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PATIENT FEEDBACK

Effective Date: 
Tue, 05/18/2021
Policy: 

In order to best serve the patients/families of our community, the UCSC Student Health Center is committed to soliciting and receiving feedback for continuous improvement. Feedback, both positive and negative, gives us unique opportunities for evaluating our delivery of care and improving internal systems and processes. A key component of patient feedback management is the systematic recording of feedback and its resolution, which is achieved through a feedback management system. The UCSC Student Health Center uses an electronic feedback management system (EFMS) called the RL Datix Feedback Module.

To be patient centered, UCSC Student Health Services evaluates patient satisfaction in multiple ways - via Quick Comments, ongoing patient surveys, benchmarking surveys within the UC system as well as unsolicited communications. The UCSC Student Health Center monitors feedback from patients, family members and concerned others via its Quality Management Committee. All feedback will be acknowledged and responded to in a timely, professional and appropriate manner. Several mechanisms will be used to collect ongoing patient feedback. A key component is the systematic recording of feedback and resolution through the electronic feedback management system (EFMS), RL Datix. Feedback is logged into the EFMS to identify trends. The aggregate data is available in order to assist in departmental quality improvement initiatives. High level insights are also shared on a quarterly basis with the Quality Management Committee, the Clinical Operations Committee and the Governing Body.
In accordance with the University of California Office of General Counsel (OGC) Guidance on Red Flags for Potential SVSH Allegations in the Patient Care Setting, the following terms, when used by faculty, staff, trainees, or patients when making complaints or providing other formal or informal feedback or evaluations, may be “red flags” for sexual misconduct or other boundaries violations. Red flags are generally defined as circumstances which could place a reasonable person on notice that improper conduct has or may have occurred. The asterisks below indicate that there may be multiple versions of a word or word root, for example “creepy, creeped-out, creep” or “flirty, flirtatious, flirted, flirt”.
assault*, caress*, creep*, exposed, flirt*, fondl*, grop*, handsy, harass*, innuendo, molest*, pervert, pervy, rape, raped, raping, rapist, sexual, SVSH, touchy, undress*, uncomfortable, violating
Feedback received related to these words should be entered into the EFMS and escalated to Title IX.

The objectives of this policy are to:
1. Assist the UCSC Student Health Center with the timely and effective management of feedback occurring within or related to the Student Health Center.
2. Establish a standard approach to handling feedback.
3. Ensure that all staff are aware of their responsibilities and are empowered to manage or report feedback.
SCOPE
This policy applies to all feedback from patients, families, and concerned others about services received at the UCSC Student Health Center. This policy applies to all UCSC Student Health Center employees.
DEFINITION(S)
I. Feedback: Verbal or written communication expressed in regards to an experience with the Student Health Center. It can be positive or negative in nature. It may be communicated in person, online, by phone, via secure message, through a written comment, etc. Written feedback can be received through the following sources: Patient feedback forms (aka Quick Comments) available in waiting areas, Open-ended comments in Satisfaction Surveys, unsolicited emails or letters.
A. Compliment: An expression of satisfaction or commendation with any aspect of the services or care provided by an individual, department or organization
B. Inquiry/Support: Request for information, education, support or advice regarding personal experience, general systems issues or how the healthcare system works. Inquiries/Support are not entered into the EFMS. Examples include but are not limited to:
1. Insurance waiver issues
2. Immunization compliance issues (with no care concerns)
C. Comment/Suggestion/FYI (hereafter referred to as “comment”): An idea or plan put forth for consideration and/or anonymous written feedback unrelated to clinical care provided. Comments do not require patient follow-up and may be escalated on a case by case basis. Examples include but not limited to:
1. Anonymous review regarding our scheduling system
2. Suggestion for aesthetic modifications
D. Complaint: Verbal dissatisfaction, unrelated to clinical care provided, that can be resolved promptly at the point of service (or within 24 hours) by the staff present. Examples include but not limited to:
1. Patient was upset with the wait time for a visit and informed staff
2. Patient had billing issues (with no care concerns)
E. Grievance: Verbal dissatisfaction that cannot be resolved promptly (within 24 hours) and all written dissatisfaction related to services provided.
F. Incident: An event consistent with the UCSC Student Health Center’s Incident Management Policy.
II. Point of Service: Where the feedback has originated or where the interaction first occurs. It is the connection between the Student Health Center and the patient/family. This is where the complaint is expected to be resolved, whenever possible.
III. Service Recovery: A courtesy gesture to enhance a patient’s satisfaction. This can include fee waivers, fee reversals, and complementary service(s).
A. Proactive Service Recovery: a gesture offered in the absence of patient complaint
B. Reactive Service Recovery: a gesture offered as a result of a complaint or grievance
IV. Assistance: An action taken to enhance a patient’s satisfaction. This can include scheduling help, insurance clarification, etc.
Patient Feedback Report: A submission of patient/family feedback into the EFMS
VI. Passive Feedback: Several mechanisms will be used to collect ongoing feedback, including but not limited to:
A. “Quick Comments” available in our waiting areas
B. Invitation on our website to provide feedback
C. A culture of listening to patients and families respectfully as they provide feedback
D. Empowerment of practice team members to encourage patients and families to reach out directly with specific comments, questions, or concerns
VII. Proactive Feedback: Several mechanisms will be used to collect ongoing feedback, including but not limited to:
A. Periodic patient surveys
B. Input from student groups
VIII. Feedback Category: A classification used to categorize feedback themes
IX. Resolution Summary: A recommended action for each patient feedback report

 

Procedure: 

