OBSERVER APPLICATION PACKET CHECK LIST

ITEMS TO BE SUBMITTED

OBSERVER APPLICANTS:

Using the checklist, send only the items listed below to the Division Coordinator

Dear Observer Applicant,

The Office of Academic Affairs has reorganized to centralize the processing of all student observers, in doing so; we will be reducing the various applications to only one. This process is also an important tool for us to track observers and to assure all applicants have an equal opportunity to observe. To facilitate the processing and tracking of all student observers please complete materials provided in this packet, when the packet is complete please forward to the division coordinator/administrative assistant.

 / PAGE / SUBMIT TO THE DIVISION COORDINATOR/ADMINISTRATIVE ASSISTANT
2 / Observer RequestApplication
Refer to page 3-4 / Addendum B – Student, Observer, Non-Employee Health Clearance Form
5 / Addendum C – Observer Status (Signed & Dated)
6 / Addendum D – Confidentiality Stated (Signed & Dated)
10 / Completed HIPAA Competency Test (Signed & Dated)
11 / Addendum F – Environment of Care Observation/Job Shadowing (Signed & Dated)

Division Coordinators:

It will be your responsibility to keep all documents in your electronic files for your records.

Feel free to contact us if you have any questions:

Martha Bustamante (323) 361-4541

Raquel Landeros (323) 361-2127

NOTE:

The CHLA picture ID cards are property of CHLA and must be returned on the final day of the rotation to Martha Bustamante or Raquel Landeros, Duque Bldg., Door 1-294.

Applicant to send all materials to requested division/department coordinator.

OBSERVER REQUEST APPLICATION
Student / Research/ Graduate/Physician in Training (PIT)
(High School Student are not eligible)
Name of Observer: (First Name – Middle Name – Last Name) / SS# /PASSPORT:
Email Address: / Cell Phone:
Current Address: / City/State: / Zip:
Institution/School: / Are you an Undergraduate
medical student?
 Yes  No / School: Year level
CHECK APPROPRIATE APPLYING STATUS:
0268 - Student /Physician
Observer
2 weeks maximum /  0273 Student /Physician
Observer
(Over 30 days)
Meds-490
Dr. Geller-Undergrad Pre-Health
& Other affiliated programs /  2064 Research Observer
(LESS than 30 days) /  0265 Research Observer
(Over 30 days)
Saban Research
& USC Keck School of Medicine
Start Date: / Start Date: / Start Date: / CCI #:
End Date: / End Date: / End Date: / HIM #:
Note: End date cannot exceed PPD expiration date
All students must provide documentation of influenza vaccine / Start Date:
End Date:
 2029 Grad Student
(Over 30 days)
UCEDD &
other affiliated Programs
Start Date:
End Date:
Division Approval:
Name of Division: / Attending Supervising Student:
First Name - Last Name / Supervising Attending Contact Info:
Phone:
Pager:
Email:
Division Coordinator: / Email: / Phone #:
CHLA Dept./Division Head or Designee Name
Name:______ Please check:  Division Head  Designee
Signature:X______Date:______
  • Coordinators must email a PeopleSoft Application to ; once the CHLA ID # is obtain it must be included on the Observer Trainee Request Form
  • Research Observers who need KIDS access Coordinators must submit a RFUA to the HELP DESK and include CCI #
  • HIM: KIDS access privileges only for 0265 Research Observer

ADDENDUM B

Clearance Process For

All Fellows, Rotating Residents, Students, Observers, etc…

(Hereafter Referred to As “Trainees”)

In order to facilitate the processing of all trainees the following must be noted:

All trainees must be cleared by the Academic Affairs Office including Health Clearance verified by a Program Coordinator before the Safety & Security/Parking Office will issue a CHLA identification badge and parking card.

The following are the “CHLA Health Screening/Clearance Requirements” from Employee Health Services and the L.A. County Department of Health

Every interim employee, student, intern, rotation resident, fellow, volunteer or persons coming to observe a procedure must provide documentation of immunization for health clearance prior to starting their employment, training rotation, or observation period at CHLA. The following documents must be provided to the program coordinator at the time clearance is being requested.

