Medical Staff House Staff Orientation Manual - Montefiore Medical ...

Medical Staff
House Staff
Orientation Manual
2005
Montefiore Medical Center
The University Hospital of the Albert Einstein College of Medicine

Welcome to Montefiore Medical Center, the University Hospital for the Albert Einstein College
of Medicine. As a member of our physician community you will be experiencing one of the most
unique and rewarding human experiences. Our common goal is to deliver the highest quality care
to our patients, their families, and the community. This manual is intended to serve as a ready
reference tool for use during your tenure here.
Congratulations on joining one of the finest health care teams in the world.
Good Luck!
Steven M. Safyer, MD
Senior Vice President
Chief Medical Officer
June, 1996
Revised: May, 1997
Revised: March, 1999
Revised: April 2001
Revised: November 2003
Revised: January 2005
2

We would like to take this opportunity to welcome you to Montefiore Medical Center. This
manual was prepared to assist and guide you through our institution. Since no manual can
possibly contain information on every hospital policy and procedure, please feel free to contact
us if you require clarification or any additional information. We would also welcome your
suggestions on any material that you would like to see in future editions of this manual.
Thank you.
Elaine M. Taylor
Director
House Staff Office
(718) 920-4091
Michael Dowling
Director
Provider Services and Network Contracting
(914)377-4668
3

MONTEFIORE MEDICAL CENTER - AN OVERVIEW
Montefiore Medical Center is a large, nonprofit, integrated health system and one of America's
foremost academic medical centers. Montefiore seeks to improve health by delivering highquality
patient care, producing superbly trained health professionals, advancing medical
knowledge through imaginative research, and by reaching out to the community with new
approaches to pressing problems that are often considered beyond the traditional medical
mission.
Montefiore is the University Hospital and Academic Medical Center for the Albert
Einstein College of Medicine and shares with that distinguished institution an outstanding faculty
of clinicians and scientists. These highly skilled professionals, engaged in exciting research
initiatives, bring to patient care and physician training the fruits of their investigations, the most
current scientific knowledge and the most sophisticated medical technologies. Countless patients
have been helped, and their lives extended and enhanced, by innovations that Montefiore
physicians have conceived, perfected and trained others to use.
Montefiore serves the 1.3 million residents of the Bronx, 500,000 neighbors in nearby
Westchester County, and persons referred from across the region and the nation. The medical
center treats people, not just diseases, and offers a full range of services, including preventive,
primary, specialty, acute and long-term care. Serving people of all ages, from newborns to the
elderly, Montefiore offers special programs for specific age groups, such as the MontePlus Club,
which provides senior citizens with a wide variety of health and fitness programs, educational
events and discounts on products and services.
Montefiore is widely recognized for its distinctive combination of cutting-edge medicine,
caring response to patients and their families and commitment to community needs. Service to
the community at large, not simply to those who come through its doors seeking help, has been a
longstanding Montefiore tradition and an explicit component of its mission. This community
commitment has resulted in a major expansion of basic health services in underserved
neighborhoods and national models for combating AIDS, lead poisoning, child abuse and other
intractable problems.
Far more than a collection of services, Montefiore is a multilevel, interconnected and
integrated delivery system, accredited with commendation by the Joint Commission on
Accreditation of Healthcare Organizations. At the center of the system are three acute care
hospitals, the 600-bed Henry and Lucy Moses Division and the 106-bed Children’s Hospital at
Montefiore, both in the northwest Bronx and the 334-bed Jack D. Weiler Hospital of the Albert
Einstein College of Medicine in the east Bronx. Together they provide nearly 56,000 inpatient
stays annually. More than 3.4 million ambulatory visits are provided annually in Montefiore's
emergency rooms, hospital-based outpatient department and primary and specialty care sites in
the Bronx and Westchester County. Montefiore operates the oldest and one of the largest
hospital-based home health agencies in the nation, with 400,000 visits made annually.
Rehabilitation care is provided at the 22-bed Lubin Rehabilitation Center on the Weiler-Einstein
Campus. A hospice program offers palliative care and family support services.
Under the leadership of President Spencer Foreman, MD, Montefiore has undertaken a
major expansion of its ambulatory care facilities, which has greatly improved access and
increased patient service. The Montefiore Medical Group, a network of neighborhood health
centers in the Bronx and southern Westchester County, has grown to more than 20 sites, which
provide more than 600,000 patient visits annually. Specialty centers in Westchester include
4

Montefiore’s Institute for Reproductive Medicine and Health in Hartsdale, the Cross County
Women’s Center in Yonkers and the Women's Center in Larchmont.
Montefiore’s Centers of Excellence coordinate a full range of care for patients with
highly specialized needs. The internationally recognized Centers of Excellence include: 1)The
Children's Hospital at Montefiore (CHAM); completed in 2001, the CHAM is a model for
pediatric care in the 21st century and the hub of a unique family-centered Child Health Network,
2) Women’s Health, which features excellent obstetrical care, a level 3 NICU, care for mothers
with high risk pregnancies, Assisted Reproductive Technology Program for women with fertility
problems, 3) Surgery, which features the Montefiore Institute for Minimally Invasive Surgery
(MIMIS), 4) Montefiore-Einstein Heart Center treats virtually every type of heart disease or
heart problem and features minimally invasive heart surgery and a designated heart transplant
center, and 5) Montefiore-Einstein Cancer Center; designated as elite NCI (National Cancer
Institute) Comprehensive Cancer Center, multidisciplinary teams offer a full range of cancer
prevention, diagnosis and treatment services.
Major new initiatives continue to enhance clinical excellence, customer service and
access to the Montefiore system. To speed the flow of information and enhance quality across its
extensive system, Montefiore has made major investments in information systems, which link
the entire network through on-line patient care and business databases. Together with the
Contract Management Organization (CMO), Montefiore has also been a leader in preparing for
managed care, building an infrastructure that can accept and handle risk and that is widely
recognized as the region's best hospital-based care-managing system.
The Service Excellence initiative promotes a commitment by all Montefiore associates to
participate in the creation of an exceptional health care delivery system that consistently meets
and exceeds patients’ and all other customers’ requirements. The Customer Relationship
Management initiative strives to provide easy access to Montefiore patients and providers by
offering centralized services for referrals, appointment scheduling and billing inquiry through the
CMO Call Center.
Montefiore’s Vision for Service Excellence
Service Excellence is a commitment by all Montefiore associates to participate in the creation of
an exceptional health care delivery system that consistently meets and exceeds patients’ and all
other customers’ requirements.
Patients prefer Montefiore because they are assured an exceptional experience that promotes
health and healing where:
• Quality clinical outcomes are achieved with a high level of responsiveness to patients’
anxiety, pain, and personal needs.
• They and their families are:
• Valued as partners in the care process,
• Listened to and educated,
• Served by associates that demonstrate our Standards for Service Excellence.
The seven Standards are:
Respect
Effective Communication
Sensitivity
Professionalism
5

Exceeding Expectations
Courtesy
Teamwork
• Services throughout the continuum are superior, coordinated and patient-centered
• The physical and emotional environments are welcoming, professional, and confidenceinspiring.
Associates prefer to work at Montefiore because they:
• Make a difference in people’s lives
• Feel listened to and valued for who they are and what they do
• Recognize, respect and thank each other
• Have opportunities for learning, career development, and advancement
• Experience a work environment that has clear expectations and is ethical, equitable, and
appreciates diversity
• Lead and are led in ways that encourage growth, innovation, and outstanding results.
• Have a competitive pay and benefits package
• Celebrate successes and have fun
• Work as a great team
6

TABLE OF CONTENTS
SECTION 1- General Information
Frequently Used Numbers 12
Banking Facilities 19
SECTION 2- Medical Staff and House Staff
MEDICAL STAFF
Credentialing Office 21
Privileges and Appointment to the Medical Staff 21
Medical Staff Reappointment 21
Change of Status 22
Change of Address/Practice Location 22
Provider Relations Office 22
MIPA/CMO 23
MIPA Referral Management Process 23
CMO Important Telephone Numbers 25
HOUSE STAFF
House Staff Office 27
Committee on Graduate Medical Education 27
General Essentials of Accredited Residencies 28
Approval and Accreditation 28
Institutional Requirements 28
Sponsoring Institution 28
Educational Administration 28
Institutional Agreements 30
Accreditation for Patient Care 30
Resident Eligibility and Selection 31
Resident Participation in Educational Activities 32
Resident Support, Benefits and Conditions of Employment 32
Resident Supervision, Duty, Hours and Work Environment 34
Licensing 35
DEA Registration Number 35
Malpractice Insurance 35
Procedures for Evaluation, Supervision, and Due Process 35
The Effects of Leave of Absence from a Program 37
House Staff Maternity Leave Policy 37
House Staff Sick Leave Policy 38
House Staff Vacation Policy 38
House Staff Benefit Plans 38
Limitation of House Staff Hours 38
Moonlighting 38
Physician Impairment and Drug Abuse Policy 39
Pre-Appointment and Annual Physical Examinations 39
7

Professional Conduct Reporting Policy 39
Meal Tickets 40
On-Call Rooms 40
Paychecks 40
Voluntary Service on MMC Administrative Committees 40
Admissions, House Staff 41
Chart Completion Policy for House Officers 42
Laundry and Linen Service 42
Parking 42
Shuttle Buses 42
Employee Assistance Program 43
Housing 44
SECTION 3- Montefiore Medical Group (MMG)
Montefiore Medical Group (MMG) 48
MMG Administration 48
MMG 1 Sites 48
MMG 2 Sites 50
MMG 3 Sites 52
MMG 4 53
School Health 53
Homeless Program 57
WIC Program 59
SECTION 4- Clinical Departments
Anesthesiology 61
Cardiology 62
Cardiothoracic Surgery 63
Child Psychiatric Outpatient Divisions 64
Dentistry 64
Emergency Medicine 65
Epidemiology and Population Health 65
Family Medicine 66
Medicine 67
Neurology 70
Neurosurgery 70
Nuclear Medicine 71
Obstetrics & Gynecology and Women’s Health 73
Oncology 76
Ophthalmology and Visual Science 78
Orthopedic Surgery 78
Otolaryngology 79
Pathology 79
Pediatrics 80
8

Plastic and Reconstructive Surgery 81
Psychiatry and Behavioral Sciences 81
Radiology 82
Radiation Oncology 85
Rehabilitation Medicine 85
Surgery 86
Urology 88
SECTION 5- Policies and Procedures
Patients’ Bill of Rights 90
Protected Health Information Uses and Disclosures 90
Advanced Directives- Health Care Proxies and Living Wills 92
Brain Death 93
Do Not Resuscitate Orders 95
Do Not Intubate Orders 97
End of Life Care 99
Foregoing Life-Sustaining Treatment 100
Informed Consent and Refusal 101
Verification of Operative Procedure Site and Patient Identification 103
Death Certificates 104
Fire Safety and Prevention 104
Infection Control Program 105
Ethical and Legal Compliance 106
Harassment 107
Drug Free Work Place 108
Smoke Free Policy 108
Equal Opportunity Employer 108
Controlled Substances in the Medical Center 109
Quality Improvement 112
SECTION 6- Service Departments
Acute Pain 116
Admitting 116
Bioethics 117
Blood Banks 118
Child Protection Center 119
Clinical Information Systems 119
Continuing Medical Education 120
Customer Services 121
Dialysis Center III 121
Division of Education and Organizational Development 121
Environmental Service 122
Food and Nutrition Services 123
9

Gift Shop 124
Health Information Management 124
Home Health Agency 129
The Tishman Learning Center Health Sciences Library 131
Mailroom 133
Office of the Medical Director 133
Operating Room 134
Occupational Health Services 134
Palliative Care 135
Patient, Family and Community Health Education Resources 137
Patient Safety 138
Pharmacy Services 139
Quality Management 142
Respiratory Care 143
Risk Management 144
Safety and Security 145
Sleep- Wake Disorders Center 146
Social Work Services 147
Staff and Alumni Association 148
Telecommunications 148
Volunteer Services 149
INDEX 150
10

SECTION 1
•
GENERAL INFORMATION
11

FREQUENTLY USED NUMBERS
Montefiore Medical Center-Moses Division 718-920-4321
Tie line to Einstein Weiler Division 712
Tie line to Fordham Plaza 713
Tie line to Einstein College of Medicine 712-52
Tie line to CHAM 715
Children’s Hospital at Montefiore (CHAM) 718-741-2426
Tie line to Moses Division 6
Tie line to Einstein Weiler Division 712
Tie line to Fordham Plaza 713
Tie line to Einstein College of Medicine 712-52
Einstein/Weiler Division 718- 904-2000
Tie line to Moses Division 51
Tie line to Fordham Plaza 51-713
Tie line to Einstein College of Medicine 52
Tie line to CHAM 51-715
Albert Einstein College of Medicine 718-430-2000
Office of Graduate Medical Education 718-430-4282
Beth Abraham Hospital 718-881-3000
Jacobi Medical Center 718-918-5000
North Central Bronx 718-519-5000
Page Operator
Moses Division
External 718- 920-5321
Internal
X8282
Emergency
X2222
CHAM
External 718-741-2426
Emergency
X2222
Einstein/Weiler Division
External 718-904-4141
Internal
X2711
Emergency
X2222
Prefix Numbers
Moses Division (M)
CHAM (C)
Einstein/Weiler Division (W)
Montefiore Medical Park (MMP)
Fordham Plaza (F)
Albert Einstein College of Medicine (A)
920+extension
741+extension
904+extension
405+extension
405+extension
430+extension
12

Contract Management Organization (CMO) 914-377+extension
DEPARTMENTS
Administration M 6400 KIau Corridor
W 2985 Room 2-60
Admitting M 5001 Rosenthal Main
W 3286 Room 1-36
AIDS M 5224 Schiff 1
Ambulatory Surgery M 7073 MAP 4th fl
W 2878 3rd Floor
Anesthesia M 4316 North 4-005
W 2872 Room 316
Audiology M 2333
M 4646 MAP
Bacteriology M 4695 North 8
Baumwritter Kidney 597-2255 1325 Morris Ave
Blood Bank M 4786 North 8
W 2868
Blood Donor
M 4810
Rosenthal 2
W 2100
Cardiology M 4116 North 2
W 2927
Cardiac Catheterization
M
W
5413
2071
Central 1
Cardiac non-Invasive
M 4807
North 2
W 2779
Cardiothoracic Surgery M 7000 3316 Rochambeau
MMP 8248
W 405-8373
Central Supply M 4371 North Main
W 2386
Chemistry M 4181
W 3423
Clinical Pathology W 2861 Room 3-33
Clinical Research M 4941 Central 3
Credentialing CMO 4690 100 Corp. Drive
Cytology M 4269 Central 3
Dental M 6266 Centennial Bldg.
Dialysis M 4974 North 4
W 2595 Room W2-60
EEG M 4311 Northwest 3
W 2766 Room 1071
EKG
M 4676
Central 1
W 2779
EMG M 4930 Klau Service Corridor
13

Emergency Room
Emergency Room
M 6295 Northwest Main
M 5731
North 1
W 3333
Emergency Room-Pediatric C 2150
Endocrinology M 4331 Hofhicimer 3
Engineering
M 4868
90 E. 210th Street
W 3284
W 4000 1st. Floor
Environmental Services M 4903 Basement
Garage M 6350 11 E. 210th Street
Geriatrics M 6721 Centennial Bldg.
M 8150 KIau 4
Gift Shop
C
W
2294
2742
Gynecology/Obstetrics M 5157
W 2797
Headache Unit M 4636 3326 Rochambeau
Hematology M 4137 North 8
Holter Monitoring
M 5166
Central 1
W 2390
Home Health Agency F 4400 One Fordham Plaza
House Staff Office M 4091 150 E. 210th St.
Immunodiagnostic M 5570 Storage Bldg.1
Immunohematology M 4785 Moses 5
Immunology Laboratory M 4695 North 8
Infection Control
M 4562
3341 Steuben
W 3422
Information Desk M 4141 Rosenthal Main
Laundry M 5357 Service Bldg. 1
Library- Medical M 4666 North 2
Loeb Center M 4696 Northwest Main
Mail Room M 5382 Moses Basement
W 8963 1st Floor
Medical Director M 6791 KIau Corridor
W 2612 Room 2-60
Medical Records M 4921 Rosenthal Main
W 2747 Room 2-70
Medicine M 7700 Centennial 4
A 4041 360 Rousso
MRI M 8209/8265 Central Main
Microbiology M 4695 North 8
Morgue M 4264 Hofheimer M
W 2820 Room 1-34
Neonatology W 4105 7 North
Nephrology A 3158 615 Ullman
14

