Policies Similar to other health care organizations, Horizon has several types of policies. Policies have been put in place throughout Horizon Health Network in order to protect patients, clients, staff, and visitors within our facilities. They help standardize practices across the organization to ensure all our facilities run smoothly, guiding staff to take the right steps when caring for our patients and clients. The following are excerpts of the most-requested policies that affect or apply to the public, including our patients, clients, visitors, designated support persons, members of the media, and more. Smoke-Free Policy There is no safe level of second hand smoke. Smoke-free hospital properties reduce harm, promote healthy choices and support a safe and healthy environment for everyone, including patients, staff and visitors. Horizon is committed to health promotion and disease prevention; this initiative supports our mission of helping people be healthy. Horizon is proud to have over 100 smoke-free facilities! Social Media Policy 1. The Communications and Community Relations department is responsible for all corporate accounts on social media sites. Standalone social media sites, such as Facebook groups for facilities, are approved by the Communications and Community Relations department. 2. Employees and non-employee personnel do not represent their personal account as a Horizon account or as a Horizon affiliate, or represent themselves in any way as speaking on behalf of Horizon. An employee may post work-related content via social media with approval from the Communications and Community Relations department. 3. Employees and non-employee personnel are respectful, professional, accurate and honest, in all communications. 4. Employees/non-employee personnel do not release, post or share through social media confidential information related to Horizon, the persons who work and learn at Horizon, patients and families, or any community partners. This includes the names or personal information of co-workers, managers or supervisors, as well as discussion of incidents that have occurred in the workplace and that are not generally known outside of the workplace. 5. Employees/non-employee personnel will obtain consent before posting on social media (corporate or personal) photos or video recordings of patients for the purposes of medical education and/or research, even when the patient cannot be readily identified [Consent for Patient Interview, Photography and/or Visual/Audio Recordings (HHN-0028)]. 6. Social media activity may not interfere with the work commitments of employees and non-employee personnel. 7. Staff in patient care roles may initiate or accept invites to connect with patients in their care via social networks when they have a relationship that pre-dates the provision of care. Therapy Animals/Service Animals Policy Horizon Health Network (Horizon) supports animal therapy as the therapeutic benefit of animal assisted interventions is well documented. Therapy animals are permitted to enter Horizon premises only if the animal is part of an established Animal-Assisted Activity/Animal-Assisted Therapy (AAA/AAT) Program and the handler is a registered Horizon Volunteer. As these animals interact with various patient populations, infection control procedures are followed to minimize the risk of transmission of infection to susceptible patients. When establishing a program, consultation with Infection Prevention and Control (IPC) is required. This policy does not apply to personal pet visitation. Role of CEO Policy Role The President and Chief Executive Officer (CEO) is the sole employee accountable to the Board of Directors for the strategic and operational leadership of Horizon Health Network. The CEO is accountable for working with the Board and community stakeholders to plan for an integrated and complementary health care system within the catchment area served by Horizon. The CEO is responsible for ensuring that the vision, mission, and inherent organizational values meet the needs of those served by the organization and that they are embraced and executed by its staff, physicians, and volunteers. The CEO must ensure that Horizon continues to provide quality health services that meet the needs of its patients, families and communities. Key Responsibilities Ensures that the resources of the organization (human, financial, and capital assets) are aligned with Horizon's mission, vision, values, and goals set out in the current and prevailing strategic plan and regional health and business plan;Maintains financial controls so that Horizon operates within available resources and within the direction of the board in its capital and operating budgets;Ensures that quality, safety and risk management are priorities of the organization so that the highest quality of care is delivered to Horizon's patient and client population;Establishes a positive, accountable and collegial working relationship with the board, characterized by candor and open communication;Acts as chief spokesperson (with the Board Chair) for Horizon to the media and the public;Creates a highly functioning, successful and empowered leadership team by developing effective structures, systems and development opportunities;Builds a positive workplace culture that embraces creativity and innovation, encourages responsible, open, transparent and effective communication and boosts staff, physician, and volunteers satisfaction;Establishes a visible and approachable presence within the hospital, fostering strong relationships with all levels of management, front line staff and the unions;Provides strong moral and organizational support to the associated foundations/auxiliaries through active participation