New Employee Orientation - OneSource Program - Implemented on March 4, 2007
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
WELCOME TO NORTHWEST COMMUNITY HEALTHCARE!
Our Mission, Vision and Values - Select
EMERGENCY CODES - Select
HAZARDOUS MATERIALS - Select
FIRE SAFETY - Select
INFECTION CONTROL - Select
RADIATION SAFETY - Select
CORPORATE COMP - Select
CODE OF CONDUCT - Select
HIPAA & CONFIDENTIALITY - Select
MEETING THE NEEDS OF OUR CUSTOMERS Code of Caring & Service
Recovery - Select
PARKING REGULATIONS - Select
FORMS TO BE COMPLETED - Select
NCH First Floor Plan -
WELCOME TO NORTHWEST COMMUNITY HEALTHCARE!
1Our Mission, Vision
and Values - Return to Top
We exist to provide quality, compassionate healthcare services to the people
of the northwest community.
We will be regarded as a leader in creating the 21st century hospital through
the innovative use of:
Our caring culture,
Clinical expertise, and
This will make it possible for patients, physicians, employees and community
to experience excellence.
Values and Guiding Principles
Customer Focus: Total customer satisfaction for internal and external
Community Needs: High quality, compassionate healthcare designed to
meet the communitys stated needs.
Excellence: Our way of life: consistently superior performance and
continuous quality improvement.
Ethical Behavior: Integrity, honesty and fairness in everything we
Fairness: Belief in the worth and dignity of the individual without
bias or prejudice, our foundation for all interactions.
Financial Reasonableness: Careful planning for future trends, wise
stewardship of resources, high quality service at a reasonable cost.
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:
Day Surgery Center
NCH employee parking garage
901 Kirchoff Bldg.- Call 911
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.
Electricity is provided to the Hospital by two feeds from Commonwealth Edison.
Selected equipment and outlets are also serviced by emergency generator power.
Emergency electrical outlets are red, lighted, or labeled "emergency". Nursing
units have boxes of emergency electrical supplies in the event of a power
Water service is provided to the Hospital by two water mains. Another water
source within the village may be accessible through valving arrangements.
Bottled water may be brought in as per a standing agreement.
Medical Gas is available in portable tanks that will be provided as per
Respiratory Care and Storeroom policies.
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
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.)
Hospital - dial 3333
Business Center - call 9-911
Treatment Centers - use intercom to overhead page; call 911 to report
901 Kirchoff Bldg - pull alarm (automated announcement is triggered)
Dial 911 if you find an individual in need of emergency care at the:
Treatment Centers & medical office buildings
Salt Creek Business Center
CSM parking garage
All parking lots
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.
- 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.
OSHA (Occupational Safety Health Act) mandates that employees have a "right
to know" about workplace hazards.
Employee Health Service maintains logs and records related to occupational
health issues and they are available upon request.
OSHA Written Hazard Communication Standard involves the following:
Written program and plan.
Centrally located in Facility Support.
Departmental plan covers chemicals in each department.
Employee training about hazardous materials includes:
The NCH Hazardous Materials policy is available online in the Administrative
Policies and Procedures section under Contents.
Department specific orientation for chemicals in your area, Check with your
Supervisor/Manager for specific:
Presence of chemicals
Accidental release of chemicals
Health and safety concerns
Material Safety Data Sheet (MSDS)
MSDS - Material Safety Data (Call 1-800-451-8346):
Chemical information sheets are prepared and provided by manufacturer on
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 -
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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" &
R: Rescue - Remove anyone from immediate danger.
A: Alarm - Pull the nearest fire alarm box. When a fire
alarm box is activated, the bell will sound, and the Fire Department,
switchboard, and maintenance area will all be notified. A listing of fire
codes is located over every manual fire alarm box. In addition to the manual
alarm boxes, heat detectors are located throughout the building. When there
is excessive heat in an area, they will be activated automatically. Also,
report the location of the fire.
Hospital - dial 3333
Business Center - dial 9-911
Treatment Centers - use intercom to overhead page, dial 911 to report
901 Kirchoff Bldg - pull alarm (automated announcement is triggered)
C: Confine - Close all doors, patient rooms, stairwells,
and all vertical openings such as chutes and elevator doors.
E: Extinguish - Attempt to extinguish the fire if it is
safe to do so.
How to Use the Fire Extinguisher:
P: Pull the pin.
A: Aim the nozzle at the base of the fire.
S: Squeeze the handle.
S: Sweep from side to side at the base of the fire.
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.
Types of Fires:
A: Ordinary combustibles, including wood, paper & fabric.
B: Burning liquids.
C: Electrical fires.
How to Remember the Right Fire Extinguisher for the Type of Fire
A: Ashes from wood and paper.
B: Barrels of burning liquid.
C: Current of electrical fires.
Some tips that can help protect both employees and patients:
Keep low, near the floor. Heat and toxic gases rise.
Know all exit routes.
Do not use elevators in case of fire. Heat and smoke affect mechanical equipment
and elevator shafts are a flue for the fire.
Stairwells can also be natural flues. Before opening a door to the stairwell,
check by feeling it at the top. If the door is warm, don't open it.
Stay calm. More injuries result from accidents during fires than from actual
Knowing what to do and acting promptly prevents accidental injuries.
The building is constructed into smoke compartments designed to protect you
from the spread of fire and smoke. If you must evacuate a patient, move him/her
beyond the smoke doors on the same floor.
Do not use elevators.
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.
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 NCHs 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
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.)
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.
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
Before and after any patient contact;
After contact with blood/body fluids or surfaces visibly soiled with blood/body
After removal of gloves;
Before clean or sterile invasive procedures;
After the use of restroom (toilet) facilities.
Hand hygiene can also be accomplished effectively with the use of
alcohol-based hand rubs. Dispensers are located throughout all patient care
Personal Protective Equipment (PPE) that may be needed:
Face protection if aerosolization (spraying) is likely, this could include
glasses or goggles and a face mask
Gown, impervious to fluid, if soilage of clothing is likely.
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,
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
Laboratory Specimens must be transported in a specimen bag.
Blood and Body Fluid Exposure List - RISKY
Cerebral spiral fluid
Saliva/sputum (dental procedure only)
Any unfixed human tissue or organ
Infection Control Exposure
Report all exposures* regardless of your antibody status to Hepatitis
B or previous vaccination with Hepatitis B vaccine.
An *Exposure is sustained if an employee suffers:
A laceration or puncture with a sharp instrument that is contaminated with
A human bite
Blood/body fluid contamination of an open wound
Oral ingestion of blood/risky body fluids
Mucous membrane or conjunctival contact with the blood or risky body fluids
of another person.