Neurology M 4656 3351 Steuben
A 3166
MMP 405-8259
Neuroradiology M 4640 North Main
W 2736 Room 3-61
Neurosurgery M 4196 3316 Rochambeau
Nuclear Medicine M 5011 North 4
W 2923 Room 1-21
Nursing Department M 4701 Rosenthal Main
W 2951 Room 2-71
Nutrition
M 4691
North Main
W 2731
Occupational Therapy M 4083 Northwest Main
W 2940
Operating Room M 4491 North 3
W 3413 Room 3-105
OR Schedules M 6308 North 3
W 2876 Room 3-104
Ophthalmology M 4609 MAP
Orthopedics M 2060 MAP 6
Otolaryngology M 4646 MAP
Outside Transportation M 5503/4407 NW Basement
Pacemaker M 4881 North 2
Pain Treatment M 5584 DTC
Palliative Care M 6378 3544 Jerome Ave.
Parking
M 6350
3324 Rochambeau
W 8763
Pathology M 4976 Central 3
Patient Information M 4141
W 4151 Main Floor
Patient Relations W 2395 Room 2-52
Pediatrics C 2460 Rosenthal 4
Pharmacy M 4526 Storage Bldg.
W 2838 Room 1-11
Plastic Surgery
M 5551
3331 Bainbridge
MMP 405-8444 Blondell
Podiatry M 5101 DTC 460
Pre-Admission
M 5596
Rosenthal
W 3188
Provider Relations CMO 4477 100 Corp. Drive
Psychiatry M 4813 Klau Basement
W 3467 Room 2S-56
Pulmonary
M
W
6054
2983
Centennial Bldg.
15

Radiation Oncology M 4361 Yellow Zone Main
W 2921 Room 1-21
Radiology M 4861 North Main X-Ray
W 3411 3rd Floor
Receiving
M 5341
Storage Bldg. Main
W 3435
Recovery Room
M 4477
North 3
W 2871
Rehabilitation Medicine M 4844 Northwest Basement
W 2296 Room 2-246
Renal M 5442
Centennial Bldg.
430-3158
Research Administration M 4151 3308 Rochambeau
Respiratory Therapy M 4969 Northwest Main
W 3214 Room W4-080
Rheumatology M 4639
Centennial Bldg.
430-2078
Risk Management M 6340 3328 Rochambeau
Safety M 5104 90 East 210th Street
Security/Transportation M 6131 3324 Rochambeau
W 2800 1st Floor Lobby
Social Service M 4545 Rosenthal C
W 2707 Room 2-198
Surgery
M 6287
MAP 4TH FL.
Telecommunications
W
M
M
W
2260
6262
5601
2701
Hofheimer 2
Hofheimer 2
Room 1-116
Telemetry Triage W 2220
Transplant M 4459 Rosenthal C
Transportation- Patient M 4911 North Main
Ultrasound
M
W
4070
2322
Urinalysis Lab M 4695 North 8
W 3425 Room 349
Urology
M 4531
MAP 5
W 4053
M 5402 MAP 5
Vascular Lab
M 6603
Klau Corridor
W 2290
Vascular Surgery
M 4108
MAP
W 2586
Volunteer
M
W
4191
2934
Blue Zone
16

MOSES NURSING STATIONS
C 741-2377 Pediatric Day Hospital CHAM 3
C 741-2600 Adolescent CHAM 6
C 741-2200 Infants CHAM 8
C 741-2100 Children's CHAM 9
C 741-2000 Pediatric Critical Care CHAM 10
C 741-2055 Epilepsy Inpatient CHAM 10
M 4631 Sickle Cell KIau 3
M 4641/6253 Medicine KIau 4
M 4651/6256 Medicine KIau 5
M 4661/6257 Medicine KIau 6
M 4621 Psychiatry Klau 2
M 4671/6273 Medicine Klau 7
M 4681/6275 Medicine Klau 8
M 6763 Stepdown Unit N7B
M 4413 CCU North 2
M 4411 MICU North 2
M 6136 CSICU North 3
M 5794 SICU North 3
M 4974 Dialysis North 4
M 6660 ICCU North 6AE
M 6660 Medical/Surgical North 6B
M 4581 Vascular Surgery North 7A East
M 4611 Orthopedic Surgery North 7A West
M 4601 CT/Plastic Surgery North 7B
M 6551 Oncology Northwest 3
M 4741 Oncology Northwest 4
M 4731 Neurosurgery Northwest 8
M 4731 Neurology Northwest 8
M 5220 NSCU Northwest 8
M 4571 Urology Northwest 8
M 4541 Pulmonary Rosenthal 1
M 5450 Pulmonary Care Unit (PCU) Rosenthal 1
M 5218 Kidney Transplant Rosenthal 4
M 5596 Adult/Same Day Care Center Rosenthal B
M 7441 Family Medicine Rosenthal D
M 4591 General Surgery
M 5045 PACUP
M 6702 LAF
17

WEILER NURSING UNITS
W 2781
2 North
W 2735
2 North
W 2595 Dialysis 2 West
W 3119 ICCU 4 Northwest
W 3415 ICU 4 Northwest
W 4032 NICU 5 North
W 2606
5 South
W 3433 Labor & Delivery 6 North
W 3431
6 South
W 2762
8 North
W 2773
8 South
W 2704
9 North
W 2210
9 South
W 2744
10 North
W 2706
10 South
W 2974
11 North
W 3492
11 South
OUTPATIENT DEPARTMENT- CLINICS - MOSES
M 6304 Administrator
M 5586 Adult #1 and #2
M 273 Adult Walk-In Clinic
M 5584 Allergy
M 5584 Arthritis
M 5949 Cardiology MAP 7
M 7373 Comprehensive Sickle Cell Center Klau 3
M 6266 Dental Centennial 2
M 7763 Dermatology (Primary Care) MAP
M 5101 Diabetic DTC 4
M 5101 Dressing DTC 440
M 5085 E.N.T. (Otolaryngology) MAP 3
M 5101 Endocrinology DTC 3
M 5584 Epilepsy DTC 440
M 4216 Eye MAP
M 5584 Gastroenterology (G.I.) DTC440
M 2273 General Medical DTC 320
M 5584 Gold Therapy DTC440
M 5157 Gynecology DTC 360
M 5584 Headache Unit DTC 440
M 5101 Hematology DTC 320
M 8542 Infectious Disease DTC 3
M 6707 Information and Referral DTC 3
18

M 5584 Lupus Clinic
M 5584 Neurology DTC 440
M 7474 Neurosurgery 3316 Rochambeau
M 5594 Nutritionist Schiff 1
M 7541 Oncology (Breast/Chemotherapy) NW3
M 2060 Orthopedics (Adult and Pediatrics) MAP 6
M 7073 Peripheral Vascular Disease (PYD) MAP 4
M 5586 Plastic Surgery DTC360
M 5101 Podiatry DTC4
M 4295 Psychiatry KIau 1
M 5584 Pulmonary DTC3
M 4361 Radiation Oncology Yellow Zone
M 4844 Rehabilitation Northwest Ground
M 7763 Renal Hypertension MAP
M 5586 Renal Transplant DTC3
M 5101 Scoliosis DTC4
M 5445 Speech and Hearing Gold Zone
M 5101 Surgery DTC4
M 4531 Urology MAP
BANKING FACILITIES
MOSES
There are automatic teller machines (ATM) and a postage stamp machine at the Gun Hill Road
Entrance in the Silver Zone.
WEILER
There is an ATM located on 4th floor.
BANKS IN THE AREA
• Chase Bank
Jerome Avenue (3 blocks west of 210th Street entrance and right on Jerome Avenue - east side
of street)
• Citibank
Jerome Avenue (2 blocks west of Gunhill Road entrance and left on Jerome Avenue - west side
of street)
• Washington Mutual
Jerome Avenue (3 blocks west of 210 th Street entrance next to Chase)
19

SECTION II
•
MEDICAL STAFF
&
HOUSE STAFF
20

MEDICAL STAFF CREDENTIALING OFFICE
Director, Provider Services & Network Contracting 914-377-4668
Michael Dowling
914 -377-4794 Fax
Director, Credentialing 914-377-4605
Rose Richter
914-377-4791 Fax
Assistant Director, Provider Information 914-377-6021
Justina Marrone
914-709-0386 Fax
The Credentialing Office is responsible for the Appointment and Reappointment of all attending
physicians and employed allied health professionals for Montefiore Medical Center and the
Montefiore Independent Provider Associations (MIPA).
Privileges and Appointment to the Medical Staff
Applications to the Medical Staff and Montefiore IPA(s) can be obtained through the
Department Chairman’s Office. All Medical Staff appointments are provisional for one year and
all medical staff are required to be reappointed every two (2) years.
Clinical departments are responsible for assembling the required credentialing documents
necessary for appointment prior to submission of the application package to the Credentialing
Office. Required documents include:
• Current curriculum vitae
• Delineation of Privileges (Completed by applicant and signed by the chairman)
• Current NY State License registration, signed by physician
• NYS Infection Control Certification
• DEA certificate
• Current malpractice insurance certificate
• Recommendation and appointment letter from Department Chairman
• Confidential Medical History and Examination
• Completed application signed by the Department Chairman
• Letters of recommendation and verification of education, training and clinical competence
• Health Plan and government programs enrollment forms
The Credentialing Office is responsible for all verifications including sanction checks,
affiliations, state licensure, DEA registration and others as required by regulatory agencies. The
Credentialing Office will be responsible for ensuring that all appropriate signatures are obtained
and that the completed file is processed and approved according to Montefiore Medical Center’s
Medical Staff By-Laws, Rules and Regulations.
Medical Staff Reappointment
Montefiore Medical Center Medical Staff members are subject to reappointment every two
years. At the time of reappointment each physician/dentist is asked to:
• review and update a General Information Profile Form which outlines biographical and
practice information
21

• list all continuing medical education credits; minimum of 150 CME credits per three (3)
years are required
• indicate hospital affiliations and any actions regarding licensure, registration and privileges
or sanctions
• complete a malpractice history questionnaire
• complete departmental delineation of clinical privileges and self evaluation forms
• submit documentation of an annual health assessment
• complete authorization to release information
• submit current certificates
• complete other forms and provide other supplemental information as required
Change of Status
All Medical Staff members and/or clinical departments are required to submit status changes
(e.g. change from Full Time to Voluntary) prior to the effective date of the change in writing.
Information may be faxed to (914)709-0386.
Change of Address/Location
Change of address or practice information must be submitted in writing to Justina Marrone using
the “Provider Change of Address” form. Forms may be faxed to (914)709-0386.
PROVIDER RELATIONS OFFICE
Bill Scesney
Director, Provider Relations
Office 914-377-4701
Fax 914-377-4794
Provider Relations is the communication link between Montefiore Medical Center, IPA
providers, and contracted health plans. Provider Relations Liaisons offer a variety of services
including orientation and educational sessions for IPA providers and office staff on CMO and
health plan policies and procedures. Along with Network Development, Provider Relations
works closely with the health plans to strengthen the IPA position in the market and grow
provider membership in the network.
22

MONTEFIORE INTEGRATED PROVIDER ASSOCIATION (MIPA) AND THE
CONTRACT MANAGEMENT ORGANIZATION (CMO)
What is Managed Care
Managed care is a broad term that is used to describe the delivery and financing of
health care services to a specific group of people (i.e., those covered under the payer's insurance
plan) across all levels of services. The services may range from a routine physician office visit to
hospital intensive care needs to healthcare provided in a home setting. The goal is to manage all
the levels of care in a way that provides quality care in a cost effective manner. There are a
variety of types of managed care benefits plans such as: Health Maintenance Organizations
(HMOs), Preferred Provider organizations (PPOs), and Point of Service (POS). Each of these
benefit plans pays the provider in a different way – usually a capitated rate or a discounted fee
for service. The patient is responsible for co-payments based on their benefit plan requirements.
MIPA and CMO Overview
The Montefiore Independent Provider Associations (MIPA) were formed to provide a
coordinated, integrated health services network (including physicians and hospital services) that
will render comprehensive quality health care in the Bronx and the surrounding communities.
The Contract Management Organization (CMO) employs staff to handle contracting with payers,
medical management activities, credentialing and processing and payment of claims. The
physicians accept the negotiated rates and may only bill patients for copayments or non-covered
services with a signed waiver. Providers send claims to a central location at the CMO for claims
review and processing.
The MIPA is governed by a Board of Directors comprised of physician and hospital
representatives. The board members are charged with broad policy decisions for the MIPA and
approval of recommendations made by specific MIPA committees. Each committee has a
specific area for which they make recommendations to the Board of Directors. In addition, the
specific committees may serve as a monitoring arm of the CMO for its particular area of focus.
The standing committees are Credentialing, Medical Management and Finance.
MONTEFIORE IPA REFERRAL MANAGEMENT PROCESS
CareLink
Care Link is an Internet based system that allows providers and office staff direct access to verify
member eligibility, submit referrals and authorizations, and check status of a
referral/authorization in real-time. The features of this application include:
• Verify eligibility for IPA Members
• Submit referrals and authorizations on-line
• View status of referrals and authorizations
• View reports of referrals and authorization activity for a particular office
Primary Care Physician (PCP) Responsibilities
• Initially determines when appropriate for a patient to be referred
23