in capital campaigns, annual giving, major gifts, and special event programming;Forges and sustains relationships at both the political and bureaucratic levels, at the provincial, regional and municipal levels, to ensure Horizon's role is understood and supported;Develops a strategy to position Horizon for future success within the evolving provincial health delivery system;Champions system integration and linkages with the community and other health care partners (locally and provincially), with a view to improving the health status of the populations served by Horizon;Ensures that Horizon establishes and maintains a strong presence in the community served, through regular and open communication and enthusiastic participation in community events. Public Participation Policy In compliance with the Regional Health Authorities Act, the Board strives to build and maintain strong and effective relationships with its communities through open public Board meetings on matters relating to the general governance and operations of Horizon Health Network. Meetings of the Board of Directors will be held in public except when, as set out in the Regional Health Authorities Act (New Brunswick), they would: reveal information specific to an identifiable individual;reveal information relating to risk management or patient care issues;prejudice security measures undertaken by the regional health authority; orcompromise Horizon Health Network's effectiveness in carrying out its duties and responsibilities. Members of the media are welcome at all public meetings of the Board. Political Activity Policy 1. Horizon Health Network (Horizon) is a politically neutral organization and does not support or endorse any political party or candidate at any level of government. 2. No employee will engage in any form of partisan political activity during his working hours or at any time engage in a political activity that could result in a perception that the person is not fulfilling the duties and responsibilities of the employee's position impartially or effectively. 3. No employee will engage in any form of partisan political activity on or off Horizon premises while wearing a uniform or Horizon Identification (ID) badge that may be associated with Horizon and/or Horizon facilities. 4. Horizon facilities will not be used for partisan political activities which includes, but is not limited to: the use of workplace communication systems (email, voice mail, bulletin boards) to promote political messages.speaking on behalf of Horizon in a public forum without being authorized by the CEO or Communications and Community Relations Department.expressing political opinions to patients or clients within Horizon.lobbying Members of Parliament (MPs) or Members of the Legislative Assembly (MLAs) or their representatives, or members of Municipal and District Government Councils on behalf of patients or clients within Horizon.as a political venue and/or backdrop by past, current, or future MPs, MLAs or their representatives, or members of Municipal and District Government Council. This includes, but is not limited to, political announcements, political receptions, political conventions, political campaigning, political rallies or demonstrations, displaying partisan political signage and other political promotional material, and touring. 5. Elected officials may access Horizon facilities for the purpose of carrying out their duties to the elected office provided they do not engage in any political activity and comply with applicable Horizon policies and all standard access requirements in place at the facility. 6. No employees will engage politicians on behalf of Horizon and/or their respective facilities, or act in a manner that could mislead others into believing such employee's personal views are that of Horizon. This includes, but is not limited to, engaging politicians: to procure funding to purchase/upgrade medical equipment;for facility upgrades and/or additions;for the hiring and/or retention of Horizon and/or facility staff;for donations to Horizon and/or facility causes; 7. As a major employer in New Brunswick, Horizon considers it important for all citizens to participate in the democratic process. Any employee who intends to run as a candidate in a federal or provincial election applies and obtains a leave of absence without pay from the appropriate VP before filing nomination papers with the returning officer. Such leave begins no later than the day the employee files the nomination papers with the returning officer and ends no later than fourteen days after the election results are officially declared. Policy Approval Policy 1. The Horizon Health Network Board of Directors approves: governance policies originating from the Board or a Committee of the Board (e.g., Vision, Mission, Goals, strategic directions, values).by exception, certain operational policies that have significant implication related to their stewardship role, public confidence, ethics, quality or risk.policies directing the actions of Board Members. 2. The Executive Management Team (EMT) approves policies related to the operations of Horizon Health Network. EMT may delegate approval to appropriate senior managers in the Policy Development and Implementation policy. 3. The EMT ensures implementation and maintenance of an effective operational policy framework for Horizon Health Network. (The framework includes accountability (persons) and processes for policy development, review, approval and implementation). Photography, Audio and Video Recording Policy In keeping with its commitment to the provision of safe and quality care, Horizon Health Network (Horizon) ensures an environment that respects patient, client, visitor, employee and non-employee privacy, dignity and confidentiality. Specifically: 1. Patients, clients, visitors, employees and non-employees obtain consent from all individuals before taking photographs and/or audio/video recordings. 