I. COMPLIMENTS:
A. Compliments are forwarded to the department manager
B. The compliment will be shared with the person(s) identified by their manager.
C. If patient contact information is available, the manager sends an acknowledgement to the sender within three business days (see Appendix A3).
II. COMMENT/SUGGESTION/FYI
1. A representative from the Quality Management Committee to collect Quick Comments from one of our five drop off areas daily and give to our Business and Information Services Director (BISD) for entry into EFMS. The BISD is a member of the Quality Management Committee and a Quality Representative.
A. Within 2 business days, the BISD will:
a. Confirm that feedback is a comment. The report will be re-tagged as a grievance or incident if appropriate
b. Review Feedback Category (see Section 1).
c. Task appropriate manager(s) for further investigation and follow- up.
C. If the patient included their contact information, the appropriate manager sends acknowledgement within three days (see Appendix A.1). In order for the communication to remain secure, it is recommended communications be sent through Secure Message or the secure Virtru email system.
D. All correspondence with the patient/family will be uploaded and attached to the report.
E. Resolution Summary determined (see Section 2) based on investigation and follow-up and event closed in the EFMS.
III. COMPLAINT
A. When a complaint is received, an attempt will be made to resolve the complaint immediately and/or within 24 hours, involving the provider or manager where appropriate. Escalation of complaints may be avoided where staff have clear authorization to resolve the complaint at the point of contact. If the complaint is resolved without issue, the matter is deemed concluded.
Complaints resolved within 24 hours are submitted to the chair of the Quality Management Committee (who will serve as the Quality Representative) and entered as a Patient Feedback Report in the EFMS
B. Within 2 business days, the Quality Representative will:
a. Confirm that feedback is a complaint. The report will be re-tagged as a grievance or incident if appropriate
b. Review Feedback Category (see Section 1).
c. Task appropriate manager(s) for further investigation and follow- up.
C. If the patient included their contact information, the appropriate manager sends the patient an acknowledgement email within 3 business days (see Appendix A.1). In order for the communication to remain secure, it is recommended communications be sent through Secure Message or the secure Virtru email system.
D. All correspondence with the patient/family will be uploaded and attached to the report.
E. Resolution Summary determined (see Section 2) based on investigation and follow-up and event closed in the EFMS.
F. It is the responsibility of the manager to identify trends and submit complaints received and resolved on their unit(s) in the EFMS if:
. there is a risk of the complaint escalating;
a. the complaint(s) suggests a pattern that involves a provider, department, and/or the organization/system;
b. the complaint involves more than one department and/or has organization/system wide impact.
IV. SOCIAL MEDIA
A. UCSC Student Health Services maintains the following social media accounts
 CARE-Instagram
 CAPS Peer Educator Program-Instagram
 SHOP-Instagram
 CAPS-Facebook
It is the responsibility of each department to monitor their sites for comments related to Student Health Services and copy the comment and response into a Patient Feedback Report in the EFMS and also report to their supervisor. Official UCSC Social Media accounts are monitored by UCSC Public Relations and they inform the Student Health Center of any comments related to Student Health Services, which are forwarded to the appropriate department manager for entry.
B. When a UCSC Student Health Center employee becomes aware of patient/family feedback on a social media platform that information is forwarded to the appropriate department manager for entry.
C. When a Social Media comment is received by the Quality Representative, it will be
acknowledged within two (2) business days and the sender will receive information on how to submit non-anonymous feedback for response/action (see Appendix B).
D. The Quality Representative will:
a. Confirm the feedback is a comment. The report will be re-tagged as a grievance or incident if appropriate.
b. Review Feedback Category (see Section 1).
c. Task appropriate manager(s) for further investigation and follow-up.
E. Resolution Summary determined (see Section 2) based on investigation and follow-up and event closed in the EFMS.
V. ANONYMOUS PATIENT FEEDBACK SURVEY:
A. All free-text feedback entered by patients in anonymous patient feedback surveys will be reviewed by the relevant Quality Representative. The Quality Manager in this case will be whichever member of the Quality Management Committee is analyzing the data.
B. The Quality Representative will:
a. Enter individualized feedback per provider as an individual report into the EFMS.
b. Assign Feedback Category (see section 1) c. Ensure that multiple, similar anonymous comments from the same survey will be aggregated and entered as one in the EFMS.
d. Task the appropriate manager for further investigation and follow-up.
C. Resolution Summary determined (see Section 2) based on investigation and follow-up and event closed in the EFMS.
VI. GRIEVANCE
A. All grievances are submitted to the chair of the Quality Management Committee (who will serve as the Quality Representative) and entered as a Patient Feedback Report in the EFMS preferably within 24 hours.
B. Within 2 business days, the Quality Representative will:
a. Confirm that feedback is a grievance.
b. Review Feedback Category (see Section 1).
c. Task appropriate manager(s) for further investigation and follow-up.
d. If contact information is provided the Manager sends the patient an acknowledgement email or secure message within 3 business days (see Appendix A.3). In order for the communication to remain secure, it is recommended that communications be sent through Secure Message or the secure Virtru email system.
e. Manager adds follow-up when action(s) completed.
f. All correspondences with the patient will be uploaded and attached to the Patient Feedback Report.
g. Resolution Summary determined (see Section 2) based on investigation and follow-up and event closed in the EFMS.
VII. INCIDENT
A. If a Patient Feedback Report falls within the definition of an incident, the Quality Representative will task the Patient Feedback Report to a member of the Quality Management Committee, who will submit an incident report in the electronic risk management system.
B. Response/action will be determined by the Quality Management Committee (See Adverse Incidents policy).
C. Resolution Summary determined (see Section 2) and event closed in the EFMS.
REFERENCES
- Adverse Incident Policies:
http://shs-manual.ucsc.edu/policy/incident-reports-0
http://shs-manual.ucsc.edu/policy/incident-management-plan
http://shs-manual.ucsc.edu/policy/iij-incident-policy http://shs-manual.ucsc.edu/document/medication-error-reduction-2

SECTION 1: Feedback Categories
1. Accessibility
2. Accommodation
3. Attitude/Courtesy
4. Care/Treatment
5. Communication
6. Coordination & Continuity of Care
7. Environment
8. Financial
9. Information
10. Loss
11. Patient Rights & Responsibilities
12. Responsiveness
13. Safety
14. Service

SECTION 2: Resolution Summary
1. Apology
2. Bill Waived
3. Acknowledgement
4. Refer to Human Resources
5. Refer to Medical Director
6. Refer to Business Operations
7. Refer to Director, Clinical Operations
8. Supervisor discussion of informal improvement plan with staff
9. Supervisor develops formal improvement plan with staff with monitoring as needed
10. Propose change to system
11. Educate all staff
12. Monitor system
13. Documentation of procedures
14. Policy instituted/reviewed/revised
15. Staffing pattern/workflow modified
16. Communications process enhanced
17. Discuss with patient/family
18. Engage in service recovery
19. Discuss with staff involved
20. Assistance
21. Refer to Risk Management Committee
22. No further action warranted
23. 805 Report
24. NPDB Report
25. Title IX Report