to a SCP (Specialty Care Physician) for consultation
• Completes an IPA Referral which should provide the following
information to the specialist:
• Specific reason the consultation is being requested
• Information and/or results regarding any tests and/or procedures which may have already
been performed
• Forwards the IPA Referral to the SCP with any pertinent results of previous testing
• Provides a copy of the Referral to the patient
Specialist (SCP) Responsibilities
• Ensures the patient is referred appropriately
• Orders diagnostic tests necessary to complete the requested consultation
• Complies with CMO requirements for notification and authorization
• Determines if additional treatment is necessary and communicates the treatment plan to PCP
• If the PCP is in agreement with the plan, the SCP coordinates
the treatment, including arranging surgery and/or inpatient hospitalization
• If SCP determines that referral to another SCP for cognitive consult
may be appropriate, the SCP must inform the PCP and the PCP coordinates as above
• Provides a follow-up written report to the PCP which outlines:
• Evaluation
• Findings
• Recommended treatment
• For extended course of treatment, the SCP provides a progress report to the PCP at intervals
agreed upon
Contract Management (CMO) Responsibilities
• Verifies network status of the provider
• Verifies member eligibility and coverage
• If the referral requires authorization, the UM Coordinator performs review
• If criteria are met, the CMO generates an authorization number
• Will provide the PCP or SCP office with the authorization number as appropriate
• If criteria are not met, the UM Coordinator refers the case to the CMO Physician Advisor for
review
• If the Physician Advisor denies the request for referral authorization, the provider is notified
of his/her right to appeal the decision through the Appeals Process
Exceptions to the Referral Guidelines
• OB/GYN: Self-referral by patients to OB/GYN providers within the IPA/HMO network is
permitted under state law for:
• Two well women visits per year
• All maternity care
• Follow-up for any abnormal findings detected during a well
woman visit
• Acute gynecological conditions
• Follow – Up to Care Received in the Emergency Department
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• Referral by the ED physician is permitted to arrange appropriate and timely follow-up to
care provided in the ED for conditions involving trauma.
• Mental Health/Chemical Dependency For Specific Health Plans
• Mental health/Chemical dependency services for IPA patients is coordinated by
University Behavioral Associates (UBA). The PCP or patient should contact UBA
directly to arrange for referral to an appropriate provider. A paper referral is not required.
• UBA: (800)401-4822
• Diagnostic testing performed in IPA participating facilities
• Lab, Optometry, Routine Podiatry (for members with benefit coverage), Influenza and
Pneumococal vaccine visits do not require referrals
Denials
The CMO tracks, monitors and responds to denials associated with inpatient hospitalizations.
Notification of denial may be received prior to, during or following
a hospitalization.
In the event a denial is received prior to or during a hospitalization that you are managing, you
may be contacted with a request to contact a Medical Director at the health plan issuing the
denial to provide additional clinical information in an effort to reverse the denial. In the event a
denial is received following the hospitalization, you may be contacted to provide additional
clinical information necessary to complete an appeal.
If you should receive verbal notification from a health plan of a denial, please contact the
Director of Denial Management at (914) 377-4678 with information regarding the patient and
health plan involved. If you receive written notification of a denial, please fax to (914) 377-4677.
CONTRACT MANAGEMENT ORGANIZATION (CMO) IMPORTANT
TELEPHONE NUMBERS
CMO Customer Service Line
888- MONTE CMO or 914-377-4400
Monday – Friday: 8:00 am – 6:00 PM
• Confirm a member’s enrollment status, benefits and co-payment information
• Confirm authorization status including all medical management inquiries
• Confirm claim status
• Resolve inquiries regarding complaints, grievances and administrative appeals
• Address any questions or needs related to the CMO
Fax: 914-375-2174
Credentialing
Phone: 914-377-4690
Fax : 914-377-4691
Medical Management
Fax 914-377-4798
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Phone: Oxford Medicare inquiries only 800-876-7455
Fax: Oxford Medicare only 914-476-4362
Provider Relations
Phone: 914-377-4477
Fax: 914-377-4794
University Behavioral Associates (UBA)
Phone: 800-401-4UBA or 914-377-4550
Fax: 914-377-4788
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HOUSE STAFF OFFICE
150 East 210th Street
Opposite the 210th Street Entrance of the hospital
Phone 718-920-4091
Fax 718-920-8403
Hours
Monday – Friday 8:30AM - 5:00PM
Notary Available: Please call for an appointment 718-920-2341
Director 718-920-4091
Elaine M. Taylor
917-506-5081 Beeper
taylor@montefiore.org
Assistant Director 718-920-4093
Justice Gaba
jgaba@montefiore.org
Credentialing Specialist 718-920-2340
Esther Gonzalez
egonzale@montefiore.org
Credentialing Specialist 718-920-4806
Gladys Velazquez
gvelazqu@montefiore.org
Data Analyst 718-920-2625
Richard Reinoso
rreinoso@montefiore.org
Data Analyst 718-920-2947
Nilsa Sambula
nsambula@montefiore.org
Reception 718-920-2341
Lackragie Singh (Drew)
lsingh@montefiore.org
Please feel free to contact us for any questions or concerns you may have.
COMMITTEE ON GRADUATE MEDICAL EDUCATION
Montefiore Medical Center’s Residency Programs are sponsored by the Albert Einstein College
of Medicine (AECOM). The Committee on Graduate Medical Education (COGME) is an
organized administrative committee of AECOM that oversees all residency programs and has the
responsibility for monitoring and advising the sponsored institution on all aspects of residency
education. The committee has representation of key academic and hospital administrators, as
well as residents. Included in the responsibilities of the COGME are the establishment and
implementation of policies that affect all residency programs regarding the quality of education
and the work environment of the residents in each program. MMC and JMC are active
participants on this committee and strongly support the mandated mission of the committee.
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Associate Dean of Graduate Medical Education
Michael Reichgott, MD, PhD 718-430-4282
Administrator GME
Linda Collazzi 718-430-4283
Administrative Secretary
Vilma Kalten 718-430-4284
GENERAL ESSENTIALS OF ACCREDITED RESIDENCIES
The following are excerpts from the Essentials of Accredited Residencies in Graduate Medical
Education. The entire text specifying the requirements every residency program must meet to be
accredited may be found in each department in the booklet listing
approved residency and fellowship programs or from: The Secretary, Accreditation Council for
Graduate Medical Education, 535 N. Dearborn Street, Chicago, Ill. 60610. A copy is also
available for review in the House Staff Office.
Approval and Accreditation
For a program to become accredited, the sponsoring institution must demonstrate a commitment
to GME. The sponsoring institution must be in substantial compliance with the Institutional
Requirements and must assume responsibility for the educational quality of its sponsored
program(s). Further information concerning a “sponsoring institution” is provided below.
Institutional Requirements
Institutional Organization and Commitment: The purpose of GME is to provide an organized
educational program with guidance and supervision of the resident, facilitating the resident’s
ethical, professional and personal development while ensuring safe and appropriate care for
patients.
Sponsoring Institution
• A residency program must operate under the authority and control of a sponsoring institution
(see definition for sponsoring institution in the Glossary under "Institution").
• There must be a written statement of institutional commitment to GME that is supported by
the governing authority, the administration, and the teaching staff.
• Sponsoring institutions must be in substantial compliance with the Institutional Requirements
and must ensure that their ACGME accredited programs are in substantial compliance with
the Program Requirements and the applicable Institutional Requirements.
• An institution's failure to comply substantially with the Institutional Requirements may
jeopardize the accreditation of all of its sponsored residency programs.
Educational Administration
There must be an organized administrative system to oversee all residency programs sponsored
by an institution. In addition, there must be a designated institutional official who has the
authority and the responsibility for the oversight and administration of the GME programs.
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• Institutions must have a GME Committee (GMEC) that has the responsibility for monitoring
and advising on all aspects of residency education. Voting membership on the committee
must include residents nominated by their peers, appropriate program directors, other
members of the faculty, and the accountable institutional official or his or her designee.
• The committee must meet at least quarterly; minutes must be kept and be available for
inspection by accreditation personnel.
• The responsibilities of the committee must include:
• Establishment and implementation of policies that affect all residency programs
regarding the quality of education and the work environment for the residents in each
program.
• Establishment and maintenance of appropriate oversight of and liaison with program
directors and assurance that program directors establish and maintain proper oversight of
and liaison with appropriate personnel of other institutions participating in programs
sponsored by the institutions.
• Regular review of all ACGME letters of accreditation and the monitoring of action plans
for the correction of areas of non-compliance.
• Regular review of all residency programs to assess their compliance with both the
Institutional Requirements and Program and the Program Requirements of the ACGME
Residency Review Committees.
• The review must be conducted by the GMEC or a body designated by the GMEC,
which should include faculty, residents, and administrators, from within the
institution but from programs other than the one that is being reviewed. External
reviewers may also be included on the review body as determined by the GMEC.
The review must follow a written protocol approved by the GMEC.
• Reviews must be conducted approximately at the midpoint between the ACGME
program surveys.
• While assessing the residency program's compliance with each of the program
standards, the review should also appraise the following:
• the educational objectives of each program
• the adequacy of available educational and financial resources to meet these
objectives
• the effectiveness of each program in meeting its objectives
• the effectiveness in addressing citations from previous ACGME letters of
accreditation and previous internal reviews
• the use of dependable measures to assess residents’ competence in patient
care, medical knowledge, practice-based learning and improvement,
interpersonal and communication skills, professionalism and systems-based
practice as defined in the section II.B, and in the Program Requirements
• the effectiveness of each program in implementing a process that links
educational outcomes with program improvement
• Materials and data to be used in the review process must include the following:
• institutional and program requirements from the Essentials of Accredited
Residency Programs
• letters of accreditation from previous ACGME reviews
• reports from previous internal reviews of the program
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• interviews with the program director, faculty, and residents in the program
and individuals outside the program deemed appropriate by the committee
• There must be a written report of each internal review that is presented to and
reviewed by the GMEC for the monitoring of areas of noncompliance and
appropriate action. In addition, this report or a succinct summary of each report is
required as part of the ACGME institutional review document.
• Although departmental annual reports are often important sources of information
about a residency program, they do not in themselves necessarily meet the
requirement for a periodic review.
• Assurance that each residency program establishes and implements formal written
criteria and processes for the selection, evaluation, promotion, and dismissal of
residents in compliance with both the Institutional and relevant Program
Requirements.
• Assurance of an educational environment in which residents may raise and resolve
issues without fear of intimidation or retaliation. This includes:
• Provision of an organizational system for residents to communicate and
exchange information on their working environment and their educational
programs. This may be accomplished through a resident organization or other
forums in which to address resident issues.
• A process by which individual residents can address concerns in a confidential
and protected manner.
• Establishment and implementation of fair institutional policies and procedures
for academic or other disciplinary actions taken against residents.
• Establishment and implementation of fair institutional policies and procedures
for adjudication of resident complaints and grievances related to actions which
could result in dismissal, nonrenewal of a resident’s contract, or other actions
that could significantly threaten a resident's intended career development.
• Collecting of intra-institutional information and making recommendations on
the appropriate funding for resident positions, including benefits and support
services.
• Monitoring of the programs in establishing an appropriate work environment
and the duty hours of residents.
• Assurance that each program provides a curriculum and an evaluation system
to ensure that residents demonstrate competence in the general areas listed in
II.B, and as defined in each set of Program Requirements.
Institutional Agreements
When resident education occurs in a participating institution, the sponsoring institution continues
to have responsibility for the quality of that educational experience and must retain authority
over the residents' activities. Therefore, current institutional agreements
must exist with all of its major participating institutions.
Accreditation for Patient Care
Institutions sponsoring or participating in GME programs should be accredited by the Joint
Commission on the Accreditation of Healthcare Organizations (JCAHO), if such institutions are
eligible. If an institution is eligible for JCAHO accreditation and chooses not to undergo such
30

accreditation, then the institution should be reviewed by and meet the standards of another
recognized body with reasonably equivalent standards. If the institution is not accredited, it must
provide a satisfactory explanation of why accreditation has not been either granted or sought.
Resident Eligibility and Selection
The sponsoring institution must have written policies and procedures for the recruitment and
appointment of residents that comply with the requirements listed below, and it must monitor the
compliance of each program with these procedures.
RESIDENT ELIGIBILITY
Applicants with one of the following qualifications are eligible for appointment to accredited
residency programs:
• Graduates of medical schools in the United States and Canada, accredited by the Liaison
Committee on Medical Education (LCME.
• Graduates of colleges of osteopathic medicine in the United States accredited by the
American Osteopathic Association (AOA)
• Graduates of medical schools outside the United States and Canada who meet one of the
following qualifications:
• Have received a currently valid certificate from the Educational Commission for Foreign
Medical Graduates, or
• Have a full and unrestricted license to practice medicine in a US licensing jurisdiction
• Graduates of medical schools outside the United States who have completed a Fifth Pathway
program provided by an LCME-accredited medical school. [Note.- A Fifth Pathway program
is an academic year of supervised clinical education provided by an LCME accredited
medical school to students who meet the following conditions:
• Have completed, in an accredited college or university in the United States,
undergraduate premedical education of the quality acceptable for matriculation in an
accredited United States Medical school
• Have studied at a medical school outside the United States and Canada but listed in the
World Health, Organization Directory of Medical Schools
• Have completed all of the formal requirements of the foreign medical school except
internship and/or social service
• Have attained a score satisfactory to the sponsoring medical school on a screening
examination
• Have passed either the foreign Medical Graduate Examination in the Medical Sciences,
Parts I and II of the examination of the National Board of Medical Examiners, or Steps 1
and 2 of the United States Medical Licensing Examination (USMLE)
RESIDENT SELECTION
The sponsoring institution must ensure that programs select from among eligible applicants on
the basis of the preparedness, ability, aptitude, academic credentials, communication skills, and
personal qualities such as motivation and integrity. Programs must not discriminate with regard
to sex, race, age, religion, color, national origin, disability, or veteran status. In selecting from
among qualified applicants, it is strongly-suggested that institutions and all of their sponsored
programs participate in an organized matching program, where available, such as the National
Resident Matching Program (NRMP).
31

ENROLLMENT OF NON-ELIGIBLES
The enrollment of non-eligible residents may be a cause for withdrawal of accreditation of the
involved program.
Resident Participation in Educational Activities-ACGME Competencies
The residency program must require that its residents obtain competence in the six areas listed
below to the level expected of a new practitioner. Programs must define the specific knowledge,
skills, behaviors, and attitudes required and provide educational experiences as needed in order
for their residents to demonstrate the following:
• Patient care that is compassionate, appropriate, and effective for the treatment of health
problems and promotion of health
• Medical knowledge about established and evolving biomedical, clinical, and cognate
sciences and the application of this knowledge to patient care
• Practice-based learning and improvement that involves investigation and evaluation of their
own patient care, appraisal and assimilation of scientific evidence, and improvement in
patient care
• Interpersonal and communication skills that result in effective information exchange and
teaming with patients, their families and other health professionals
• Professionalism, as manifested through a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population
• Systems-based practice, as manifested by actions that demonstrate an awareness of and
responsiveness to the larger context and system for health care and the ability to effectively
call on system resources to provide care that is of optimal value
In addition, institutions must ensure that residents achieve the following:
• Develop a personal program of learning to foster continued professional growth with
guidance from the teaching staff
• Participate fully in the educational and scholarly activities of their program and, as required,
assume responsibility for teaching and supervising other residents and students
• Participate in appropriate institutional committees and councils whose actions affect their
education and/or patient care
• Submit to the program director or to a designated institutional official at least annually
confidential written evaluations of the faculty and of the educational experiences
Resident Support, Benefits and Conditions of Employment
Sponsoring and participating institutions should provide all residents with appropriate financial
support and benefits. Compensation of residents and distribution of resources for the support of
education should be carried out with the advice of the GMEC.
• Financial Support: Adequate financial support of residents is necessary to ensure that
residents are able to fulfill the responsibilities of their educational programs.
• Applicants: Applicants for GME programs must be informed in writing of the terms and
conditions of employment and benefits including financial support, vacations, professional
leave, parental leave, sick leave, professional liability insurance, hospital and health
insurance, disability insurance, and other insurance benefits for the residents and their family,
32

and the conditions under which living quarters, meals and laundry or their equivalents are to
be provided.
• Contracts: Sponsoring institutions must provide residents with a written agreement. or
contract outlining the terms and conditions of their appointment to an educational program,
and the institutions must monitor the implementation of these terms and conditions by the
program directors. The contract must contain or reference at least the following:
• Financial support
• Vacation policies
• Professional liability insurance in conformity with II.C.5
• Disability insurance and other hospital and health benefits for the residents and their
family in conformity with II.C.6
• Professional, parental, and sick-leave benefits in conformity with II.7
• Conditions under which living quarters, meals, and laundry or their equivalents are to
be provided
• Counseling, medical, psychological, and other support services in conformity with
IIC.8
• Institutional policies covering sexual and other forms of harassment
The contract must also delineate or reference specific policies as follows:
• Resident’s duration of appointment and conditions of reappointment
• Professional activities outside the educational program in conformity with II.C.II
• Grievance procedures in conformity with I.B.3.f.4
• Nonrenewal of Contracts: Institutions must ensure that programs provide their residents with
a written notice of intent not to renew a resident’s contract no later than 4 months prior to the
end of the resident’s current contract. However, if the primary reason(s) for the nonrenewal
occurs within the 4 months prior to the end of the contract, institutions must ensure that
programs provide their residents with as much written notice of the intent not to renew as the
circumstances will reasonably allow, prior to the end of the contract. Resident must be
allowed to implement the institution’s grievance procedures as addressed in section I.B.3.F.4,
when they have received a written notice of intent not to renew their contracts.
• Liability Insurance: Residents in GME must be provided with professional liability coverage
for the duration of training. Such coverage must provide legal defense and protection against
awards from claims reported or filed after the completion of GME if the alleged acts or
omissions of the residents are within the scope of the education program. The coverage to be
provided should be consistent with the institution's coverage for other medical/professional
practitioners. Each institution must provide current residents and applicants for residency
with the details of the institution's professional liability coverage for residents.
• Disability Insurance: Institutions sponsoring GME must provide access to insurance, where
available, to all residents for disabilities resulting from activities that are part of the
educational program.
• Leave of Absence: There must be a written institutional policy on leave (with or without pay)
for residents that complies with applicable laws. The institution must provide residents with a
written policy concerning the effect of leaves of absence, for any reason, on satisfying the
criteria for completion of a residency program.
• Counseling Services: GME places increasing responsibilities on residents and requires
sustained intellectual and physical effort. Therefore, institutions should facilitate resident
33

access to appropriate and confidential counseling, medical and psychological support
services.
• Physician Impairment: Institutions must have written policies that describe how physician
impairment, including that due to substance abuse, will be handled. In addition, institutions
should provide an educational program for residents regarding physician impairment,
including substance abuse.
• Residency Closure/Reduction: If an institution intends to reduce the size of a residency
program or to close a residency program, the institution must inform the residents as soon as
possible. In the event of such a reduction or closure, institutions must allow residents already
in the program to complete their education or assist the residents in enrolling in an ACGMEaccredited
program in which they can continue their education.
• Moonlighting: All sponsoring institutions must have a written policy that addresses
professional activities outside the educational program to include moonlighting.
• Restrictive Covenants: ACGME-accredited residencies must not require residents to sign a
non-competition guarantee.
Resident Supervision, Duty, Hours and Work Environment
Institutions must ensure that their GME programs provide appropriate supervision for all
residents, as well as a duty hour schedule and a work environment, that is consistent with proper
patient care, the educational needs of residents, and the applicable Program
Requirements.
• Supervision: There must be sufficient institutional oversight to assure that residents are
appropriately supervised. Residents must be supervised by teaching staff in such a way that
the residents assume progressively increasing responsibility according to their level of
education, ability, and experience. On-call schedules, for teaching staff must be structured to
ensure that Institutional Requirements supervision is readily available to residents on duty.
The level of responsibility accorded to each resident must be determined by the teaching
staff.
• Duty Hours: The sponsoring institution must ensure that each residency program establishes
formal policies governing resident duty hours that foster resident education and facilitate the
care of patients.
• The educational goals of the program and learning objectives of residents must not be
compromised by excessive reliance on residents to fulfill institutional service obligations.
Duty hours, however, must reflect the fact that responsibilities for continuing patient care
are not automatically discharged at specific times. Programs must ensure that residents
are provided appropriate backup support when patient care responsibilities are especially
difficult or prolonged.
• Resident duty hours and on-call time periods must not be excessive. The structuring of
duty hours and on-call schedules must focus on the needs of the patient, continuity of
care, and the educational needs of the resident.
• Work Environment: Sponsoring institutions must provide services and develop systems to
minimize the work of residents that is extraneous to their educational programs,. ensuring
that the following conditions are met:
• Residents on duty in the hospital must be provided adequate and appropriate food
services and sleeping quarters.
34

