 it will be illegal to violate this code.

HIPAA Rules

What is Confidential?
All information about a patient that is written, spoken, or in the computer is considered “protected health information”. This includesname, address, phone number, social security number, diagnosis, age, medical history, medications, test results, and much more. Revealing any information to someone who does not need to know is a violation of the patient’s confidentiality.

When can I use Health Information?
You can use health information for:

How do I know if I can use/access a Patient’s Health Information?
Before looking at a patient’s health information, ask yourself one simple question: “Do I need to know this information to do my job?” If the answer is “No” then stop. If the answer is “Yes” you have nothing to worry about.

Patient Rights

Protecting a Patient’s Privacy

Computer Usage

E-mail

Faxing

Complaints
Refer any patient with a concern about a privacy concern to the Ombudsman/Patient Representative at 847-618-4390. Do not try to handle complaints on your own.

10MEETING THE NEEDS OF OUR CUSTOMERS - Return to Top

CODE OF CARING

First Impressions

Meet & Greet Standards
Our customer’s most basic expectation is to be treated with courtesy and respect. Through the simple act of a smile and a friendly greeting, we create an atmosphere of welcome and foster positive feelings about the services we provide.

Hallway Etiquette
A hallway encounter is an opportunity to create a favorable impression, reinforcing the caring culture of our organization.

Elevator Etiquette

Telephone Etiquette
Excellence in telephone courtesy is every employee's responsibility. We must be committed to listening attentively in order to fully understand the customer's needs. Our message to the customer should be delivered with courtesy, clarity, and care. We must avoid confusing our customers, and speak in terms they can easily understand.

Professional & Personal Appearance
As employees of Northwest Community Healthcare, our appearance must be professional, tasteful, and discreet while on duty. In order to convey our concern and willingness to serve our customers, we must take into consideration our customer's expectations in how we present ourselves. Studies have shown that customers will judge an organization's quality of care based on its employees' be required.

STANDARD ACCEPTABLE UNACCEPTABLE
Hygiene Daily bathing and oral hygiene are essential. Use of deodorant and personal hygiene products.

Breath mints.

Complimentary makeup.

 Any strong or excessive perfume or after shave (due to increasing asthmas, allergies, and environmental allergies).
Body/mouth odor.
Gum chewing.
Excessive makeup.
Hair Neat, clean, natural style. Hair coloring outside of natural shade. Unkempt facial hair.
Fingernails Clean, trimmed that do not exceed ½” from fingertip. Dirty, ragged nails. Nails longer than ½ “ from fingertip.
Hosiery Hosiery or socks with all undergarments. Outfits in a shade that compliment the appearance. Appropriate undergarments worn at all times. Bare legs, bare feet.
Overall Clothing Clean, neatly pressed, in good repair and appropriate size. No blue denim material. Soiled, wrinkled, faded, torn or clothing worn to tight.
Name Badges Must be worn at all times in a visible spot on upper torso, over outer layer of clothing. No badge worn or a badge worn in a place that is difficult to read i.e. waistband, or lower lab coat pocket.
Shirt Conservative, non-revealing neckline. Unbuttoned, shirttail out, t-shirts with logos, writing. Any shirt that reveals backs, midriffs, shoulders or plunging necklines i.e. tank tops or sundresses.
Pants Appropriate length and size with finished hems. No blue jeans. No leggings, spandex or lycra pants/stirrups. Stretch pants, shorts, biking shorts, sweat pants or jogging suits.
Skirt/Women Appropriate length and size with finished hems. Items shorter than 3 inches above knee, high or dramatic slits.
Shoes/Boots Clean, polished with laces tied. Safe for work environment. Unlaced hi-tops, casual sandals or thongs.
Jewelry Complimentary to clothing. Work related pins, service awards, professional pins. No more than 3 earrings per ear. No other visible body piercing.
Body/Art Tattoos All tattoos/body art must be covered during work hours. Exposed tattoos/body art.
Hats Professional, head/gear/surgery hats worn within department (religious head covering may be acceptable per dept. standard. Any non-work related hats.

Privacy & Confidentiality Standard
We at Northwest Community Healthcare consider personal privacy and confidentiality to be essential for creating and maintaining a secure and trusting environment.

Environmental Standard
The appearance of our facility and grounds is a direct reflection of our attitude, competence, and compassion that characterize our organization. We will maintain all aspects of our environment in a clean, safe, orderly, and attractive manner. We will take ownership of our organization. When we see a problem, wherever it is, we will take the necessary steps to fix it, immediately.

Responsiveness – Customer Waiting Standard
We recognize that our Customer’s time and family support are very valuable. At all NCH facilities, we will strive to provide prompt service; always keeping customers informed if delays occur.

Additional Standards for Inpatient Waiting

Transportation Standard
Transportation of patients between multiple departments is crucial to diagnosis, treatment, and recovery. A safe and efficient internal transportation system will ensure that vital link between services.

Anyone (nursing, volunteers, transporters) involved in the transport of a patient provides them with the opportunity to witness our 5-star service.

