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SSeeccttiioonn II

Introduction

WWeellccoommee ttoo NNoorrtthhwweesstt CCoommmmuunniittyy HHeeaalltthhccaarree!!

Contract Staff & Students should:

1) Read the guide. 2) Complete the review questions. 3) Fill in the appropriate information on all documents & quiz. 4) Have your supervisor or instructor sign the form before you begin your

assignment. 5) Present the completed form to the Human Resources Department to receive your

I.D. Badge. 6) Wear your badge at all times while you are here at Northwest Community.

ADDITIONAL INFORMATION - Orientation Documentation Form/Unit Checklist - Orientation Quiz - Contract Staff/Student Orientation Checklist - NCH Information Password Security Agreement/Code of Conduct

Acknowledgment Form

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Our Mission, Vision and Values

Mission

We exist to improve the health of the communities we serve and to meet individuals’ healthcare needs.

Vision Statement

Northwest Community Healthcare will be an Integrated System of Care that delivers innovative, exceptional and patient-centric coordinated care while creating value for the populations we serve.

Cultural Values

COMPASSION: We genuinely care about the well-being of people.

COMMITMENT: We are committed to those we serve and their individual needs are at the center of all decisions.

EXCELLENCE: We are committed to exemplary service, clinical practice, quality and safety.

INTEGRITY: We are good stewards in doing the right things in the right ways.

COLLABORATION: We leverage teamwork and partnerships to deliver optimal outcomes, treating everyone with dignity and respect.

ADVANCING KNOWLEDGE: We are dedicated to professional development and the process of applying and sharing knowledge.

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About Northwest Community Healthcare

Facilities and Facts

We opened our doors December 2, 1959—over 50 years ago—marking the culmination of a multi-year community effort led by a group of visionary civic and business leaders who perceived the need for quality, community-focused healthcare in the northwest suburbs of Chicago.

Over the years, we have continued to grow with you, to meet your changing needs. Today, we’re a 496-bed hospital and a world-class medical provider – combining compassionate care with a healing environment and state-of-the-art medical facilities including:

The South Pavilion has 200 private rooms to enhance patient safety and convenience.

The William J. and Marion H. Busse Center for Specialty Medicine, an eight-floor facility housing physician offices, medical specialty services and advanced diagnostic technology

Four Immediate Care Centers, located in Buffalo Grove, Lake Zurich, Mount Prospect and Schaumburg

Seven accessible outpatient imaging locations that provide advanced imaging technology, including open MRI, CT, ultrasound, X-ray, mammography and more.

The Day Surgery Center, a same-day outpatient surgery center

The Youth Center, for adolescents struggling with substance abuse problems

Northwest Community Hospital Home Care

Occupational Health Services provided at five convenient locations.

The Wellness Center in Arlington Heights

Over 16 medical office locations

Patients Cared for Annually

24,000 inpatients

350,000 outpatient visits, including visits to the Hospital Emergency Department and Immediate Care Centers

37,000 home care visits

2,700 newborn deliveries

More than 16,000 inpatient and outpatient surgical cases, ranging from open heart surgery and joint replacement to neurosurgery and minimally invasive procedures

NCH staff consists of:

Over 1,000 physicians with offices throughout the northwest suburbs

NCH Medical Group, an employed physician group focusing on primary and specialty care

Approximately 3,800 employees including nurses, allied health professionals, administrative and support personnel

Approximately 800 volunteers providing more than 100,000 hours of service annually

Additionally:

NCH is governed by the NCH Board of Directors, a volunteer board made up of community members and business leaders.

The NCH Foundation provides charitable opportunities for individuals, groups and corporations to invest in the future of the organization and its vital mission

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Hospital Campus

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Locations Medical Groups

800 W. Central Road

Arlington Heights, IL 60005

847-618-1000

880 W. Central Road, Suite 5000

Arlington Heights, IL 60005

847-618-3800

880 W. Central Road, Suite 7100

Arlington Heights, IL 60005

847-392-7810

1051 W. Rand Road, Suite 102

Arlington Heights, IL 60004

847-342-8220

1051 W. Rand Road, Suite L02

Arlington Heights, IL 60004

847-410-6435

1538 N. Arlington Heights Road

Arlington Heights, IL 60004

847-253-6464

1700 W. Central Road, Suite 140

Arlington Heights, IL 60005

847-259-6200

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2101 S. Arlington Heights Road, Suite 108

Arlington Heights, IL 60005

224-404-6500

3295 N. Arlington Heights Road, Suite 107

Arlington Heights, IL 60004

847-797-0587

1632 W. Central Road

Arlington Heights, IL 60005

847-253-8050

1450 Busch Parkway, Suite 100

Buffalo Grove, IL 60089

847-459-7860

1450 Busch Parkway, Suites 103-105

Buffalo Grove, IL 60089

847-725-8453

135 N. Arlington Heights Road, Suite 152

Buffalo Grove, IL 60089

847-465-9600

1217 S. Rand Road

Lake Zurich, IL 60047

847-550-4700

199 W. Rand Road, Suite 203

Mount Prospect, IL 60056

847-618-5450

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455 S. Roselle Road, Suite 121

Schaumburg, IL 60193

630-671-4980

500 N. Hicks Road

Palatine, IL 60067

847-221-8700

Immediate Care Centers

1201 S. Rand Road

Lake Zurich, IL 60047

847-540-8088

199 W. Rand Road

Mount Prospect, IL 60056

847-618-5400

519 S. Roselle Road

Schaumburg, IL 60193

847-985-0600

15 S. McHenry Road

Buffalo Grove, IL 60089

847-459-6100

NCH Easy Access

423 E. Dundee Road

Palatine, IL

847-618-2440

Atheron Heart Failure Clinic

199 W. Rand Road

Mount Prospect, IL 60056

847-618-2440

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SSeeccttiioonn IIII

Hazardous Materials

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.