• Patient support services, such as intravenous services, phlebotomy services, and
laboratory services, as well as messenger and transporter services, must be provided in a
manner appropriate to and consistent with educational objectives and patient care.
• An effective laboratory, medical records, and radiological information retrieval system
must be in place to provide for appropriate conduct of the educational programs and
quality and timely patient care.
• A medical records system that documents the course of each patient’s illness and care
must be available at all times and must be adequate to support the education of residents,
support quality-assurance activities, and provide a resource for scholarly activity.
• Appropriate security and personal safety measures must be provided to residents in all
locations including but not limited to parking facilities, on-call quarters, hospital and
institutional grounds, and related clinical facilities (e.g., medical office building).
Licensing
According to the New York State Education Department, interns and residents participating in an
accredited training program need not be licensed. It is the Medical Center's recommendation that
all Clinical/Fellows, chief residents, and senior chief residents at the Medical Center be in
possession of a New York State license or limited permit on July 1 of the academic year in
question. Applications for licensure or limited permit are available on the internet at
www.op.nysed.gov or by calling NYS Education @ (518) 474-3841.
DEA Registration Number
In order to prescribe and administer narcotics to Hospital inpatients or outpatients, each member
of the House Staff will use the nine-digit Hospital DEA number with their own personal threedigit
suffix. The individual three-digit suffix will be assigned by the House
Staff Office (920-4091). A plastic blue card is issued to all House Staff that write prescriptions
with their name imprinted on it. This card is available through the House Staff Office.
Malpractice Insurance
Risk Management provides an annual in-service for new residents reflecting the parameters of
their malpractice coverage under Montefiore Medical Center's Umbrella Malpractice policy. For
more information regarding your coverage, please contact
Risk Management at (718) 920-6733.
Procedures for Evaluation, Supervision and Due Process
EVALUATION
The Director of Service is responsible for evaluating and reviewing each member of the House
Staff. The Director of Service will include consideration of:
• Professional and clinical performance
• Physical and mental health status
• Completion of education and training requirements
• Attendance at departmental conferences, meetings and rounds
• Timely completion of medical records
• Compliance with Medical Staff By-Laws, Rules and Regulations and with hospital policies
35

Performance evaluation will be kept on file within each department. House staff will be apprised
of their performance at least annually.
SUPERVISION
The House Staff may provide patient care at Montefiore Medical Center only as part of an
accredited training program. All patient care activities provided by House Staff will be
supervised by the Attending Physician responsible for the care of the patient. Attending
Physician supervision will be appropriately documented in the medical record.
DELINEATION OF CLINICAL PRIVILEGES
Each Service Director will recommend individual clinical privileges for each member of the
House Staff. Delineation of privileges is based upon the requirements of the training program in
conjunction with the House Staff member's periodic performance evaluation.
DUE PROCESS
Montefiore Medical Center has established a process for resident evaluation and corrective
action, in accordance with ACGME standards. Montefiore residents are entitled to due process
to ensure that the resident is afforded the opportunity for fair adjudication of complaints or
grievances which could result in termination or threaten
his or her career development. Montefiore's due process procedure consist of several progressive
steps:
• An informational departmental resolution
• A departmental ad hoc committee review
• A due process hearing consisting of five physicians, at least two of which are residents
• An appeal to the President of the medical center
Please note that due process procedures of the employing institution of the resident govern, and
may vary somewhat from the steps outlined above. Detailed information on due process
procedures are contained in the "Hearing and Appeal Policy and Procedures for Redress of
Adverse Actions and Grievances of Residents," which is available to
Residents through the House Staff Office. In general, Montefiore's Due Process Policy provides
as follows:
• Applicability: If an adverse action is taken which would prevent the resident from
completing the current training year or residency program, or which would prevent the
resident from achieving admissibility status to take a certification examination of the
American Medical Specialty Board, the resident is entitled to due process. Note that
placement on academic probation in and of itself does not entitle the resident to due process.
• Summary or Interim Action: In cases in which a resident's performance or actions are
deemed to endanger the health or safety of others or to threaten the integrity of research, or
when Montefiore reasonably believes that the resident engaged in illegal or immoral act(s)
which pertain directly to the practice of medicine, the resident may be suspended or
terminated immediately. In this circumstance, although the resident is entitled to due process,
he or she will remain suspended or terminated until or unless the suspension or termination is
reversed or modified as a result of the due process procedure.
• Step One: Informal Resolution by the Department: In the event an adverse action is
contemplated, the department will first attempt to resolve the underlying issues
informally. Procedures for such informal resolution may include some or all of the
36

following: counseling, appointment of a faculty advisor, development of a program for
remedial training, and the imposition of a term of probation.
• Step Two: Departmental Ad Hoc Committee Review: If the matter cannot be resolved
informally, the department chairperson may, in his or her discretion, convene a
departmental review with written notice to the resident. If a departmental review is
convened, the department chairperson shall appoint a departmental ad hoc committee
consisting of at least three attending physicians from the department who were not
involved in the underlying matters giving rise to the adverse action. The proceedings of
the departmental ad hoc committee consist of interviews with the resident and other
individuals and review of relevant documents. Thereafter, the departmental ad hoc
committee shall issue a report, a copy of which shall be provided to the resident. If no
resolution is achieved, the resident is entitled to request a due process hearing within a
certain time limit. If a hearing is not requested in a timely manner, the resident is deemed
to have waived his or her right to a hearing and to have accepted the adverse action.
• Step Three: Due Process Hearing: When the resident requests a hearing, the Senior Vice
President - Chief Medical Officer or designee shall appoint a formal hearing panel
consisting of no more than five physicians, at least two of whom shall be Montefiore
residents, and the balance of which shall be full-time attending physicians. The
department and the resident may be represented by legal counsel throughout the hearing.
At the hearing, the department and the resident shall have the right to call witnesses and
introduce relevant evidence. Testimony will be taken under oath, and a stenographer will
record the proceedings. Upon conclusion of presentation of the evidence, the hearing
panel will make written findings and render its decision. The party against whom an
adverse decision has been made has the right to appeal the decision of the hearing panel
by giving written notice to the President of Montefiore. The President shall undertake an
appellate review of the matter and shall make a final determination.
Please note that Montefiore's Due Process Policy is reviewed annually and may be changed
based on annual review. The version of the policy that is in effect at the time the resident is
given notice of his or her right to due process shall apply. Residents are encouraged to
review Montefiore's Due Process Policy, for further information.
The Effects of Leave of Absence from a Program
Due to the fact that all training programs have different curriculums and training requirement
needs, each department has their own policy entitled Policy on Effect of Leave for Satisfying
Completion of Program. This policy is available through your training program director or
residency coordinator.
House Staff Maternity Leave Policy
During period of disability resulting from pregnancy the House Staff Officer will first use all
accrued and unused sick leave. After sick time is exhausted while still within the disability
period, they will then be eligible for NYS Statutory Disability.
The disability period is defined as follows:
• Starts with first day out
• Up to four weeks prior to delivery
• Up to six weeks post-delivery (normal delivery)
• Up to eight weeks post-delivery (C-Section)
37

During the disability period MMC will supplement the disability with a payment to bring the
combination of disability and supplemental payment to 2/3 of their pay.
House Staff Sick Leave Policy
Each full time House Staff Officer earns paid sick leave at the rate of one day per month which is
to be used for bonafide illnesses. The House Staff Office may advance sick time of up to one
year's entitlement during your period of continuous disability or the expiration of your Resident
Agreement, whichever is earlier. Each House Staff Officer is responsible for notifying the
director of their training program, his/her Chief Resident or the residency coordinator when the
House Staff Officer is sick. The director of training or residency coordinator will notify the
House Staff Office in writing of this sick time.
House Staff Vacation Policy
One of the benefits provided to each full time House Staff Officer is 4 weeks paid vacation per
contract year. The vacation time off is granted in accordance with the individual training
program's departmental policy.
House Staff Benefit Plans
Montefiore Medical Center provides comprehensive benefit programs. You will attend a benefit
orientation wherein materials will be provided to you describing your options under the Choice
and other programs. In order to avail yourselves of these programs, you
must complete and return the appropriate forms to the Benefits Office. The number for Benefits
Office is (718) 405-4670.
Limitation of House Staff Hours
New York State Hospital Code limits post-graduate trainee working hours to 80 hours per week
averaged over a four-week period. House Staff will not be scheduled to work more than 24
consecutive hours. An additional 3 hours is permitted beyond the 24-hour limit if the purpose is
for transfer of patient information. The 3 hours may not be used to assign additional patient care
activity and the additional time is included in the 80-hour schedule. Scheduled rotations must be
separated by at least eight non-working hours and at least a 24-hour period of non-working hours
assigned each week. The Accreditation Council on Graduate Medical Education requires
scheduled rotations to be separated by at least 10 non-working hours.
Moonlighting
The Program Director must approve any employment outside the training program. House Staff
who have worked the maximum number of hours permitted by the New York State Hospital
Code are prohibited from working additional hours as physicians providing patient care.
Employment outside the training program must be pursuant to a written contract with the
Medical Center, approved by the Office of Legal Affairs. Credentialing as a member of the
medical staff with appropriate privileges is required.
Such employment is not permitted within the same clinical department in which the House Staff
member is training, even if the area of employment is outside of the training program. The Office
of Legal Affairs must approve exceptions in advance, based on new developments or
clarifications of the applicable law. The Policy is available in the
House Staff Office.
38

Physician Impairment and Drug Abuse Policy (Impaired Professionals JH23.1)
This policy governs possible impairment of all licensed professionals who provide direct, skilled
patient care and are employees and/or have clinical privileges at Montefiore, including
physicians, registered professional nurses (including nurse practitioners and certified nurse
midwives), licensed practical nurses, pharmacists, physician’s assistants, occupational and
physical therapist and social workers. This policy shall also apply to interns, residents and
fellows enrolled in formal postgraduate training programs at Montefiore. A complete copy of
the policy is located in the Administrative Policy and Procedure Manual (JH23.1). A copy of
this manual is in the House Staff Office, 150 East 210th St. or in the Administrator's office of
your individual departments.
Pre-Appointment and Annual Physical Examinations
New York State Hospital Code and Hospital Policy require each House Staff officer to complete
a pre-employment and annual examination. If you fail to complete the annual physical you will
be subject to probationary or disciplinary procedures. The pre-employment examination provides
required immunizations and skin tests and
includes a urine toxicology examination.
Professional Conduct Reporting Policy
The New York State Department of Health requires all hospitals to report in writing, the denial,
suspension, restriction, termination or curtailment of training, employment, association of
professional privileges or the denial of certification of completion of training of any physician
licensed by New York State for the following reasons:
• Alleged mental or physical impairment, incompetence, malpractice, misconduct or
endangerment of patient safety or welfare
• Voluntary or involuntary resignation or withdrawal of association or of privileges with the
Hospital to avoid the imposition of disciplinary measures
• The receipt of information concerning a criminal conviction of a crime
The Hospital must also report, in writing, to the New York State Department of Education any
change in professional status for any student or participant in a clinical clerkship, fellowship or
residency. The Hospital must report, in writing, to the Department of Health any information
which reasonably appears to show that a physician
is guilty of professional misconduct as defined in the New York State Education Law 6509. As
set forth in Section 6509, professional misconduct includes, but is not limited to, the following:
• Obtaining a Medical License Fraudulently
• Practicing the profession fraudulently, beyond his/her authorized scope, with gross
incompetence, with gross negligence on a particular occasion or negligence or incompetence
on more than one occasion
• Practicing the profession while the ability to practice is impaired by alcohol or drugs,
physical disability or mental disability
• Being habitually drunk or being dependent on or a habitual user of narcotics, barbiturates,
amphetamines, hallucinogens, or other drugs having similar effects (Refer to Adm. Pol # JH
23.01on impaired professionals)
39

