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New ANTHC policy and procedure updates: February 2024

Click this post to read updates on key changes and where to find updated policies and procedures.

The following policies and procedures have been recently updated. Below is an update on key changes and where to find the updated policies and procedures.

  • Administrative Bill Adjustment Due to Quality of Care Concerns Procedure: This is a new procedure which outlines the process for making billing adjustments in response to actual or perceived quality of care concerns and/or Preventable Adverse Events.
  • Inpatient Visitors Guide and Quiet Hours Procedure: This procedure establishes guidelines regarding visitation and quiet hours on the ANMC campus allowing patients the opportunity for visitors while providing a safe environment for the patients, visitors, and staff working at ANMC. Revisions include addition of Visiting Hours (7:00 AM to 8:00 PM) and Quiet Hours (8:00 PM to 7:00 AM), clarification that visitors remaining or arriving after 8:00 PM will be asked to sign-in at the ANMC Security Desk located in the Emergency Services Department to obtain a visitor’s pass, and updates to the section providing guidance to staff who are asked questions about visitation of a patient who has opted out of Directory listing.
  • Administrative Closure of Medical Records Procedure: This new procedure is written to define guidelines for filing incomplete medical records for providers who have resigned, are deceased, or who are on leave of absence to ensure that records are complete and closed. There are some circumstances when a record may not be closed by the responsible provider and in those cases, the record will be closed by Health Information Management using the steps in this procedure.
  • Bulletin Boards Policy: This policy identifies a means for the dissemination of important ANTHC and employment-related information. Changes include adding electronic bulletin boards.
  • Overtime Policy: This policy ensures ANTHC complies with applicable wage and hour laws in the administration of overtime pay. Changes include adding Bereavement Leave in the definition of “Time Worked” and changing the wording in section 4.4 to more accurately reflect Holiday Overtime.
  • Paydays Policy: This policy establishes regular paydays. We changed section 3.4 to encourage participation in the direct deposit program.
  • Information Privacy, Security, and Integrity Management Policy: This policy ensures the privacy, security, integrity, and accessibility of critical, sensitive, proprietary, and confidential information. Changes include adding a definition for “Critical, Sensitive, Proprietary, and Confidential Information” and a requirement for staff to report and help resolve potential equipment theft or loss.
  • Social Media Policy: This policy defines the appropriate use of web-based and social media tools. Changes include changing the owner from Communications and Marketing Director to Vice President of Communications.
  • Medical Billing and Coding Compliance Policy: There were no edits from the previous version of this policy.
  • Breach Notification Rule Policy: This policy ensures all required notices are provided for breaches of unsecured PHI in accordance with applicable law, including HIPAA’s Breach Notification Rule. There were no edits from the previous version.
  • Business Associates and Health Information Policy: This policy establishes requirements for business associate agreements in accordance with HIPAA. There were no edits from the previous version.
  • Privacy Complaints Procedure: This procedure provides a process for individuals to lodge a complaint regarding the privacy or security of PHI at ANTHC and any related policies, procedures, and processes in accordance with the Privacy Rule. There were no edits from the previous version.
  • Corrective Actions Policy: This policy promotes effective operations through establishing and maintaining standards of employee conduct, managing employee relations, and encouraging positive change in employee performance; and addressing, correcting, and preventing repetition of undesirable behavior. Changes were made to clarify conduct that warrants disciplinary action.
  • Research Misconduct Policy: This policy ensures research integrity and a swift and prudent response to any allegation of misconduct involving research or research training, applications for support of research or research training, and related research activities. Changes include assuring definitions are consistent with other research policies and procedures and correcting department titles.
  • Dispute Resolution Policy: This policy enables ANTHC to address and resolve work-related concerns, disagreements, and disputes among employees and other members of the workforce. Changes include edits to Section 3.9 regarding complaints about executives other than the President/CEO, and a conforming edit to section 3.7.1.
  • Digital Recording of Trauma Resuscitation Procedure: This procedure is written to facilitate Quality Improvement and teaching objectives of the Trauma Program, while protecting the confidentiality of medical quality assurance records. It has been reviewed to add clear language and definitions related to Medical Quality Assurance programs and to make it clear that all recorded information is managed according to those standards as well as HIPAA.
  • Specimen Labeling Procedure: The Specimen Labeling Procedure has been revised with clarifying edits to ensure that the procedure matches staff actions at ANMC to ensure that training is easier and more consistent for all staff that may be labeling specimens.
  • Trauma Team Activation Procedure: The trauma team will be mobilized to provide efficient diagnosis and treatment of patients with major and multiple system injuries. This procedure has been reviewed to ensure that the roles of all staff member involved in a trauma response are clear and accurate.
  • Vehicle Use Policy: To ensure the safe and legal operation of Alaska Native Tribal Health Consortium (ANTHC) and personal vehicles used to perform work. Changes include adding insurance requirements, requiring an employee to receive official authorization prior to driving a vehicle for work-related purposes, and adding sections on accidents and international travel.
  • Conflict of Interest Policy: This policy protects against actual or apparent conflict of interest or impropriety. Changes include adding language on honoraria and to clarify that $100 is the maximum total allowable amount for all gifts from a vendor to address the possibility of receiving multiple gifts valued under $100 from the same vendor.
  • Donations and Contributions Policy: This policy authorizes ANTHC to make donations, sponsorships, and contributions to tribal, non-profit, and other entities in support of activities to promote health or benefit the Alaska Native community. Changes include adding sponsorships and changing recording, tracking, and reporting authority to the ANTHC Administrative Officer.

Staff who may need help or training to access the Policy Portal may find a training on HealthStream at this link.