I. OSHA (Occupational Safety Health Act) mandates that employees have a "right to know" about workplace hazards.

A. Employee Health Service maintains logs and records related to occupational health issues and they are available upon request.

II. OSHA Written Hazard Communication Standard involves the following: A. Written program and plan. 1. Centrally located in Facility Support. 2. Departmental plan covers chemicals in each department. 3. Employee training B. Employee training about hazardous materials includes: 1. The NCH Hazardous Materials policy is available online in the Administrative Policies and Procedures section under Contents. 2. Department specific orientation for chemicals in your area, Check with your

Supervisor/Manager for specific: a. Presence of chemicals b. Accidental release of chemicals c. Emergency procedures d. Health and safety concerns e. Material Safety Data Sheet (MSDS) C. MSDS - Material Safety Data (Call 1-888-362-7416): 1. Chemical information sheets are prepared and provided by manufacturer on request.

2. Contact the number when a spill occurs. Have available the product name, product

number, manufacturer name, and UPC code. The phone number is listed on all phones with an orange sticker.

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Occurrence/Safety Report Form: If an employee observes a safety concern at any Northwest Community Healthcare facility, the organization strongly encourages the completion of an Occurrence Report form, which is available on the Intranet.

Submit Occurrence Report forms electronically on the NCH Intranet under ‘Contents’.

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Emergency Codes

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: Hospital, all floors (South, North, East and West Pavilions) Day Surgery Center CSM (Busse Center for Specialty Medicine) public areas floors 1-2 Dial 3333 and 911: CSM (Busse Center for Specialty Medicine) public areas floors 3-8 CSM (Busse Center for Specialty Medicine) parking garage NCH employee parking garage All open parking lots Dial 911: Busse Center for Specialty Medicine offices floors 3-8 Kirchoff Center Wellness Center Immediate Care Centers Medical office buildings Salt Creek Business Center Visitor parking garage

Provide EXACT location. A Pediatric Code Blue should be called for anyone 17 years or younger. 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.

Assistance Alert – When anyone (excluding inpatients) experiences a fall or illness and IS AWAKE, ALERT AND SPEAKING while in outpatient areas of the hospital i.e. parking garages, hospice unit on 9E, outside the hospital on campus grounds. If the victim is not awake and/or unable to speak, a Code Blue should be called.

To initiate an Assistance Alert:

Outpatient areas of the hospital

Dial 3333

Tell operator you have an Assistance Alert

Give exact location

Outside the hospital on campus grounds

Dial 3333

Tell operator you have an Assistance Alert

Call 911 & give exact location

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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. Two-way 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 failure.

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. Call 911 and then 3333 for Security.

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. Employees should move to cover all exits.

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. Hospital - dial 3333 Business Center - call 911 Immediate Care Centers (Treatment Centers) - use intercom to overhead page; call 911 to report Kirchoff Center - pull alarm (automated announcement is triggered)

Code Triage – 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. Refer to Administrative Policy #SQ-905.

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Code Silver – (Bomb Threat) If a staff member receives a bomb threat or locates a suspicious device

they should not touch it or go near it & clear the immediate area.

If threat is received by e-mail: KEEP the MESSAGE ON the SCREEN. DO NOT turn off the computer or delete the message.

If threat is received by phone: Immediately write down the information as close to a quote as possible. Words are important as they will help in evidence analysis.

Call “9-1-1” using a landline phone. Cease all use of hand-held phones (tweet, text, etc) or radios because radio frequencies can detonate a device. Clearly report the threat of/or location and brief description of a suspicious device.

Call Security (# 3333) by landline phone only. Report the location and brief description of a suspicious device or the nature of the threat.

Complete “The Bomb Threat Checklist” and bring to HICS (if established) as soon as possible. If HICS not established, bring to main security desk. Reference Administrative Policy: SQ-908 Bomb Threat.

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Fire Safety

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 and students 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 and student 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 and students 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 911

Immediate Care Centers - use intercom to overhead page, dial 911 to report

Kirchoff Center- 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.

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.

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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.

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 fire- related injuries. 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.

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Radiation Safety

Radiation Areas at Northwest Community Hospital

• 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: The shorter the time interval that one is exposed to the radiation source, the less the amount of radiation that will be absorbed.

Distance: Radiation exposure and distance are inversely related. The intensity of radiation decreases by the square of the distance from the source.

Shielding: 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 radiation exposure.

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:

Radiation Oncology Department at extension or pager 6560

Radiation Safety Officer at extension or pager 6592

Nursing Supervisor extension 7933 or pager 0050

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Infection Prevention Northwest Community Healthcare has an Infection Prevention & Control (IP&C) Program designed to protect patients, employees, volunteers, and visitors. The goal of this program is to prevent the acquisition of healthcare-associated infection.

Information about NCH’s Prevention program can be found on the NCH Intranet Contents page under “Infection Prevention.” There are a variety of resources and policies related to the program there for your reference.

NCH has three Infection Prevention Practitioners: Brigette Bucholz, Manager (x4372, pager: 4372), Sally Houghton (x4386), and Jenny O’Brien (x4374). You can call any of the IP&C staff if you have a question related to infection prevention.