• Failure to follow universal precautions regarding blood-borne pathogens as mandated by the
Department of Health
• Committing unprofessional conduct, as defined by the Board of Regents in its rules or by the
Commissioner in regulations approved by the Board of Regents
Physicians, the Hospital's Medical Director, the President of the Medical Board and the Director
of each Service are also required by law to report any information, which reasonably appears to
show that a physician is guilty of professional misconduct. However, a physician is not required
to report any information which the physician
learned solely as a result of rendering treatment to another physician.
Meal Tickets
Residents on MMC payroll or on Jacobi Payroll but doing a rotation at MMC are provided at no
charge with weekly meal tickets for up to three meals a day while they are on duty. The tickets
are given to the residency departmental coordinators for distribution every four weeks. The
coupons can be used at the MMC Food Pavilion (located in Silver Zone on 2nd Fl.), the cafeteria
at Einstein Hospital or the kiosk in the Children’s Hospital at MMC (CHAM).
On-Call Rooms
The hospital will provide each House Staff Officer with an on-call room, which is cleaned daily,
in good condition and secure. The on-call rooms are located in the Blue Zone - Loeb Building in
the rear of the Activity Room on the first floor (opposite Nurse's Station). To access a room,
please see the Security Officer in the 210th Street Lobby of the Moses site. He will present you
with a key upon checking his copy of the on-call schedule. Please check with your department
for location of additional on-call room sites.
Paychecks
Paychecks are issued every other Thursday and are available to the House Staff. The checks
may be picked up at the House Staff Office located at 150 East 210th Street. Residents may
enroll in Direct Deposit to the bank of their choice however, there is a policy they must read and
adhere to before direct deposit is allowed. The applications are available in the House Staff
Office. Direct Deposit Slips will be kept in the House Staff Office for pick-up or mailed to your
home.
Voluntary Service on -MMC Administrative Committees
The Committee on Graduate Medical Education (COGME) is an organized administrative
committee of the Albert Einstein College of Medicine that oversees all residency programs and
has the responsibility for monitoring and advising the sponsored institution on all aspects of
residency education. The committee has representation
of key academic and hospital administrators, as well as residents. Included in the responsibilities
of the COGME are the establishment and implementation of policies that affect all residency
programs regarding the quality of education and the work environment of the residents in each
program. MMC and JMC are active participants on this committee and strongly support the
mandated mission of the committee. It is the intention of MMC that residents have active
participation on important hospital committees that serve to formulate hospital policy. All
residents are invited to provide voluntary service on the administrative committees of this
Institution. The representation of residents on our administrative committees will give the
40

participants the opportunity to communicate and exchange information on their working
environment and their educational programs. Any resident who is interested in providing this
voluntary service
can pick up a form from the House Staff Office or call Elaine Taylor or Justice Gaba at the
House Staff office (718) 920-4091 and a form can be faxed to your location.
Admissions, House Staff
Montefiore Medical Center shall accept patients whose care and treatment are appropriate to an
acute care hospital, based upon accuracy and bed availability, to either a teaching or nonteaching
service, based upon the policies and procedures of each admitting/clinical
department. The hospital shall admit as patients only those persons who require the type of
medical service authorized by the hospitals operating certificate. These services shall include:
medicine, neurology, neurosurgery, ophthalmology, pediatrics, surgery, radiation oncology,
oncology, cardiac surgery, thoracic, vascular, oral surgery, otolaryngology,
plastic surgery, urology, orthopedics, gynecology and psychiatry. Except in emergencies, the
hospital shall not admit any patients to a clinical service which it is not authorized to provide by
the current operating certificate. No person shall be denied admission to the hospital because of
race, creed, color, natural origin, sex, etc. (see policy # EEO statement or Institution) or source of
payment except for fiscal capability thereof. Patients may be admitted only by those physicians
holding active appointments to the Medical Staff. The responsibility for initiating the admitting
process resides with the attending physician, or his/her designee. Each patient admitted shall
have an attending physician at the time of admission. The attending physician shall be
responsible for the
medical care and treatment of each of his/her patients throughout the hospital stay.
Except in cases of emergency, no patient shall be admitted until a provisional diagnosis has been
stated. In cases of emergency, the provisional diagnoses shall be stated as soon as possible
following admission. Each patient shall be admitted to that service of the hospital appropriate to
the treatment of the condition of the patient. Each intensive and special care unit has a Medical
Director responsible for managing the care within the unit. Admissions and transfers to/from the
units are the responsibility of the Unit Medical Director, or designee in consultation with the
attending physician/house officer and nursing services. No patient on a teaching service shall be
exempt from participation
in a medical student or house staff educational program. Each patient on a teaching service shall:
• Be seen by a house officer on the admitting service promptly following admission (on nonteaching
services, the attending provider or his/her designee will see the patient promptly
following admission).
• Each patient must have a complete history and physical examination including a breast,
uterine cytology and rectal examination, as appropriate, documented in the medical record
within 24 hours of admission.
• The Attending Physician or designee shall be responsible for countersigning the history and
physical examination.
• Qualified oral surgeons who admit patients without medical problems may perform the
history and physical examination on those patient, if the oral surgeon has been granted
privileges.
• If a qualified member of the hospital's medical staff has obtained a complete history or has
performed a complete physical examination within seven (7) days prior to the patient's
41

admission to the hospital, a durable, legible copy of the report may be used in the patient's
medical record, provided that an internal admission note is recorded that includes all
additions to the history and any changes in the physical findings subsequent to the original
report.
• When a patient is readmitted to this hospital within 30 days for the same or related problem,
an interval history and physical examination reflecting subsequent history and changes in
physical findings may be used, provided the original information is readily available.
• A history and physical examination appropriate to the ambulatory surgery patient must be
performed prior to surgery.
Chart Completion Policy for House Officers
Purpose: To provide a process by which disciplinary action can be applied to house officers who
fail to comply with chart completion standards.
Mandate: Both NYS and the JCAHO mandate a time frame for completion of medical records.
Failure to meet the requirements of these standards places the Medical Center at risk for both
financial and operational hardships.
Authority: Signing of the MMC House Staff contract indicates that the house officers agree to
comply with the rules and regulations of MMC and its sub-divisions including the completion of
medical records.
Laundry & Linen Service
Residents are required to wear prescribed apparel in training. The lab coats or jackets are cleaned
free of charge when they are dropped off at the laundry office located at the rear of the Food
Pavilion in the North Building (Silver Zone) second floor.
The hours of operation are:
Mon., Wed., Fri. 7:00AM - 3:00PM
Tues., Thurs. 9:00AM - 5:00PM
Uniform Room: (718) 920-5357
Parking
Subsidized garage parking is available to all incoming House Staff doctors on the Hospital
premises. There is also garage parking available at 3450 Wayne Ave. (MH-II) and 3636 Waldo
Ave. (MH-III) There is an additional charge for parking. Phone Number: (718) 920- 6131
Shuttle Buses
AECOM SHUTTLE
Residents, Medical Students and designated faculty are provided with transportation to the East
and West Campuses. (see schedule)
AECOM Shuttle Stop Locations
WAECOM 1600 Tenbroeck Avenue
AECOM in front of Belfer Educational Center Building
BMHC Entrance to outpatient Clinics on Pelham Parkway
MMC Montefiore No. Bldg. entrance Gun Hill Rd.
Note: You must show your I.D. Card to use the bus
42

WALDO AVENUE SHUTTLE
Those residents living at 3636 Waldo Avenue in Riverdale have access to a commuter van which
brings them to and from the Moses Campus. The schedules are available in the House Staff
Office or the Housing Office at 3450 Wayne
Avenue, 2nd floor.
Waldo Avenue Shuttle Schedule: Monday - Friday
Departs from Waldo to Monte: 6:30AM, 7:30AM, 8:30AM
Departs from Monte to Waldo: 5:00PM, 6:00PM, 7:00PM
FORDHAM SHUTTLE
The shuttle is located at the 210th Street entrance to Montefiore. The shuttle departs from Moses
site every hour beginning at 8:00 AM. The shuttle departs from Fordham Plaza every half-hour
beginning at 8:30 AM.
AECOM- MMC MEDICAL CENTER SHUTTLE SCHEDULE
Buses operate Monday through Friday. Riding time between campuses is 12-15 minutes. Please
wait if it is delayed–the bus will not leave before departure time.
BMHC RHINE WHAE - AECOM MMC BMHC AECOM
COM
8:10am 6:25am 8:15am 6:30am 6:50am 7:03am 7:15am
8:55 6:55 9:00 7:00 7:20 7:40 7:45
9:40 7:10 9:45 7:15 7:35 7:48 7:51
10:25 7:40 10:30 7:45 8:05 8:25 8:30
11:10 8:12 11:15 8:20 8:50 9:03 9:06
11:55 8:57 12:00pm 9:05 9:35 9:55 10:00
12:40pm 12:45 9:50 10:20 10:33 10:36
1:25 1:30 10:35 11:05 11:25 11:30
2:10 2:15 11:20 11:50 12:03pm 12:05pm
2:55 3:00 12:05pm 12:35pm 12:55 1:00
3:40 3:45 12:50 1:20 1:33 1:36
4:25 4:30 1:35 2:05 2:25 2:30
5:10 5:15 2:20 2:50 3:03 3:06
5:55 6:00 3:05 3:35 3:55 4:00
3:50 4:20 4:33 4:36
4:35 5:05 5:25 5:30
5:20 5:50 6:03 6:06
6:05 6:35 6:55 7:00
Employee Assistance Program
The Employee Assistance Program (E.A.P.) is available to assist employees with emotional,
substance abuse and interpersonal problems. All self-referrals are confidential.
(718) 882-5920 (Moses Division)
(718) 518-8107 (Weiler Division)
43

Housing
Montefiore Medical Center Housing refers to Montefiore Hospital Housing Co., Inc.
There are three types of apartments available: One and Two Bedroom units and studios.
• MH-I: 3411 Wayne Avenue, Bronx, N.Y.
Constructed in 1965. The Apartment building has very limited availability. There is 24 hour
security guard service, seven (7) days a week. Each apartment has an intercom and buzzer
system to speak into which connects you to the Security desk in the lobby.
• MH-II: 3450 Wayne Avenue, Bronx, N.Y
Constructed in 1972. The building is a 28 story hi-rise with central air conditioning and all units
have terraces and include utilities (Gas and Electric). There is 24-hour security guard service,
seven (7) days a week. Each apartment has an intercom and buzzer to speak into which connects
you to the Security desk in the lobby.
• MH-III: 3636 Waldo Avenue, Riverdale, N.Y.
Constructed in l991. There is 24-hour security guard service, seven (7) days a week. There is an
intercom and individual security system for each apartment. Shuttle Bus service is available (see
section “Shuttle Buses”).
MONTEFIORE HOUSING POLICIES AND PROCEDURES
Due to increased demand for staff housing the following occupancy and lease policies are
effective as of this date for all Montefiore housing:
• The units are available only to those employees of the medical center who are in residency or
fellowship programs approved by the Accreditation Council for Graduate Medical Education
or employees who are in the Surgical Physician Assistant Training Program.
• Montefiore employees other than house officers, fellows or physician's assistants referred to
above currently residing in staff housing may continue to lease their current apartments as
long as they are employed by the medical center.
• Montefiore employees who have terminated or will terminate through retirement or
permanent disability prior to July 1, 1996, while tenants of Montefiore staff housing, will be
eligible for lease renewals in accordance with the terms and rents established by Montefiore.
• Montefiore employees who terminate by reason of retirement or permanent disability after
July 1, 1996, who at the time of termination are tenants of Montefiore staff housing, may
remain in their units no longer than six (6) months after the date of termination.
While individuals may request a particular building or size of apartment, no assurance can be
given that such a request can be met. Due to the shortage of apartments, it has been necessary to
establish priorities for the assignment of housing.
First priority for housing will be given to incoming House Staff- First Year Residents
arriving from long distances. Proof of your current residence must be given to the Housing
Office. Whenever possible, the first year residents will be assigned housing at MH-I, MH-II.
After the needs of these residents have been satisfied, any apartments that may still be available
will be assigned in the following order:
• Second year residents (According to distance)
• Physician Assistants – For internship year only
• Fellowship programs approved by the Accreditation Council for Graduate Medical
Education.
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First Year Residents: Assignments of incoming first year residents will be based upon
information provided to the Housing Office. Assignments will be made according to distance.
The farther away he/she is coming, the more likely they are to receive housing. Family
composition is also considered. Proof of the resident's current address (Telephone bill, utility
bill, etc.) must accompany the Housing application. To the extent possible, they will be assigned
apartments according to their preferences and needs. Priority for MH-I and MH-II housing will
be given to first year residents coming long distances. All other applicants will be referred to the
Riverdale apartments (MH-III). Guidelines for Apartment Assignments:
• Studio apts. may be shared by no more than two (2) individuals. Single residents will receive
studios, provided there are no married couples in need of these accommodations. (Proof of
marriage is required).
• One Bedroom Apts. must be shared by a minimum of two (2) individuals. A married couple,
after providing acceptable proof of marriage will receive a one-bedroom apartment when
available.
• Two Bedroom Apts. must be shared by a minimum of three (3) individuals. An employee
may occupy an apartment with spouse and children only.
WAITING LIST
Anyone who is not assigned an apartment in May, will go on a waiting list. All applications are
separated by size of apartment, (2 bedrooms, 1 bedroom, Studio ). Each category is then further
defined by the distance to be traveled by the doctor.
The groups are then further separated as follows: Married with children first; singles who will
share apartments next; married without children; and singles last.
All those doing clinical work will get priority over doctors who will not have direct patient
contact . We will go down the waiting list as apartments open up during the
year.
ADDITIONAL HOUSING POLICIES AND PROCEDURES
• Entering tenants must deposit one month's rent as a security deposit and pay the first month's
rent before obtaining the key to an apartment. Separate checks are required. The security
deposit check must be either a Certified Check or Money Order. Cash is not accepted. The
move-in date for House Staff residents is July l of each year.
• Eligibility - If a resident leaves Montefiore Medical Center at any time during the term of
their House Staff contract, the lease agreement is terminated and the tenant must vacate the
apartment within thirty (30) days.
• House Staff residents, upon completion of residency must vacate their apartment, even if
continuing in employment with the Hospital under another status, no later than June 30 th of
the year of completion of residency.
• Residents may not sublet their apartments. All rentals must be arranged directly through the
Housing Office. Individuals who abuse this policy will have their leases terminated and will
be subject to eviction.
• Sharing - Each employee in a shared apartment must sign a separate lease agreement. If one
party moves, the remaining tenant will be responsible for the full rent. If the remaining
tenant is occupying a one or two bedroom apartment, the Housing Office will assign a new
co-employee. The original employee will have the option of moving to a studio if one is
45

available. A single remaining employee may not occupy the apartment alone on a continuing
basis.
MOVE-OUT PROCEDURES
• The Housing Office should be notified in writing 30 days prior to your move-out date. Your
forwarding address should be included in order that we may return your security deposit.
• Return your apartment, mailbox and front door keys to the Housing Office. Failure to do so
will result in a $50.00 charge against your security deposit.
REPAIRS AND SERVICES
Maintenance requests must be called into the Housing Office at (718) 920-5088. Repairs will be
performed between the hours of 8:00AM to 4:00PM You must either leave your top lock
unlocked, allowing us permission to enter, or someone must be home.
LAUNDRY ROOMS
The Laundry room is located on the lobby level at MH-I and MHII, and in the basement of MH-
III.
MAILBOXES
When coming to pick up your bulk mail you will be asked for a proper form of identification.
Proper identification will be a driver’s license or a Hospital Identification badge with the same
name as the name on the parcel.
AIR CONDITIONING
The apartments at MH-I, MH-II and MH-III are air-conditioned.
CABLE TV
Cable TV is available at all locations at a nominal charge.
TERRACES
All apartments at MH-II have terraces. There is a limited amount of terraces at MH-I. All other
buildings do not have terraces.
46

SECTION III
•
MONTEFIORE MEDICAL GROUP
47

MONTEFIORE MEDICAL GROUP (MMG)
Montefiore Medical Group offers a full range of comprehensive primary care services to adults
and pediatrics including OB/GYN, family planning, preventive health care, nutrition and health
education. Employing approximately 1,000 physicians, physician extenders, nurses, medical
technicians, support staff and administrators in 21 sites throughout the Bronx and Southern
Westchester, MMG is committed to improving the health and well-being of the communities
served. Members of the MMG team work in partnership with patients and their families, sharing
in the responsibility and accountability for the maintenance and improvement of their health. In
addition to the core primary care services, MMG offers supplemental targeted programs
including:
• HIV outreach, screening, counseling
• Care for the Homeless Team
• School Health
• Women, Infant, Children (WIC) Program
What makes MMG unique is its relationship to the Medical Center. Through its 21
neighborhood offices, MMG gives patients access to primary, obstetric and gynecological care
and provides referrals to the Medical Center's specialty services. Information regarding MMG
Administration and the individual sites is listed below.
Montefiore Medical Groups Administration:
3411 Wayne Avenue, 1st floor
Bronx, NY 10467
Tel: 718-920-4245
Fax: 718-405-2097
Executive Director: Terry Goodwin
Director of Operations: Arnel Tirado
• MMG 2 and 4
Director of Operations: Michael Bookchin
• MMG 1 and 3
Medical Directors:
• MMG 1: Arthur Hopkins, MD
• MMG 2: Jonathan Swartz, MD
• MMG 3: Donald Raum, MD
• MMG 4: James Stulman, MD (Internal Medicine)
Andrew Racine, MD (Pediatrics)
MMG 1 SITES:
Astor Avenue Pediatrics
1500 Astor Avenue
Bronx, NY 10469
Tel: 718-881-0100
Fax: 718-881-7752
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Administrator: Jennifer Ortiz
Medical Director: Richard Weiner, MD
Specialty: Pediatrics
Burke Avenue
941 Burke Avenue
Bronx, NY. 10469
Tel: 718-654-5900
Fax: 718-654-0053
Administrator: Laurie Fuentes
Medical Director: Michael Bagner, MD
Specialties: Internal Medicine and Pediatrics
Co-Op City (Bay Plaza)
2100 Bartow Avenue
Bronx, New York 10475
Tel: 718-320-5300
Fax: 718-320-1116
Administrator: Camille Costa
Medical Director: W. Roy Michaelis, MD
Specialties: Internal Medicine, Pediatrics
Eastchester
685 White Plains Road
Eastchester, NY 10709
Tel: 914-395-1530
Fax: 914-395-1559
Administrator: Rita Punch
Medical Director: Howard Garson, MD
Specialties: Internal Medicine, Pediatrics, Allergy, Adolescent Medicine, Endocrinology, Sleep
Disorder
Greene Medical Arts Pavilion (MAP)
3400 Bainbridge Avenue
Bronx, New York 10467
Tel: 718-920-8888
Fax: 718-519-1164
Administrator: Angie Mercado
Internal Medicine Medical Director: Anna Maria Assevero, MD
Peditric Medical Director: Mohini Kaul, MD
Specialties: Internal Medicine, Pediatrics, Infectious Diseases, Endocrinology, and Pediatric
Hemotology.
Riverdale
3510 Johnson Avenue
Bronx, NY 10463
49