Patient Information/Education Standard
At NCH we take pride in providing our customers and their families with the information they need to make positive personal health choices. Utilizing a multidisciplinary approach to customer education, we provide information about health, diet, tests, procedures, medications and discharge in an understandable manner.

Charity Care / Financial Assistance at Northwest Community Hospital

SERVICE RECOVERY
COMPLAINTS ARE VALUABLE BECAUSE THEY PROVIDE - Service Recovery. Service Recovery allows us to focus on unmet customer needs by acknowledging missed opportunities to provide 5 Star Service. The surest way to recover from a service mishap is to respond immediately to resolve customer problems. As employees, we must view every issue brought to our attention as an opportunity to improve service. The initial response to a complaint is critical. Each employee must respond to our customers by following the C.A.R.E. Formula:

Carefully listen.

Apologize with empathy.

Respond to the need.

Evaluate the results.

Service Recovery need not be limited to these examples:

Lost personal property; please attempt to retrieve from Security, ext.7550.

If unsuccessful, please refer to the Patient Representatives at ext. 4390.

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NORTHWEST COMMUNITY HOSPITAL
ADMINISTRATIVE POLICY

11SUBJECT: PARKING FACILITIES AND REGULATION

PURPOSE:
To designate areas available for employee, volunteer, physician, sales and outside service parking and to speci~' enforcement provisions.

POLICY:

  1. All Northwest Community Healthcare employees are required to use parking lot P. Entry to and exit from parking will be through the use of the employee ID badge. For time keeping purposes, employees must badge in again in their own department.
    Contract employees will park in designated lots i.e.: Center for Specialty Medicine garage 5th level.
  2. Volunteers may park in any lot (see section on prohibited areas).
  3. Medical Staff may park in the lower level of the employee garage and the East side doctors' lot. Medical staff may park in any other area not prohibited (see section on prohibited areas) and must display a parking permit when parking in spaces reserved for physicians to avoid towing provisions of this policy.
  4. Visitor/patient parking will be in the Center for Specialty Medicine garage and open surface lots with the exception of lots that are specially designated for doctors.
  5. Sales center service vehicles will park only the 3&4 lots directly North of the Day Surgery. It is the responsibility of the Materials Management Department and any department buying supplies or services directly to inform these outside personnel of our parking regulations.
  6. An employee visiting the Hospital in a non-work related capacity may park in any area reserved for visitors. To avoid being cited for a parking violation, it is required that the employee (or Family Member) contact Security on entry to the building at Ext. 7550/7551 or pager #4141 to advise them of the location and type of vehicle.
  7. Citations are given to the motor vehicle in question and it is the responsibility of the owner to make sure that all operators are aware of the parking policy.
  8. Employees with special physical disabilities, either temporary or permanent, may apply for special permit parking through the Employee Health Department. All special permit parking for employees is located in Employee Parking Deck, Level 2.
  9. All students will park in lot 7.
  10. Car pooling employees have designated parking spaces in Employee Parking Deck, Level 2. Car pool stickers and placards are issued at the security desk. Stickers and placards must be displayed when vehicle is parked in Car Pool spaces.

Any vehicle will be considered to be in violation of Hospital Policy #194 if it commits a moving violation. A moving violation may consist of driving in excess of posted speed limits, failure to obey posted signs, careless and/or reckless driving and any violation described in the Village Traffic Ordinance.

ENFORCEMENT:

  1. Tow Away Zones - There are certain areas for which towing may immediately apply without further notice. These areas include access roads, entrances, receiving areas, fife lanes, handicapped parking and any area specifically signed as a tow away zone.
  2. First Parking Violation - Any vehicle owned or operated by an employee, volunteer or member of the medical staff found in an area which constitutes a violation of any provisions of this policy will be issued a courtesy violation and the license number and name, if available, will be logged at Security. If there are no other occurrences within the next 12 calendar months, the record will be cleared.
  3. Second Parking Violation - Any vehicle owned or operated by an employee, volunteer or member of the medical staff found in violation of the provisions of this policy a second time the owner/operator will receive notification that the car will be towed or impounded on the next violation. The record of the violation is retained for 24 calendar months from the date of the first violation. A copy of the warning letter will be mailed to the appropriate Manager and Administrative Personnel.
  4. Third Parking Violation - Any vehicle owned or operated by an employee, volunteer or member of the medical staff that is found to be in violation of the provisions of this policy a third time will be towed and Security must be contacted to obtain a release. The offender will be responsible for towing charges. Employees will additionally receive written counseling from their Department Director to be added to their personnel file.
  5. Moving Violation - Any vehicle observed on the Hospital campus committing a moving violation will be considered in violation of Hospital policy. A violation will be issued to the vehicle owner/operator at the time of the incident or as soon as the situation warrants. A copy of the violation will go to the Chief of Security, the violator and to the Department Director. A moving violation issued to an employee may result in disciplinary action. Violations will remain on file with Security for one year.
  6. The Arlington Heights Police regularly patrol the Hospital campus and are empowered to enforce any violations of the municipal code and can be requested by Security to cite violators.

PROHIBITED AREAS:
The following areas are prohibited from use by the employees, volunteers and members of the medical staff on all shifts:

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