Please provide a copy of your documented immunization record containing:

  1. Written document of two measles, mumps, rubella (MMR) vaccinations as a child in persons born after 1950, or one MMR after the age of seventeen (17)

Or

Serologic (antibody titers) evidence of immunity to measles and rubella (German Measles).

  1. Serologic evidence of immunity to chicken pox (varicella) or verbal knowledge of having the disease.
  2. MUST BE CURRENT to the end date of the rotation:Written documentation and report of TB skin test (Mantoux) or T-Spot / Quantiferon TB Test within the previous twelve months

Or

In skin test positive persons, a written report of chest x-ray results taken within the previous year.

  1. Written documentation of one Tdap given as an adult
  2. Written documentation of Hepatitis B Vaccine series

6. Written documentation of recent influenza vaccination (MUST BE UPDATED during flu season during the months of October – April)

Parking cards and identification will not be issued without Immunization clearance. If the above is not carried out, the trainee will be considered unauthorized to begin training at CHLA and is not permitted to be on campus.

ADDENDUM C

Academic Affairs – MS #71

Ext. 12127 or 14541

Observer Status

I understand that my role as a visiting/shadowing student / undergraduate student/ Research Observer/ Required Scholarly Program Student (RSP), USC UCEDD , Physician in Training (PIT) does not allow me to obtain a patient’s history, act as a translator, examine patients, or interact with any patient being seen at CHLA or at any other sites affiliated with or contracted by CHLA. As many staff and faculty members, residents, etc., may not be aware of my status, I will explain my role whenever asked to interact with a patient. If I feel that undue pressure is being applied, I will report the situation to the Chief of Medical Staff at CHLA. I will honor privacy and not remove or share any confidential patient information.

I also understand no grade or certificate of completion will be issued for this experience.

X______X______

Signature – ObserverSignature–Witness (Supervising Physician)

______

Print-Observer’s Name (first-middle-last)Print-Witness’ Name (Supervising Physician)

______

DateDate

ADDENDUM D

CONFIDENTIALITY STATEMENT

In order to protect the confidentiality of patient care and hospital matters, Children’s Hospital Los Angeles considers all information regarding its patients, their families, hospital employees and hospital business as confidential. All board members, officers, employees, volunteers, residents/fellows, students, Medical Staff members or practitioners with temporary privileges are required to adhere to this policy and not release or disclose any information without appropriate written authorization. The hospital complies with all applicable federal (HIPAA) and state law regarding the release of protected health information.

This policy includes the confidentiality of medical staff records and procedures, all patient information, employee personnel files and information contained in the hospital computer systems.

Board members, officers, employees, volunteers, residents/fellows, students, Medical Staff members or practitioners with temporary privileges are also asked to refrain from discussing any patient information or hospital business in public areas, including corridors, elevators, the cafeteria, McDonalds, hospital lobbies or waiting rooms.

ACKNOWLEDGEMENT:

I______, have read and agree to

PRINT NAME

comply with the Children’s Hospital Los Angeles, Confidentiality Policy. I understand that I am prohibited from divulging any information regarding patients, their families, employees or matters related to hospital business except as mandated by hospital policy and/or law.

SignatureX______Date______

ADDENDUM E

HIPAA

(Health Insurance Portability and Accountability Act)

OBSERVATION/JOB SHADOWING

Primary Goals of the HIPAA Legislation

  • Assure health insurance portability
  • Reduce healthcare fraud and abuse
  • Simplify electronic administrative processes
  • Guarantee security and privacy of health information

HIPAA is the most sweeping legislation to affect healthcare since Medicare in 1965. Nearly everyone will be affected: payors, employers, providers, clearinghouses, practice management system vendors, billing agents, and service organizations. In regard to protecting patient information, security is defined as the protection of information, data and systems from accidental or intentional access by unauthorized users. Common threats to patient information security include talking about patients, using identifiable information such as names, diagnosis, etc, in public areas.