2. Patients, clients, visitors, employees and non-employees are permitted to bring photographic equipment and/or camera/video equipped cellular devices with them to Horizon facilities. 3. Clinicians and research staff may consent to photographs and/or audio/video recordings of themselves by patients, clients, or visitors during clinical and/or research encounters. 4. No photographs and/or audio/video recordings are permitted of standardized assessment, diagnostic tools and/or research tools that are protected under copyright. 5. Patients, clients, visitors, employees and non-employees do not take photographs and/or audio/video recordings in Horizon facilities for commercial use except in compliance with Media Relations (HHN-CO-002). 6. This policy does not apply to the use of radio, television, film crews, and photographers by media while they are on Horizon properties. Refer to Media Relations (HHN-CO-002). 7. Patients, clients, visitors, employees and non-employees who witness non-compliance with this policy ask the person not in compliance to stop taking photographs and/or audio/video recordings, and request for them to delete the photographs and/or audio/video recordings. If there is further non-compliance, an employee or non-employee may call their manager or security for assistance; and, patients, clients and visitors may call security or the patient representative for assistance. 8. Managers, security and the patient representative, after receiving notice of non-compliance with this policy, take appropriate action within their rights and responsibilities, to stop the patient, client, visitor, employee or non-employee from photographing or making audio/video recordings of individuals who did not consent. 9. At Horizon facilities/Foundation events and activities (such as media announcements, celebrations) where there is a reasonable expectation and/or notification that people attending the event/activity may be included in photographs and/or audio/video recordings, it is the responsibility of individuals who do not wish to be photographed and/or audio/video recorded to communicate their wishes to the event organizers and/or the employee(s) taking the photographs and/or audio/video recordings, and move out of the view of cameras and recording devices. Official Languages Policy Let’s Talk Horizon is Horizon’s online platform which enables us to gather feedback in a strategic, yet meaningful and convenient way. We want to hear about your communication needs and your language experience with us! Please complete this brief survey, share your story with us, and share your ideas to help us learn from your health care experience and identify areas for improvement. Join the conversation! Language of Work: In accordance with the Official Languages Act and the Regional Health Authorities Act, the language of work throughout Horizon Health Network (Horizon) is English. Language of Service: In accordance with the Official Languages Act, the Regional Health Authorities Act and the Government of New Brunswick (GNB) Language of Service Policy, Horizon: actively offers and provides services of equal quality to patients and the public in both official languages during all hours of operation without undue delay. ensures that patients and members of the public have the right to communicate in their official language of choice, no matter where health services are offered. ensures that positions staffed throughout the network: follow established linguistic profiles to ensure capacity for delivery of service in the language of choice; meet the minimum linguistic proficiency for the position. ensures linguistic considerations are considered in every day basic operations, including, but not limited to, scheduling of employees/non-employee personnel and assignment of interim positions. ensures that official communications with the media and the general public are issued in both official languages. provides the necessary tools, guidance and support to employees and non-employee personnel to ensure that services of equal quality are provided in both official languages in accordance with this policy. Horizon conducts periodic assessments of the effectiveness and application of this policy. Adherence to this policy is monitored through audits and/or reviews of records. In cases of misconduct or non-compliance with this policy, appropriate responses and corrective measures may be implemented by Horizon management in consultation with Human Resources, and other services as deemed necessary. These measures may include progressive disciplinary measures up to an including termination of employment. An individual disciplined for failing to comply with this policy has the right to appeal the decision through the applicable grievance process. Naming of Facilities and Features Policy Horizon Health Network (Horizon) recognizes that providing appropriate donor recognition is an important component to the success of the fundraising programs conducted by the Foundations in support of Horizon health care facilities and features. Such recognition may include the offering of naming opportunities. The Horizon Board recommends to the Minister of Health the naming of any of the facilities and features entrusted to and operated by it, subject to the laws of, and in consultation with, the Province of New Brunswick. Media Guidelines Horizon effectively uses media relations to communicate with the public to support its vision, mission and values. Horizon maintains open and honest communication with media