Tel: 718-601-8205
Fax: 718-601-8693
Administrator: Joanne Gasparini
Medical Director: David Levey, MD
Specialty: Internal Medicine
White Plains Road
2100 White Plains Road
Bronx, NY 10462
Tel: 718-892-1626
Fax: 718-892-7060
Administrator: Laurie Fuentes
Medical Director: Michael Bagner, MD
Specialties: Internal Medicine, Pediatrics
MMG 2 SITES
Castle Hill
2175 Westchester Avenue
Bronx, New York 10462
Tel: 718-829-6770
Fax: 718-904-9145
Administrator: Jonas Attuh-Mensah
Medical Director: Frank Silagy, MD
Specialties: Family Medicine, OB-GYN, Dental
Comprehensive Health Care Center (CHCC)
305 E. 161st Street
Bronx, New York 10451
Tel: 718-579-2500
Fax: 718-579-2599
Administrator: Donald Velazquez
Medical Director: Andrea Rich, MD / Pediatric
Medical Director: Joeseph Deluca, MD / Internal Medicine
Medical Director: Ronald Dedek, MD / OBGYN
Specialties: Internal Medicine, Pediatrics, OB/GYN, Podiatry, Ophthalmology, Dermatology,
Dental
Comprehensive Family Care Center (CFCC)
1621 Eastchester Road
Bronx, NY 10461
Tel: 718-405-8040
Fax: 718-405-8050
Administrator: Carol Lau, FNP
50

Medical Director: Marta Rico, MD, Andrew Racine, MD and Peter Bernstein, MD
Specialties: Internal Medicine, Pediatrics, OB/GYN, Ophthalmology, Surgery, Dental,
Nephrology-Renal, Gastroenterology, Endocrine, Immunology, Allergy, Pulmonary,
Rheumatology, Podiatry, Neonatology-Developmental, HIV/AIDs care.
Family Health Center (FHC)
360 East 193 rd Street
Bronx, NY 10458
Tel: 718-933-2400
Fax: 718-367-8168
Administrator: Jose Delgado
Medical Director: Zach Rosen, MD
Specialties: Family Medicine, Podiatry, Cardiology
Fordham Family Practice (FFP)
One Fordham Plaza
Bronx, New York 10458
Tel: 718-405-4010
Fax: 718-405-4058
Administrator: Geraldine Bennett
Medical Director: Marion Bobb-McKoy
Specialties: Family Medicine, OB/GYN
Marble Hill (MHFP)
5525 Broadway
Bronx, NY 10463
Tel: 718-884-0279
Fax: 718-548-3867
Administrator: Jean Guilloteau
Medical Director: David Savarese, MD
Specialties: Internal Medicine, Pediatrics, OB-GYN, Dental
University Avenue Family Practice
105 West 188th Street
Bronx, NY 10468
Tel: 718-563-0757
Fax: 718-563-0756
Administrator: Gloria Farre-Munoz
Medical Director: Robert Clarick, MD
Specialties: Internal Medicine, Pediatrics, OB/GYN
West Farms Family Practice
1055 East Tremont Avenue
Bronx, NY 10460
Tel: 718-842-8040
Fax: 718-842-8394
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Administrator: Jonas Attuh-Mensah
Medical Director: Clement Landanno, MD
Specialties: Family Medicine, OB/GYN
Williamsbridge Family Practice Center (WBFP)
3448 Boston Road
Bronx, New York 10469
Tel: 718-547-6111
Fax: 718-547-4749
Administrator: Blanche Doati
Medical Director: Noel Brown, MD
Specialties: Family Medicine, OB/GYN, Cardiology
MMG 3 SITES
Bronx East
2300 Westchester Avenue
Bronx, NY 10462
Tel: 718-829-1900
Fax: 718-409-8023
Administrator: Denise Taylor
Medical Director: Donald Raum, MD
Specialties: Internal Medicine, Pediatrics, Ophthalmology, Optometry, Surgery, Urology,
Radiology, Physical Therapy
Co-Op City (Dreiser Loop)
115 Dreiser Loop
Bronx, New York 10475
Tel: 718-320-6300
Fax: 718-379-1688
Administrator: Kathy Raftery
Medical Director: Sheila Rabinowitch, MD
Specialty: Internal Medicine
Cross County
1010 Central Park Avenue
Yonkers, N.Y. 10704
Tel: 914-964-4000
Fax: 914-964-4044
Administrator: Linda Woolsey
Medical Director: Norbert Wolloch, MD
Specialties: Internal Medicine, Pediatrics, Surgery, Ophthalmology, Optometry, Rehabilitation
Medicine, Radiology
Grand Concourse
52

2532 Grand Concourse
Bronx, New York 10458
Tel: 718-960-1500
Fax: 718-960-1501
Administrator: Kenneth Siegel
Medical Director: Arthur Weiner, MD
Specialties: Internal Medicine, Pediatrics, Surgery, OB/GYN, Radiology
MMG 4
Family Care Center
Montefiore Medical Center
3344 Kossuth Avenue
Bronx, NY 10467
Tel: 718-920-7332/5859
Fax: 718-653-5294
Administrator: Jorge Rodriguez
Internal Medicine Medical Director: James Stulman, MD
Pediatrics Medical Director: Andrew Racine, MD
Specialties: Internal Medicine, Pediatrics, OB/GYN, Developmental Psych, GI, Podiatry,
Palliative Care, Neurolgy, Hematology, Pulmonary, Endocrinology, Plastic Surgery, Sleep/Wake
Disorders
SCHOOL HEALTH
ADMINISTRATION
3380 Reservoir Oval
Bronx, New York 10467
Fax: 515-7741
David Appel, MD
Director
Phone: 718-696-4070
Shanti Jimenez, MBA
Operations Manager
Phone: 718-696-4071
Megan Charlop
Director of Community Health
Phone: 718-696-4053
Carmen Correa
Office Coordinator
Phone: 718-696-4056
53

Isseline Collazo
Account Representative
Phone: 718-696-4061
Kari Collins, Ph.D.
Director of Mental Health
Phone: 718-696-4065
Annie Dhanraj
Research Assitants
Phone: 718-696-4064
Claire Fong, MPH
Site Administrator
Phone: 718-696-4067
Ennis Jackon
Data Manager
Phone: 718-696-4059
Linda Juszczak
Director of Training and Education
Phone: 718-696-4054
John Leo, MD
Medical Director
Phone: 718-696-4069
Michelle Odlum, MPH
Research Program Coordinator
Phone: 718-696-4058
Lynn Reitman, MD
Director of Psychiatry
Phone: 718-696-4068
S. Kenneth Schonberg, MD
Consultant
Phone: 718-696-4062
Mayris Webber, Ph.D.
Director of Research
Phone: 718-655-0037
P.S. 8
54

Briggs Avenue Academy
3010 Briggs Avenue
Bronx, New York 10458
Provider: Amy Hanson, MD
Mental Health Provider:
Leah Murphy, PhD
Arielle Goldklang
Tim Silverman, CSW
Nurse: Practice Collins, LPN
Receptionist: Maggie Martinez
Marie Nieves
Phone: 718-563-5263/584-5014
Fax: 718-295-4587
CES 28
1861 Anthony Avenue
Bronx, New York 10457
Provider: Jackie Kelderhouse, FNP
Mental Health Provider:
Kari Collins, Ph.D.
Annette Zygmunt, PhD
Nurse: Iris Pimentel, LPN
Receptionist: Isseline Collazo, PCT
Phone: 718-901-2849
Fax: 718-583-6453
M.S. 45
2502 Lorillard Place
Bronx, New York 10458
Provider: Glenda Long, FNP
Mental Health Provider:
Chrystal Hurst, CSW
Nurse: Audrey Murphy, LPN
Receptionist: Issabelle Perez
Phone: 718-584-2936/ 718-295-4628
Fax: 718-367-9668
P.S./M.S. 95
3961 Hillman Avenue
Bronx, New York 10463
Provider: Samantha Fuster, FNP
Karen Haddad, FNP
Mental Health Provider:
Jennifer Cleveland, PhD
Nurse: Royrie Larkins, LPN
Receptionist: Lissette Aybar
55

Phone: 718-796-3440
Fax: 718-601-2357
P.S. 105
725 Brady Avenue
Bronx, New York 10462
Provider: Frances Douglass, MD
Lorraine VonEeden, PNP
Mental Health Provider:
Andrea Vaccarriello, CSW
Nurse: Nicole Gomez, LPN
Receptionist: Martha Colon
Phone: 718-828-3235
Fax: 718-828-3235
I.S.216/217
Rafael Hernandez Academy
977 Fox Street
Bronx, New York 10459
Provider: JoAnn Thomas, PNP
Mental Health Provider:
Laura Guy, CSW
Nurse: Joyce Dixon, LPN
Receptionist: Millie Ayala
Phone: 718-617-4449
Fax: 718-617-4756
South Bronx High School
701 St. Ann's Avenue, 3rd Fl
Bronx, New York 10455
Provider: Carla Hundt, MD, FAAP
Mental Health Professional: Kori Eldean, Ph.D.
Nurse: Roseann Alston, LPN
Receptionist: Marta Ramos
Phone: 718-402-7618
Fax: 993-4672
DeWitt Clinton
100 W. Mosholu Parkway
Bronx, New York 10468
Provider: Norma Ellis, FNP
Margee Rogers, FNP
Linda Juszczak, FNP
Neal Hoffman, MD
Mental Health Professional: Rob Diamond, CSW
Christina Lima, CSW
56

Nurse: Maria Campos, LPN
Sheila Montegue, LPN
Receptionist: Yocasta Veasquez
Sandy Valoy
Phone: 718-549-8022/549-7934
Fax: 718-549-7977
Martha Neilson/Bronx Regional
979 Rogers Place
Bronx, New York 10459
Provider: Margret Rosenberg, MD
Mental Health Provider:
Tanya Johnson, CSW
Nurse: Angela Chaney, LPN
Receptionist: Romana Moreira
Phone: 718-589-5665
Fax: 718-589-5509
Walton High School
2780 Reservoir Oval
Bronx, New York 10468
Provider: Gail Shafran, FNP
Mental Health Provider: Rachel Sheffet, PhD
Nurse: Millie pabon, LPN
Receptionist: Mari Valentin
Phone: 718-364-2450
Fax: 718-562-4357
HOMELESS PROGRAM
ADMINISTRATION
MMG Family Health Center (FHC)
360 E. 193rd Street
Bronx, NY 10458
718-405-4067
Fax # 718-405-4148
Administrator
Deborah Barrow
MMG FHC Care for the Homeless Program provides comprehensive primary health care
services, health maintenance/preventive care, to adults and pediatric populations residing in
shelters, soup kitchens, assessment shelters, drop in centers and to the street homeless.
JACKSON AVENUE FAMILY RESIDENCE
691 E. 138th Street
Bronx, NY 10454
57

718-993-8900 x51
Fax # 718- 993-1865
Crosby Inman - Director
NELSON AVENUE FAMILY RESIDENCE
1605 Nelson Avenue
Bronx, NY 10453
718-299-5550 x319
Fax # 718- 299-5558
Marjorie Jeamnot – Director
P.O.T.S (PART OF THE SOLUTION)
2763 Webster Avenue
Bronx, NY 10458
718-220-4892
Fax # 718-220-5603
Sr. Mary Alice Hannan - Director
THORPE FAMILY RESIDENCE
2252 Crotona Avenue
Bronx, NY 10457
718-933-7312
Fax # 718-933-7311
Sr. Madeline Cipriano - Director
LIVINGROOM
890 Garrison Avenue
Bronx, NY 10474
718-893-3606
Fax # 718-893-3680
Noel Conception - Director
H.E.L.P. SUPPORTIVE EMPLOYMENT SHELTER PROGRAM
1 Wards Island
New York, NY 10035
212-534-3866 ext. 170 (Provider)
212-534-3866 ext. 171 (RN)
212-534-3866 ext. 170 (Medical Assistants)
Fax # 212 -369-3763
Jerry Heaney - Director
LOVE GOSPEL
2315 Grand Concourse
Bronx, NY 10457
718-295-6366
Fax # 718-733-2689
58

Gloria Feliciano – Director
FRANKLIN WOMEN SHELTER
1122 Franlin Avenue
Bronx, NY 10456
718-842-9797
Fax # 718-842-0859
Joan Alston – Director
JAMAICA ASSESSMENT CENTER
175-10 88 th Avenue
Queens, NY 11432
718-262-1288
Fax # 718-298-5439
Franca Okeya – Director
WIC PROGRAM
Manager
Jennifer Klein RD
MMG WIC - SITE 1
22 Westchester Square
Bronx, NY 10461
718-829-4001
Fax # 718-239-2546
Supervisor: Lisa Fermin
MMG WIC - SITE 2
4782 Third Avenue
Bronx, NY 10458
718- 405-4066
Fax # 718-405-4148
Supervisor: Claudette Robinson
MMG WIC - SITE 3
3 05 E. 16 1st (CHCC)
Bronx, NY 10451
718-579-2589
Fax # 718-681-4203
Supervisor: Elaine Jones
59

SECTION IV
•
CLINICAL DEPARTMENTS
60

ANESTHESIOLOGY
Chairman 718-920-2802
Albert J. Saubermann, MD 718-881-2245
Residency Program Director
Allison Spinelli, MD 718-920-4383
Site Directors:
Moses – John Wasnick, MD 718-920-4316
Weiler - Robert Lagasse, MD 718-904-2872
Administrative Staff:
Unified Administrator: Samuel Hamilton
Penny Sanchez, Practice Manager
Residency Coordinator: Debbie Rivera
Technical Supervisor: Andrew Nembhard (Moses) – George Davidson (Weiler)
Anesthesiology Departmental Offices at both sites are open from 8:00 AM to 5:00 PM, Monday
through Friday.
MOSES
Main Number 718-920-4316
Control Number 718-920-5268
WEILER
Main Number 718-904-2872
Control Number 718-904-2798
Fax Number 718-822-6180
Graduate Medical Education Office 718-920-4383
718-653-2367
Unified Administrator 718-920-4440
OB Anesthesiology - Weiler 718-904-2979
Anesthesiology Technical Support
Moses
Weiler
Billing Services
Penny Sanchez: Practice Manager
Marie Ficarra
Research Services
718-920-5275 Moses
718-904-2875 Weiler
718-920-2409 Moses
718-904-2250 Weiler
718-920-4316 Moses
61

CARDIOLOGY
Interim Division Director
Mark Greenberg, MD
Scott Monrad, MD
Fellowship Directors
James Scheuer, MD (Einstein Cardiology) 718-920-5979
Kevin Ferrick, MD (Bronx-Lebanon Cardiology)
John Fisher, MD
(Electorphysiology)
Scott Monrad, MD (Interventional Cardiology)
The Cardiovascular Division provides comprehensive diagnostic and therapeutic cardiac services
with a commitment to clinical excellence, administrative leadership, educational responsibility
and research development.
CONSULTATIVE SERVICE
Moses Division 718-920- 4116
Weiler Division 718-904-2927
Sophisticated, evidence based consultative cardiological services are provided at both campuses.
NON-INVASIVE CARDIOLOGY
Moses Laboratory Director
Daniel Spevack
Weiler Laboratory Director
Garet Gordon, MD 718-920-7638
The non-invasive laboratories at the Moses and Weiler Divisions provide a full range of services
including echocardiography, transesophageal echocardiography, stress testing, exercise stress
testing, dobutamine echocardiography and holter monitoring
CARDIAC CATHETERIZATION
Moses Director
Mark Greenberg, MD 718-920-4212
Weiler Director
E. Scott Monrad, MD 718-904-2071
The Heart Center has six modern cardiac catheterization laboratories, with three located at the
Moses division and three at the Weiler divisions. They provide a full range of diagnostic and
interventional services. The physician interventionalists are available around the clock through a
24-hour on call system. They are supported by a staff of physician assistants, nurses, x-ray
technicians and cardiovascular technicians.
ELECTROPHYSIOLOGY (EP)/ ARRHYTHMIA
62