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.
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:
Airborne Precautions are designed for patients documented or suspected to
be infected with highly transmissible or epidemiologically important pathogens
for which additional precautions beyond Standard Precautions are needed to
interrupt transmission in hospitals (i.e., tuberculosis, measles, varicella
viruses) Use Airborne Precautions for patients known or suspected to be infected
with microorganisms transmitted by airborne droplet nuclei (evaporated droplets
containing microorganisms that remain suspended in the air and that can be
dispersed widely by air currents within a room or over a long distance).
Droplet Precautions are used when transmission occurs by coughing and sneezing
and from procedures such as suctioning bronchoscopy. These droplets generally
travel within three feet of the patient and can infect the nose and mouth
of a susceptible person. Common infections requiring droplet precautions
are: influenza, whooping cough, and bacterial and viral pneumonias. An isolation
mask is required to enter the room. If the patient is actively coughing and
sneezing they must wear a surgical mask when outside their room.
In addition to Standard Precautions, use Contact Precautions for specified
patients known or suspected to be infected or colonized with organisms that
can be transmitted by direct contact with the patient (hand or skin-to-skin
contact that occurs when performing patient care activities that require
touching the patients dry skin) or indirect contact (touching) with
environmental surfaces or patient care items in the patients environment
or by droplets (droplets that can be generated by the patient during coughing,
sneezing or the performance of procedures) likely to aerosolize micro-organisms.
Respiratory Protection - Preventing the Spread of TB
There is a continuing concern about the increase in the numbers of reported
TB cases in the U.S.
TB is spread from person to person through the air. When a person with infectious
TB coughs or sneezes, droplet nuclei containing Mycobacterium tuberculosis
are expelled into the air. These droplet nuclei can remain suspended in the
air. Another person, who inhales the air containing these droplet nuclei,
may become infected with TB.
There is a difference between having TB infection and TB disease. A person
who is infected has a positive TB skin test but no symptoms of TB. This person
has an increased risk of developing TB disease, but is not infectious to
others unless active TB disease develops. A person who has active TB disease
does have symptoms and a positive sputum (AFB) for M. Tuberculosis. This
person with active untreated TB disease is infectious to others.
Common signs and symptoms of TB include an abnormal chest x-ray, persistent
productive cough, chills, fever, night sweats, bloody sputum, fatigue and
Special controls at Northwest Community Healthcare help prevent the
transmission of TB.
Special policies and procedures located in each department.
Education programs for staff.
Documentation of care and record keeping.
Criteria for early identification of persons with possible TB.
Special signage - "Airborne Precautions"
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.
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
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Radiation Areas at Northwest Community Healthcare
Nuclear Medicine Department
Radiology, CT, Cath Lab, Pathology Lab
Radiation Oncology Department
Rooms with patients containing radioactive materials
Portable xray machines may occasionally be used throughout the organization
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:
Time: Limit time around or near radioactive material. The shorter
the time interval that one is exposed to the radiation source, the less the
amount of radiation that will be absorbed.
Distance: The farther you are away, the safer you are. Radiation exposure
and distance are inversely related. The intensity of radiation decreases
by the square of the distance from the source.
Shielding: Putting something between you and the radiation source. The
type of shielding device recommended depends on radioactive source. Lead
is the most commonly used shielding material in the hospital. The use of
lead shielding has both advantages and disadvantages; in practice, it is
cumbersome to work around but it may be a constant reminder to limit the
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
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:
Knowing and following all rules, regulations, and statutes that govern the
provision or payment of healthcare services:
Medicare, Medicaid, JCAHO.
The purpose of a Compliance program:
To prevent, detect and correct improper business practices: coding and billing
What resources provide guidance:
NCH Code of Conduct (see attached)
Compliance Line: 1-888-203-2523
Patient safety concerns may be directed to the JCAHOs Office of
Fax: (630) 792-5636
Mail: Office of Quality Monitoring
One Renaissance Blvd.
Oakbrook Terrace, IL 60181
Individuals may call (800) 994-6610 regarding any questions. Complaints
will not be taken over the phone.
What is your personal obligation?
Stop, think and clarify any issue you are unsure about.
Report any activity by anyone that appears to violate applicable laws, rules,
regulations, or the Code of Conduct.
8CODE OF CONDUCT -
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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 employees
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
dont 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.
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
Your Personal Accountability - Who Should Read This?
All employees are expected to read and comply with the Code. Employees
who have questions about the Code should direct them to his/her Manager,
Director, a Leadership Team member, the Director of Corporate Compliance
or call the confidential Compliance Line.
Learning the Law
We have faith that all employees will perform every aspect of their job with
honesty, fairness, and integrity. All employees are also required to perform
their jobs in accordance with any applicable state and federal regulations.
Consequently, all employees are expected to attend compliance training courses,
read new or updated regulatory publications, review policies/procedures,
and ask questions to insure they are performing their job function properly
and within legal or regulatory guidelines.
The Cost of Breaking the Law
Violations of the law can greatly harm NCHs reputation and ability
to deliver safe, quality healthcare. Violations of healthcare law have resulted
in large fines, penalties and even jail terms for many in the healthcare
industry. NCH intends to comply with the law and help its employees do the
Duty to Report or Detect Wrongdoing
NCH is committed to ethical and legal conduct that is compliant with all
relevant laws and regulations and to correcting wrongdoing wherever it may
occur in the organization. Each employee has an individual responsibility
for reporting any activity by any employee, physician, subcontractor, or
vendor that appears to violate applicable laws, rules, regulations, or this
Code. In addition, all Directors and Managers have a duty to detect and correct
staff conduct that a person should reasonably know is unlawful, unethical
or that violates the Code.
Enforcement and Discipline
We have faith that our employees will obey the law and abide by our standards
of conduct. But NCH recognizes the need to discipline any employee who violates
the law or who knowingly fails to report to NCH a violation in an area for
which he/she is responsible. Employees who fail to meet these obligations
may face disciplinary action, up to and including termination.
Employee Compliance Training
All newly hired employees will receive compliance training during their general
orientation program. Employees are required to complete and pass computer-based
compliance training annually. Directors or Managers are also required to
review department-specific compliance topics or policies with employees during
departmental orientation training and again during annual employee performance
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 anothers) are compliant with the law
or our policies, please follow the process below:
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.
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.
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:
Callers can report concerns anonymously and without fear of being penalized
Callers cannot be identified and calls are not recorded
The callers information or question will be formally documented and investigated
Callers will be given a code number and call back date for follow-up purposes
The Compliance Director will monitor the matter until it is successfully
To call the Compliance Line dial 1-888-203-2523.
