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Central Texas Veterans Health Care System
Self–Study
Orientation and Information Guide
Welcome to the Central Texas Veterans Health Care System (CTVHCS). We are pleased that you are here.
This Self-Study Orientation Guide contains some excerpts and paraphrasing from the VA Handbook and local administrative documents. The general outline and subject content originated at VA Medical Center, Fargo, ND. This guide is for non-regular affiliates: Locum Tenens, Students, Work-study, WOC, Contractors, Volunteers, and Fee basis employees
Please note that the references contained herein are not all inclusive. Full access to local policy documents is available on the Central Texas Veterans Health Care System intranet.
This booklet will assist with documentation of your orientation to our facility; it contains essential orientation topics and resource information that will help you while employed here.
You must successfully complete a written test (enclosed) after reviewing this booklet and return it to Human Resources Management Services before you begin your affiliation here. Successful completion of the post test and Abbreviated Mandatory Orientation and Information Checklist will document your completion of your mandatory orientation. Human Resources Management Services will grade and sign the test and review the Abbreviated Mandatory Orientation and Information Checklist for completeness. The original documents will remain in Human Resources Management Services and copies will be kept on file at your work site.
TABLE OF CONTENTS
Chapter One: Overview...... 4
- Available Services...... 4
- Our Mission...... 4
- Our Vision...... 4
- Our Values...... 4
- Our Creed………………………………………………………………………………………….….4
Chapter Two: Key Medical Center Programs, Policies and Highlights...... 5
- Performance Improvement...... 6
- Customer Service...... 6
- Code of Ethics…………………………………………………………………………………………6
- Compliance…………………………………………………………………………………………….6
- VHA Privacy Policy…………………………………………………………………………….……6-7
- Information Security………………………………………………………………………………...7-8
- Patient Abuse Recognition and Reporting………………………………………………………….9
- EEO/Sexual Harassment……………………………………………………………………………..9
- Smoking…………………………………………………………………………………………….…10
- Use of Government Telephone……………………………………………………………………..10
- Whistle Blower Policy...... 10
- Your Pay...... 10
- Risk Management...... 11
- Labor and Management Relations………………………………………………………………11-12
Chapter Three: Age Specific Guidelines and Care of Special Patient Populations...... 13
- Adults...... 13
- Geriatrics...... 13
- Cultural and Religious Diversity...... 13
Chapter Four: Environment of Care...... 14
- Emergency Events...... 14
- Emergency Cardiac Event...... 14
- Utilities Failure Events...... 14
- Electrical Failure Event…………………………………………………………………14-15
- HVAC Failure Event...... 15
- Workplace Violence Event and Assault Intervention Team…………………………………..15-16
- Threat Event……………………………………………………………………………………….16-17
- Fire and Smoke Event...... 17
- Bomb Threat Event…………………………………………………………………………………..18
- Tornado Event…………………………………………………………………………………….18-19
- Hazardous Material/Waste Management...... 19
- Regulated Medical Waste...... 19
- Safety and Body Mechanics……………………………………………………………………..19-20
- Police and Security……………………………………………………………………………………21
- Medical Equipment……………………………………………………………………………………21
Chapter Five: Patient Safety...... 22
- Overview...... 22
- Environmental Health...... 22
- Infection Control...... 22
Chapter Six: Compliance and Business Integrity…………………………….…………….………23-24
Acknowledgement, Acceptance and Chapter Checklist ………...…………………………….………25
CHAPTER ONE: Overview
Available Services
With the integration in 1995 of the Olin E. Teague Veterans’ Center, the Waco VA Medical Center, the Thomas T. Connally VA Medical Center, and four outpatient clinics, these entities together became the CTVHCS. The CTVHCS is one of the largest integrated healthcare systems in the Department of Veterans Affairs, and contains one of the newest VA hospitals, one of the largest inpatient psychiatric facilities, and one of the few Blind Rehabilitation Centers in the country. The CTVHCS is primarily affiliated with the Texas A&M University, College of Medicine, however affiliations have been established with University of Texas Medical Branch in Galveston, Brazos Family Medicine Residency Program in College Station, and Austin Medical Education Program in Austin.