Examples of Protected Health Information

  • Clinical information
  • Name and social security numbers
  • Names of relatives, family name, and employer
  • Health plan numbers and account numbers
  • Telephone numbers, fax numbers and emails
  • All dates related to the individual, i.e., birth, etc
  • Geographic subdivision smaller than state
  • Any information that can reasonably identify a patient

Penalties for Non-compliance with HIPAA Regulations

Monetary Penalty /

A.Term of Imprisonment

/

B.Offense

$100 / N/A / Single violation of a provision.
Up to $25000 / N/A / Multiple violations of an identical requirement for prohibition made during a calendar year.
Up to $50000 / Up to 1 year / Wrongful disclosure of individually identifiable health information.
Up to $100000 / Up to 5 years / Wrongful disclosure of individually identifiable health information committed under false pretenses.
Up to $250000 / Up to 10 years / Wrongful disclosure of individually identifiable health information committed under false pretenses with intent to sell, transfer, or use for commercial advantage, personal gain, or malicious harm.

Failure to implement transaction sets can result in fines of $225000 per year or more.

($25,000 per requirement, times nine transactions)

Failure to implement privacy and security measures can result in imprisonment.

Patient’s Rights

  • Patients have the right to

-Look at and obtain a copy of their health information.

-Know how their health information has been used and to whom it has been disclosed.

-File a formal complaint if their privacy has been violated.

-Patient or parental consent must be obtained before a patient’s health information can be released to family members.

-Protecting patient information includes electronic, written and verbal communication.

Notice of Privacy Practices

Covered Entities must provide a simple explanation of their privacy practices. Direct treatment providers must make a good faith effort to obtain written acknowledgment of receipt of the notice of privacy practices.

Minimum Necessary

Employees should use only the information minimally necessary to do their job.

Business Associates

Covered Entities may disclose PHI to business associates. They are required to have contracts that require their business associates to observe certain privacy standards listed in the regulations.

Personal Representatives (Parents)

  • HIPAA gives control of a minor’s PHI to the parent, guardian, or person acting in loco parentis with certain exceptions.
  • HIPAA does not overturn state laws that give providers discretion to disclose PHI to parents or prohibit the discloser of PHI to a parent.
  • Verification of the personal representative’s identity is a critical overlap with physical security.

PRIVACY DO’S

  • Immediately remove all patient health information from printers, fax machines and photocopiers.
  • Dispose of protected health information in the appropriate confidential bin.
  • When conducting a conversation regarding a patient, do so in a private place or speak quietly so you can’t be overheard.
  • Keep medical records and other documents containing personal health information out of public view.
  • When possible, close patient/examining room doors or draw curtains and speak softly when discussing patient’s health information.
  • Treat other people’s confidential information as if it were your own.
  • Password protect your laptop computer and your personal digital assistant.
  • Report privacy violations in the hospital to the Privacy Officer, at extension 2302 so we can improve our organization’s privacy practices.

PRIVACY DON’TS

  • Don’t share confidential patient information with anyone who doesn’t need to know in order to do his or her job.
  • Don’t share passwords on your computer.
  • Never access information about a patient unless you need it to do your job.
  • Don’t walk away from open medical records, lab results, or computers, etc. Close records first and use a bookmark, if necessary.

HIPAA Competency Test

OBSERVATION/JOB SHADOWING

Please circle correct answer:

  1. Which of the following statements about confidentiality and protecting patient information are true?
  1. Only authorized people are allowed to look at or use patient information
  2. Any health information that can identify a person must be treated as confidential
  3. Confidential information should be shared only with those who have the “need to know”
  4. All of the above
  1. In regards to protecting patient information, security is defined as:
  2. The requirement that all patient information either be under lock and key or protected by security officers
  3. The protection of information, data and systems from accidental or intentional access by unauthorized user
  4. None of the above
  5. All of the above
  1. Which of the following standards require health care organizations to protect patient information?
  2. Chain of Trust (COT)
  3. Prospective Payment System
  4. Health Insurance Portability and Accountability Act (HIPAA)
  5. Outcomes Assessment Information Set (OASIS)
  1. Organizations that violate patient privacy and security standards can suffer penalties such as:
  2. Fines, possibly in the thousands of dollars
  3. Imprisonment
  4. Bad public relations
  5. All of the above
  1. Common threats to patient information security include:
  2. Talking about patients, using identifiable information such as names, diagnosis, etc, in public areas
  3. Not logging off the computer when finished
  4. Maintaining patient listings and other information in full view of unauthorized people
  5. All of the above
  1. Patients have the right to:
  2. Look at and obtain a copy of their health information
  3. Know how their health information has been used and to whom it has been disclosed
  4. File a formal complaint if their privacy has been violated
  5. All of the above
  1. Protected health information (PHI) is any information that can identify a patient
  2. True
  3. False
  1. Talking about a patient’s condition or diagnosis, while in a public area, would be a violation of patient privacy even if the patient’s name were not mentioned.
  2. True
  3. False
  1. Patient or parental consent must be obtained before a patient’s health information can be released to family members
  2. True
  3. False
  1. Protecting patient information includes all forms of communication—electronic, written and verbal.
  2. True
  3. False

