The Joint Commission on Accreditation of Healthcare Organizations has developed standards in this area that are to be implemented in all institutions seeking accreditation starting January 1, 2001. 

All medical staff must read this module and sign the attestation sheet.

Please note that this information is a "requirement" when you are eligible for re-appointment.  This documentation must be on file in the Department of Medicine Administration. 

In an effort to ensure that your departmental file is up to date – please review the historical information below and confirm whether or not you have completed the respiratory fit testing by returning a copy of your certification card via mail to the address below or fax (also below). 

If you do not have the certificate of completion please sign the attached attestation and return that in its place. 

Historical Data

When the OEM & UHS completes a fit test, the employee is given a card titled: "Certificate of Completion." The date of completion, type of respirator, and size of respirator (e.g. regular, small, medium, large) are on the certificate. Each certificate is wallet size. The employees are encouraged to keep the certificate in their wallets and make a copy of the certificate for their supervisor or equivalent.

Clarification - all active medical staff are required to have a respirator fit test.  The announcement was in the Medical Staff Minutes of August 2003.  For active medical staff that have not had a fit test you may schedule it as noted below with the Occupational and Environmental Medicine Program who has reserved blocks of time.  University Health Services is also an option at 275-2662.  Other questions can be directed to Karen Crotinger's Office at 273-4401.

Please instruct the Providers on the following criteria with respect to appointment scheduling:

1. Call Occupational & Environmental Medicine at 275-7795, option #1 (during business hours 7:30am - 5:00pm) to schedule the fit test appointment.  Please have them indicate that they are a "Physician or Faculty".
   
2. No eating or drinking 20 minutes before the appointment (food or liquid interferes with tastes buds & the solution used for qualitative fit testing).
   
3. If an individual has a beard, they must specify a class for "PAPR Training" (cannot fit test an individual with facial hair for an N95 mask, they will not have an adequate seal for protection).
   
4. Class times are scheduled in one hour intervals (e.g. 7:00 am - 8:00 am; 8:00am - 9:00 am, etc...), with 5 individuals per class.  It is imperative that individuals come on time or they may be asked to reschedule.
   
5. If they are unable to attend their scheduled appointment, call at least 24 hours in advance otherwise a missed appointment fee of $25 will be charged.

Please note that this information is a "requirement" when you are eligible for re-appointment.  This documentation must be on file in the Department of Medicine Administration. 

HIPAA job-specific training is required for everyone in the Strong Health organization, including physicians, students, volunteers, and employees.  Job-specific training for Strong Health is applicable at both SMH and Highland Hospital.

All training is self-study; no classes will be held.  No formal testing is required.

Eight modules are required for everyone, regardless of job responsibilities. Please note: individuals will be held accountable for understanding and following URMC/Strong Health policies and procedures that are relevant to their job.

The three versions below were created to make it easy for departments to access the materials they need quickly. 

• Version 1 - Recommended modules for all members of the workforce who may not have contact with patient information (PHI), including glossary of terms and scenarios.(OP2, OP4, OP5, OP8, OP14, OP23.1, OP28, OP19)
  
• Version 2 - Modules included in Version 1, as well as those modules recommended for members of the workforce who have contact with PHI, including glossary of terms and scenarios.(OP1, OP7.1, 7.2, 7.3, OP9, OP10, OP11, OP12, OP13, OP16, OP19, OP20, OP23.2, OP24.1, OP24.2, OP27, OP29) 
  
  Please note that anyone doing research or clinical case studies must also read OP25
  
• Version 3 - Entire book (all modules, scenarios, glossary, etc.)

Online Options

If you prefer to read the modules online, you can access them on the web at http://Intranet.URMC.Rochester.Edu/HIPAA or you can access them through Prometheus at http://prometheus.urmc.rochester.edu/

Accessing Prometheus

You must have an E-mail address to complete the online HIPAA Job-Specific Training program. The site address is http://prometheus.urmc.rochester.edu/  Once you have entered this address, you will be brought to a logon screen; click on the ‘Log On’ button.

If this is the first time you have used the program, click “Create a New Student Account” below the user name and password boxes to create your own.

HIPAA Policies

Corresponding HIPAA policies and procedures can be found at http://intranet.urmc.rochester.edu/policy/hipaa 

Attached is an attestation form that must be completed & signed.  Please return the original to your Divisional Unit Chief or Unit Administrator.

Mandatory Inservice Requirememts 2004

The manual & test can be accessed on our Web Site:

http://www.urmc.rochester.edu/HRD/manual/

The completed test must be returned to your Divisional Unit Chief or Unit Administrator.