CTVHCS is a tertiary care system that consists of two hospitals located in Temple and Waco. The Olin E. Teague Veterans Hospital in Temple operates 146 medical/surgical beds. The hospital in Waco includes 206 psychiatric beds. Outpatient services are provided by the Olin E. Teague hospital along with one stand-alone clinic in Austin and four community based outpatient clinics located in Brownwood, Cedar Park, College Station, and Palestine. The system operates two nursing homes in Temple and Waco with a combined total of 272 nursing home beds. A 408-bed domiciliary in Temple is the second largest domiciliary rehabilitation facility in the VA. The Waco facilities also include a Blind Rehabilitation Unit and two patient, rehabilitation units for post-traumatic stress disorder and severely mentally ill life enhancement.
CTVHCS serves a veteran population of 238,349 veterans, who reside in 39 counties stretching over 35,000 square miles. In Fiscal Year 2007, CTVHCS provided care at 829,011 outpatient visits; 7,847 acute inpatients were treated. Total unique veterans served totaled 68,154.
The Olin E. Teague Veterans’ Center has been a principal teaching campus for the Texas A&M University Health Science Center College of Medicine since the College’s inception in 1977. Medical students participate in clinical training in the specialties of general surgery, orthopedics, urology, ophthalmology, plastic surgery anesthesiology, internal medicine, pulmonary disease, hematology, oncology, cardiovascular disease, gastroenterology, sleep medicine, psychiatry, family medicine, and pathology
Our Mission
CTVHCS is committed to the delivery of quality comprehensive care and health related services to veterans through:
Applied clinical research, education, and preparation of its staff to focus on and meet veterans’ needs.
Promotion of an environment that encourages staff, volunteer, and patient partnership, creativity, and satisfaction.
Enrichment of the Central Texas area through community service and enhancement of relationships with other healthcare organizations.
Our Vision Statement
To deliver exceptional service and the highest quality health care to our nation’s veterans.
Our Values
Teamwork, Empowerment, Trust, Courtesy, Innovation, Respect, Commitment, Compassion, Integrity, Excellence
Our Creed
I am proud to honor and serve our veterans.
CHAPTER TWO: Key Center Programs, Policies and Highlights
All Medical Center staff must be aware of key policies and programs that guide appropriate and quality patient care as well as provide a safe working environment for staff.
Performance Improvement
All direct and indirect patient care activities will participate in the system-wide approach to performance improvement and efforts to achieve customer satisfaction. Identified opportunities for improvement will be approached utilizing the Plan-Do-Check-Act (PDCA) cycle for Continuous Quality Improvement (CQI).
Plan the Improvement
Do Improvement, Collect Data, and Analyze It
Check and Study the Results
Act to Hold the Gain and to Continue to Improve the Process
It is the philosophy of CTVHCS to pursue excellence in the delivery of health care services through an organized, comprehensive, coordinated and continuous effort to identify opportunities for improvement. Based upon this all services, committees and functions that impact directly or indirectly on patient care shall be integrated into a unified philosophy of CQI. This reflects our leadership philosophy, which promotes a process of positive organizational change through participation and team building, and is based upon a commitment to the following principles:
Top management must lead CTVHCS in planning, directing, implementing, coordinating, and improving services
Most opportunities for improvement are in improving process weaknesses, not individual performance (although individual performance will be reviewed and dealt with when appropriate)
Services and programs must work collaboratively
Internal and external customers’ needs and expectations must be met or exceeded;
Due to resource constraints, opportunities to improve must be prioritized
Need to systematically improve by improving important processes
Measurement of important processes needs to be done on a continuing basis
The PDCA cycle will be utilized as a road map to achieve process improvement
The System Plan for Performance Improvement is designed to comprehensively measure, assess and improve all important patient care and organizational functions. This includes all clinical and administrative services and programs of CTVHCS. Included are internal and external review programs, internal and external performance measures, and CQI activities.