through an established process which involves members of Horizon’s Executive Leadership Team. Horizon provides consistent and accurate information in a timely manner to the media and public while respecting patient/client privacy and confidentiality. Personal Health Information Privacy Statement The New Brunswick Personal Health Information Privacy and Access Act (the PHIPAA), protects the privacy of your personal health information, including information about you maintained by Horizon Health Network. Under this Act, you have certain rights and choices regarding how this information is used and disclosed. As a custodian of your personal health information, Horizon Health Network is required to comply with this act. Our organization includes, among others, the following components: Public HealthAddiction and Community Mental Health servicesCommunity Health CentresHospitalsHealth centres and clinics The following document outlines the approach adopted by Horizon Health Network to protect your privacy. Everyone working within Horizon Health Network must adhere to the terms stated herein. How do we collect your personal information? We collect personal health information about you directly from you or from the person acting on your behalf. The personal information we collect may include: demographic data such as your name, address, phone number, date of birth, marital status;your Medicare number;the names of those individuals who may make decisions on your behalf;information about your physical and mental health;information about your personal insurance and health care benefits;your religious belief or associations;information about your occupational health;financial information relating to payments or eligibility for health care. Occasionally, we collect personal health information about you from other sources if we have obtained your consent to do so or if the law permits. For example, we may collect personal information from another regional health authority, nursing homes, EM/ANB, Department of Social Development, Veterans Affairs Canada, or the New Brunswick Prescription Drug Program. We only collect the information that is required to provide care, manage the health care system, and communicate with you. We do not collect any other information, or allow information to be used for other purposes, without your verbal or written consent, except where authorized to do so by law. Who can see and use your personal health information? We must document the services and care we provided to you and share your personal information with other health care professionals involved in your care, including physicians, nurses, pharmacists, medical laboratory technologists, dietitians, physiotherapists, etc. We may also collect, use, and give out your personal health information to others, as reasonably necessary, without your prior consent in order to: obtain payment for your health care (and hospital services);plan, manage, and administer health care programs and services, or to fulfill reporting obligations to certain authorized organizations for use in the planning and management of the health care system;facilitate organ and tissue donation;conduct quality control studies and peer reviews;fulfill other purposes as permitted or required by law. Your Consent We must obtain your written consent before using or disclosing your information for purposes other than providing care; here are some examples: disclosing your information to media or third parties;using your information in research projects;giving insurance companies or legal counsels access to your health record or other information on your health condition;asking your support for a fundraising initiative. There are some situations where we are legally required to disclose your personal information without your consent. These situations include, but are not limited to: billing provincial health plans;reporting infectious diseases;reducing potential physical or mental harm to an individual or the public;responding to a court order;providing information for an inquiry for internal purposes, a professional disciplinary body, or to a regulating body. Your Rights and Choices The PHIPAA identifies specific rights that individuals have with respect to their personal health information. You have the right, subject to certain limited exceptions, to: Ask us not to give out your personal health information to other health care providers or other parties, in which case we will not give out this information unless permitted or required by law to do so.Request to examine or receive a copy of your personal health information. If you wish to view the original record, one of our staff members must be present to maintain the integrity of the record. A reasonable fee may be charged for providing a copy. Requests for access to your health record can be made verbally or in writing to the Health Records Department or the person in charge of the sector from which you received care (in the absence of a Health Records Department).Ask us to make corrections to inaccurate or incomplete personal health information.Designate another person to make decisions about your personal health information.File a complaint with the Privacy Office of Horizon Health Network if you believe your rights have not been respected. The Ombud’s Office for the Province of New Brunswick has oversight over the Personal Health Information Privacy and Access Act. If you have any questions about the provincial privacy legislation or the mandate of Ombud’s Office, please visit its website: ombudnb-aip-aivp.ca Visit the “Personal Health Information Privacy and Access” section for additional information. The Ombud’s Office can be reached at: Office of the Ombud - Access and Privacy Division65 