VENDOR REPRESENTATIVES HANDBOOK

Transcription

1 VENDOR REPRESENTATIVES HANDBOOK

2 DEAR BUSINESS PARTNER: Thank you for partnering with Memorial Health University Medical Center (MHUMC). We have instituted a Vendor Access Management Program to ensure a safe and secure environment for our patients, staff, visitors, and vendor representatives. The program enforces specific guidelines regarding access and movement throughout our facilities. When conducting business within any of our facilities, it is important that all representatives of your firm abide by the Vendor Access Management Program guidelines. All representatives of manufacturers, distributors, suppliers, contractors, or service organizations that wish to introduce a product, equipment, or service at MHUMC must register through the Vendor Access Management Program administered by our materials management department. This program also applies to off-site ambulatory facilities and physician practices within the Memorial Health system. This handbook outlines the requirements of our Vendor Access Management Program as well as expectations for vendor conduct when doing business with MHUMC. PART I PART II PART III Description of the Vendor Access Management Program and outline of Memorial Health s policies and procedures for vendors. Information about MHUMC s emergency codes, hand hygiene, confidentiality, and patient safety. The role and function of compliance and audit services, including how to report a compliance concern and key expectations for vendor conduct as it relates to compliance. At the end of this handbook, you will find a vendor acknowledgment of receipt of information that you must complete and sign prior to receiving your vendor badge.

3 PART I VENDOR ACCESS MANAGEMENT PROGRAM REQUIREMENTS Definition of Terms Vendor company any manufacturer, distributor, supplier, contractor, or service organization that provides or wishes to provide services and/or goods for, or on behalf of, Memorial Health University Medical Center (MHUMC). This also includes organizations to which MHUMC patients are referred for clinical services (e.g., home health providers). Vendor representative any salesperson, representative, or other employee of a vendor company who is not also an MHUMC faculty member, medical staff member, employee, or student. MHUMC recognizes that different types of vendors interact with the organization in different ways. As such, this policy defines three categories of vendors based on the nature of their interaction with the organization. Level One Vendor those vendor representatives who provide services for, or on behalf of MHUMC, and require access inside the operating room, cath lab, or special procedures area. Level Two Vendor those vendor representatives who provide services for, or on behalf of MHUMC, but who do not require access inside the operating room, cath lab, or special procedures area. This category includes, but is not limited to, pharmacy, radiology, and physician office vendor representatives and durable medical equipment suppliers who invoice MHUMC. Level Three Vendor those vendor representatives who may require access to patient care areas or patient information, but who do not provide services for, or on behalf of MHUMC (e.g., home health providers, durable medical equipment suppliers who do not invoice MHUMC). This level also includes those vendor representatives who require access to the MHUMC campus but do not require access to patient areas or patient information (e.g., service supply technicians, information systems, gardeners, and facilities). MHUMC campus property that is owned by MHUMC or an affiliate thereof, including physician practices. Registration Requirements Vendor representatives that visit MHUMC three or more times a year must visibly wear their vendor badge to conduct business at MHUMC. All short-term vendor representatives (those who visit less than twice a year) must wear a temporary MHUMC vendor badge to conduct business at MHUMC. Short-term vendors are exempt from the annual fee but must provide proof of an updated tuberculosis (TB) skin test. Depending on the nature of the service provided, some vendors may be required to complete and adhere to a Business Associates Agreement in accordance with the Health Information Portability and Accountability Act of 1996.