Director
John Fisher, MD 718-920-4291
The Electrophysiology/Arrhythmia Service has two EP laboratories, and provide a full range of
diagnostic procedures, including tilt-table testing, signal-averaged EKG, heart-rate variability
studies and ST segmented analysis for ischemia. The arrhythmia specialists are expert in the
implantation of cardiac defibrillators and pacemakers as well as radio frequency ablations. The
program offers pacemaker and defibrillator implants on both campuses, and the other invasive
services at the Moses Campus.
CONGESTIVE HEART FAILURE
Directors
Thierry LeJemtel, MD W 718-904-2193
M 718-920-2248
The Congestive Heart Failure (CHF) Service employs an integrated, multidisciplinary treatment
program. It is a major testing site and research center for treatment innovations. A major focus
of the CHF Service is on helping older patients with heart failure feel better while increasing
their ability to function independently. Services are available on both campuses.
HEART TRANSPLANT
In a coordinated program with Cardiothoracic surgery, the heart transplant service provides stateof-the-art
device based hemodynamic support and cardiac transplantation in patients with endstage
myocardial failure. This service is supported by Dr. LeJemtel
and can be contacted at 920-2483.
HEALTHY HEART PROGRAM
Director
Robert Forman, MD
The Healthy Heart Program reaches out to people in the community, particularly senior citizens,
who are at risk for heart disease through ongoing screenings, education and prevention
initiatives. The Heart Center conducts exciting new research, such as studies of angiogenesis, the
body's natural ability to grow new blood vessels, which may change the way cardiac patients are
treated in the future.
INFORMATION SERVICES
The Cardiovascular Division is committed to the highest standards of patient care, which today
requires immediate, around-the-clock access to all clinical information. This goal is being met
by the integration of the following systems within the practice:
• Phamis LastWord – “spine” system for medical information
• Apollo Cardiology Information System – records cardiology specific information
• MUSE system - manages electrocardiographic information
• MedCon Digital Imaging Archiving System – for recording electrophysiological,
electrocardiographic, and catheter-based angiographic studies
CARDIOTHORACIC SURGERY
Acting-Chairman
63

Steven Keller, MD
Residency Program Director
Jeffrey P. Gold, MD 718-920-7000
Residency Program Coordinator
Jerilyn Moreschi 718-920-7000
Administrator – To be determined 718-920-5381
West Campus: 3400 Bainbridge Ave. 5th Floor
East Campus: 1575 Blondell Avenue. Ste 125 718-920-8248
CHILD PSYCHIATRIC OUTPATIENT DIVISION
Medical Director
Carol Hnetila, DO 718-920-7255
Director Child/Adolescent Psychology
Director Adolescent Depression and Suicide Program
Alec Miller, PsyD 718-920-7666
Chairperson Quality Improvement
Carol Hnetila, DO 718-920-7255
Director Consultation Liaison
Ruben Gonzalez, MD 718-920-5463
Intake Coordinator
Margaret Lescher 718-920-5466
DENTISTRY
Chairman
Richard Kraut, DDS 718-920-4984
Administrator
Charles Brockett 718-920-4167
RESIDENCY COORDINATORS
General Practice
Agueda Maldonado 718-405-8193
Oral Surgery
Cathlene Castillo 718-920-5993
Prosthodontics
Christine Clarke 718-920-5996
Orthodontics
Cheri Williams 718-920-5997
Pediatric Dentistry
64

Christine Clarke 718-920-5996
PROGRAM DIRECTORS
General Practice
Julie Kazimiroff 718-920-5142
Oral Surgery
Richard Kraut, DDS 718-920-4984
Orthodontics
Anthony Maganzini, DDS, MSD 718-920-2385
Prosthodontics (Interim Director)
Barry Goldman, DDS 718-920-2381
Pediatric Dentistry
Nuntia Kakanantadilok, DDS 718-519-3304
EMERGENCY SERVICES
Proffessor and Chairman
E. John Gallagher, MD 718-920-7459
Site Residency Director
Lynne Holden, MD 718-920-2066
Moses Division Medical Director
Michelle Davitt, MD 718-920-4049
Weiler Chief of Service
Joseph Braverman, MD 718-904-2905
Vice President, Clinical Services
Peter Semczuk, DDS, MPH 718-741-2570
EPIDEMIOLOGY & POPULATION HEALTH
Chairman
Tom Rohan, PhD 718-430-2358
Vice Chairman
Ellie Schoenbaum, MD 718-655-1809
Executive Administrator:
John Cecconi 718-430-3029
Moses Administrator 718-920-6742
Ingrid Symes
718-652-1343 Fax
Moses Division
65

3347 Steuben Avenue
Mail: 111 East 210 th Street
Weiler Division- AECOM 718-430-2281
Belfer 13, 1300 Morris Park
FAMILY MEDICINE
Department Chairman
Peter Selwyn, MD 718-920-2434
3544 Jerome Avenue
Albert Einstein College of Medicine 718-430-2900, 2154
1300 Morris Park Avenue, Belfer 902 718-430-8816 Fax
Chief of Service 718-920-7088
Jonathan Swartz
718-575-5416 Fax
Administrator 718-920-7802
Paul Meissner
718-515-5510 Fax
Secretary
Evelyn Rivera-Lipnicky 718-920-8434
FAMILY PRACTICE
3544 Jerome Ave.
Residency Coordinator
Nicole Lewis 718-920-2815
Residency Program Director
Mary Duggan, MD 718-920-5521
Family Practice has a strong commitment to changing and improving the quality of care for
individuals and families primarily in underserved areas of the inner city. The department's
residents receive inpatient and outpatient training in a wide variety of medical and surgical
general and subspecialty services with additional training in nutrition prenatal care, family
systems psychosocial evaluation and the care of HIV infected patients.
SOCIAL MEDICINE
3544 Jerome Ave.
Residency Program Director
Jerry Paccione, MD 718-920-5521
The Social Internal Medicine residency program emphasizes training in continuity care for innercity
adults. The three year program includes training in inpatient services including subspecialty
electives, a broad spectrum of medical conferences, outpatient clinical experiences and the
innovative primary care curriculum of ambulatory morning rounds, clinical Epidemiology
courses, behavioral medicine, community oriented primary care, and health and human rights.
66

SOCIAL PEDIATRICS
3544 Jerome Ave.
Residency Program Director
Philip Ozuah, MD 718-920-5521
The pediatric residency program emphasizes training in continuity care for inner-city infants and
children. The three year program includes training in inpatient services for newborns, infants,
children and adolescents and outpatient care in emergency services and primary care in a
community practice site.
MEDICINE
The Department of Medicine is the largest department at at Montefiore Medical Center, the
University Hospital of the Albert Einstein College of Medicine (AECOM). Two campuses
provide a full range of services to patients and are a major teaching and research resource in the
Bronx.
The Moses and Weiler sites train one-half of each AECOM class in Internal Medicine,
and 155 Internal Medicine residents in the categorical, preliminary, primary care, and social
internal medicine residency programs. Strong subspecialty programs contribute to patient care,
provide consultative support to the House Staff, and provide excellent training for over 100
fellows.
The house staff and fellows also rotate through Jacobi Hospital, and some Fellows rotate
through North Central Bronx hospital, both part of the Health & Hospital Corporations (NYC)
System.
Approximately 230 full-time and a number of voluntary faculty members provide
supervision of the residents and students and participate in the teaching activities of the
programs.
Between them, the Moses and Weiler sites provide care to a daily census of over 400
Internal Medicine inpatients and to an ever-increasing number of outpatient patients around the
Bronx. The Department also provides a wide range of diagnostic and therapeutic services
including: Cardiac Catheterization, Interventional Angioplasty,
Echocardiography, Holter Monitoring, Stress Testing, Renal Dialysis, GI Endoscopy, Pulmonary
Function Studies, Diabetes care, and Diabetes education and consultation.
Chairman 718-430-2906
Victor Schuster, MD 718-920-7701/7710
718-430-8659 Fax
718-515-6103 Fax
Vice Chairman for Clinical Affairs 718-920-6327
Philip D. Lief, MD 718-904-2500
718-515-6103 Fax
718-904-2827 Fax
Vice Chairman for Academic Affairs 718-430-2694
Milford Fulop, MD
Administrator AECOM
67

Shelly Motzkin 718-430-3041
Administrator MMC 718-920-4416
Jonathan Tamir
718-515-6103 Fax
Medical Credentialing
Faculty & Hospital Appointments
Vicky Ruiz 718-920-2146
INTERNAL MEDICINE RESIDENCY PROGRAMS
Centennial 3
Program Director
Internal Medicine
Sharon Silbiger, MD 718-920-6098
Program Administrator
Donna Chinea 718-920-4417
Firm I
Marta Rico, MD 718-920-5496
Firm II
Darlene LeFrancois, MD 718-920-2839
Firm III
Joseph DeLuca, MD 718-920-6738
Primary Care
Gerald Paccione, MD 718-920-6097
Social Internal Medicine
Gerald Paccione, MD 718-920-6097
FELLOWSHIP PROGRAM DIRECTORS
Allergy
David Rosenstreich, MD 718-405-8074
Cardiology
James Scheuer , MD 718-920-5979
Scott Monrad, MD 718-904-3216
Cardiac Electrophysiology
John D. Fisher, MD 718-920-4291
Critical Care
68

Vladimir Kvetan, MD 718-920-5440
Dermatology
Michael Fisher, MD 718-918-4272
Endocrinology
Martin Surks, MD 718-920-4331
Gastroenterology
David Greenwald, MD 718-920-4846
Geriatrics
Laurie Jacobs, MD 718-920-6721
Hematology
Shirley Levine, M.D. 718-430-3564
Infectious Diseases
Grace Minamoto, MD 718-920-5224
Nephrology
Vaughn Folkert, MD 718-597-2255
Pulmonary
Andrew Berman, MD 718-405-8300 x 2113
Rheumatology
Chaim Putterman, MD 718-430-4266
DIVISION DIRECTORS
Allergy
David Rosenstreich, MD 718-405-8074
Cardiology
Interim Moses
Mark Greenberg, MD 718-920-4212
Interim Weiler
E. Scott Monrad, MD 718-904-3216
Dermatology
Michael Fisher, MD Van Etten 718-918-4272
Endocrinology
Norman Fleischer, MD Belfer 701 718-430-2908
Gastroenterology
69

Larry Brandt, MD RA 718-920-6032
Geriatrics
Laurie Jacobs, MD Centennial 2 718-920-6122
Hematology
Ronald Nagel, MD Ullmann 718-920-6310
718-430-2186
Infectious Disease
Arturo Casadevall, MD Belfer 610 718-430-3665
Nephrology
Victor Schuster, MD Ullmann 615 718-430-3158
Pulmonary
Thomas Aldrich, MD Centennial 4 718-920-6054
Rheumatology
Chaim Putterman,MD Ullmann 718-430-4081
NEUROLOGY
Chairman
Mark Mehler, MD 718-430-2407
Administrator
Sally Hershkowitz 718-920-4715
Residency Coordinator
Tina Rubano 718-430-3166
Adult Neurology Residency Program Director
Sheryl Haut, MD 718-920-6402
Pediatric Neurology Residency Program Director
Karen Ballaban-Gil, M.D. 718-405-8148
Clinical Neurolophysiology Fellowship Program Director
Fred Lado, M.D.
Neurology produces a 114-Page Orientation manual for the Adult
Neurology Program Residents.
East Campus: Albert Einstein College of Medicine
1300 Morris Park Avenue
West Campus: 3351 Steuben Avenue, 3rd Floor
NEUROSURGERY
3316 Rochambeau Avenue 718-920-7400
Chairman &
70

Residency Program Director
Eugene S. Flamm, MD
Administrator &
Residency Coordinator
Rachel Fink 920-7400
NUCLEAR MEDICINE
Chairman
M. Donald Blaufox, MD, PhD
Administrator
Mitchell H. Stromer
Assistant Administrator
Thomas Huvane
Phone: 718-405-8468
Fax: 718-824-1369
Hours
Monday-Friday 8:00am – 9:00pm, Saturday and Sunday 8:00am – 4:00pm
All other times, evening and weekends, emergency scans can be requested through the
Radiology Resident on-call. All inpatient and outpatient procedures are performed in the
Department of Nuclear Medicine located on the 4 th floor in the Silver Zone. No procedures can
be performed until the request and referral form, if necessary, has been received. The request
must be filled out completely and may be submitted by fax to 718-920-2311 or by ordering the
procedure on CIS. If prior Nuclear Medicine or other imaging tests are available from another
institution, it is always helpful if the patient or the referring physician makes these available at
the time of the procedure.
Some categories of illnesses require that the patient be accompanied be a doctor or nurse.
Call the department at (718)920-5011 for any of the following:
• To request a procedure
• To discuss potential procedures with a physician
• To obtain preliminary results
• To discuss any other issues related to Nuclear Medicine
Cardiovascular Nuclear Medicine Stress Test Scheduling 718-920-5144
Positron Emission Topography (PET)
Outpatient Scheduling 718-405-8461
Inpatient Scheduling 718-904-2923
All outpatient Nuclear Medicine and Positron Emission Tomography (PET) procedures are
performed in the Montefiore Medical Park, 1695A Eastchester Road.
71

Positron Emission Tomograpy (PET) procedures are performed in the Montefiore Medical Park
Division, 1695 A Eastchester Road.
Weiler/Einstein Division
Chief of Service: David M. Milstein
Supervisor: Philip Paul
Phone: 718-904-2923
Fax: 718-904-2012
MOSES
Vice Chairman and Director
Leonard M. Freeman, MD
Supervisor
Khalid Saleemi 718-920-5013
Hours
Monday - Friday 8:00AM - 5:00PM
All other times, evenings and weekends, emergency scans can be requested through the Weiler
Operator. All inpatient Nuclear Medicine Procedures will be performed in the first floor
Department of Nuclear Medicine.
Montefiore Medical Park Division
1695A Eastchester Road
Bronx, NY 10461
Chief of Service: David M. Milstein, M D.
Supervisor: Philip Paul
Phone: 718-405-8461
FAX: 718-824-0830
Hours
Monday – Friday 8:00AM to 5:00PM for routine testing. All outpatient Nuclear Medicine
procedures, including PET/CT, will be performed on the first floor. Call the department at 718-
405-8461 for any of the following:
• To request a procedure
• To discuss potential procedures with a physician
• To obtain preliminary results
• To discuss any other issues related to Nuclear Medicine
72

No procedure can be performed until the request has been received. The request must be filled
out completely and may be submitted by fax 718-824-0830. If prior Nuclear Medicine or other
imaging tests are available from another institution, it is always helpful if the patient or the
referring physician makes these available at the time of the procedure.
OBSTETRICS & GYNECOLOGY AND WOMEN'S HEALTH
Chairman
Irwin R. Merkatz, MD 718-430-4192
1300 Morris Park Ave
Belfer Educational Center - Rm 502
Bronx, New York 10461
Senior Administrator
Adrienne Kapel 718-430-8739
Residency Program Director
Brian Cohen, MD 718-430-4031
Residency Coordinator
Kathy Regan 718-430-4031
Undergraduate Medical Education
Nadine Katz, MD 718 - 430-3206
Undergraduate Medical Education Coordinator
Linda Gillespi 718-430-3205
DIVISION OF MATERNAL FETAL MEDICINE
1300 Morris Park Ave
Belfer 502
Irwin R. Merkatz, MD, Director 718-430-4192
Cynthia Chazotte, MD 718-904-2794
Jack D. Weiler Hospital of the Albert Einstein College of Medicine
Administrative Office 718-904-2794
Patient Referral 718-904-2725
DIVISION OF GYNECOLOGIC ONCOLOGY
Gary L. Goldberg, MD, Director
1695 Eastchester Road - Suite 601
Bronx, New York 10461
Administrative Office 718-904-2893
Patient Referral 718-405-8210
DIVISION OF REPRODUCTIVE ENDOCRINOLOGY
Nanette Santoro, MD, Director - Bronx Site
73