APPENDIX A

Follow-up Email Templates
1. Acknowledgement of Patient Comment/Suggestion/FYI Received Subject: Patient Feedback Follow-up
Greetings,
This email is to acknowledge your feedback regarding your recent experience at the UCSC Student Health Center. We appreciate you bringing this to our attention and allowing us the opportunity to review our practices.
The evaluation of our services by patients is critical to our organization’s efforts to maintain and strengthen the quality of care.
Should you have any further comments, please do not hesitate to reach out. Kind Regards,

2. Manager’s Positive Patient Feedback Follow-up Subject: Patient Feedback Follow-up
My name is XXX and I am the _____ Manager at the UCSC Student Health Center here on campus.
Thank you for providing feedback about your recent experience. The evaluation of our services by patients is critical to our organization’s efforts to maintain and strengthen the quality of care.
Best,

3. Manager’s Negative Patient Feedback Follow-up Subject: Patient Feedback Follow-up
My name is XXX and I am the ____ Manager at the UCSC Student Health Center here on campus. I received the feedback you provided about your recent experience. I apologize and appreciate you bringing this to our attention. We are committed to exceptional service to all of our patients. The evaluation of our services by patients is critical to our organization’s efforts to maintain and strengthen the quality of care.
Please let us know if you would like to schedule a time to discuss your concerns.
Best,

APPENDIX B
Social Media Response Script
Positive Review:
Thank you for taking a moment to review your experience at the UCSC Student Health Center.
The evaluation of our services by patients is critical to our organization’s efforts to maintain and strengthen the quality of care. If you would like to personally recognize any of the staff, please feel free to send them a compliment here: healthcenter@ucsc.edu

Negative Review:
Thank you for taking a moment to review your experience at the UCSC Student Health Center. We appreciate your feedback. The evaluation of our services by patients is critical to our organization’s efforts to maintain and strengthen the quality of care. We would like to discuss your recent visit with you in more detail. Please let us know at healthcenter@ucsc.edu if you would like a Student Health staff member to be in touch with you to discuss this further. Thank you for your time and feedback.

ATTACHMENT 1 (Sample) Patient/Family Feedback Policy Summary

Feedback Types Type Definition Example(s)
Compliment
Expression of satisfaction with any aspect of the services or care provided by an individual,
department or organization
Positive provider review from Inquiry/Support Request for information, education, support or advice regarding personal experience, general systems issues or how the healthcare system works. Insurance waiver issues; Immunization compliance issues (with no clinical concerns)
Comment/Suggestion/FYI
An idea or plan put forth for consideration and/or anonymous written feedback unrelated to
clinical care provided
Anonymous review regarding system; Suggestion for aesthetic
Complaint

Verbal dissatisfaction that can be resolved promptly at the point of service (or within 24 hours) by the staff present and is unrelated to clinical care provided Patient dissatisfied with the wait and informed staff
Grievance
Verbal dissatisfaction that cannot be resolved promptly (within 24 hours) and all written dissatisfaction related to services provided
Written negative feedback with information; Free-text on anonymous feedback survey; Free-text expressed social media profile managed Student Health Center
Incident

An event consistent with UCSC Student Health Incident Management Policy See Policy http://shs-manual.ucsc.edu/policy/incident

PATIENT SATISFACTION AND STUDENT COMPLAINTS

Effective Date: 
Fri, 05/14/2021
Reviewed: 
Tue, 05/18/2021
Revised: 
Tue, 05/18/2021
Policy: 

In an effort to uphold our student centered mission, vision and values, which includes all legal and ethical healthcare standards, UCSC Student Health Services (SHS) solicits and evaluates student patient satisfaction. Input on our services provides opportunities to celebrate successes and to improve services for UCSC students.

To that end:

  • Patient feedback is actively solicited
  • Specific performance targets are established
  • Survey results allow internal and external benchmarking
  • The appropriate manager follows up with patients who request to be contacted and who leave contact information
  • All results are logged, trended and reported regularly to the QM committee, and to the Governing Body for their review
  • Quality Improvement Initiatives are developed using feedback from patients 
  • Collated results are shared with the staff

Feedback is solicited in multiple different ways via:

  • Quick Comments
  • Regular surveys for the medical clinic
  • Regular surveys for Counseling and Psychological Services (CAPS)
  • Benchmarking surveys with the other UC Student Health Centers
  • Unsolicited comments, emails, social media posts etc.

Patient feedback is shared with staff to improve patient satisfaction with SHS. Significant complaints or grievances are investigated carefully and memoralized as incidents in RL Datix - the electronic incident reporting system, and/or feedback reporting system which is shared with the University of California Office of the President.

Complaints are sent to the appropriate manager and addressed as soon as possible.  Any staff member who is aware of a complaint or a breach in conduct shared by a student must report the information to their manager on the day of that knowledge for immediate documentation, reporting and follow up.

 

Procedure: 

Staff involved in Patient Satisfaction duties will collate and document patient satisfaction and dissatisfaction in the prepared processes below, or if received as unsolicited, will document in the appropriate RL system.