4 The Vendor Access Management Program requires all frequent vendor representatives to submit their company information and update, at least annually, the items listed below: Vendor Level LEVEL ONE LEVEL TWO LEVEL THREE Registration Requirements A) Submission of current shot records, to include MMR or immunity, Hepatitis B or its declination, proof of flu shot, titer results or proof of two vaccines for varicella/chickenpox, and negative TB skin test or chest X-ray. B) Verification that neither the representative nor the representative s company is an excluded party as defined in sections 1128 and 1156 of the Social Security Act. This validation must be provided before business can be conducted at MHUMC. C) A signed vendor representative acknowledgment of receipt of information (at the back of this handbook) indicating review and acknowledgment of receipt of the handbook and the compliance and audit services vendor information sheet (located in this handbook). The handbook and information sheet may be amended from time to time as needed in accordance with federal and state regulations and/or organizational changes. D) Verification that a background check has been conducted and cleared and submission of company liability insurance. E) $75 annual fee, renewable January 1 of each year. A) Submission of a record of a negative TB skin test and proof of a flu shot. B) Verification that neither the representative nor the representative s company is an excluded party as defined in sections 1128 and 1156 of the Social Security Act. This validation must be provided before business can be conducted at MHUMC. C) A signed vendor representative acknowledgment of receipt of information (at the back of this handbook) indicating review and acknowledgment of receipt of the handbook and the compliance and audit services vendor information sheet (located in this handbook). The handbook and information sheet may be amended from time to time as needed in accordance with federal and state regulations and/or organizational changes. D) Verification that a background check has been conducted and cleared and submission of company liability insurance. E) $75 annual fee, renewable January 1 of each year. A) Submission of a record of a negative TB skin test and proof of a flu shot. B) Verification that neither the representative nor the representative s company is an excluded party as defined in sections 1128 and 1156 of the Social Security Act. This validation must be provided before business can be conducted at MHUMC. C) A signed vendor representative acknowledgment of receipt of information (at the back of this handbook) indicating review and acknowledgment of receipt of the handbook and the compliance and audit services vendor information sheet (located in this handbook). The handbook and information sheet may be amended from time to time as needed in accordance with federal and state regulations and/or organizational changes. D) Verification that a background check has been conducted and cleared and submission of company liability insurance. E) $5 annual fee, renewable January 1 of each year.

5 Level One Vendors Specific Requirements Level one vendors provide services for, or on behalf of MHUMC and require access inside the perioperative areas (O.R., cath lab, or special procedures). Vendor representatives with approved appointments or scheduled surgical cases must log on to the computer provided in the designated perioperative area for tracking purposes. Vendor representatives needing after-hours access to surgery or other areas of MHUMC must have their Vendor Access Management Program badge visible. After-hours representatives are still required to log on to the vendor tracking computer located in the perioperative areas. Vendor representatives are not permitted to scrub for a procedure. In order for a vendor representative to observe a procedure, the scheduling staff from the physician s office must notify the O.R. clinical supervisor when the vendor representative is needed. The O.R. purchasing agents will process a visitor permit and obtain the required patient approvals for the holding or Day Surgery staff. The vendor representative may act as a resource regarding the representative s product only and may not participate in patient care unless their company contract states otherwise. Vendor representatives observing surgical procedures are required to wear a brown scrub suit in all perioperative areas, including central sterile processing, cardiovascular (CV) suite, Day Surgery, gastrointestinal diagnostic unit (GIDU), labor and delivery, pre/post anesthesia care unit (PACU), and women s services. The vendor representative is responsible for supplying his or her own scrubs. The scrubs must be clean, neat, and laundered prior to entering the O.R. and any perioperative areas. Vendor representatives who need items sterilized for MHUMC cases must have these items at MHUMC by 1 p.m. the day before they are to be used. Approved, new implants must be in the MHUMC O.R. at least 48 hours prior to the case. A list of items for sterilization must be presented to the O.R. staff with the items. Vendor representatives may not leave their instruments at MHUMC for more than 24 hours after case completion or cancellation. MHUMC is not responsible for trays left after case completion or cancellation. For each tray left after 24 hours, the vendor company will be charged a $5 per day (per 24 hours) fee. Emergency After Hours and Weekend Instrument Loans Vendor representatives who request to deliver an instrument set to a surgery must: Obtain approval from the O.R. materials coordinator and O.R. sterile processing manager. Provide a count sheet to the sterile processing technician and count the instruments prior to leaving the set. Both the vendor representative and the sterile processing technician will sign the count sheet. Upon return of the instrument set, the vendor representative and the sterile processing technician will inventory the set to verify that it is complete. Both will sign the reviewed count sheet. Special order or nonstick implants (bill only) purchase requests, known as pink sheets, should be filled out by the company representative to include complete product description, re-order number, quantity used/wasted, and correct pricing. The pink sheet should be completed at the end of the case, or if on a weekend, by noon on the following Monday. Upon completion of the surgical case,