Standard Precautions According to the Centers for Disease Control & Prevention, Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of whether or not infection status is confirmed or suspected. NCH staff members who provide direct patient care must always adhere to standard precautions. Standard precautions include the following:

1. Hand hygiene 2. The use of personal protective equipment (e.g. gloves, gown, mask) 3. Safe injection practices 4. Safe handling of potentially contaminated equipment or surfaces in the patient environment 5. Respiratory hygiene/cough etiquette

Infectious agents such as the human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) can be present in the blood and other body fluids of people who appear to be perfectly healthy. Routine screening every patient for a potentially infectious disease would be impossible to do. Consequently, we must treat every patient as if they are infected and exercise proper caution.

1. Hand Hygiene

Cleaning your hands, either with alcohol-based hand rub or by washing with soap and water, is the single most important thing that you can do to prevent the spread of infection. Both sinks and alcohol-based hand rub dispensers are available in patient care areas for your convenience and use. Hand hygiene must be performed at the following times:

1. Before and after any patient contact, including contact with the patient’s environment

2. After removal of gloves 3. After contact with blood/body fluids or when hands are visibly

soiled 4. Before clean or sterile invasive procedures 5. After use of restroom (toilet) facilities

There are a number of other times when hand hygiene is appropriate and necessary. For more details on hand hygiene at NCH, refer to the Hand Hygiene policy on the IP&C Intranet page.

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2. Personal Protective Equipment (PPE)

PPE refers to wearable items that protect you from exposure to or contact with potentially infectious materials. PPE includes gloves, gowns, face masks, respirators, goggles, and face shields. Choosing PPE depends largely on the nature of the interaction you have with a patient and the potential for exposure to blood, body fluids, or other potentially infectious agents. PPE may be worn during venipuncture, specimen collection, any dental procedure, arterial punctures, handling linen or articles soiled with body fluids, processing of specimens, when applying pressure to a bleeding site, when handling or transporting potentially infectious medical waste, and during suctioning, among other activities. PPE must also be worn to be compliant with isolation precautions. The type of PPE necessary in these situations will depend on the type of isolation a patient requires. Gloves are used to enhance the barrier provided by intact skin. They must be worn when:

Touching blood/body fluids, mucous membranes or non-intact skin of any patient

Handling items/surfaces soiled with blood/body fluids

Performing venipuncture or other vascular access procedures

Gloves must be changed between patients!

Gowns must be worn to protect clothing during procedures that are likely to cause soiling or splashing from blood or risky body fluids.

Face protection, such as masks, goggles, and face shields must be worn to protect mucous membranes of the mouth, nose, & eyes. You should don these types of PPE for the following:

During any procedure when splattering of blood/risky body fluids may occur

3. Where aerosolization of blood/risky body fluids is likely (e.g. intubating a patient)

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Safe Injection Practices

Needles and other sharp instruments must be disposed of in a puncture resistant container. Needles

must not be bent or broken. Do not attempt to re-cap a needle!

Safe injection practices not only help to protect NCH employees, but our patients as well.

Never reuse a single syringe, with or without the same needle, to administer medication to

multiple patients.

Never re-insert a used syringe, with or without the same needle, into the same medication vial or

solution container (e.g. a saline bag) to obtain more medication for a single patient and then use

that vial or solution container for different patients

Do not prepare medications in close proximity to contaminated supplies or equipment.

4. Safe Handling of Contaminated Equipment and Surfaces

NCH has many policies and procedures that relate to the cleaning and disinfection of patient care

equipment, medical devices, and environmental surfaces. IP&C and Environmental Services work

together to ensure that we match the appropriate cleaning agent to the device or surface that needs to be

cleaned. Instructions for proper use of cleaning agents are available on the label; if you’re unsure on how

to clean something, either ask a colleague or read the label.

At a minimum an assistive ventilatory device must be used when performing CPR.

Laboratory specimens must be transported in a specimen bag.

*Low risk body fluids may be considered high risk if they contain blood.

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Exposures to Blood Borne Pathogens

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

1. An exposure is sustained if an employee suffers: a. A laceration or puncture with a sharp instrument that is contaminated with blood/body

fluid b. A human bite c. Blood/body fluid contamination of an open wound d. Oral ingestion of blood/risky body fluids

2. 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.

Hepatitis B Virus (HBV) Vaccination

All unvaccinated employees who could potentially have blood/body fluid contact or sharp-contaminated instrument contact should be vaccinated against HBV.

The HBV Vaccine is available free of charge, to any employee who may have blood/body fluid contact and/or sharp contaminated instrument contact during the performance of job duties.

The vaccine is administered in the Employee Health Service department and after hours in the ER located on the first floor of the Hospital.

o The Employee Health Service department is open Monday through Friday, 7:30am - 4:00pm.

The HBV vaccine should produce antibodies in greater than 90% of all persons who receive all three shots appropriately administered with minimal side effects. A sore arm is the most frequently reported side effect. Protect yourself from the potential morbidity/mortality caused by HBV and get vaccinated!

5. Respiratory Hygiene / Cough Etiquette

In some cases, infection prevention measures can be implemented at the point of entry to the hospital. To prevent transmission of influenza and other respiratory infections in NCH, respiratory hygiene/cough etiquette is implemented in patient care waiting areas and other areas where patients and visitors commonly gather.

Staff, patients, and visitors are educated on the importance of containing respiratory secretions to help prevent the transmission of influenza and other respiratory viruses.