Quick Comments

  • Feedback forms (called “Quick Comments” forms) are available in the 5 waiting areas in the Student Health Center for individuals to provide any compliments, concerns or suggestions
  • Completed forms are deposited in the collection box in each waiting area
  • Forms are collected daily by the Assistant to the Director
  • Forms are forwarded to the Quality Management Director and then to other managers or staff as indicated for reviewing and responding to the comments
  • When a patient leaves contact information, the students are contacted
  • Patient feedback is summarized and reported at least annually for the Quality Management Committee
  • Summaries, compliments, and changes resulting from this feedback are shared with staff as appropriate
  • Individual provider feedback is given if indicated to a provider by their supervisor
  • Feedback is entered into the RL Feedback system

 

Patient Satisfaction Surveys

  • UCSC SHC Patient Satisfaction Surveys (PSS) are sent out at least quarterly during the academic year to all SHC patients who had medical and/or CAPS encounters during a specified time period
  • The UC System-Wide SHC PSS goes out once a week to 100 randomly selected SHC patients who had medical encounters during the given week
  • Patients are sent a secure message with a link to the online survey. The survey remains open for at least 1 week to maximize return rate
  • Once the survey is closed, the survey summary of results and comments are collated and analyzed
  • Respondents who leave their contact information are contacted by the appropriate manager/designee for follow up
  • Survey results are reported to the Quality Management Committee
  • Survey results are also reported periodically to staff
  • Students are randomly selected to win an incentive for their participation to maximize the return rate

If a staff member is individually identified, this information is shared with the staff person and their manager.  For medical providers, feedback is given if indicated to a provider by their supervisor

Student Complaints

If a student contacts SHS about dissatisfaction with services or gives negative written feedback and identifies themselves, the manager or designee communicates directly with the student.

Several options can be presented to the dissatisfied student in an attempt to resolve their complaint or concern.  The student can discuss their concerns solely with the manager, or to the appropriate director, and the student can be provided with appropriate resources and referrals.

A student may discuss dissatisfaction with the director or with a designee of the director.  If they cannot resolve the issue, along with informed consent from the student, the issue can be discussed with the Associate Vice Chancellor of Student Health and Wellness.

Complaints are documented by the manager/s in RL Datix and analyzed as necessary to determine the need for any changes to overall policy or personnel.

Reports are reviewed to the Governing Body.

 

 

 

COVID -19 VACCINES

Effective Date: 
Thu, 04/29/2021
Reviewed: 
Thu, 04/29/2021
Policy: 

Vaccinating against COVID-19 (SARS-CoV-2) is one component of a comprehensive strategy to help protect students, faculty, and staff and slow the spread of COVID-19.  UCSC Student Health Services (SHS), follows strict vaccine administration and distribution guidelines based on directions as set by the County of Santa Cruz Health Agency, the California Department of Public Health (CDPH), the University of California Office of the President (UCOP) and vaccine manufacturers.  Initially, in order to get access to vaccines, California vaccinating providers need to register for the California Immunization Registry (CAIR) program, sign the COVID-19 Provider Agreement and agree to a number of specific conditions. As vaccine availability and distribution processes evolve UCSC SHS will comply.

Per UCOP requirements,  appropriate information about all vaccinations shall be submitted to the California Immunization Registry (CAIR) or such other registries as may be required by applicable public health agencies or University policy.  The UCSC SHS electronic medical record (EMR) is configured to automatically upload required vaccine information to CAIR.

The storage, handling, administering and logging COVID-19 vaccines is a multi-pronged process that will evolve as needed. 

Procedure: 

STORAGE AND HANDLING

COVID-19 vaccines must be stored and handled properly from the time they are manufactured until they are administered to maintain the cold chain, thus protecting the potency and effectiveness of the vaccine and ensuring vaccine recipients are fully and safely protected from vaccine-preventable diseases.  Manufacturer’s and CDC guidelines for storage and handling of the vaccine are strictly followed and documented.   Campus EH&S (Environmental Health and Safety) have freezers that meet the specific storage requirements for Pfizer and Moderna COVID vaccines.  All calibration and monitoring of the COVID-19 vaccine specialty freezers are monitored by Campus EH&S and the Office of Research. 

At times, COVID vaccine may be delivered directly to Student Health Services (SHS) for storage and administration within the determined guidelines for non-deep freeze vaccine.  COVID vaccine delivery times are pre-arranged and are only accepted by  the Clinic Director or designee.  Upon arrival, vaccines are immediately:

Unpacked and checked for signs of physical damage
The cold chain monitor (CCM), a device used to monitor vaccine temperatures during transport (if one was included) is checked for any indication of a temperature excursion during transit
The packing list and contents are checked against each other to be sure they match.
Both vaccine and diluent expiration dates are checked to ensure no expired or soon to expire products have been received.
Placed in storage at recommended temperatures

(see attached UCSC Cold Chain Log form and linked “CDC Vaccine Storage and Handling Toolkit with COVID addendum”)  All records related to COVID-19 vaccine management are kept for a minimum of three years.

 

MASS VACCINATION CLINICS

Mass vaccination clinics were established to assure vaccine supply is distributed as close to being received as is possible.  Vaccine supply distribution is regulated by the County of Santa Cruz and State of California Public Health Departments.  COVID-19 mass vaccination clinics must be efficient while maintaining important infection control safety standards such as masking and social distancing.  Appointments and work stations are spaced so that social distancing can be maintained.  Every effort is taken to assure no dose is wasted, including midday and near end of day counts and a “Same Day Waitlist” process.  In order to be scheduled for a first dose, patients must agree to be available for the second dose at the appropriate time.  The UCSC SHS electronic medical record has a direct link to CAIR,  thus assuring compliance with reporting requirements.   (see attached “COVID 19 Mass Vaccination Workflow”)

Anaphylaxis response at mass the vaccine clinics follow the standard UCSC SHS Anaphylaxis  Response process adapted for offsite vaccine clinics  (see attached link)

 

STAFF TRAINING

UCSC SHS staff involved in administering COVID 19 vaccine are required to complete CDC approved training modules specific to each vaccine.  (see attached links)

NON-COMPLIANT STUDENT

Effective Date: 
Wed, 04/14/2021
Reviewed: 
Wed, 04/14/2021
Revised: 
Wed, 04/14/2021
Policy: 

Students who are non-compliant with treatment recommendations potentially jeopardize their physical and mental health. Examples include:

A student with a serious mental illness (e.g.-schizophrenia, bipolar disorder) not taking prescribed psychotropic medication
A student deemed to be a high active suicidal risk not attending scheduled appointments
Students whose condition warrants a higher level of care (e.g.-Intensive Outpatient Program, residential program) but refuse to follow-thru on recommendations. These situations might involve one of the following:

Eating Disorder
Dual Mental Health and Substance Abuse Diagnosis
Severe Personality Disorder
Ongoing psychotic symptoms

In primary care, consideration of non-compliance should be diagnosis specific. For instance, a student who has been terminated from treatment of their diabetes due to non-compliance, would still be eligible for services around other conditions.