6 the pink sheet is to be given to the O.R. circulator. If any products are left off the purchase order, or if an incorrect quantity is entered, the extra products will be considered donated items for the case. Level Two Vendors Specific Requirements Level two vendors provide services for, or on behalf of MHUMC, but do not require access inside the O.R., cath lab, or special procedures areas. This category includes, but is not limited to, pharmacy, radiology, and physician office vendor representatives and durable medical equipment suppliers who invoice MHUMC. All pharmaceutical representatives are required to follow the Vendor Access Management Program process but will coordinate the presentation of new medications, supplemental feeding products, and other services through pharmacy administration. All other meetings to discuss pharmacy products should be coordinated and approved through pharmacy administration. Pharmaceutical vendors are not allowed to promote non-formulary medications within MHUMC. Level Three Vendors Specific Requirements level three vendors may require access to patient care areas or patient information but do not provide services for, or on behalf of MHUMC (e.g., home health providers, durable medical equipment suppliers who do not invoice MHUMC). This level also includes vendor representatives who require access to the MHUMC campus but do not require access to patient areas or patient information (e.g., service supply technicians, information systems, gardeners, and facilities). All service technicians, construction workers, and other non-mhumc persons providing services will report to the respective plant engineering and construction areas as appropriate. Product and Equipment Introduction Materials cannot be shipped or hand-carried into MHUMC without an authorized purchase order and delivery document or packing slip. Any violation of this procedure shall result in non-payment of the resulting invoice. Any product or equipment brought in without prior purchase order authorization shall be seized and held for vendor pick up. All invoices must be delivered or mailed to the following address only: Memorial Health University Medical Center Attn: Accounts Payable P.O. Box Savannah, GA Prior to any evaluation or trial by a specific department, all vendor representatives must coordinate the presentation of new products, services, and equipment through the materials management corporate director or the appropriate perioperative clinical supervisor for consideration in accordance with MHUMC s policies and procedures.

7 New product introduction must meet the following criteria prior to use: 1. Product must be available for trial at the vendor s expense 2. Offered for clinical review by all physicians in a particular service with a goal of standardization 3. Product must meet all FDA requirements for efficiency and safety Product samples should be left with the appropriate Team Leader who shall coordinate the evaluation of the items through MHUMC internal policies and procedures. If the representative wishes to demonstrate the product within an area of use, such arrangements will be made at the discretion of materials management and the department director involved. A hold harmless agreement is required for products or equipment left at MHUMC for evaluation. This agreement may be obtained from materials management. Vendor Conduct 1. All vendor representatives must have a prescheduled appointment with a specific individual at the facility where they are conducting business. Representatives are not permitted to call directly on any department or physician without first obtaining clearance from materials management. 2. Vendor representatives on the MHUMC campus should park behind the main hospital in the Team Member parking area and enter through the Heart & Vascular Institute entrance. There are designated parking spaces in the receiving /loading dock area that are limited to 15 minutes for loading and unloading deliveries. Please note that vendor parking is prohibited at the main entrance of the hospital and at the emergency room entrance. 3. The presentation of gifts and gratuities is prohibited. Suppliers expressing an interest in supporting MHUMC through donations should contact the Memorial Health Foundation at In accordance with Internal Revenue Service requirements, all donations must be for the general/unrestricted use of MHUMC versus for a specific department. Procedure for Addressing Vendor Infractions The following infractions of MHUMC policies will result in disciplinary action against a vendor representative: Minor infractions: Failure to obtain and/or wear a vendor s badge. Failure to log in and out of the Vendor Access Management Program badge system while on campus. Calling and/or visiting MHUMC personnel who have not expressed interest in their products, services, or capital equipment. Accessing MHUMC facilities to conduct business without a scheduled appointment or prior authorization from the respective department or materials management. Failure to obtain a purchase order number before shipping products, services, and/or capital equipment into MHUMC, including items for trial and evaluation purposes.

8 Failure to maintain service levels, such failures may include: - Shortages on a consistent basis - Over-shipments on a consistent basis - Inadequate in-service sessions - Catalogs and price lists not current - Communication lines not maintained - Vendor representatives non-responsive to hospital needs - Shipping products to wrong locations - Failure to honor prices quoted Failure to provide resources and necessary documentation to maintain account in good standing: - Failure to provide invoices, copies of invoices, or proof of delivery, upon request - Failure to reconcile outstanding account issues within 90 days of invoice date - Unauthorized use of credits to offset open invoices Major infractions: Failure to ship the specified product, service, or capital Failure to follow the proper procedure, as outlined earlier in this policy, for presenting new products, services, or equipment (i.e. back-door selling tactics) Failure to provide adequate safeguarding of protected health information Offering unethical inducements to MHUMC personnel Failure to notify materials management of product recalls Harassment of MHUMC personnel (i.e. inappropriate language and/or physical actions) Failure to provide required Vendor Access Management Program paperwork as well as appropriate shot records The progressive steps in the disciplinary action process may be waived or escalated by the corporate director of materials management if the vendor commits a major infraction. Materials management shall review the performance of all vendors and initiate the following disciplinary actions if applicable. Minor or major infractions of this policy may result in the following: First minor infraction documented verbal counseling of the vendor representative. Second minor infraction letter to vendor and vendor representative s immediate supervisor. Third minor infraction or serious first or second major infraction, or if the issues remain unresolved could result in termination of privileges at MHUMC.