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.
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.
The Board of Directors responsibility is to implement an effective
Compliance Program, to assure that corporate information and reporting system
is properly maintained, and to insure NCHs 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:
To our patients: We are committed to providing quality care that is sensitive,
compassionate, promptly delivered, and cost effective.
To our employees: We are committed to a work setting, which treats all employees
with fairness, dignity, and respect, and affords them an opportunity to grow,
to develop professionally, and to work in a team environment in which all
ideas are considered.
To our physicians: We are committed to providing a work environment, which
has excellent facilities, modern equipment, and outstanding professional
support. We encourage our physicians to comply with this Code and to adopt
their own. To the community: We are committed to understanding the particular
needs of the communities we serve and providing these communities with quality,
cost-effective healthcare. We realize as an organization that we have a
responsibility to help those in need.
To our volunteers: The concept of voluntary assistance to the needs of patients
and their families is an integral part of the fabric of healthcare. We are
committed to ensuring that our volunteers feel a sense of meaningfulness
from their volunteer work and receive recognition for their volunteer efforts.
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
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 patients 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
patients 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)
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 patients 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.
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 patients 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 patients written
authorization. (See Administrative Policy #87, Release of Patient Information)
No NCH employee or physician has a right to access any patients 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)
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.
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:
We do not pay for patient referrals. We accept referrals and admissions based
solely on the patients 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
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.
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:
A signed physicians order will be requested and retained for all services
Patients will be appropriately registered and their insurance information
will be verified accurately
Clinical documentation will be sufficiently detailed to reflect the actual
services and medical supplies/equipment provided
The Chargemaster will be reviewed regularly and updated when needed
Patient charges will be entered accurately and timely
Diagnosis and procedure coding will be assigned based on documentation in
the medical record
Billing claims will be submitted within specified time limits and in required
Compliance risk assessments will be conducted on a regular basis to identify
and correct any erroneous billing practices
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.
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.
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 governments 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
Accuracy, Retention, and Disposal of Documents and Records
Each employee and physician is responsible for the integrity and accuracy
of the organization's documents and records, not only to comply with regulatory
requirements but also to ensure that records are available to defend NCH
business practices and actions. No one may alter or falsify information on
any record or document.
Medical records and business documents are retained and destroyed in accordance
with the law and NCH policy. Medical and business documents include paper
documents such as letters and memos, computer-based information such as e-mail
or computer files on disk or tape, and any other medium that contains information
about the organization or its business activities. Records must not be removed
or destroyed prior to the required retention periods. (See Administrative
Policy #60 Records Retention)
Confidential Business Information
Confidential information about the organization's strategies and operations
is a valuable asset. Although employees may use confidential information
to perform their jobs, it must not be shared with others outside of NCH or
the department unless the individuals have a legitimate business need
to know or the information has become public. Confidential information
includes personnel data, patient lists and clinical information, pricing
and cost data, affiliations, financial data, research data, strategic plans,
marketing strategies and techniques, supplier and subcontractor information,
and proprietary information such as computer software. (Refer to the Human
Resources Policy #303 Confidentiality) If an individuals employment
or contractual relationship with NCH ends for any reason, the individual
is still bound to maintain the confidentiality of information viewed, received
or used during the employment or contractual business relationship with
All communications systems, electronic mail, Intranet, Internet access, or
voice mail are the property of NCH and are to be primarily used for business
purposes. Limited personal use of the NCH communications systems is permitted;
however, do not assume that these communications are private. Patient or
confidential information should not be sent through Intranet or the Internet
unless its confidentiality can reasonably be secured.
NCH reserves the right to periodically access, monitor, and disclose the
contents of Intranet, Internet, e-mail, and voice mail messages. Access and
disclosure of individual employee messages may only be done with the approval
of a Leadership Team member. Employees may not use internal communication
channels or access the Internet at work to post, store, transmit, download,
or distribute any threatening malicious, false, obscene or illegal materials
giving rise to civil or criminal violations of law.
News Media Requests
NCH wants to be responsive to inquiries by the community and welcomes inquiries
from the news media. To ensure NCH preserves the confidentiality of patients
while providing accurate information, NCH has created a Marketing Communications
team to handle media requests in a timely and consistent manner. Without
the express permission of Marketing Communications, employees should politely
decline to answer any questions from the press or news media. All requests
from the news media or proposed press releases must be forwarded immediately
to Marketing Communications at 847/618-5506 for review during weekday business
hours. Should an employee receive an inquiry during evening or weekend hours,
page 708/999-0661 and a member of the Marketing Communications team will
respond. (See Administrative Policy #24, Release of Information to News
Financial Reporting and Records
NCH maintains a high standard of accuracy and completeness in the documentation
and reporting of all financial transactions. Financial records serve as a
basis for managing the business of NCH and are important in meeting obligations
to patients, Medicare, other third party payers, suppliers, and others. They
are also necessary for compliance with tax and financial reporting
False or artificial entries shall not be made in the accounting books or
financial records of NCH for any reason. Doing so may result in criminal
and/or civil penalties to NCH and/or the employee. No employee may engage
in an arrangement that in any way may be interpreted or construed as misstating
or otherwise concealing the nature or purpose of the financial records and
accounting books of NCH.
All financial information must reflect actual transactions and conform to
generally accept accounting principles. No undisclosed or unrecorded funds
or assets may be established. NCH maintains a system of internal controls
to provide reasonable assurances that all transactions are executed in accordance
with management's authorization and are recorded in a proper manner so as
to maintain accountability of the organization's assets.
Tax Exempt Status
NCH employees and physicians will preserve the tax-exempt status of NCH and
its subsidiaries by using resources to benefit the community. NCH will avoid
compensation arrangements or other transactions in excess of fair market
value. Employees will accurately report payments to appropriate taxing
authorities, including the filing of any required tax forms and information
returns. Employees may only use the NCH tax exemption number to purchase
NCH assets or to fund NCH sponsored events or business-related activities.
Review and Signing of Contracts
NCH will not enter into a contract or quote fixed fees for services without
the review by and approval of the appropriate Vice President. NCH will not
enter into contracts or arrangements that exceed fair market value. (See
Administrative Policy #57,Contract Review)
Workplace Conduct and Employment Practices
Conflict of Interest
Employees and physicians must avoid situations where their personal interests
could conflict or appear to conflict with the interests of NCH. A conflict
of interest may occur where outside activities or personal interests, including
those of a family member, influence or appear to influence an employees
ability to make objective decisions in the course of his or her job
responsibilities. Conflicts of interest may also arise when an individuals
position or responsibilities with NCH present an opportunity for personal
gain apart from the normal compensation provided through employment. A conflict
of interest may exist if any outside activities cause an employee to use
NCH resources for other than NCH purposes. Employees should avoid outside
employment or activities that would have a negative impact on their job
performance at NCH, or conflict with their obligations to NCH. No employee
may engage in personal activities that conflict with the best interests of
NCH or its patients.