Procedure: 

If a clinician believes that a student they are working with is non-compliant, and that non-compliance potentially jeopardizes their physical and/or mental health, the situation should be documented in the EHR and brought to supervisor’s attention.  With supervisor agreement, the clinician (if possible) should meet with the student and warn them that continued non-compliance will result in termination of the current treatment relationship.  A time frame should be established for the student to get into compliance (2-4 weeks) and the interaction documented in the EHR.

If the student remains non-compliant, a follow-up meeting should be held, including clinician’s supervisor, explaining that the current treatment relationship is being terminated. This should be documented in the EHR. A letter should be sent to the student (See Dismissal of a Patient at UCSC SHC Policy).

Student should be informed that CAPS crisis services will remain open to them if they meet crisis criteria. Primary care same day services will also be available if a student is terminated from on-going treatment in Primary Care.

If a student subsequently demonstrates compliance with treatment recommendations, Student Health services can be resumed.

OPEN NOTES

Effective Date: 
Wed, 04/14/2021
Reviewed: 
Thu, 05/13/2021
Revised: 
Thu, 04/15/2021
Policy: 

Background:

The Federal Rules on Interoperability and Information Blocking, and Open Notes has expanded immediate access to information in our medical record.

With a start date of April 5, 2021, the program rule on Interoperability, Information Blocking, and ONC Health IT Certification, which implements the 21st Century Cures Act, requires that healthcare providers give patients access without charge to all the health information in their electronic medical records “without delay.”

The eight (8) types of clinical notes that must be shared are outlined in the United States Core Data for Interoperability (USCDI), and include:

·       consultation notes

·       discharge summary notes

·       history & physical

·       imaging narratives

·       laboratory report narratives

·       pathology report narratives

·       procedure notes

·       progress notes

Further, all clinicians and organizations are required to share medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

Procedure: 

Students will be able to access their records through the student portal, Health e-Messenger,  by logging in to the portal, accessing  Visits/Allergies/Medication/Labs, then the item(s) they wish to review. There are certain exceptions to allowing immediate access that are listed below.  “Psychotherapy notes” are also an exception but our mental health progress notes do meet the definition of “Psychotherapy notes.”

·       Preventing Harm Exception: It will not be information blocking for an actor to engage in practices that are reasonable and necessary to prevent harm to a patient or another person, provided certain conditions are met.

·       Privacy Exception: It will not be information blocking if an actor does not fulfill a request to access, exchange, or use EHI in order to protect an individual’s privacy, provided certain conditions are met.

·       Security Exception: It will not be information blocking for an actor to interfere with the access, exchange, or use of EHI in order to protect the security of EHI, provided certain conditions are met.

·       Infeasibility Exception: It will not be information blocking if an actor does not fulfill a request to access, exchange, or use EHI due to the infeasibility of the request, provided certain conditions are met.

·       Health IT Performance Exception: It will not be information blocking for an actor to take reasonable and necessary measures to make health IT temporarily unavailable or to degrade the health IT's performance for the benefit of the overall performance of the health IT, provided certain conditions are met.

·       Content and Manner Exception: It will not be information blocking for an actor to limit the content of its response to a request to access, exchange, or use EHI or the manner in which it fulfills a request to access, exchange, or use EHI, provided certain conditions are met.

·       Fees Exception: It will not be information blocking for an actor to charge fees, including fees that result in a reasonable profit margin, for accessing, exchanging, or using EHI, provided certain conditions are met

·       Licensing Exception: It will not be information blocking for an actor to license interoperability elements for EHI to be accessed, exchanged, or used, provided certain conditions are met.

While all of these situations potentially represent an exception to the prohibition against information blocking, the most common occurrence at the Student Health Services is expected to be preventing harm.  The law is clear that this does not include potential emotional or psychological distress.  The key conditions to utilizing a prevention exception are explained below:

• The actor must hold a reasonable belief that the practice will substantially reduce a risk of harm;

• The actor’s practice must be no broader than necessary;

• The actor’s practice must satisfy at least one condition from each of the following categories: type of risk, type of harm, and implementation basis; and

• The practice must satisfy the condition concerning a patient right to request review of an individualized determination of risk of harm.

If one of these conditions is met, the clinician can choose to block access to a particular note by selecting “Hide Note on Portal/Exception Reason” and then selecting the reason from the dropdown list. If necessary, staff also have the option of adding exception details.

Key Points: 

Prior to implementing this practice, three conditions must be met:

·       “Open Notes” must be successfully integrated into our EHR

·       Proper communications to students must be in place informing them of this new practice

·       Staff must be educated about this new practice

Some lab results (such as sexually transmitted infection test and biopsy results) will not be released immediately because they require the review of a health care provider before they are released.  Individual department notes will be released as they meet the above criteria.   Per our existing procedure, all students currently have a mechanism to get copies of their health records.

COVID -19 CASE INVESTIGATION, CONTACT TRACING, ISOLATION AND QUARANTINE GUIDELINES

Effective Date: 
Mon, 01/04/2021
Policy: 

Case Investigation, Contact Tracing, Isolation and Quarantine are components of a comprehensive strategy to help protect students, faculty, and staff and to mitigate the spread of COVID-19.  