9 PART II GENERAL INFORMATION ABOUT MHUMC POLICIES Memorial Health Mission: With compassion, we heal, teach, and discover. Vision: We will be the healthcare system of choice by demonstrating excellence in everything we do. Values: Safety, Trust, Respect, World-Class, Enjoyment, and My Memorial Medical Waste and Biohazard Spills There are two types of waste. General waste consists of items such as paper products, newspaper, magazines, soda cans, and patient care items that are not soiled with blood or body fluids. Medical waste in the red trash bags contains patient care items soiled with blood or body fluids. If you recognize a blood or body fluid spill, notify a hospital employee. Do not attempt to clean up the spill. Hazardous Warning Symbols Do not touch anything with these symbols: Quiet Please remember that you are in a hospital and people are resting. Keep voices low and minimize other noise. Parking You may park in visitor parking. Please use the receiving area for deliveries and pick-ups. Receiving area parking is limited to 15 minutes. Security Make sure your identification is displayed at all times. Report any suspicious activity to security by calling

10 Smoking Smoking is NOT permitted anywhere on our campus, indoors or outdoors. Emergency Drills We periodically conduct emergency preparedness drills. If a drill is conducted while you are on site, wait for instructions from a department leader. Fire If a fire occurs, remember the RACE procedure: Remove anyone in immediate danger Activate fire alarm by pulling the alarm and calling 118 Contain the fire by closing the door to the fire Extinguish the fire There are fire alarms throughout the hospital. Locate the fire alarm near your work area. Locate the fire extinguisher in your area. To use a fire extinguisher, remember the PASS procedure: Pull the pin Aim the nozzle Squeeze the handles Sweep back and forth across base of fire MHUMC Emergency Codes To report a code, dial 0 or the numbers listed below from any telephone inside Memorial Health University Medical Center. Code Triage: mass casualty, report to your assigned area Code Red: fire, follow RACE and PASS, call 118 and/or Code Blue: cardiac and respiratory arrest, call 8888 Code Silver: active shooter, call 118 and/or Code Orange: hazardous materials, call 0 or 118 Code Pink: infant abduction, notify charge nurse, call and 115 Code Gray: security incident such as a fight or disturbance, call Code Black: bomb threat, notify department leader and call Infection Control Whether or not you work directly with patients, you should practice the following precautions to protect yourself from exposure to infection: Wear gloves for all patient contact Wear gloves if handling blood or body fluids Wear a gown, mask, eyewear, and gloves if there is a chance of fluid splatter or splashing

11 Hand Hygiene Use alcohol-based hand sanitizer before: Patient contact Putting on gloves Inserting any devices or performing non-surgical invasive procedures Use alcohol-based hand sanitizer after: Patient contact Removing gloves Contact with patient beds, furniture, or in-room supplies or equipment Wash hands with soap and water for at least 15 seconds when they re soiled, after using the toilet, or after contact with a patient s body, fluid, or dressing. Use only hospital-approved hand lotion. Do not wear artificial nails. Confidentiality You may become aware of confidential information regarding patients. You should not seek information that is not required to do your job while at MHUMC. The unauthorized sharing of confidential information at any time during or after your affiliation with MUMC is strictly prohibited. Health Insurance Portability and Accountability Act (HIPAA) Only individuals with a legitimate need to know may access, use, or disclose patient and/or MHUMC information. This includes all activities related to treatment, payment, and healthcare operations. Individuals may only access, use, or disclose the minimum information necessary to perform a designated role, regardless of the extent or access provided. For further HIPAA guidelines, please call our compliance team at Patient Safety Patient safety is the responsibility of all MHUMC employees, volunteers, and vendors. Report any unsafe condition to the department leader immediately.

