Khadijah Matin
Associate Director
Organizational Learning
CORE VALUES
COMPASSION
DIGNITY
RESPECT
INCLUSIVITY

Compassion: We care for all persons as
we would wish to be cared for ourselves –
with sensitivity, empathy, and
understanding , regardless of their ability
to pay
CORE VALUES

Dignity: We recognize that each individual
is created in the image of God and
inherently valued as a gift of God
CORE VALUES

Respect: We treat everyone with equity,
fairness, and consistency; we respect the
rights of all to privacy and selfdetermination; we promote shared moral
deliberation in all decision-making and
communicate honestly and openly.
CORE VALUES

Inclusivity: We are committed to
providing equitable access to the highest
quality care in a diverse, multi-cultural,
multi-faith context; we maintain the
highest possible standards and practices
of religio-cultural competence.
CORE VALUES

Before we begin our discussion of the
HIPAA and Privacy Laws…let me talk
about keeping a secret…being discrete…
HIPAA AND PRIVACY

Basically, the Privacy Rule
◦ Imposes restrictions on the use and disclosure
of personal health information
◦ Gives patients greater access to their medical
records
◦ Gives patients greater protection of their
medical records
HIPAA: PRIVACY COMPLIANCE
HIPAA

What is Protected health information
(PHI)?
◦ PHI is any information that applies to a health
condition now, in the past or in the future.
◦ PHI includes data that would let somebody
identify the patient
HIPAA Privacy Rule

The following items are PHI because they
contain a patient’s name, or ID number
and information about his or her health:
◦ X-rays, lab reports and other test results
◦ Prescriptions
◦ Health insurance claims and billing
records
PHI
What is Disclosure?
 To disclose is to give out PHI.

◦ Providing information about a person for the
purpose of care or billing is one type.
◦ Talking about a patient’s condition in a public
place is an example of inappropriate disclosure
DISCLOSURE

Be aware of:
◦ Information you say aloud while talking to or about a
patient
◦ Printed information that is posted in a public place
◦ Computer monitors that can be viewed by passersby
Keeping PHI Private
If you have patients sign-in, ask only for their
name, and not the reason for their visit
 When you call out a patient’s name, don’t reveal
any other information about the patient’s
condition or reason for the visit or reveal the
medication the person is using/picking up.

PHI
Remember to return files to their proper and
secure location
 You should create a barrier to make the space
private as possible whenever you need to
discuss health information with a patient.
 You should also only discuss PHI with
authorized staff who need to know the
information to treat the patient or to carry out
other acceptable duties.

PHI
A requirement under the HIPAA federal
regulations.
 Applies to how we make sure that
protected health information (PHI) on our
computers stays protected and is not
sabotaged, attacked or allowed to escape.

HIPAA SECURITY

Confidentiality – protected records are
kept private
Integrity – records aren’t changed without
authorization
 Availability – records can be accessed
when needed.

Main Security Issues






Patient safety/medical care is
compromised
Negative publicity
Increased costs
Identity theft
Legal liability/lawsuits
And just as important: your self
assessment in any situation
Consequences of Security failure?
Follow all approved security procedures
 Never share your password with anyone!
 Don’t give out patient information without
proper authorization
 Use only authorized software

What YOU can do….
Be mindful and do the right thing.
 For more information check out the
Compliance webpage on the LMC Intranet.

HIPAA…It’s about what you do!
Sexual Harassment
Training
The Types
Of
Sexual Harassment
At Lutheran HealthCare
O We have ZERO TOLERANCE of any form of
discrimination or harassment.
O Today we’ll talk about Sexual Harassment.
The Types of Sexual
Harassment
O Quid Pro Quo – this for that
O Hostile Work Environment
O Third Party
Quid Pro Quo
O Unwelcome sexual advances, request for
favors, and other verbal or physical conduct
of a sexual nature constitute SH when
submission to such conduct is made a term
of condition of employment
O “If you have sex with me, I’ll hire you…or how
much do you want this promotion…”
Hostile Work Environment
O Unwelcome sexual advances, requests for
sexual favors and other verbal or physical
conduct of a sexual nature constitute SH
when such conduct has the purpose or
effect of unreasonably interfering with an
individual’s work performance or creating an
intimidating, hostile, or offensive work
environment.
Examples of Hostile Work
Environment
O Assault & battery
O Insults, obscene
O Inappropriate
gestures
O Personal
questions/comment
s
O Inappropriate
pictures, posters,
jokes, comments
O Inappropriate gifts
O
O
O
O
O
touching
Stalking, staring
Exposure
Threats
Propositions
Horseplay
Third Party HWE
O The offender is someone outside of the
institution – such as patient, vendor, visitor.
Zero Tolerance
O Speak up when you see or hear something
offensive. Not just offensive to you but to
others – use the reasonable person
standard.
O Have questions…concerns…contact
Compliance at 877-77-COMPLY.
DO’s
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Neat, Clean, and Presentable
Casual business attire
Gentlemen: Shirt & Tie
Ladies: Blouse & Slacks or Knee
Length Skirts/Dresses
DON’Ts
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Jeans
Leggings
Stretch Pants
See-Through Clothing
Beachwear
Sweatshirts or Sweatpants
Shorts
Tank Tops
T-Shirts
Bare Midriffs
Extreme Form Fitting or Revealing
Fashion
Hats, Caps
What’s Wrong?
What’s Wrong?
What’s Wrong?
Additional Pointers
• No open-toed
shoes are allowed
within clinical
areas.
• No strong
fragrances
• No excessive
makeup
Sneakers
Sneakers may not be worn
with business attire or in
public or office areas. In
areas where sneakers may
be worn, they must be clean
and properly laced. Socks or
stockings must be worn at all
times while at work.
Fingernails and
Artificial Nails
Any hospital employee who has
direct patient contact, who
handles food, medications,
blood or body fluids may not
wear artificial nails, extenders,
wraps and decals. All hospital
employees’ hands and nails
should be clean, tidy and free of
chipped or peeling nail polish.
Natural nail tips must be kept
less than a ¼ inch long.
Scrubs Suits
Scrub suits worn in sterile
areas should not be worn
outside these areas unless
properly covered with a lab
coat. House Staff who are not
required to wear scrub outfits
are not to wear them in lieu of
their normal professional
attire. Employees are not to
wear their scrub suits outside
of the Medical Center and are
required to change into other
clothes if they are leaving the
building.
Shoe covers, caps and masks
should be removed before
going into general patient care
or public areas of the hospital
and placed in the appropriate
receptacle for disposal.
While at work employees are
expected to be neat, clean and
presentable whether in uniform or
street clothes.
Those employees who wear
uniforms are responsible to make
sure that they are neat and clean.
The purpose of this policy is to ensure that as employees of Lutheran
Medial Center we present an image of trust in confidence to the
public. Appearance plays an important role in fostering this feeling.