It is the obligation of each employee to avoid conflicts of interest in the
performance of his or her job responsibilities, and disclose potential conflicts
to the employees supervisor. Certain employees managers, board
members and physicians will be asked on an annual basis to disclose all outside
interests that could result in a conflict, per the Conflict of Interest Policy,
Administrative Policy # 158. If an individual has any question concerning
NCHs Conflict of Interest Policy, the employee must contact his or
her manager or a Leadership Team member for further guidance.
Some employees routinely have access to prescription drugs, controlled
substances, and other medical supplies. Many of these substances are governed
and monitored by specific regulatory agencies and must be administered upon
physician order only. To minimize risks to patients and to NCH, it is extremely
important that these items be handled properly and only by authorized
individuals. If an employee becomes aware of the diversion of drugs from
the organization, the incident should be reported, immediately.
Diversity and Equal Employment Opportunity
NCH is committed to providing an equal opportunity work environment where
everyone is treated with fairness, dignity, and respect. NCH will comply
with all laws, regulations, and policies related to non-discrimination, including
those related to individuals with disabilities. (See Human Resources Policy
#402, Equal Opportunity Employment and #405, Reasonable Accommodation)
Harassment and Workplace Violence
Each NCH employee has the right to work in an environment free of harassment
and violence. Degrading or humiliating jokes, slurs, intimidation, or other
harassing conduct is not acceptable in the workplace. Sexual harassment is
strictly prohibited. NCH prohibits employees from possessing firearms, other
weapons, explosive devices, or other dangerous materials on NCH premises.
Employees who observe or experience any form of harassment or violence should
report the incident immediately. (See Human Resources Policy #308 Harassment-Free
Workplace, #317 Employee Rules and Regulations, and Administrative Policy
# 117B, Disruptive Medical Staff Member Policy).
Health and Safety
All NCH facilities must comply with all government regulations and with NCH
policies that promote the protection of workplace health and safety. NCH
policies have been developed to protect employees from potential workplace
hazards. It is the responsibility of each employee to become familiar with
and understand how these policies apply to his or her specific job
responsibilities and to seek advice from his or her manager whenever a question
or concern arises. It is important to advise management of any serious workplace
injury or any situation presenting a danger of injury so that timely corrective
action may be taken to resolve the issue.
License and Certification Renewals
Employees and independent contractors in positions which require professional
licenses, certifications, or other credentials are responsible for maintaining
the current status of their credentials and shall comply at all times with
Federal and Illinois requirements applicable to their respective disciplines.
NCH will not allow any employee or independent contractor to work without
valid, current licenses or credentials.
Personal Use of NCH Resources
It is the responsibility of each employee to preserve NCH assets including
time, materials, supplies, equipment, and information. NCH assets are to
be maintained for business related purposes. As a general rule, the personal
use of any NCH asset without the prior approval of management is prohibited.
The occasional use of items, such as copying facilities or telephones, where
the cost to NCH is insignificant, is permissible. The appropriate manager
must approve any community or charitable use of NCH resources in advance.
Any use of NCH resources for personal financial gain unrelated to NCH's business
Relationships among NCH Employees
In the usual day-to-day operations of NCH, there are issues that arise which
relate to how people in the organization deal with one another. One issue
that commonly arises involves gift giving among employees for certain occasions.
While NCH wishes to avoid any strict rules, no one should ever feel compelled
to give a gift to anyone, and any gifts offered or received should be appropriate
to the circumstances. A lavish gift to anyone in a supervisory role would
not be appropriate. Another situation, which commonly arises, is a
fund-raising or similar effort, in which no one should ever be made to feel
compelled to participate.
Relationships with Subcontractors and Suppliers
NCH must manage vendor relationships in a fair and reasonable manner, consistent
with all applicable laws and ethical business practices. NCH promotes competitive
procurement practices. The selection of subcontractors, suppliers, and vendors
will be made on the basis of objective criteria including quality, technical
excellence, price, delivery, and adherence to schedules, service, and maintenance
of adequate sources of supply. (See Administrative Policy #74, Gift Accepting,
Fundraising and Charitable Donations.)
Purchasing decisions will be made on the supplier's ability to meet needs,
not on personal relationships, friendships or vendor gifts. Employees are
expected to exercise the highest ethical standards in business practices
in source selection, negotiation, determination of contract awards, and the
administration of all purchasing activities. Employees must not communicate
to third-party confidential information given to us by suppliers unless directed
in writing to do so by the supplier. Employees must not disclose contract
pricing and information to outside parties.
Fitness for Duty
To protect the interests of employees and patients, NCH is committed to an
alcohol and drug-free work environment. All employees and physicians must
report for work free of the influence of alcohol and illegal drugs. NCH may
use drug testing as a means of enforcing this policy. Individuals taking
prescription and/or over-the-counter drugs, which could impair judgment or
other skills required in job performance, should notify his or her manager
upon reporting to work. (See Human Resources Policy #307, Employee Fitness
for Duty, and Administrative Policy #117A, Impaired Physician Policy).
NCH defines its competitors to include other health systems, providers of
health services, physicians and facilities in markets where NCH operates
or serves patients. Antitrust laws are designed to create a level playing
field in the marketplace and to promote fair competition. These laws could
be violated by discussing NCH business with a competitor, such as how prices
are set, disclosing the terms of supplier relationships, allocating markets
among competitors, or agreeing with a competitor to refuse to deal with a
At trade association meetings, be alert to potential situations where it
may not be appropriate to participate in discussions regarding prohibited
subjects with competitors. Prohibited subjects include any aspect of pricing,
services in the market, key costs such as labor costs, and marketing plans.
If a competitor raises a prohibited subject, end the conversation immediately.
At all costs we must avoid collaboration with competitors by discussing
prohibited subjects. In general, avoid discussing sensitive topics with
competitors or suppliers without first having obtained the advice or guidance
of Legal Counsel. Do not provide any information in response to oral or written
inquiry concerning business practices discussed above without first consulting
Gathering Information about Competitors
It is not unusual to obtain information about other organizations, including
competitors, through legal and ethical means such as public documents, public
presentations, journal and magazine articles, and other published and spoken
information involving third parties. However, it is not acceptable to obtain
proprietary or confidential information about a competitor through illegal
means. It is also not acceptable to seek proprietary or confidential information
when doing so would require anyone to violate a contractual agreement, such
as a confidentiality agreement with a prior employer.