In pursuing the system mission, vision, and values, and strategic and operational plans, this organization conducts ongoing and continuous monitoring and evaluation to ensure compliance with regulations, high quality medical care and administrative practices, and conformance with established standards. The performance improvement process consists of several integrated systems for collection of data for review; measurement, analysis, and communication; and taking corrective action, including follow up of effectiveness of actions taken.
Goals of the performance improvement process include:
Improve patient satisfaction with services provided
Improve employee satisfaction
Assure coordination and accountability of all performance improvement activities
Assure quality of patient care, medical records, and support services provided
Enhance performance improvement through employee involvement
Enhance effective utilization of resources
Reduce and/or eliminate unnecessary and correctable risks and hazards to patients
Provide information for use in planning and decision making and
Assure organizational compliance with all VA regulations, JCAHO standards, federal regulations, and requirements of other accrediting bodies
Customer Service
We need to understand the needs of all our customers and act in a manner that not only meets, but also exceeds their expectations. Improving customer service takes a conscious effort by all employees, but the benefits of making a great impression far outweigh a poor impression. If you encounter an unsatisfied customer, remember to listen to the complaint and maintain a positive and respectful attitude. Acknowledge the problem and try to correct it or bring it to the attention of someone who is able to make it right. It is easy to identify the patient as our customer, but in a broader sense, anyone you come in contact with is a potential customer. The goal of any CTVHCS activity is to exceed customer expectations.
A detailed description of patient rights is posted throughout the Medical Center or can be obtained by contacting the Patient Advocate.
The Customer Service Committee oversees all processes and activities covered by the Customer Service Center goal and key function and coordinates implementation, evaluation and compliance with customer service standards and directives developed by VHA, i.e., VA Central Office, VISN, local level.
Code of Ethics
The Patient Rights and Organization Ethics Committee interfaces with all processes covered by the Patient Rights and Organization Ethics key function, including those Medical Center Committees, Services, and Programs involved in those processes. The goal of the committee is to help improve patient care outcomes by promoting respect of each patient’s rights and to conduct business relationships with patients and the public in an ethical manner.
The CTVHCS is committed to “Putting Veterans First” through fulfilling our responsibility of providing quality health care to veterans and acting as a responsible health care provider in the community. Fulfilling this responsibility is demonstrated through ethical business and patient care operations as defined by our mission, values, strategic plan, and healthcare facility policies and procedures. Such ethical practices include, but are not limited to, appropriate relationship boundaries between patients/former patients/immediate family members and therapeutic staff; all areas of patient rights; billing practices; marketing and public relations practices; admission, transfer and discharge practices; and avoidance of conflict of interest in contractual relationships.
The organization’s Ethics Committee provides support for addressing ethical concerns and problems. The service is available at all times to patients and their families, employees, and affiliates. Employees are defined as all individuals acting on behalf of the CTVHCS and Regional Office Center, in an official capacity, temporarily or permanently, in the service of the United States Department of Veterans Affairs, whether with or without compensation. Questions or confidential comments may be directed to the Chair of the Hospital Ethics Committee.
Compliance
Compliance is a process that allows us to demonstrate that we are working in the best interest of the patients - thus ensuring the integrity of our employees, our processes and services to the Veteran.
Although VHA has key differences from the private sector health care, VHA is now facing many of the same challenges previously faced by colleagues in the private sector. Insurance companies and other third party payers like Blue Cross, AARP, and Medicare have billing guidelines that identify the services they will pay for. With the implementation of reasonable charges, VHA has been required to comply with requirements regardless of the fact that we do not bill Medicare to receive reimbursement from the third party payers.
If necessary, further information on this subject will be provided by your supervisor. Compliance is further discussed in Chapter 6.
Veterans Health Administration (VHA) Privacy Policy
Every patient has a right to privacy and it is your responsibility to protect that confidentiality. This means keeping information about patients’ health care private. Both federal law (the Health Insurance Portability and Accountability Act or “HIPAA”) and VHA mandates require the protection of all Patient Identifiable Health Information, including all identifiers, images and other information which could be used to determine the identity of a patient. The privacy laws apply to all forms of patient health information including, paper, electronic and verbal information.