The following measures are employed when following respiratory hygiene/cough etiquette:

Covering the nose/mouth with a tissue when coughing or sneezing

Using tissues to contain respiratory secretions and disposing of them in the nearest waste receptacle after use

Performing hand hygiene after having contact with respiratory secretions and/or objects that are contaminated with respiratory secretions

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Tuberculosis (TB) at NCH

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 has symptoms and a positive sputum sample (AFB) for M. tuberculosis. An individual 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 weight loss. IP&C prevents the transmission of TB at NCH in a variety of ways:

1. Administrative

Policies and procedures (see Infection Prevention page on NCH Intranet)

Education programs for staff.

Documentation of care and record-keeping

Criteria for early identification of persons with possible TB 2. Special signage - "Airborne Precautions"

Negative Pressure Isolation Rooms a. Patients with TB or those who meet the criteria for suspected TB will be placed in these

rooms and into Airborne Isolation b. NCH clinical staff is responsible for notifying engineering to activate negative pressure c. It is very important to always keep the room doors closed for the airflow to work properly

3. N-95 Respirator PPE a. This is a special mask that filters the TB droplet nuclei from the air. b. In order to use this respirator you need to be properly fit-tested, given a medical

evaluation, education and training on proper usage. c. Your department will inform you if you need to be fit-tested to use a respirator. d. You must wear a 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 may not protect you from inhaling infectious airborne droplet nuclei.

i. Visitors to a patient who is in airborne precautions may wear either a surgical mask or an N-95 mask, depending on their preference. They will not be formally fit-tested if they request to wear an N-95.

All employees with direct patient contact will be tested for TB on at least an annual basis. Monitoring includes a TB skin test. However, if a person has had a previously positive TB skin test, they will have to complete a surveillance questionnaire about their health instead.

Some employees will be monitored twice a year or quarterly depending on where they work. Also, employees will be monitored after an exposure. The monitoring will be done in Employee Health Service.

The requirement for annual surveillance of employees will be determined each year following the TB risk assessment performed by Infection Prevention.

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SSeeccttiioonn IIIIII

Corporate Compliance

Doing Right Things Right! Consistent ethical behavior is the key to our long term:

Success

Reputation

Competitiveness

Leadership in healthcare

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, The Joint Commission.

The purpose of a Compliance program:

To prevent, detect and correct improper business practices: coding and billing fraud.

What resources provide guidance:

NCH Code of Conduct (see attached) Decision Tree Compliance Line: 1-888-203-2523

Submission of unresolved or unaddressed patient care or quality issues may go to: Mail: The Joint Commission Office of Quality Monitoring

One Renaissance Blvd. Oakbrook Terrace, IL 60181

E-mail: complaint@jointcommission.org Call: (800) 994.6610

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. Start with the lowest resource on the Decision Tree when reporting violations.

1) Your supervisor 2) Human Resources 3) The Compliance Line

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Corporate Compliance Policy And Guide (Revised 1-24-14)

PURPOSE:

To insure all employees of Northwest Community Hospital (NCH) are aware of their legal and ethical

responsibilities and that they have they have education, guidance, and tools available to them to meet

those responsibilities.

POLICY:

It is the policy of NCH to comply with all laws, rules, and regulations applicable to the services we

provide. This includes federal, state, and local laws. NCH accepts the responsibility to diligently self-

govern and monitor adherence to the requirements of law and to ethical business standards.

Your Personal Accountability

A. Who Should Read This?

Board members

Medical staff

Leadership Team

Directors

Employees

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. To call the Compliance Line dial 1-888-

203-2523.

B. Learning the Law

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.

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C. The Cost of Breaking the Law

Violations of the law can greatly harm NCH’s 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.

D. 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.

E. Enforcement and Discipline

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.

F. 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

reviews.

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

encourages 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

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manager first. In any event, if you are unsure of whether your own actions (or another’s) are compliant

with the law or our policies, please follow the process below:

A. 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.

B. 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. If you are not comfortable with contacting these resources, then take

the next step.

C. 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 resolved

To call the Compliance Line dial 1-888-203-2523.

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D. 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.

E. 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.

Important Laws and Responsibilities

A. HIPAA

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that

establishes national standards for protecting health data. HIPAA limits how Personal Health

Information (PHI) can be used, transferred, or disclosed. PHI is any individually identifiable health

information, which is a deliberately broad definition. If a piece of information can be used to

identify a patient, it is probably PHI. PHI can be, but is not limited to:

Physical documents

Electronic documents or visible screens (ePHI)

Pictures

Verbal conversations

Any information that can be used to identify a patient

As a general rule of thumb, HIPAA imposes the "minimum necessary" rule in the use and disclosure

of PHI. That is, when a covered entity uses or discloses PHI, the covered entity must undertake

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"reasonable efforts" to limit the amount of PHI it uses, discloses, or requests to the minimum

necessary to accomplish the purpose for which the use, disclosure, or request is made. (See

Administrative Policy HP-003, Disclosing and Requesting only the Minimum Necessary amount of

Protected Health Information)

All NCH patients must receive the “Privacy Notice” that describes how medical information may be

used and disclosed by the hospital/NCH entity. Patients must sign that they received the notice.

Employees must not release or discuss our patients’ PHI with another unless it is necessary to serve

the patient or required by law. Releases or disclosures of PHI for purposes not related to treatment,

payment, business operations, or as required by law are permissible only after obtaining the

patient’s written authorization. (see Administrative Policy HP-017, Release of Patient Information)

The unauthorized disclosure or use of PHI is considered a HIPAA violation. Depending upon the

nature of the incident, these violations can result in both civil and criminal penalties. All known or

suspected violations must be reported to the Compliance Officer.