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.
Receiving Business Courtesies
For purposes of developing NCH business relationships with existing or potential
business associates, employees may wish to accept an invitation to attend
a local social event. The event and the associated costs must be reasonable
and appropriate, including transportation. The host should not cover travel
costs (other than in a vehicle operated by the host) or overnight lodging.
As a general rule, this will mean that the total cost to the host will not
exceed $100.00 per person. Exceptions, including appropriateness issues,
should be pre-approved by a Leadership Team member.
Sometimes a vendor will extend training and educational opportunities that
include travel and overnight accommodations without charge to NCH. Similarly,
there are some circumstances where employees are invited to an event at a
vendors expense, such as to receive information about new products
or services. Prior to accepting any such invitation, the approval of a Leadership
Team member must be obtained.
It is permissible to accept perishable or consumable gifts offered to a
department or group such as flowers, food, or refreshments. Such gifts should
not exceed a value of $500 from an individual vendor or business associate
in a calendar year. Moreover, it is permissible to accept non-perishable
non-cash gifts offered to a department or group from an individual vendor
or business associate provided the value of the gift does not exceed $500
in a calendar year. In any one year, an employee may accept non-cash gifts
($100.00 or less in total) from an individual or organization having a business
relationship with NCH. Finally, under no circumstances may an employee solicit
a gift, other than for the NCH Foundation. (See Administrative Policy 74
Gift Accepting, Fundraising and Charitable Donations)
Extending Business Courtesies to Patients
It is permissible to offer our patients inexpensive gifts other than cash
to promote goodwill. However, the Office of Inspector General limits the
gifts to those having a retail value of no more than $10 individually, and
no more than $50 in the aggregate annually per patient. NCH may offer patients
more expensive items or services falling within the following categories:
waivers of cost-sharing amounts based on financial need,
properly disclosed non-routine waivers of co-payments; or
incentives to promote the delivery of certain preventive care services.
Extending Business Courtesies to Non-referral Sources
This section, "Extending Business Courtesies to Non-referral Sources," does
not apply to any individual who makes or is in a position to make referrals
There may be times when an employee may wish to extend to a current or potential
business associate (other than someone who may be in a position to make a
patient referral to NCH) an invitation to attend a social event in order
to further or develop the business relationship. During these events, topics
of a business nature must be discussed and the NCH host must be present.
These events must not include expenses paid for any travel costs (other than
in a vehicle owned privately or by NCH) or overnight lodging. The cost associated
with such an event must be reasonable and appropriate. As a general rule,
this will mean that the cost will not exceed $100.00 per person. Such invitations
with respect to any particular individual must be infrequent, which, means
not more than quarterly, and preferably less often.
With regard to the $100.00 guideline, if the event unforeseeably exceeds
this guideline a report to that effect with the relevant details must accompany
the expense reimbursement form. If it is known ahead of time that an event
will exceed the $100.00 guideline, advance approval by a Leadership Team
member is required. Such approval requires showing the business necessity
and appropriateness of the proposed invitation.
NCH will routinely sponsor events with a legitimate business purpose in which
reasonably priced meals and entertainment may be offered. In addition,
transportation and lodging can be paid for.
All elements of such events, including these courtesy elements, must be
consistent with our guiding principles.
It is critical to avoid the appearance of impropriety when giving gifts to
individuals who do business or are seeking to do business with NCH. Employees
must never use gifts or other incentives to improperly influence relationships
or business outcomes. As a general rule, gifts to business associates must
not exceed $50.00 per year per recipient. Employees may never give cash or
cash equivalents, such as gift certificates. Business courtesies may from
time to time allow for modest flexibility in order to permit appropriate
recognition of the efforts of those who have spent meaningful amounts of
volunteer time on behalf of NCH.
The Federal, Illinois and Cook County governments have strict laws limiting
gifts, meals, and other business courtesies offered to elected officials
and government employees. Before extending courtesies, consult with the
Compliance Director or Legal Counsel.
Extending Business Courtesies to Possible Referral Sources
Any social invitation or gift offers involving physicians or other persons
who are in a position to refer patients to NCH must be conducted in accordance
with state and federal law. Please consult with Legal Counsel before offering
a service or item of value to a physician
Political Activities and Contributions
Because of its not-for-profit status, the law limits NCHs 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 NCHs 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
The NCH Compliance Program is designed to effectively insure legal business
operations as well as professional and ethical conduct on the part of all
employees and agents as they carry out their various duties and responsibilities
for NCH. The Compliance Program is comprised of the following individuals,
committees and activities:
The Finance Committee of the Board is charged with high-level oversight of
the Compliance Program.
The Compliance Working Committee oversees the correction of identified compliance
Legal Counsel is responsible for the interpretation of and compliance with
healthcare and business laws.
The Director of Corporate Compliance is responsible for implementing Compliance
Program elements organization wide, and for compliance with the Health Insurance
Portability and Accountability Act (HIPAA) Privacy Standards.
The Information Security Officer is responsible for compliance with the (HIPAA)
Risk Management oversees compliance with malpractice and patient rights-related
QMI oversees compliance with accreditation standards and professional
The Director of each department is responsible for knowing and complying
with regulatory requirements applicable to their area(s), and may implement
a department-specific compliance plan through a team of key individuals.
All of these individuals or groups are prepared to support each employee
in meeting the standards set forth in this Code.
Internal Investigations of Reports
NCH is committed to investigate all reported concerns promptly and confidentially
to the fullest extent possible. The Compliance Director will coordinate any
findings from the investigations and immediately recommend corrective action
or changes that need to be made. NCH expects all employees and physicians
to cooperate with investigation efforts.
Where an internal investigation substantiates a reported violation, it is
the responsibility of management to initiate corrective action, including,
as appropriate, notifying the appropriate governmental agency, instituting
whatever remedial action is necessary, and implementing systemic changes
to prevent a similar violation from recurring.
Violations of the Code will be subject to corrective action. The precise
form of corrective action will depend on the nature, severity, and frequency
of the violation. Certain violations may result in immediate termination
of employment. (See Human Resources Policy #304, Corrective Action and #317
Employee Rules and Regulations)
Internal Audit and Other Monitoring
NCH is committed to the monitoring of compliance with its policies. Much
of this monitoring effort is provided by the respective departments in the
form of spot-checking for errors and other quality assurance initiatives.