Print Name:

Signature: Date:

ADDENDUM F

ENVIRONMENT of CARE

OBSERVATION/JOB SHADOWING

Please keep this information, and sign and return the enclosed statement indicating that you have read and understand your role in the safety, security, and environment of care at Children’s Hospital Los Angeles. Codes (Overhead Page) (Ext. 33)

  • Code Blue - Medical Team Emergency
  • Code Green - Hazardous Spill
  • Code Yellow - Trauma Team
  • Code Red – Fire
  • Code Orange - Disaster
  • Code 10 – Missing Patient
  • Code 12 – Bomb Threat
  • Code 13 – Community Disturbance
  • Code 99 – Hospital Lockdown
  • Dr./Mr. Strong – Violent Behavior (Ext. 711)
  • Dr./Mr. Adam Strong – Armed Individual (Ext. 711)

Identification Badges

  • Your CHLA ID badge must be worn at
all times when on the CHLA premises
  • Your ID badge must be worn on the upper
body with the photo and name facing outward
  • If you loose your ID, you must report it
missing to Security (Ext. 2313) and the
Parking Office (Ext. 2214)

Visitor Badges

  • All visitors to CHLA (whether parents, guardians families, vendors, etc.) must have a visible ID badge
    on their person
  • Visitor badges are as follows:
  • Yellow Badge – visitors to inpatient care areas
  • Orange Badge – visitors to outpatient clinics,
labs, and the Emergency Dept.
  • Blue Badge – Visitors to general/non-patient care areas

Wrong Badge or No Badge

  • All Medical Staff, House Staff, and pre- & post-
doctoral fellows and employees are responsible for:
  • Escorting visitors without badges to the Guest
Services Desk at the main entrance, or calling
Security
  • Asking if you can assist a visitor with the wrong
badge who is in the wrong area. Example: Visitor
with a blue badge is seen in an inpatient care area.

Safety

  • Know location of the Safety Manual
  • Know how to complete a Patient/Visitor
Event Report in the event something
unusual happens to you or your patient

Hazardous Materials/Waste

  • Wear proper protective gear
  • Inquire regarding proper disposal
of chemicals
  • Require labels on all chemicals
that are used by you
  • Know where the MSDS for chemicals in your area are located
/

Fire/Life Safety

  • Rescue endangered patients. Close doors
  • Activate the alarm system
  • Call Ext. 33 to report fire
  • Contain the fire
  • Extinguish the fire
  • Know where the fire alarm & fire
extinguishers are located
  • Know that the hospital has a series of smoke
compartments designed to prevent the
spread of smoke and fire
  • Know that you may be needed to help
transfer patients to another area

Fire Extinguisher Use – PASS

  • Pull the pin
  • Aim the hose/extinguisher
  • Squeeze the handle
  • Sweep from side to side

Evacuation Procedure

  • Move horizontally beyond next fire/smoke door
  • Move vertically, two floors minimum or unit capable
of receiving patient type
  • Meet at designated assembly area
  • Account for all staff and patients
  • Notify emergency operations center Ext. 2342
of status/missing persons
  • Patient Priority – those closest to danger, ambulatory,
those you can move yourself,
those you need help to move

Emergency Preparedness/Disaster Procedure

  • Code Orange will be announced overhead
  • All available hospital personnel report to the
Command Center

Medical Equipment Malfunction

  • Remove from service and sequester any
medical equipment you suspect or know
was involved in a patient incident
notify Risk Management immediately
  • Assure that all equipment is reviewed by
the Biomedical Dept. before it is used in
patient care

Utilities Failure