12 PART III COMPLIANCE AND AUDIT SERVICES INFORMATION FOR VENDORS The compliance and audit services department of Memorial Health, Inc. (Memorial) has prepared this information to help you understand our expectations for your conduct when providing services to, or on behalf of, Memorial. Compliance and Audit Services The compliance and audit services department of Memorial oversees regulatory compliance in all areas of the Memorial system. If you have any questions or wish to report a concern, we can be contacted at Memorial also has a hotline for reporting concerns anonymously. That number is Vendor Conduct Memorial values its relationships with its vendors. Although not employed by Memorial, our vendors are an extension of our team. Therefore, we encourage and expect our vendors to help us ensure the integrity of the services we provide to the patients who entrust us with their care. There are two key areas we wish to highlight: conflicts of interest and patient privacy. Conflicts of Interest Conflicts of interest happen when one of our Team Member s personal or business relationships affect or could affect decisions that are made on the job. Although vendors are not required to submit conflict-of-interest disclosures, it is important that you be aware of our requirements for our Team Members. Memorial conducts its business by buying and selling products and providing services solely on the basis of their value and merit. When making purchasing and contracting decisions for Memorial, Team Members have a responsibility that objectivity of judgment must not be compromised. All Team Members and physicians participating in evaluation and or selection processes are required to disclose potential competing interests. All Team Members engaged in external relationships on behalf of Memorial are required to observe the following general guidelines. - Team Members may offer or accept entertainment, but only if the entertainment is reasonable, occurs infrequently, and does not involve lavish expenditures. The entertainment of customers and suppliers at cultural and sporting events that are sponsored by Memorial is acceptable within this policy. - Accepting or providing an occasional meal or refreshment in the nominal course of business is permitted if circumstances dictate that a business meal is necessary.

13 - Team Members may give or accept gifts of nominal value. An item has nominal value when it is promotional in nature, imprinted with corporate advertising, and typically distributed widely as a promotional item to others. Any other gift, to be considered nominal when it does not fit this definition, must have a retail value of $100 or less. There are times that it may be considered appropriate for a Team Member to accept travel expenses from a vendor. Approved vendor-funded travel is allowed when the travel is a condition of a contractual relationship, provides education directly related to the vendor s product, or is required to examine a product. Patient Privacy Some vendors need to access patient information in providing a service to, or on behalf of, Memorial. If this is the case, the vendor s company must sign a Business Associate Agreement. This should be done at the same time the service agreement is executed. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule was developed to protect individual s medical records and other personal health information, collectively known as protected health information (PHI). PHI is any patient information, including demographic information that can be used to identify the patient (e.g. Social Security number). PHI also includes information that relates to any healthcare provided to a person, whether in the past, present, or future. Although the Business Associate Agreement will outline the specific requirements of the business associate with respect to PHI, there are some important points to remember whether or not a vendor is a business associate of Memorial as defined by HIPAA: You may only access or share PHI in the performance of the specific service for which you have been engaged by Memorial. In other words, only the minimum necessary information required for Memorial to provide treatment, secure payment for Memorial s services, or to conduct and improve Memorial s operations. Communicating PHI over social networking sites or other media and the digital capture of images of our patients are strictly forbidden. All suspected violations of patient privacy should be reported to compliance and audit services, and all substantiated violations will be sanctioned. Even if you are not a business associate under HIPAA, if you become aware of a possible breach, you should notify compliance and audit services at or

14 VENDOR REPRESENTATIVE ACKNOWLEDGMENT OF RECEIPT OF INFORMATION Please check each box indicating that you have read and understand what is being stated. c c c c c c I, the undersigned, acknowledge that I have been provided a copy of the Memorial Health University Medical Center (MHUMC) Vendor Access Management Program Handbook for vendor representatives and understand the requirements outlined therein. I also understand this handbook applies to all representatives and/or subcontractors of my affiliated company that may accompany me as an authorized visitor while I conduct business at MHUMC. I acknowledge receipt of the general in-service education and emergency protocols information. I acknowledge that I have received and reviewed the compliance and audit services vendor information sheet and that I understand the expectations regarding my conduct when working with MHUMC. I acknowledge that I have been provided information regarding patient confidentiality, including information on the Health Information Portability and Accountability Act (HIPAA) and understand that the unpermitted or unauthorized access, use, or sharing of protected health information (PHI) is strictly prohibited. I acknowledge that when conducting business with MHUMC, I will park in the employee parking area behind the hospital and enter through the Heart & Vascular Institute entrance. I also acknowledge that I am aware of the designated vendor parking spaces located by the loading dock, which are for loading and unloading of equipment only. I acknowledge that I have received information on the annual registration requirements and will provide the proper documentation to the materials management department. By signing this form you agree that you have thoroughly read and understand all requirements and expectations of your conduct while doing business with MHUMC and that you acknowledge all of the above. NAME (PLEASE PRINT) COMPANY TITLE ADDRESS (PLEASE PRINT) WORK PHONE/CELL PHONE SIGNATURE DATE