In addition, the Compliance Director will oversee routine internal compliance
audits of issues that have regulatory or compliance implications. The
organization may seek other means of ensuring and demonstrating compliance
with laws, regulations, and NCH policy, including the use of outside
NCH requires all employees to sign an acknowledgment confirming they have
received the Code and understand it represents mandatory policies of NCH.
New employees will be required to sign this acknowledgment as a condition
of employment. Adherence to and support of NCHs Code of Conduct and
participation in related activities and training will be considered in decisions
regarding hiring, promotion, and compensation for all candidates and employees.
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 employees understanding of how the specific guidelines
must be applied.
The Compliance Program
If I have a question about workplace conduct or observe something that
I think is wrong, whom should I contact?
NCH offers several resources one may turn to with such concerns. Human Resources
encourage employees to talk to their immediate supervisor or manager, first.
However, if for any reason an employee does not feel comfortable talking
to their manager or if the manager did not answer the question or address
the problem to the employees satisfaction, other options exist. Try
to speak with someone else in management, or a Leadership Team member, or
contact the Compliance Director, or call the Compliance Line at 1-888-203-2523.
NCH encourages employees to try to resolve matters within the department
when possible and appropriate.
If I report something suspicious, will I get in trouble if my suspicion
turns out to be wrong?
As long as an employee honestly has a concern, the Code prohibits an employee
from being reprimanded or disciplined. Each employee has the responsibility
to report suspected problems. In fact, employees may be subject to discipline
if they witness something but do not report it to the company. The only time
someone will be disciplined for reporting misconduct is if he or she knowingly
and intentionally reports something that he or she knows to be false or
misleading in order to harm someone else.
What should I do if my manager asks me to do something that I think violates
the Code of Conduct, NCH policy, or is illegal?
Don't do it. The status or rank of the person making the request is not relevant.
If it is wrong to do, refuse to do it, and immediately report the request
to a higher level of management, or to a Leadership Team member, or use the
Ethical Behavior Generally
How do I know if I am on ethical "thin ice?"
If you are worried about whether your actions will be discovered, if you
feel a sense of uneasiness about what you are doing, or if you are rationalizing
your activities on any basis (such as perhaps the belief that "everyone does
it"), you are probably on ethical "thin ice." Stop, step back, consider what
you are doing, get advice, and redirect your actions to where you know you
are doing the right thing.
Accuracy, Retention, and Disposal of Documents
In preparation for an accreditation visit, my manager has asked me to
review medical records and to fill in any missing signatures. May I do
No. It is absolutely wrong to sign another healthcare providers name
in the medical record. The Code obligates employees to provide only complete
and fully accurate information to accrediting groups.
A patient with a chronic health condition is frequently admitted to the
hospital for treatment. He routinely tips his primary nurse around $100.
May the nurse accept it?
No. Cash gifts for personal use must never be accepted from anyone with whom
NCH has a business relationship.
May I accept a basket of fruit or flowers that a patient sent?
Yes. Gifts to an entire department may be accepted if they are consumable
Conflicts of Interest
A director is planning a dinner meeting at the hospital. Her daughter
owns a catering service in town. May she pick her catering service if the
prices are comparable to other restaurants?
No. This may seem unfair, but certain NCH employees must avoid even the
appearance of favoritism. Those affected by this Policy include, the Board
of Directors, selected medical staff members with administrative
responsibilities, management members and other affected employees.
These individuals will be asked to complete an annual conflict of interest
Do the conflict of interest polices apply to distant relatives, such as
cousins or in-laws or friends?
The Conflict of Interest Policy generally applies to immediate family members
(parents, spouse and children). However, if any relationship could influence
an affected employees objectivity or create the appearance
of impropriety, apply the Policy.
There is a physician who sometimes requests medical records, whether he
is taking care of the patient or not. Other than for NCH quality assurance
reasons, is he allowed to do this?
No. Only the attending, covering, or consulting physicians may have access
to patient medical records. Employees are responsible for protecting the
confidentiality of patient information from interested third parties as well
as from NCH staff. Patients are entitled to expect confidentiality, the
protection of their privacy, and the release of information only to authorized
Personal Use of Organization Resources
Can I type my spouse's resume on my computer?
Possibly. If the computer is used during non-working hours, and upon request,
a manager may in his or her discretion permit an employee to type personal
I volunteer for Big Brothers. May I copy a fundraising leaflet?
NCH encourages all employees to participate in volunteer activities. Organization
equipment, however, must not be used for non-NCH purposes without prior manager
Political Activities and Contributions
I do volunteer work for a local candidate for office. May I use the copy
machine to make flyers?
No. Employees may not use NCH time or resources to support political activities
that are undertaken on a personal basis, as is the case here.
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 doctors offices,
hospitals, and long-term care facilities. Effective April, 2003 it will be
illegal to violate this code.
Provide for continuity of healthcare coverage
Protect the security & privacy of all healthcare information
Give patients the right to access their medical records and restrict who
sees their information
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 patients confidentiality.
When can I use Health Information?
You can use health information for:
Treatment, i.e. doctors, nurses, technicians, and therapists caring for patients
Payment, i.e. billers sending out claims and coders applying codes to procedures
Healthcare operations, i.e. quality assurance staff performing reviews and
transcriptionists typing reports
How do I know if I can use/access a Patients Health Information?
Before looking at a patients 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.
Staff who are not providing care or consulting on a patients care do
not need to use/access health information. If you overhear private health
information as you do your day-to-day work and you keep it to yourself, you
have nothing to worry about.
Authorization - Healthcare organizations must obtain authorization from patients
before using their health information for reasons other than treatment, payment
or healthcare operations, i.e. research, marketing, fundraising.
Notice of Privacy Practices - Outlines the facilitys uses of patient
information and patient rights regarding that information and will be given
to all patients at time of registration or treatment/admission.
Patient Directory - Patients can choose not to be listed in the directory.
Staff cannot even acknowledge that those patients are present in the facility.
For patients listed in the directory, staff can tell visitors or callers
who ask for the patient by name only, the patients location in the
facility and the patients general condition, such as stable or good.
Protecting a Patients Privacy
Close curtains and speak softly when discussing treatment in shared clinical
Dont discuss patients in public areas such as elevators or cafeteria
Dont leave patients records lying around.
Dispose of patient information in locked shredder containers.
Report any patient information in open trash containers to the supervisor.
Dont leave information about a patients health on an answering
Do not share your password with co-workers.
Staff sharing passwords may be held responsible for a co-workers
inappropriate use/access of records.
Keep computer screens pointed away from the public.
Always log off the computer when you are finished.
Double-check the address line of the message before you send the e-mail.
Insert the confidentiality statement for e-mails sent outside NCH.