Definitions  (as they pertain to this policy):

Case Investigation:  the identification and investigation of patients with confirmed or probable diagnoses of COVID-19 with the intention of  preventing the spread of communicable disease 

Contact Tracing:   the identification, monitoring, and support of contacts who have been exposed to, and possibly infected with, the COVID-19 virus with the intention of preventing the spread of communicable disease

Isolation:  the separation of a person or group of people known or reasonably believed to be infected with the COVID-19 virus and potentially infectious from those who are not infected to prevent spread of the communicable disease 

Quarantine: the separation and restriction of movement of persons who, while not yet infected with COVID-19, have been exposed to COVID-19 and therefore may become infectious. Quarantine measures help prevent the spread of COVID-19 by separating these individuals from others

UCSC Affiliates:  currently active UCSC staff, students and faculty

SHS COVID Team:  a trained team led by the Medical Director that includes the Campus COVID Nurse, RNs, Case Managers and other staff as needed,  to facilitate Case Investigation, Contact Tracing, Isolation and Quarantine management and tracking

Close Contacts:  individuals in close contact with a positive case of COVID-19 as defined by regulatory agencies 

 

Per CA State regulations, local health departments are responsible for leading case investigations, contact tracing, and outbreak investigations.  Due to the large number of COVID-19 cases reported to the Santa Cruz County Health Department, the local health department’s limited resources, and in response to how easily and quickly COVID-19 (SARS-CoV-2) can spread, a partnership was developed between Santa Cruz County Public Health Department and UCSC SHS.  This partnership supports the best possible use and sharing of resources to aid in limiting the spread of COVID-19 in the local community.  Under the terms of this partnership, UCSC SHS, initiates Case Investigation and Contact Tracing for UCSC affiliates that have tested positive for COVID-19 at one of the UCSC campus testing locations and then report these findings to the Santa Cruz County Public Health Department.  Information about non-UCSC affiliates, collected in the course of these investigations is forwarded to the Santa Cruz County Public Health Department – UCSC is not responsible for notification or tracking of non-UCSC affiliates.  Once UCSC staff and faculty have been notified of their positive results, tracking and other processes are covered under broader campus protocols; the remainder of this policy pertains specifically to UCSC students.

 

Procedure: 

For on-campus testing, a positive COVID-19 result is received by SHS via the Electronic Medical Record (EMR).  The Medical Director or designee notifies the patient of the positive result, assesses symptoms, risk, work location,  educates and assesses isolation capabilities, and informs them to expect a Contact Tracer call shortly.

Off campus test results are received in several ways – including from supervisors for student workers and employees, directly from the patient, Health Department notifications.  Students in these cases are contacted by a member of the SHS COVID Team to ascertain symptoms, acuity, risk, work location, educate and assess isolation capabilities and resource needs, and initiate Contact Tracing if indicated.

Contact Tracing for UCSC students is performed by a member of the SHS COVID Team based on standards set by regulatory agencies.  Results are documented in the EMR and forwarded to the County Public Health Department with the required Confidential Morbidity Report (CMR).  Close Contacts that are UCSC students are notified that they are a close contact, educated and assessed for quarantine capabilities or other needs.  UCSC employees who are identified as close contacts are referred to the campus Assistant Director of Workers' Compensation and their PCPs for next steps.  For identified Close Contacts that are not UCSC affiliates, the case patient is instructed to notify the contacts directly. 

Isolation and Quarantine guidelines are determined by Federal, State and Local agencies and evolve as data is collected.  UCSC SHS follows the most current guidelines as set by these agencies.  Students that require assistance with housing, food or other Isolation or Quarantine concerns are referred to a campus team including representatives from housing, dining, Dean of students office, and transportation.  On-campus Isolation and Quarantine housing and food service is available to students living both on and off campus.  On-campus students are required to move to on-campus designated Isolation or Quarantine housing per campus protocol.

During the time students are in Isolation or Quarantine, they are monitored by the SHS COVID team for symptom development, acuity, and other needs.   The team meets regularly to review cases.  Students are expected to complete a daily Isolation or Quarantine survey; results of these surveys help monitor symptoms and acuity.  Clearance from Isolation or Quarantine is determined by current guidelines set by regulatory agencies.  

As the situation evolves, the most current process instructions can be accessed via the electronic medical record references and the shared documents.

 

EMPLOYEE HEALTH: COVID -19 DISEASE SCREENING

Effective Date: 
Mon, 01/11/2021
Revised: 
Mon, 01/25/2021
Policy: 

As part of the UCSC campus COVID-19 mitigation strategies,  daily screening has been implemented for all employees who will be working on-site at a UCSC owned or leased property.  As defined healthcare personnel (HCP), employees of UCSC Student Health Services (SHS) provide direct patient care and are essential to maintaining appropriate staffing ratios and services.  Routine COVID-19 screening and testing processes  are essential to providing a safe work environment for healthcare personnel (HCP) and safe patient care.

In alignment with University of California Consensus Standards for Operation and other federal, state and county guidance, and to help protect staff and students from avoidable COVID-19 disease exposure, UCSC SHS provides a mechanism for daily COVID-19 symptom screening for all HCP working that day.

Procedure: 

An electronic monitoring system was implemented for employees to complete prior to arrival at the facility.  This system has employees report absence of fever and symptoms of COVID-19, absence of a diagnosis of COVID-19 infection in the prior 14 days, and confirmation that they have not been exposed to others with COVID-19 infection during the prior 14 days.  Employees are encouraged to actively take their temperature at home or have their temperature taken upon arrival at SHS.  

UCSC SHS utilizes a daily email symptom check questionnaire, which will provide either a certificate of clearance to work on-site, or a notice to not report to work on-site.   A message is automatically sent to the employees supervisor noting if the employee is “cleared” or “not cleared” to work that day.  Additionally, SHS employees are offered regular asymptomatic COVID testing at no cost to the employee.  

All supervisors will follow these steps:

1.  If an employee reports “yes” to any symptoms on the daily screening questions they will need to be cleared before returning to work.  The employee has 2 options:

 a.  They can consult with their PCP for a COVID-19 symptom and risk assessment,  and clearance to return to work.  

Or

b.  They can consult with the UCSC SHS Medical Director, the COVID Nurse, or the Clinic Director regarding COVID symptom and risk assessment, and complete a COVID test on-site at SHS, at no cost to the employee.  A negative COVID Risk assessment and a negative COVID test reviewed by the Medical Director will suffice as clearance to return to work.

2.        If an employee reports that they have had a positive COVID-19 test or are a definitive close contact with a positive COVID-19 case:

·        The supervisor should first consult with the Medical Director or the COVID Nurse as soon as they are notified by the employee

·        All positive employee cases must be reported to the campus Assistant Director Workers' Compensation within 24 hours and the Director, Environmental Health & Safety and Risk Services must be notified ASAP.  If an employee chooses to consult their Primary Care Providers (PCP's) for clearance to return to work, SHS can override the clearance if the PCP doesn't follow current Cal OSHA or California Department of Public Health (CDPH) guidelines

3.     For situations where an SHS staff member tests positive for COVID or is identified as a definitive close contact, documentation must be submitted in RL Datix.  Supervisors are responsible for this data entry.