All HIPAA complaints from patients arriving in person shall be directed to the Patient Advocate for

resolution.

B. Anti-Kickback Statute

The federal Anti-Kickback Statute is a criminal statute that prohibits the exchange (or offer to

exchange), of anything of value, in an effort to induce (or reward) the referral of federal health care

program business. Any business arrangement with a physician must be structured to comply with

legal requirements. Such arrangements must be in writing and approved by Legal Counsel. In

negotiating and entering into business arrangements with physicians, NCH will adhere strictly to

two primary rules:

1. We do not pay for patient referrals. We accept referrals and admissions based solely on

the patient’s clinical needs and the ability of the organization to render the needed

services. Violation of this rule may have grave consequences for the organization and

the individuals involved, including civil and criminal penalties, and possible exclusion

from participation in federally funded healthcare programs.

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2. We do not accept payments for referrals that we make. No NCH employee or any other

person acting on behalf of the organization is permitted to solicit or receive anything of

value, directly or indirectly, in exchange for the referral of patients. Similarly, when

making patient referrals to another healthcare provider, we do not take into account

the volume or value of referrals that the provider has made (or may make) to us.

C. Physician Self-Referral (Stark Law)

There is a federal law known as the “Stark Law” which prohibits physician referrals of designated

health services for Medicare and Medicaid patients if the physician (or an immediate family

member) has a financial interest or relationship with the entity. Violation of Stark Law can result in

large civil penalties and possible exclusion from participation in the Medicare and Medicaid

Programs. NCH treats these violations as a conflict of interest.

D. Billing Compliance and The False Claims Act

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 physician’s 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 standard format

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Compliance risk assessments will be conducted on a regular basis to identify and correct any

erroneous billing practices

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.

The Federal False Claims Act prohibits knowingly submitting (or causing to be submitted) a false or

fraudulent claim for payment or approval to the federal government or a state Medicaid program.

Consequences for violating this law include: obligation to repay all of the falsely obtained

reimbursement, civil penalties of up to $11,000, plus three times the amount of actual damages

sustained by the government as a result of the prohibited conduct for each violation of the Act. In

addition to being liable for damages and civil penalties, violating the Federal False Claims Act can

subject a person or entity

to exclusion from participation in Federal health care programs, such as Medicare and Medicaid.

The Compliance Director should be immediately notified concerning inquiries from the HHS Office

of Inspector General. For coding questions, contact Health Information Management (Medical

Records). For questions concerning billing issues, contact Patient Financial Services.

References:

PC-038 Patients’ Rights and Responsibilities

FN-004 Gift Accepting, Fundraising and Charitable Donations

GO-031 Just Culture Policy

HR-007 Employee Compliance Education

IS-006 Role Based ePHI Access

IS-014 Clinical Devices Containing PHI

MR-030 Physical Security of PHI

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Code of Conduct – A Note From the President and CEO

Dear Colleague and Fellow Employee,

For over four decades, Northwest Community Healthcare (“NCH”) has provided quality, compassionate

healthcare services to the people of the northwest community. As an important part of this mission, we

integrate ethical conduct standards and regulatory compliance into our approach to healthcare

delivery and business management. The attached Code of Conduct is being provided to you to as a

helpful resource that supports our care giving mission and the business integrity of NCH.

The purpose of the Code of Conduct (“Code”) is to provide guidance to ensure that our work is done in

an ethical and legal manner. It emphasizes some of the most important laws and policies that we are

expected to know and comply with as healthcare providers. It also identifies resources that can help

answer questions about appropriate conduct in the work place. Please review it thoroughly. Adherence

to its spirit, as well as its specific provisions, is critical to our future.

If you have questions regarding this Code or become aware of any situation or behavior that you believe

violates any provisions of this Code or other policies, you should immediately consult your supervisor, a

Leadership Team member, or the NCH Compliance Director. You may also call the NCH Compliance Line

at 1-888-203-2523. You have my personal assurance there will be no retaliation for asking questions or

raising concerns about the Code or for reporting possible improper conduct.

Each of you plays an important role in creating a culture within NCH that supports the Values and

Guiding Principles that are essential to achieving our mission. As a healthcare team, we are dedicated

to excellence as a basic performance standard. Therefore, we expect all of our employee’s actions to

reflect the high standards set forth in this Code.

In your daily work experiences, if you encounter a situation or are considering a course of action that

you are not sure is the right thing to do, please don’t struggle alone. Instead, discuss the situation with

any of the resources referenced above. We trust you as a valuable member of our healthcare team and

ask you to assist us in supporting the underlying values and guiding principles, which are critical to

achieving our mission.

Sincerely,

Steve Scogna

President and Chief Executive Officer

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Code Of Conduct (Revised 1/24/14)

PURPOSE:

The purpose of this Code of Conduct is to support our caregiving mission within a framework of

corporate integrity, honesty, and compliance. These rules and regulations apply to our relationships

with patients, physicians, third-party payors, subcontractors, independent contractors, vendors,

consultants, and one another. It is the obligation of all NCH employees to familiarize themselves with

this Code of Conduct and hold themselves to a professional standard of excellence.

SCOPE:

This policy applies to:

Board members

Medical staff

Leadership Team

Directors

Employees

POLICY:

The Code of Conduct is an important part of our Compliance Program. The Board of Directors has

adopted this Code to ensure that NCH has a formal compliance function and established standards of

conduct to guide the staff in carrying out their duties and responsibilities. A current copy of the Code is

maintained for reference in the Health Resource Library and in departmental copies of the

Administrative Policy Manual. It is policy for all employees and other applicable parties to abide by

the guidelines set forward in this Code and/or to seek appropriate assistance if needed.