Do not open attached files from unknown sources.
Do not use work e-mail for personal business.
Double-check the fax number before sending.
Fax using a cover sheet with a confidentiality statement.
Take faxes off the fax machine immediately.
Do not conduct personal business with work fax machines.
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.
NEEDS OF OUR CUSTOMERS - Return to Top
CODE OF CARING
C: Customer Interactions
- Meet & Greet
- Hallway Etiquette
- Elevator Etiquette
- Telephone Etiquette
- Professional Personal Appearance
- Call Lights
- Wait Times/Transportation
- Meeting Customer Needs
- Recovery Process
- Privacy & Confidentiality
People form very firm and often lasting impressions of you in the first minutes
of your first encounter. But, people can and do shift from a first impression
to a secondary impression. However, it takes much more time and more data
for them to reform their impression (and feelings) about you and the
First impressions are made by things people notice about you during those
crucial first few minutes. They include your appearance, facial expressions,
movement, tone of voice, as well as your words. Also included would be your
listening behavior, your body orientation, your personal space, your social
If that first impression is positive, youre on your way to a successful
Since you cant choose to not make an impression, it seems reasonable
to know what behaviors put you across favorably and which to avoid.
Meet & Greet Standards
Our customers 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
Welcome every customer immediately by making eye contact, smiling and greeting.
Welcome to NWCH. How may I help you?
When rendering any service, introduce yourself with your name, title, and
Good morning. My name is ________ from ______ and I need
ID badges must be displayed on the upper torso, unless the department has
Call the customer by proper name, Mr./Mrs./Miss/Ms., unless directed by the
customer to do otherwise.
Respond quickly to the customers needs. Provide directions and/or
assistance as needed. Offer to walk the customer to their destination. Assume
ownership of the customers concerns.
Explain any and all delays in service. If customers need to wait; update
them every 15 minutes.
At the conclusion of a service rendered, bring closure to the interaction.
Handoff from one area to another. Thank the customer for using our
Is there anything else I can do for you?
This is _____ from ______ and (patient) will be coming up to you by
wheelchair to room 999.
A hallway encounter is an opportunity to create a favorable impression,
reinforcing the caring culture of our organization.
Acknowledge and greet every person you pass in the hall, maintaining eye
Actively seek out customers needing assistance and ask May I help
Always display a willingness to help the customer.
Whenever possible; escort the customer to their destination.
Be considerate of others. When passing in the hall, make sure to stand to
the side. Use hallway mirrors to avoid traffic in the hall and open doors
Only discuss confidential information on a need to know basis
and never in a situation where it might be overheard.
Always use appropriate language in casual conversation. Remember, anyone
can hear you.
Take ownership of the organization:
Keep environment clean
Report any safety concerns
Know where services are located
Let customers enter and exit first at all times, before entering or exiting
Help customers on and off the elevator.
When entering the elevator, acknowledge the customers and move to the back.
Transport patients, supplies, equipment, and food for meetings in the designated
Never discuss patients, hospital business, or personal issues on the elevator.
Avoid crowding the elevators; wait for the next one or take the stairs.
All food and drinks carried on the elevator must be covered.
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.
Answer telephone calls in as few rings as possible. A maximum of five (5)
rings is standard.
Identify yourself by department, your full name, appropriate title, and "
May I help you?"
Listen carefully. Always use a pleasant tone of voice. Convey friendliness
and caring. Never sound impatient or angry even if you feel justified.
Avoid side conversations while on the telephone. Put down your work. Your
caller deserves your full attention.
Never eat or drink while talking on the phone. If your mouth is full when
the telephone rings, wait a few seconds before answering.
Before placing a caller on hold, always ask, " May I put you on hold? " and
then wait for their answer before proceeding.
Before transferring, tell the caller whom you are transferring them to and
why. Give them the person's extension in case they are cut off.
All incoming and outgoing personal calls should be for emergency only. Conduct
these calls where you cannot be observed by customers.
When taking a message, make sure you have accurate and detailed information.
(i.e. correct spelling of caller's name, telephone number).
Messages should include name of person or department, hours of operation,
timeframe for returning call, current information if absent, and alternative
means of reaching someone in emergency situations.
Check messages at least twice a day.
Greetings should be changed when absent from area for more than 24 hrs, excluding
holidays and weekends.
Be mindful of privacy and confidentiality at all times.
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.
||Daily bathing and oral hygiene are essential. Use of deodorant and personal
|Any strong or excessive perfume or after shave (due to increasing asthmas,
allergies, and environmental allergies).
||Neat, clean, natural style.
||Hair coloring outside of natural shade. Unkempt facial hair.
||Clean, trimmed that do not exceed ½ from fingertip.
||Dirty, ragged nails. Nails longer than ½ from fingertip.
||Hosiery or socks with all undergarments. Outfits in a shade that compliment
the appearance. Appropriate undergarments worn at all times.
||Bare legs, bare feet.
||Clean, neatly pressed, in good repair and appropriate size.
||No blue denim material. Soiled, wrinkled, faded, torn or clothing worn
||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.
||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
||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.
||Appropriate length and size with finished hems.
||Items shorter than 3 inches above knee, high or dramatic slits.
||Clean, polished with laces tied. Safe for work environment.
||Unlaced hi-tops, casual sandals or thongs.
||Complimentary to clothing. Work related pins, service awards, professional
||No more than 3 earrings per ear. No other visible body piercing.
||All tattoos/body art must be covered during work hours.
||Exposed tattoos/body art.
||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
Knock on the door before entering a patients room whether the door
is opened or closed. This should be done at night as well.
Pull the curtains or close the door when discussing patient information or
Interview customers in privacy. Allow the patient to decide when visitors
or family need to step outside the room.
Provide a proper size gown for our patients.
To protect our patients modesty, provide a robe or second gown while
ambulating; when in a wheel chair or cart cover with a sheet or blankets.
Patient information should be accessed and shared on a need to know basis
Medical records are confidential; do not look at medical records if they
do not pertain to your job. Assure that individuals reviewing medical records
are authorized to do so.
Protect the medical record during transport.
Information should not be left on a computer screen for anyone to access.
Discussions including confidential information should be held where they
cannot be overheard. (Including phone conversations.)
Only nursing supervisors and members of the marketing staff are authorized
to release information about patients to the public/press.
When friends or family are hospitalized, disclose their admission and/or
visit them only upon their request.
Respect coworkers privacy by eliminating gossip.
Remember that privacy and confidentiality extend beyond the walls of all
Northwest Community facilities.
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,
Hallways & Grounds
Always pick up trash from the floor-never walk past.
Keep hallways free from clutter and store equipment appropriately.