Regent St., Suite 230Fredericton, N.B. E3B 7H8Phone: 506-453-5965Fax: 506-453-5963Toll-free: 1-877-755-2811Email: email@example.com Additional Information Safeguards are in place to protect the security of your information. These safeguards include a combination of physical, technological, and administrative security measures that are appropriate to the sensitivity of the information. These safeguards are aimed at protecting personal information against loss or theft, as well as unauthorized access, disclosure, copying, use, or modification. We retain patient/client records as required by law and professional regulations. When information is no longer required, it is destroyed in a secure manner, according to set procedures that govern the storage and destruction of personal information. Contact Us If you have any questions regarding our privacy practices, or wish to express a concern about how we have handled your personal health information, please contact: Privacy Office Kelly A. Chase, Chief Privacy Officer1-877-422-8717 (toll-free)135 MacBeath Avenue,Moncton, NB, E1C 6Z8Kelly.Chase@HorizonNB.ca Disclosure Policy When a patient experiences harm while receiving healthcare services, full and complete disclosure of the event will occur. The use and implementation of the following disclosure procedure is a deliberate action that requires effective, honest and transparent communication between all members of the healthcare team and the patient and/or family/substitute decision maker (SDM). Disclosure is not necessarily a single event but can be a dialogue over time (Canadian Disclosure Guidelines, 2011). Horizon Health Network also encourages and supports disclosure when an event occurs where no harm has resulted but the potential for harm exists that requires a change(s) from the intended plan of care. Disclosure of a no harm incident and near-miss event is a matter of clinical and professional judgement and is determined on a case by case base by the healthcare provider in consultation with risk management. In any circumstance, all media communication related to disclosure is managed through the Communications Department in consultation with the Chief Executive Officer (CEO) or designate. Confidentiality Policy 1. Horizon Health Network (Horizon) is committed to collecting, using, disclosing and disposing of confidential information including personal information (PI) and personal health information (PHI) entrusted to it in a manner that is accurate, confidential, secure and private. Horizon is committed to protecting the confidentiality and privacy of PI and PHI in its custody or control. 2. Horizon is subject to and complies with the Right to Information and Protection of Privacy Act (RTIPPA) and the Personal Health Information Privacy and Access Act (PHIPAA) and the regulations under these Acts. 3. Horizon has established obligations for the handling of confidential information by employees and non-employee personnel, and promotes compliance by requiring the signing of the Confidentiality - Declaration of Understanding. 4. Employees and non-employee personnel access, use, and disclose confidential information, PI and/or PHI on a need-to-know basis only, and as defined or required by their role within the organization. 5. Employees and non-employee personnel may see, hear or be given access to confidential or sensitive information about employees, patients, and the operations of business partners/associates, and the operations of the health partners. Such information is to be held in strict confidence and is not to be disclosed or discussed with anyone other than those authorized to receive such information, in the course of performing their duties. 6. Access to Horizon's records and information or the records and information of business partners/associates, or the records and information of the health partners, by employees and non-employee personnel is granted only for the purpose of performing employment duties, or conducting business as per a contract or agreement. Employees and non-employee personnel are strictly prohibited from accessing records and information to which they are not entitled within the scope of their duties. 7. Managers or their delegate are required to review this policy with each of their employees at the time of hire and also at the time of each performance review. Each employee, at the time of hire and at the time of the performance review, after reviewing the policy, signs a Confidentiality - Declaration of Understanding. Managers remain responsible to ensure this has been done. 8. Employees, with the exception of physicians, complete the Privacy in Healthcare e-learning modules at the time of hire and also at the time of each employee performance review. 9. Non-employee personnel, with the exception of physicians, who have access to confidential information within the scope of their work related duties or contract / agreement are required, on an annual basis, to: review this policy,sign a Confidentiality - Declaration of Understanding, andcomplete the required Privacy in Healthcare e-learning modules. 9.1 All Physicians review this policy and sign a Confidentiality - Declaration of Understanding and complete the Privacy in Healthcare e-learning modules, at the time of hire, and every 2 years thereafter, upon application for reappointment. 10. Any breach or suspected breach of this policy, such as unauthorized access, collection, use or disclosure, is to be reported immediately to the appropriate manager; the manager notifies the Chief Privacy Officer (CPO) as per Privacy Incident and Breach Management. 