GUIDELINES:

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 or are mandated by federal or state law and may require

further explanation about how they may affect your duties. Please see below:

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Patient Care and Rights

NCH treats all patients with respect and dignity and provides care that is medically necessary and

appropriate. NCH makes no distinction in the admission, transfer or discharge of patients or in the care

it provides based on race, color, religion, sex, or national origin. Clinical care is based on patient needs,

not on a patient’s ability to pay or organization economics. Upon admission, NCH will issue each patient

a written statement of patient rights. This statement includes the rights of the patient to make decisions

regarding medical care and conforms to Federal and Illinois law.

NCH assures patients' involvement in all aspects of their care. Working together, the attending physician

and employees will provide patients with an explanation of care which may include diagnosis, treatment

plan, right to refuse or accept care, care decision dilemma advice, advance directive options, and an

explanation of the risks and benefits associated with available treatment options. Patients and their

representatives will be accorded confidentiality, privacy, security and protective services, opportunity

for resolution of complaints, and pastoral counseling. Additionally, NCH maintains processes for prompt

resolution of patient grievances, which include informing patients of whom to contact regarding

grievances and informing patients regarding the grievance resolution. (See Administrative Policies PC-

038, Patient Rights and Responsibilities, PC-037, Patient Visitor 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 are indigent, uninsured, or have limited financial

resources, who require medically necessary services. We provide financial counselors to answer

patient’s billing and insurance questions or assist with payment issues. Financial counselors can be

called at 847.618.4542. (See Charity Care and Financial Assistance, Administrative Policy # 152)

Emergency Treatment

NCH complies with the Emergency Medical Treatment and Active Labor Act by providing an emergency

medical screening examination and stabilizing treatment to all patients, regardless of their ability to pay.

Under EMTALA, all patients have rights equally, regardless of age, race, religion, nationality, ethnicity,

residence, citizenship, or legal status. 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

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if the patient’s medical needs cannot be met at NCH and appropriate care is knowingly available at

another facility. Unless the patient requests a transfer, patients may only be transferred after they have

been stabilized and are formally accepted by the receiving facility.

Patient Information

Patients can expect that their privacy will be protected. NCH collects patient information for treatment,

payment and business purposes. We realize the sensitive nature of this information and are committed

to complying with the Privacy and Security standards outlined in the Health Insurance Portability and

Accountability Act (“HIPAA”) when collecting, using or disclosing protected health information (“PHI”)

Employees must not release or discuss our patient’s PHI with others unless it is necessary to serve the

patient or required by law. Releases or disclosures of PHI for purposes not related to treatment,

payment, business operations, or as required by law are permissible only after obtaining the patient’s

written authorization. (See Administrative Policy HP-017, Release of Patient Information) No NCH

employee or physician has a right to access any patient’s PHI other than the amount that is minimally

necessary to perform his or her job. (See Administrative Policy HP-003, Disclosing and Requesting only

the Minimum Necessary amount of Protected Health Information)

Research

All patients asked to participate in an approved research project are given a full explanation of the goals

and objectives of the project as well as the alternative services that might prove beneficial to them. They

are also fully informed of potential discomforts and are given a full explanation of the risks, expected

benefits, and alternatives. These patients are fully informed of the procedures to be followed, especially

those that are experimental in nature. Refusal of a patient to participate in a research project will not

compromise their access to services. Any individual applying for or performing research of any type is

responsible for maintaining the highest ethical standards in any written or oral communications

regarding the research project as well as following appropriate research guidelines set forth by the

Institutional Review Board.

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

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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 GC-006 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,

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 individual’s 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 NCH.

Electronic Media

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

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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 HP-016, Release of Information to News Media)

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 payors, suppliers, and others.

They are also necessary for compliance with tax and financial reporting requirements.

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 accepted 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.

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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 LE-002, Contract Review)

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 employee’s ability to

make objective decisions in the course of his or her job responsibilities. Conflicts of interest may also

arise when an individual’s 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 employee’s supervisor. Certain employee’s

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 NCH’s Conflict of Interest Policy, the employee must contact

his or her manager or a Leadership Team member for further guidance.

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Controlled Substances

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 Policies #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.

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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. Any community or charitable use of NCH resources must be approved in

advance by the appropriate manager. Any use of NCH resources for personal financial gain unrelated to

NCH's business is prohibited.

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, adherence to schedules, service, and maintenance of adequate

sources of supply. (See Administrative Policy FN-004, Gift Accepting, Fundraising and Charitable

Donations.)

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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 a 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 that 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).

Antitrust

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 supplier.

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 Legal Counsel.

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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.

Environmental Compliance

Immediately alert a manager of any situation involving the discharge of a hazardous substance,

improper disposal of medical waste, or any situation that may be potentially damaging to the

environment. It is NCH policy to comply with all environmental laws and regulations and operate each

NCH facility with the necessary permits, approvals, and controls. Employees must diligently follow the

proper procedures with respect to handling and disposal of hazardous waste, including medical waste.

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 vendor’s 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

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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 FN-004 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 to NCH.

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

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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. Before extending courtesies, consult with the Compliance Director or Legal Counsel.

Political Activities and Contributions

Because of its not-for-profit status, the law limits NCH’s participation in political activities. NCH funds or

resources are not to be used to contribute to political campaigns or for gifts or payments to any political

party or their affiliated organizations. NCH resources include the use of work time and telephones to

solicit for a political cause or candidate and loaning property for use in the political campaign.