 

See attached document for supervisor  directions for entering into RL Datix.

 

USE OF SECURE UCSC EMAIL WITH VIRTRU

Effective Date: 
Tue, 09/29/2020
Policy: 

UCSC has adopted a product called Virtru for secure Email (Gmail via Chrome browser) and Documents (Google Drive).  Select units have been given access to Virtru including many categories and departments of SH&W including management, supervisors, primary care, psychiatry, CAPS, case management, health information management, insurance, ancillary services, SHOP and CARE.

Virtru users can send email containing P3 and P4 data (includes PII or PHI) including attachments as long as they have Virtru enabled correctly and follow the procedures articulated in this policy.

Procedure: 

Eligibility

Contact your supervisor if you fall into one of the approved categories above or feel you have a business need to have secure email

Users are managed via google group named virtru-provisioning.
Only SHS and ITS admins can administer the group.

Installation and Use

It is responsibility of the user to ensure that Virtru is installed and enabled correctly.
Step 1 Install & Activate for email

a. Gmail users install the Chrome extension or Outlook for email add-in (How to for Outlook)
b. You may also install for your Android or IOS Device for email encryption.
c. In the setup process I am being asked to grant Virtru access to information, for both the email and drive installation is this okay? 
d. Yes, Virtru has passed a supplier security review with UCSC.

Step 2 Install & Activate for Google Drive

a. Install for Drive
b. In the setup process I am being asked to grant Virtru access to information, for both the email and drive installation is this okay?
c. Yes, Virtru has passed a supplier security review with UCSC.

When to use Virtru

a. When sending any information containing level P3 or P4 data (includes PII or PHI) including email messages and attachments, send securely with Virtru protection on.

https://its.ucsc.edu/policies/data-protect.html 

b. For student communication – it should be last resort; secure message should be used first.
c. Do not use for PCI (credit card) data

Step 3 Start using

a. How to use Virtru
b. The subject line is clear text – never put anything secure (patient name) into subject line.
c. You can use Virtru to communicate with other staff, vendors, insurance companies, outside providers, etc.

NOTE: they need to already have an approved usage of the data. Don’t just email random people our secure data.

d. Virtru does not replace documenting in the patient/client record. (i.e. I emailed this to a patient).  Document in the note to cover you.

References

https://its.ucsc.edu/policies/data-protect.html 

 

Link to instructions:

https://docs.google.com/document/d/1T0fKybxBd8RQcx_OSv1f9FnrF5XYhC86L0INf628mDo/edit?usp=sharing

SUBPOENAS

Effective Date: 
Fri, 09/04/2020
Reviewed: 
Thu, 05/13/2021
Revised: 
Thu, 05/13/2021
Policy: 

Subpoena Requests

A subpoena is a request for the production of documents to appear in court or other legal proceeding. It is court-ordered command that essentially requires you to do something, such as testify or present information that may help support the facts that are at issue in a pending case. The term "subpoena" literally means "under penalty".

All subpoena requests are processed by the UCSC Information Practices Department.

Subpoena requests are not accepted at Student Health Services.

All are to be directed to Information Practices - Located at the Chancellor’s office in Kerr Hall.

Procedure: 

1. Server presents at registration or Medical Records - Do not engage - contact the Health Information Systems Administrator (HISA) STAT, if HISA is out of office contact Business & Information Systems Director. If unable to contact page another manager or supervisor.

2. Server will be directed to the Chancellors office. Under no circumstances are we to accept/sign for the subpoena.

Telephone Call:

Phone call is received requesting information in regards to a subpoena, forward to the HISA at (831) 459-1628.

FAX:
Subpoena is received via fax; notify the HISA immediately, if HISA is out of office contact the Business & Information Systems Director, who will forward.

MAIL:
Subpoena is received via U.S. Mail; Notify the HISA immediately, if HISA is out of office the Business & Information Systems Director, who will forward to the Chancellors office.

 

 

 

ONLINE BIRTH CONTROL REQUEST

Effective Date: 
Mon, 01/13/2020
Policy: 

ONLINE BIRTH CONTROL PROGRAM

Rapid, easy access to contraception is critical to preventing unintended pregnancy. This standardized procedure allows patients to be evaluated for clinical appropriateness for self-administered birth control (pill, patch, or ring) via an online questionnaire. Once the questionnaire is submitted, it is reviewed by a clinician within 3 business days and if appropriate, the clinician submits a prescription for birth control to the pharmacy directly. With this program, the patient does not have to be evaluated in person.

Patient eligibility:

1.       Registered UCSC students

2.       The program is 100% covered for students with UC SHIP or Cruz Care.

3.       The program is fee for service for students who do not have UC SHIP or Cruz Care.

Procedure: 

Patient Procedure:

1.       The student logs into the student health portal (My Health e-Messenger) and schedules an “Online Birth Control Request.”

2.       The appointment date and time are placeholders and do not require the student to come to the clinic or speak with the clinician during that specified time.

3.       The student is prompted to complete the online questionnaire regarding their most recent blood pressure, birth control history, medical history, and preferred pharmacy.

 

Clinician Procedure:

1.       The clinician (physician, nurse practitioner, or physician assistant) goes to the “Online Request” schedule. This schedule is found on the most right hand column of “Primary Care” in Department view.

2.       The clinician right clicks on the appointment to “View Appt Questionnaire.” If the patient has not completed the questionnaire, the clinician would send a secure message to the patient to complete the questionnaire.

3.       If the patient has completed the questionnaire, the clinician right clicks on the appointment to change the status to “Check In” and then right clicks again to change the status to “Start Visit.”  If a window pop-up requests the number of labels to be printed, please click “Cancel.”The clinician clicks on OpenChart to access the associated encounter note.

4.       The clinician opens the encounter note associated with the appointment and reviews the patient-submitted questionnaire.