11. Violation of this policy may result in disciplinary action, up to and including termination. In the case of non-employee personnel, violation of this policy may result in the termination of negotiations of a potential contract/appointment, or of an existing contract/appointment with Horizon, and may result in legal action. Family Presence Policy Because of COVID-19, Horizon's Family Presence Policy was modified to help us prevent the spread of the virus in our facilities and safely provide quality care. We recognize these current precautions are a difficult adjustment for patients, their family and friends, and health care staff. We will continue to review the risks and look forward to reintegrating family presence in our facilities as soon as it is safe to do so. Please see Horizon's current social visitation guidelines and strategies to help connect with your loved one. As part of our Patient and Family Centred Care Philosophy, Horizon Health Network (Horizon) recognizes that family and friends are integral to patients’ healing process. As a result of COVID-19, Horizon has modified our Family Presence Policy to ensure the health and safety of our patients and health care providers. Family Presence is balanced with patient, family and staff safety while protecting the confidentiality and privacy of all patients. This program is intended to be flexible in order to respond to the diverse and individual needs and preferences of each patient. For further information about Horizon’s family presence approach, please see our Designated Support Person (DSP) Program. Family/friends who support patients will be defined as Designated Support Persons (DSPs). This term emphasizes that they are respected as an essential member of the healthcare team and are “more than a social visitor”. DSPs are active partners in care and can provide physical, psychological, and emotional support. This care can include decision making support, care coordination and continuity of care. Horizon also recognizes social visitors have an important social role but do not participate as DSPs who are active partners in care. Roles and Responsibilities DSPs provide support, comfort, and important information during a hospital stay or ambulatory visit. This is determined in collaboration with the patient, healthcare provider and the DSP. DSPs are not limited to social visitation hours. DSPs are welcomed according to patient preferences and in coordination with the patient care team. Horizon welcomes all social visitors regardless of age to visit during social visitation hours. Social visitors under 12 years of age must be supervised at all times by an adult who is not the patient or a member of the healthcare team. All visitors, including children over the age of two (2) must practice hand hygiene, physically distance from others, and wear a medical-grade face mask when required by policy. For ambulatory visits, the presence of a DSP is encouraged according to patient preference as space and safety considerations allow. The overall number of DSPs permitted and number of DSPs who can be present at one time varies depending on the patient’s condition and the COVID-19 activity levels within the hospital and community. Please see Horizon’s current DSP and visitor guidelines for the number of allowable DSPs and social visitors. There may be interruptions to Family Presence to protect the privacy rights of other patients or to maintain safety, security or clinical requirements. Noise and Disruptive Behaviour: Visitors and DSPs must abide by safety procedures including infection prevention and control measures at all times. Visitors and DSPs will be mindful and sensitive to the needs of other patients, families, and staff members by keeping noise and disruption to a minimum. Disruptive behavior or unsafe practices are not tolerated. This includes but is not limited to: alcohol or illicit drug use; foul language; aggressive or disrespectful behaviour to staff members, patients or other family members; etc. If behaviour becomes disruptive to any patient, family, staff, or other visitor, or interferes with the general comfort, care, care planning, or decision making of any patient, the person causing the disruption will be asked to leave the facility by a member of the care team or Security Services. Process: During the daytime, visitors and DSPs enter our facility through the main entrance. During the overnight hours, DSP entrance is made through a mutually agreed upon location. To ensure the health and safety of all patients, visitors, and staff, all those visiting must perform proper hand hygiene with soap and water or alcohol-based hand sanitizer before entering and exiting the patient room and the patient care unit, and wear a medical-grade face mask when required by policy. All DSPs and visitors are also requested to refrain from using scented products. There should be no eating or drinking in patient rooms. Personal pet visitation is pre-arranged with the unit manager or member of the patient care team as per the Pet Visitation policies. Visits may be interrupted by healthcare practitioners to provide patient care. The bedside presence of children is supported based on the preference of the patient and the care team. An adult (other than the patient or a staff member) must supervise children under the age of 12 at all times. The stay of DSPs may be interrupted if circumstances change with the patient or with the health status of other patients on the unit (i.e. flu season, infection prevention and control precautions, etc.) If a visitor or DSP is unwell, we ask them to stay home. Every effort is made to keep the DSP informed and involved with the plan of care for the patient. Overnighting: In exceptional circumstances, DSPs may be able to stay overnight with a patient. Please consult with the health care team if this appears to be a patient need.