Clean up your own spills.
Report large spills or needed cleanup to Environmental Services.
Keep chairs and floor free from trash and papers.
Discard any outdated reading material.
Staff should not use lobbies and waiting areas for eating or breaks.
Adjust the volume of the TVs/Radio as needed.
Monitor the condition of the furniture for maintenance, repair, or cleaning.
Dispose of waste in receptacles and notify Environmental Services if receptacles
Wipe the tables if necessary.
Make sure the room looks neat for the next group.
Keep free from clutter.
Dont use the windowsill for storage of equipment or linen.
Dispose of gloves, linen and garbage in appropriate receptacles.
Make sure trashcans are emptied regularly and replace needle boxes when full.
Keep the area neat and tidy.
Keep personal items at front desk to a minimum.
Food and other snacks should be kept in the break room.
Update messages and other posting often.
Keep departmental and staff notices out of our customers view.
Display only public notices that follow corporation standard.
Keep all public areas clean and orderly including bathrooms, cafeteria, vending
areas, and lobbies.
Report any incidents or problems or needed clean-ups to Facility Support
Responsiveness Customer Waiting Standard
We recognize that our Customers 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.
Provide a comfortable atmosphere for waiting customers.
Educate patients and families about the process, including that procedures
generally do not begin as soon as they enter the area. Encourage customers
to ask for an update at anytime.
If a scheduled procedure or exam will be delayed, inform customers at the
Customers may experience delays while undergoing multiple tests or while
patients with more serious conditions are being treated. In such situations,
make customers aware that they will be updated regarding their status.
While a customer is undergoing a procedure, update family members regularly.
Customers will never be told that they are waiting due to a staffing situation.
Always thank customers for waiting, and apologize for delays.
Additional Standards for Inpatient Waiting
Each day, customers will be informed about the plan of care, including any
scheduled tests and treatments.
At any time the caregiver is unavailable, an appropriate co-worker should
meet a patients needs.
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.
Transporters will introduce themselves to the patient.
Individuals transporting will confirm correct patient identity prior to patient
Individuals transporting patients will be present for the patient and will
avoid side conversations that do not include the patient.
Patients modesty, comfort and confidentiality will be provided for
while being transported.
Transporters will notify appropriate staff of the arrival and departure of
patients and any identified concerns of patient.
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
Collaborate with each patient's physician to help reinforce information that
Use clear and concise, understandable language when giving patients information.
Avoid technical or professional jargon.
Adapt methods and materials according to individual patient and family needs.
Reinforce verbal instruction with teaching protocols or other written material.
Customers with special needs (i.e., translators for non-English speaking
customers; interpreters, amplification devices and closed-captioned television
for the hearing impaired) will have those needs addressed by appropriate
Discharge planning and/or instructions begin at the time of admission to
any area of the organization; where treatment is provided include contact
number for questions or problems that may arise.
Charity Care / Financial Assistance at Northwest Community Hospital
NCH exists to provide quality, compassionate healthcare services to the people
of the northwest community.
For those individuals who may have difficulty affording the care they need,
NCH may be able to provide charity care or financial assistance based upon
the information provided by the patient through an application process.
Indigent, uninsured or underinsured patients may be eligible for free or
discounted services through this program.
If a patient of family member expresses the need to speak with someone about
their hospital bill, refer the individual to the financial counselors who
can be reached at 847-618-4542.
There is information about the charity care / financial assistance program
on our website at NCH.org
A copy of the policy is available to anyone upon request.
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:
Listen to the whole story.
Only ask clarifying questions.
Dont jump to a solution.
Realize that by listening respectfully, youre validating the persons
right to feel upset or angry and giving them a chance to get it off
their chest and calm down.
Apologize with empathy.
Apologizing is not the same as accepting the blame for what happened.
Apologizing with empathy means telling the customer you are sorry for how
they feel, e.g., Im sorry weve upset you by making you
wait so long.
If you were responsible for the problem, do take responsibility. Dont
blame others or make excuses.
Dont take the customers behavior personally! It will only put
you on the defensive.
Dont make any statement that indicates you feel the persons complaint
Respond to the need.
Recovery must be equivalent to the severity of the problem.
Suggest a solution to the problem. Explain what is going to happen.
If there is no immediate fix for the problem, apologize again for the
inconvenience. Ask if there is anything further that you can do. If applicable,
let the customer know youll make sure the information gets to the right
place for future action.
When appropriate a service recovery certificate may be presented to the customer
with sincere acknowledgment of customer inconvenience,
If the customer is still upset, get someone else involved (your Charge Person,
Facilitator, Director, or the Administrative Consultant).
Evaluate the results.
Follow up to make sure the solution actually occurred, and solved
the problem to the customers satisfaction.
Before leaving the customer, ask, Have I/we taken care of your
concerns? or Is there anything else I/we can help you with?
Thank the customer for their understanding, patience, etc.
Service Recovery need not be limited to these examples:
When we move a patient based on our needs, for example high census, isolation,
Long delays for service for any reason, such as bed placement, diagnostic
testing, or treatments.
It is important to use your own good judgment to identify a customer need.
Lost personal property; please attempt to retrieve from Security, ext.7550.
If unsuccessful, please refer to the Patient Representatives at ext. 4390.
View Current Northwest Community Redevelopment Roadmap -
View Northwest Community - Occurence Report -
Here for PDF
NORTHWEST COMMUNITY HOSPITAL
11SUBJECT: PARKING FACILITIES
To designate areas available for employee, volunteer, physician, sales and
outside service parking and to speci~' enforcement provisions.
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
Contract employees will park in designated lots i.e.: Center for Specialty
Medicine garage 5th level.
Volunteers may park in any lot (see section on prohibited areas).
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
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
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.
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.
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.
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,
All students will park in lot 7.
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
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
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.
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.
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.
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.
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.
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.
The following areas are prohibited from use by the employees, volunteers
and members of the medical staff on all shifts:
Handicapped areas unless proper identification is exhibited (sticker or plates).
All areas posted for Restricted Parking.
Designated Emergency Parking Spaces.
Day Surgery Center entrances and parking areas.
All areas marked with yellow curbs or designated as fire lanes (violation
of Village ordinance).
Access roads, entrances or receiving areas.
The Center for Specialty Medicine parking garage (except for designated employees
Employee of the month parking (unless designated by Human Resources)
Wellness Center parking lot. (Wellness Center employees are to use the Lot
Southwest of the 901 building by the grounds storage lots).
View Current Northwest Community Redevelopment Roadmap -
Here - Return to Top
12Download Current Forms for
Here for PDF Files - Return to Top