Staff and all affiliates are required to only use or access that amount of patient information that is minimally necessary to complete a task, responsibility or function. You are responsible to only use and access information on patients if you are providing care, or information that you may need to complete a task that is part of your responsibilities.
Failure to comply may lead to disciplinary or legal action against the employee and the Medical Center. Confidential information includes a wide variety of information about a patient’s health care. Examples of confidential information include:
Patient identifiers such as medical record number, name, date of birth, Social Security Number, address, phone number, contact information, photographic images and any other unique code or characteristic that could be used to identify an individual patient:
Details about illnesses or conditions
Information about treatments
Healthcare provider’s notes about a patient
Patient billing information
Conversations between a patient and a healthcare provider
Patients have certain rights granted under federal and state law to control their protected health information, including the right to access and receive a copy of their health information, request addendums to or changes to their health information, request restrictions on how and to whom their information is used or disclosed, request alternate methods for communicating with them, and to obtain a list of individuals or organizations to whom the Medical Center has provided access to their information. These rights apply to both the patient’s medical and billing records.
CTVHCS is committed to creating an environment that promotes compliance with medical record coding and the billing process. Use of the proper code for the service provided will create an environment, which will be an ongoing collaborative process between the clinical staff and documentation in the medical record.
The Supervisor for Coding and Processing of Health Information Management Section, Health Services Administration Section, Patient Financial Support Service, holds the responsibility for the accuracy and the quality of coding medical record documentation.
Information Security: Guidelines for Protecting Patient Confidentiality
Information Security Awareness
Information security is an integral part of health care delivery in VA and as a result, our patients, employees, and customers have a right to expect absolute confidentiality, integrity, and availability of the data we process for them. Information security is also known as Cyber Security and is the knowledge and awareness that VA employees, contractors, volunteers, and entire workforce utilize to protect VA computer systems and data. Anyone who has access to any VA information system is required to complete a mandatory annual Cyber Security Awareness Training. As an authorized user of the VA information systems you will be given sufficient access and privileges to perform your assigned official duties. Access granted and use of VA resources is for official and authorized purposes only. Every VA facility has an assigned Information Security Officer (ISO). All known or suspected information security incidents or misuse of VA information systems must be immediately reported to Anita A. Baez, ISO, at 254-743-0547 (or extension 40547) or Michelle Lands, Secondary ISO, at 254-743-0010 (or extension 40010). It is everyone’s responsibility to comply with information security regulations.
Passwords are an important tool for getting your job done. They ensure you have access to the information you need. VA requires strong passwords on all information systems and they must be changed at least every 90 days. Protect all of your security codes (i.e., access/verify codes, passwords, electronic signature codes, usernames). Do notdisclose these codes to anyone including family, friends, fellow workers, supervisor(s), and subordinates for any reason. You are strictly prohibited from letting anyone use any of your security codes and from using anyone else's security codes. Keep your password secret to protect yourself and your work. You are solely responsible for everything done under your access codes. All employees are responsible for logging off (or locking if appropriate) their computer systems and not leaving a computer with open access unattended.
Protect sensitive information and respect privacy. In VA, confidentiality is a must. Confidentiality is the condition in which VA’s information is available to only those people who need it to do their jobs. A breach in confidentiality can occur when you walk away from your computer without logging off or when paper documents are not adequately controlled. Confidential/sensitive information not only refers to electronic medical records, but it also includes written documentation (printed data), and communication of verbal information. You must ensure printed data is protected, in a secured area, and viewed only by authorized staff.Be cautious when speaking about sensitive information where others, including patients, visitors, or other employees, might overhear. Sensitive information must not be shared with anyone who does not have access or a need to know. Access to patients’ medical records information is limited to those VA employees with a need for the information in the performance of their official duties. Just because an employee may have the privilege to access patient medical records, it does not mean the employee has the right to access any medical record. Sensitive information should not be sent using e-mail unless it can be done securely and by using the approved VA Public Key Infrastructure. For further guidance on the use of electronic mail, refer to Station Policy 00-003-06. Privacy is very important and is a matter that pertains to each and every employee. We all are responsible for protecting patients’ and employees’ privacy.