It is important to separate personal and corporate political activities in order to comply with the

appropriate rules and regulations relating to lobbying or attempting to influence government officials.

Employees may, of course, participate in the political process on personal time and at their own

expense. In doing so, care should be taken to avoid giving the impression that such involvement is on

behalf of or connected with NCH. Employees cannot seek to be reimbursed by NCH for any personal

contributions for such purposes.

At times, NCH may ask employees to make personal contact with government officials or to write letters

to present NCH’s position on specific issues. In addition, it is a part of the role of some management to

interface on a regular basis with government officials. When making these communications on behalf of

the organization, the spokesperson should be familiar with any regulatory constraints involved and

observe them. Guidance is always available from the Compliance Director and Legal Counsel as

necessary.

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Appropriate Use of Computing Devices

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SSeeccttiioonn IIVV

Quality Customer Service

This chapter includes:

Definition of Quality NCH Experience Center Code of Caring Customer Service Standards

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Dear Employee: I am asking for your help to make this organization the best it can be. We all need to work together to fulfill our mission and to achieve the highest level of customer satisfaction possible. To achieve our mission, the following performance standards have been developed for all employees to follow. We strive to demonstrate respect and caring for one another, our physicians and our patients and their families. Everyone deserves excellent service and it is the key to sustaining our success. All employees have the opportunity to make a difference. I ask you to join me in making a commitment to service excellence! Thank you for your support. Steve Scogna President and Chief Executive Officer

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DEFINITION OF QUALITY

Quality on the job can be defined as,

“Meeting or exceeding customers’ needs by

doing right things right.”

To evaluate how well we are meeting or exceeding our customer’s needs, NCH’s ongoing measurement with:

Surveys of patients, physicians, employees

Review of compliance to best practice standards

Internal & external prospective reviews

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NNCCHH EExxppeerriieennccee CCeenntteerr

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Employee/Patient Survey

Your opportunity to give us comments.

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CCOODDEE OOFF CCAARRIINNGG

NCH CUSTOMER SERVICE STANDARDS

CC: Customer Interactions

Interact immediately by acknowledging your customer whether in-person or on the telephone.

AA: Appearance

Maintain a professional, neat, clean appearance personally and environmentally.

RR:: Responsiveness

Respond quickly to our customer’s needs and explain any delays.

EE:: Education/Information

Educate and provide information to customers about what is being done, using words they can understand.

SS:: Service Recovery

Anticipate concerns or complaints before they become an issue. If a customer complains listen, apologize and respond effectively to the problem.

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CC -- Customer Interactions

Meet, Greet, Hallway, Elevator

o Welcome every customer immediately by making eye

contact, smiling and greeting. “Hello, how may I help

you?”

o Introduce yourself with name, title and department.

o Address the customer by proper name, Mr., Mrs. Miss,

Ms., unless directed otherwise by the customer.

o Close the conversation with “Is there anything else I

can do for you?”

o Actively seek customers needing assistance, “May I

help you?”

o Whenever possible escort the customer to their

destination.

o Transport patients, supplies, equipment and food in

designated elevators only.

o Cover all food and drinks in the hallways and elevators.

o Before providing service confirm patient identity.

o Protect patient’s modesty, privacy, confidentiality and

security of their belongings at all times.

o When in the presence of a customer, avoid any side

conversations that do not include the customer.

o Refrain from eating/drinking in view of customers. (i.e.

nurses station)

o Always remember the customer first.

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Telephone

o Answer telephone in 5 rings or less

o Identify yourself by department full name and title and

“May I help you.”

o Never eat or drink while on the phone.

o Ask if you can put the caller on hold and check back

frequently.

o Before transferring, tell the caller whom you are

transferring them to and why and give them the

extension in case they get cut off.

o Personal calls should be for emergencies only. Use of

personal cell phones for calls and texting are restricted

to off duty time and away from the workstation.

o Voice mail:

Message should include name and department

reached, hours of operation or timeframe for

returning calls, current information if absent from

department and alternative way to reach person

in emergency.

Check messages at least twice daily.

Greetings should be changed if absent for more

than 24 hours.

Call forward if away from desk for extended

period of time.

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Language

o Languages spoken, and communication utilized, should

support “getting the job done.”

o In work situations, English will be spoken, unless the

individuals present have requested, or consented to,

the speaking of another language.

o In non-work situations, employees are welcome to

converse in English, or languages other than English,

but are encouraged to be respectful and to

acknowledge the presence of others who may or may

not speak their language.

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AA –– Appearance Standards

Policy HR-301

Individuals, who represent Northwest Community Hospital, are

expected to project professionalism in their appearance, as this is

an important element of customer service.

Business attire or appropriate uniforms are required at all times.

APPROPRIATE APPEARANCE STANDARDS INAPPROPRIATE APPEARANCE STANDARDS

Body Art/

Tattoos

All tattoos/body art need to be covered during work hours.

Exposed tattoos/Body art

Fingernails Clean, trimmed, that do not exceed ½ inch from fingertip.

Dirty, ragged nails Nails longer than ½ inch from fingertip. For employees with direct patient care: any artificial fingernails or extenders

Footwear Clean, polished, laces tied. Safe for the work environment.

Unlaced hi-tops, casual sandals and thongs

Hair Neat, clean, natural style Hair coloring outside natural shades Unkempt facial hair

Hats Professional head gear/surgery hats worn within the department (religious head coverings may be acceptable per department standard).

Non-work related hats

Hosiery/

Undergarments

Hosiery or socks with all outfits in a shade that compliments the appearance. Appropriate undergarments worn at all times.