5.       The clinician completes the provider section of the template:

a.       Patient Request: new start, refill or other

b.       Medications: review current medication list

c.       Allergies: review current medication/material allergy list

d.       Problem List: review medical history

e.       Blood pressure: review whether patient has had a blood pressure taken in the clinic the past 12 months or whether the patient has had a recent self-measurement within the past 6 months

f.        Assessment: indicate whether patient meets CDC U.S. Medical Eligibility Criteria for Contraception

g.       Diagnosis: indicate most appropriate diagnosis, e.g. “Contraceptive Management”

h.       Encounter Code: click on the encounter code which reflects the time spent reviewing the patient questionnaire and responding to the request, e.g. “Professional:  ONLINE EVAL/MANAGEMENT SERVICE 5-10 MINUTES (99421)”

i.         Medication Orders: if appropriate, prescribe birth control. If it’s a new start, Tarina Fe 1/20 or Aubra EQ 1/20 would be prescribed.  If appropriate, prescribe 1-year prescription (13 packs if taking placebos or 16 packs if continuous dosing). If patient needs follow-up in 3 months, prescribe 3-month supply.

j.         Contraception Prescription: indicate whether 12 months or 3 months prescribed.

k.       Patient Education: indicate what patient education information will be sent in secure message. Or: click the applicable patient counseling topics that will be submitted in the secure message (see text macros at the end of this document).

l.         STI Screening: review patient’s chart for most recent STI results. Indicate whether patient has had STI screening within the past year or not.

m.     HPV Vaccination: review patient’s immunization record and/or scanned documents for documentation of HPV vaccine. Indicate whether patient has completed or not completed HPV vaccine series.

n.       Cervical Cancer Screening: review patient’s chart for most recent pap. Indicate whether patient is up-to-date or due for pap test.

o.       Handouts: click on appropriate patient education handouts to be posted on the student health portal for patient to review, e.g. Combined Contraceptive Pill, HPV FAQ, Asymptomatic STI screening, PAP FAQ, etc. 

6.       The clinician sends a secure message to the student informing them that their online birth control request has been reviewed and what was prescribed or advised.

7.       The clinician returns to the appointment page and right clicks on the appointment to turn the status to “Check Out” after signing the note.

 

SPECIAL CONSIDERATIONS

1.       Blood pressure – if there hasn’t been a blood pressure taken within the past year or if the blood pressure measurement is borderline or elevated, can ask patient for blood pressure to be obtained in clinic or self-measured. Adjust number of packs prescribed accordingly.

2.       “Yes” responses – if there are any “yes” responses, can send a secure message to the student to clarify or schedule a telephone visit to obtain additional information.

3.       Nuvaring – acceptable to refill

4.       Contraceptive patch – acceptable to refill

 

EXAMPLES OF TEXT MACROS

No Patient Questionnaire Submitted (.onlineNF)

Thanks for signing up for the online birth control pill request!

I see that you haven't completed your questionnaire.

Would you log back into Health e-Messenger (https://healthcenter.ucsc.edu/information/make-appointment.html) and complete the questionnaire?

Once you complete the questionnaire, let me know by replying to this message.

Prescription Dispensed (.onlineOCP)

Thanks so much for submitting the online birth control pill request form!

 

[  ] I have sent a birth control prescription to the on-campus pharmacy with 12 refills. The pharmacy will give you a quarter's supply of pill packs at a time. This prescription will be ready for pick up within 1 school day.

 

[  ] I have sent a birth control prescription to the on-campus pharmacy with 3 refills. The prescription will be ready for pick up within 1 school day. Within the next 3 months, please schedule an in-person appointment at the Student Health Center to receive additional refills. Call (831) 459-2500 to schedule. I recommend calling sooner than later because there can be a one-month wait for appointments.

 

[  ] Based on your responses, we would like you to schedule an in-person appointment at the Student Health Center. Call (831) 459-2500 to schedule.

 

[  ] Because we don't have a recent blood pressure measurement for you, please measure your own blood pressure at the blood pressure station outside of Student Health Outreach and Promotion (SHOP) next door to the pharmacy. Reply to this message with your blood pressure measurement. Or you can stop by the Student Health Center on the first floor and tell the receptionist that you need to get your blood pressure checked for online birth control.

 

This is the birth control prescription I sent to the pharmacy:

 

It is common to have spotting (bleeding) during the first 3 months after starting the birth control pill. After 6 months, your periods may become lighter or with no bleeding. If this worries you, please complete the online birth control request form again. Let us know you have too much spotting and/or too light of periods. We can switch you to a different pill.

 

Please see below for additional important information.

Let me know if you have any questions!

 

*************************************************

 

I posted some handouts on your portal, including:

Combined Oral Contraceptives - The Pill

Self-Directed STI Screening - Asymptomatic

Pap Test - Latest Recommendations

HPV FAQs

Progesterone Only Pill

 

The pill handout provides information about how to start the pill, potential side effects, and important reminders. Look out for severe adverse side effects and warning signs of a blood clot, including "ACHES" (Abdominal pain, Chest pain or shortness of breath, Headaches, Eye or vision problems, and Severe leg/calf pain or swelling). Stop the pill and return to the Student Health Center or go to the Emergency Department if any blood clot signs/symptoms develop.

 

If you are traveling on a long train, plane, or car ride, reduce your risk of a clot by walking around at least hourly.

 

Stop by SHOP for more information about birth control options and use.

 

If you're interested in STI screening, read the instructions in the self-directed STI screening handout.

 

Starting at age 21, we recommend pap tests (cervical cancer screening) once every 3 years. If you're 21 years old or older and haven't had a pap test (cervical cancer screening) within the past 3 years, schedule an appointment at the Student Health Center by calling (831) 459-2500.

 

If you haven't completed your HPV (human papillomavirus) vaccine series, please read the HPV handout for more information. Schedule an appointment at the Student Health Center to receive your HPV vaccine.

 

Skipping placebo – new start (.skip)

If you're interested in skipping your periods, I recommend taking the pill as packaged (with the placebo week, 4th week of the pill) for the first 3 packs, and then you can skip the placebo pills afterwards. This is to allow your body to adjust to the pill first before skipping your periods.

 

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