Bare legs, bare feet

Hygiene Essentials are daily bathing and oral hygiene, the use of deodorant and personal hygiene products. Breath mints. Complimentary make-up.

Due to patient and employee respiratory sensitivities, allergies and asthma; any fragrance which produces a scent or odor, strong enough to be perceived by others including; but not limited to colognes, perfumes, aftershave, and lotions are not to be worn at work Odor from tobacco products Body or mouth odor Excessive make-up Chewing Gum

Jewelry Complimentary to the clothing. Work related pins, service awards, and professional pins.

More than 3 earrings per ear Visible body piercing besides the ears

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APPROPRIATE APPEARANCE STANDARDS INAPPROPRIATE APPEARANCE STANDARDS

Name Badges Must be worn at all times in a visible spot on upper torso, over outer layer of clothing.

No badge worn or badge worn in a place that is difficult to read Ex: waistband or lower pocket of lab coat

Overall

Clothing

Clean, neatly pressed or wrinkle free, in good repair and appropriate size.

Blue denim material Soiled, wrinkled, faded, frayed, torn, or clothing worn too loose or too tight

Pants Appropriate length and size with finished hems. Low rise styles of blue jeans, leggings, spandex or lycra stirrups/pants, stretch pants, shorts, sweat pants, jogging suits

Shirts Conservative, modest neckline. Unbuttoned, shirttail out, T-shirts, shirts with logos other than an NCH logo and/or writing. Any shirt that reveals bare backs, midriffs, shoulders, or plunging necklines, including tank tops

Skirts Appropriate length and size with finished hems. Skirts or slits in skirts shorter than 3 inches above the knee or form fitting styles.

On holidays or special events, employees may wear clothing or accessories appropriate for the observance.

Clinical Staff Uniform Color Permitted Color Under Uniform

Nurses Royal Blue White / Grey

Patient Care Techs/ Unit Secretaries Teal White / Grey

Licensed Clinical Personnel Hunter Green White/Grey

Transporters Grey White / Grey

Lab coats (warm-ups) must be the uniform color. RNs may wear white lab coats (warm-

ups).

Scrub uniforms are worn to provide a hygienic environment and infection-free conditions.

Scrub uniforms are the property of NCH and, as such, may not be removed from hospital

grounds. NCH-issued scrub uniforms are worn only by on-duty employees in the following

areas:

Anesthesia

Operating Room (Surgery)

PACU

SPA

PAT

Day Surgery Center

Sterile Processing

Cath Lab

Labor & Delivery

NICU (to be ready if called to L&D)

Radiology

Emergency Department

Endoscopy

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Environmental guidelines

See Environmental Standards tab on the Experience Center site

for more information.

o Always pick up trash – never walk past.

o Clean up your own spills and call Environmental

Services to clean up large ones.

o Keep workspaces, meeting rooms, and patient care

areas free of clutter.

o Staff should not use lobbies or waiting areas for eating

or breaks.

o Report any incidents or areas that need to be cleaned

to Environmental Services at extension 2301 (24/7).

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RR -- Responsiveness

• Educate patients and families about what they will be experiencing.

• Encourage customers to ask for an update at anytime.

• Inform customers of a delay at the earliest opportunity.

• Update family members regularly.

• Never tell customers that they are waiting due to a staffing situation.

• Thank customers for waiting and apologize for delays.

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EE -- Education & Information

Customers will be informed each day about their plan of care, including

any scheduled tests and treatments.

Collaborate with patient’s physician to reinforce information that the

physician provided.

Use clear, concise, and understandable language when giving patients

information. Avoid technical or professional jargon.

Adapt methods and materials according to individual needs.

Reinforce verbal instruction with written information whenever possible.

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SS -- Service Recovery

Carefully listen:

By listening respectfully you are validating the patient’s right to

feel upset or angry and it gives them a chance to calm down.

Apologize with empathy:

o Apologizing with empathy means you are sorry for how they

feel.

o If you are responsible for the problem, take responsibility. Don’t

blame others, other departments or make excuses.

o Don’t take the person’s behavior personally.

o Don’t make any statement that the person’s complaint is

unimportant.

Respond to need:

o Suggest a solution to the problem.

o If it can’t be fixed immediately apologize for the inconvenience.

o Use a service recovery coupon or gift basket with a sincere

acknowledgment of the inconvenience.

o If the customer is still upset, get someone else involved such as

Manager, Director, Administrative Supervisor, or Patient

Advocate.

Evaluate the results:

o Follow up to make sure the solution has actually occurred and

solved the problem.

o Before leaving the customer ask, “Have I taken care of your

concerns?” “Is there anything else I can help you with?”

Thank the customer for their understanding and patience.

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DDEEFFIINNIINNGG QQUUAALLIITTYY SSTTAANNDDAARRDDSS

CONTINUOUS QUALITY IMPROVEMENT

Customer Focus

Total Involvement

Measurement

Systematic Support

Continuous Improvement

Continual Learning

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NORTHWEST COMMUNITY HEALTHCARE POLICIES

ADMINISTRATIVE POLICIES ARE LOCATED ON THE NCH INTRANET > CONTENTS > POLICY STAT

HUMAN RESOURCE POLICIES ARE LOCATED ON THE NCH INTRANET > CONTENTS > HUMAN RESOURCES > POLICIES

EMPLOYEE HEALTH POLICIES ARE LOCATED ON THE NCH INTRANET > CONTENTS > EMPLOYEE HEALTH & SAFETY