1300 Morris Park Ave - Mazer 301
Bronx, New York 10461
Academic Office 718-430-3152
Administrative Office/Patient Referral 718-997-1060
DIVISION OF REPRODUCTIVE GENETICS
Harold M. Nitowsky, M.D, Co-Director
Susan Gross, MD, Co-Director
Institute for Women's Health, Genetics and
Human Reproduction
1695 Eastchester Road
Bronx, New York 10461
Administrative Office/Patient Referral 718-405-8150
DIVISION OF UROGYNECOLOGY AND RECONSTRUCTIVE
PELVIC SURGERY
Dr. Magdy Mikhail, Division Director
Centennial Women’s Center
3332 Rochambeau Avenue
Bronx, NY 10467
Administrative Office/Patient Referral 718-920-5157
PROGRAM/CLINICAL SITES
MMC - Weiler Division
Ira Karmin, MD
Director, GYN
Patient Referral/Administrative Office 718-904-2797
MMC-Weiler Division
Cynthia Chazotte, MD
Director, OB
Administrative Office 718-904-2794
Patient Referral 718-904-2725
MMC - Moses Division
Mark Levie, M.D.
Director of Obstetrics and Gynecology
Administrative Office 718-920-2864
Patient Referral 718-920-5157
FACULTY PRACTICE OFFICES
Institute for Women’s Health, Genetics and Human Reproduction
1695 Eastchester Road, Suite L2
74

Bronx, New York 10461
Administrative Office/Patient Referral 718-405-8200
Nancy Perugini
Cassandra Duckett Jones
On Site Coordinators
CFCC - OB/GYN and Women's Health
1621 Eastchester Road 718-405-8040
Peter Bernstein, MD - CFCC
Nancy DeVore, CNM Director of Ambulatory Care
Grand Concourse Women’s Center
2532 Grand Concourse
Bronx, NY 10458
Administrative Office/Patient Referral: 718-960-1546
Site Administrator: Annette Mussenden
Maternal/Fetal Assessment Center
1825 Eastchester Road; 2 Floor
Bronx, NY 10461
Cynthia Chazotte, MD 718-904-2725
Centennial Women’s Center
3332 Rochambeau Avenue, Suites A, B, C
Bronx, NY 10467
Patient Referral/Administrative Office 718-920-5157
Ultrasound & Bone Densitometry
Multi-Site
Patient Referral 718-405-8200
WESTCHESTER SITES
Larchmont Women's Center 914-834-0444
Larchmont, New York 10538
Patient Referral/Administrative Office 914-834-4422
Site Administrator: Rose Ghelarducci
Montefiore’s Institute for Reproductive Medicine and Health
141 South Central Avenue; Second Floor
Hartsdale, New York 10530
Patient Referral/Administrative Office 914-997-1060
Site Administrator: Piera Graven
Cross County Women’s Center
6 Xavier Drive, Room 610
Yonkers, New York 10704
75

Patient Referral/Administrative Office 914-376-9100
Site Administrator: Susan Weiss
In-Patient Obstetrical Units
Jack D. Weiler Division of the Montefiore Medical Center
Antepartum 718-904-3431
Labor and Delivery 718-904-3433
Postpartum 718-904-3431
7N Conference Room 718-904-2767
Jacobi Medical Center
Antepartum 718-918-6358
Labor and Delivery 718-918-6380
Postpartum 718-918-6358
Perinetal and Genetics Consultants
700 White Plains Road
Scarsdale, NY 10583
Administrative contact: Rose Gheralducci
Administrative Contact Phone: 914-833-2730
Patient Appointment: 914-423-4111
ADDITIONAL PROGRAMS
Midwifery Program
Nancy E. DeVore, CNM, Director 718-405-8039
Patient Education
Margaret Comerford Freda, Consultant 631-423-8600
Office of Community Affairs
Karla Damus, PhD 718-430-2576
ONCOLOGY
Chairman
Roman Perez-Soler, MD 718-920-4001
Director, Cancer Center
I. David Goldman, M.D 718-430-2302
Albert Einstein Cancer Center
Acting Director, Cancer Services
Richard Daversa 718-920-4674
Associate Chairman of Clinical Research
Director, Clinical Trials Office Albert Einstein Cancer Center
Joseph Sparano, M.D. 718-904-2555
76

Director, Education Programs
Rasim Gucalp, M.D. 718-920-7100
Director, Bone Marrow Transplantation
Ira Braunschweig, M.D. 718-920-7100
Director, Oncology Pharmacy
Royston Brown, R.Ph. 718-920-5778
Moses Outpatient Oncology Unit
Northwest 3 718-920-4057
Moses Inpatient/Infusion Oncology Unit
Northwest 4 718-920-4742
Montefiore Medical Park Outpatient Oncology Unit
1695 Eastchester Road 718-405-8505
Montefiore Medical Park Infusion Oncology Unit
1695 Eastchester Road 718-405-8520
Weiler Hospital
Inpatient 11 South 718-904-3492
Moses Division Physicians 920-7100
Weiler/Einstein Physicians 904-2900
Bone Marrow Transplant Coordinator
Ruby Yusay 718-920-6322
Nursing Director
Barbara Binder 718-920-4075
Administrative Nurse Manager (Moses)
Peggy Wallace 718-920-4742
Administrative Nurse Manager
Montefiore Medical Park/Weiler
Marilynn Silverberg, RN 718-405-8513
Research Nurse Moses
Cathy Sarta, RN 718-920-2059
Research Nurse MMP
Una Hopkins, NP 718-405-8520
77

Moses PA 718-920-4933
718-920-2090
Weiler PA 718-904-3492
718-904-3492
OPHTHALMOLOGY & VISUAL SCIENCE
Interim Chairman
Residency Program Director 718-920-7646
Harry M. Engel, MD 718-920-6665
Centennial 3: 3332 Rochambeau Ave.
718-881-5439 Fax
Administrator
Samuel Hamilton
Centennial 3
Practice Manager
Annette Shehu, 718-920-4233
3400 Bainbridge Avenue 718-655-2464
ORTHOPEDIC SURGERY
Chairman
Neil J. Cobelli, MD 718-405-8131
Residency Program Director
I. Martin Levy, MD 718-405-8132
Montefiore Medical Park
1695 Eastchester Road 2nd Floor
Bronx, New York 10461
Administrator
Lissen Simonsen 718-920-2929
3400 Bainbridge Ave Map 6 718-653-1587 Fax
Bronx, NY 10467
Academic/Residency Coordinator
Tanya Riedl 718-920-2966
3400 Bainbridge Ave-Map 6 718-653-1587 Fax
Bronx, NY 10467
Director
Dean Lorich, MD 718-918-4922
Jacobi Medical Center, Room 218
718-918-4914 Fax
Pelham Parkway South & Eastchester Road
Bronx, NY 10461
78

North Central Bronx Hospital 718-519-4946
DeKalb & Kossuth Ave. Room 8C01
Bronx, NY 10467
OTOLARYNGOLOGY
MOSES
3400 Bainbridge Avenue
Map Building, 3rd Floor
Professor and University Chairman 718-920-2991
Residency Program Director
718-405-9014 Fax
Marvin P. Fried, MD
Professor and Vice Chairman 718-920-4267
Director of Head and Neck Services
718-405-9014 Fax
Richard V. Smith, M.D.
Administrator 718-920-8425
Jarrett Stern
718-405-9014 Fax
Appointments/ Information 718-920-4646
The Department of Otolaryngology at Montefiore Medical Center, the University Hospital for
the Albert Einstein College of Medicine, provides comprehensive patient care for diseases of the
ear, nose and throat. Our multidisciplinary team includes highly specialized physicians,
audiologists, and physiologists, including voice, speech and swallowing therapists. These team
members work directly with other related specialties, forming specialty centers which include the
Center for Voice Disorders, the Speech and Swallowing Disorders Center, Head and Neck
Surgery, Cranial Base and the Craniofacial Center. The department is involved in extensive
research and has received national and international recognition for its significant contributions
to the field of Otolaryngology-Head and Neck Surgery.
Services: Audiology, Head/Neck Surgery, Otology, Neurotology, Pediatric Otolaryngology,
Rhinology- Nasal/Sinus and Diseases/Surgery, and Voice- Speech and Swallow Pathology
PATHOLOGY
Chairman 718-920-2456
Michael B. Prystowsky, MD, Ph.D.
718- 882-8461 Fax
Vice Chairman 718-920-4540
Ira Sussman, MD
718-881-2976 Fax
Senior Administrator 718-920-4523
Vera Solomon
718-881-2976 Fax
79

Associate Administrator
Michele Maimone-Schoen
718-904-3279 Weiler
718-920-4161 Moses
718-881-2976 Fax
Director, Surgical Pathology 718-920-4976
James Pullman, MD
718-920-7611 Fax
Director, Anatomic Pathology 718-904-2174
Kathleen Whitney, MD 718-904-2256
Core Laboratory – Moses: Chemistry, Hematology, Lab Services, Microbiology, Protein
Separation Lab
718-920-4695
718-881-4397 Fax
Rapid Response Laboratory – Weiler: Chemistry, Hematology, Laboratory Services, Phlebotomy
PEDIATRICS
3415 Bainbridge Avenue
Chairman
Gabriel G. Haddad, M.D.
Vice Chairman Research Affairs
Harris Goldstein, M.D.
Vice Chairman Affiliate and Network Affairs
Frederick J. Kaskel, M.D., Ph.D.
Vice Chairman Clinical and Educational Affairs
Philip O. Ozuah, M.D., Ph.D.
Director, Residency Program 718-741-2466
Catherine C. Skae, M.D
718-654-6692 Fax
Education Administrator
Mary McGuire 718-741-2460
Director of Administration 718-741-2490
Mary R. Doncourt
Associate Administrator 718-741-2411
Ann Allowe
Assistant Administrator for Sectional Affairs
80

Arlene Saunders 718-741-2492
Administrative Supervisor
Mary Ellen Watson 718-241-2464
Credentials Coordinator 718-741-2487
Loretta Garin
718-654-6692 Fax
The Department of Pediatrics is dedicated to delivering and teaching pediatric primary care
serving as the mainstay for subspecialty and tertiary care for the children of our region and to
advancing pediatric research efforts. The Department’s faculty and House Staff deliver care and
teaching at the University Hospital of the Albert Einstein College of Medicine at Montefiore
Medical Center, the Children’s Hospital at Montefiore and the Jack. D. Weiler Hospital in
addition to numerous outpatient and community-based venues. The pediatric faculty provides
supervision of the three-year residency and numerous fellowship programs.
PLASTIC AND RECONSTRUCTIVE SURGERY
Chairman
Berish Strauch, MD 718-405-8444
1625 Popular St., Suite 200
Administrative Supervisor
Agneta Gustafsson 718-920-6168
Administrative Office 718-920-6168
Director of Academic Affairs
Dr. Lee Landres 718-920-4449
The departmental offices are open during normal business hours. There is a resident on call inhouse
at all times at both the east and west campus and in the Burn Unit at Jacobi Medical
Center. The Department provides the full range of Plastic and Reconstructive Surgical Services
including aesthetic surgery, craniofacial surgery, microvascular surgery, reconstructive surgery,
replantation surgery, breast reconstruction, facial paralysis surgery, hand surgery, head and neck
reconstruction, maxillofacial surgery, and burn care.
PSYCHIATRY & BEHAVIORAL SCIENCES
Chairman
T. Byram Karasu, MD 718-920-4813
Exec.Vice Chairman & Clinical Director
Bruce J. Schwartz, MD 718-920-4040
Administrator
George J. Como 718-920-6215
81

Residency Program Director
Peter Buckley, MD 718- 931-7102
Consult Liaison Director (West Campus)
Mary Alice O'Dowd, MD 718-920-4441
Consult Liaison Director (East Campus)
David Preven, MD 718-904-3467
RADIOLOGY
Chairman
E. Stephen Amis, Jr., M.D. 718-920-5113
Chief of Service – Moses
Seymour Sprayregen, M.D. 718-920-4200
Chief of Service – Einstein
Nogah Haramati, M.D. 718-904-2965
Administrator
Richard Alaimo 718-920-4848
Chief Technologist – Moses 718-920-2290
Chief Technologist – Einstein 718-904-2768
Nursing Station – Moses 718-920-4877
Nursing Station – Einstein 718-904-2378
MOSES DIVISION
The Department of Radiology offers complete imaging services and consultation. The
department also performs a wide variety of diagnostic and therapeutic invasive procedures.
Consultation includes review of completed studies and recommendations for the most efficacious
sequencing of imaging studies for diagnosing a particular condition. During normal working
hours, radiologists are available in the reading room in the Silver Zone and in subspecialty
reading areas. After hours, and on weekends and holidays, consultation is available in the
Radiology reading room or by paging the radiology resident through the page operator.
Verbal reports are available as soon as the films have been dictated. Access to the report can be
obtained through the RTAS system by dialing extension 5848 (920-5848 from outside the
hospital) and then entering the patient's medical record number.
SCHEDULING ROUTINE IN-PATIENT EXAMS
All requests for in-patient radiologic exams must be submitted on a Montefiore Medical Center
x-ray requisition or electronically through the PHAMIS system. The requisition must contain:
the radiologic exam requested, clinical history, demographic information, legible signature and
82

printed name of the referring physician, and beeper or phone number where referring physician
can be reached. Radiologic exams are provided only at the request of referring physicians with
clinical privileges or other practitioners authorized by the medical staff and the governing body
to order radiologic service.
Fax Numbers:
MRI 718-920-7705
CT 718-920-7647
Sonography 718-655-1203
Scheduling 718-655-2142
In-patients 718-920-7799
SCHEDULING PROCEDURES FOR AMBULATORY PATIENTS
During regular work hours, routine radiologic studies can be scheduled by calling the following
extensions:
Sonograms 4070
CT, barium studies, IVP 5492
Mammograms
5400 (MIC)
MRI 4409
Neuroangiograms & myelograms 4640/4630
Angiographic/interventional procedures 5729
Nuclear Medicine 5011
AFTER WORKING HOURS
There is always at least one credentialed radiology resident in the hospital to interpret studies,
assist in determining the appropriate radiologic work up for a patient and to
schedule emergent cases. The resident can be reached through the page operator or at extension
4879.
REVIEW OF CASES
Barium studies are reviewed in the reading area in the Silver zone starting at 2:30 p.m. Monday
Friday. To review neuroradiology cases (head and spine CT and MRI as well as other
neuroradiology procedures), inquiries should be made in the neuroradiology reading room. To
review musculoskeletal cases, inquiries should be made in the musculoskeletal reading room.
Pediatric cases are reviewed in the pediatric reading area. ED cases and plain films of the chest
and abdomen can be reviewed in the Silver Zone reading room. Information about ultrasound
can be obtained at the ultrasound reception desk. Information about CT and MRI scans of the
chest and abdomen can be obtained in the Body CT & Chest reading areas. Information about
visceral and peripheral angiograms and interventional procedures can be obtained in the
angiography suite or office. Nuclear Medicine cases are viewed by the Department of Nuclear
Medicine located on the 4th floor of the Silver Zone.
FILM CONTROL
The Department of Radiology is mandated by law to maintain radiographic studies for a period
of seven years for adults and a period of seven years after a pediatric patient reaches the age of
83

21 years. All studies are the property of the Radiology Department. Studies must not be
removed from the department prior to the official interpretation.
When it is necessary to check out films, this should be done only after the films have been
formally interpreted and dictated by a radiologist and after signing the films out of the file room.
The main file room is located in the Yellow Zone. Films must not be
kept in offices or clinics for long periods of time; to do so can seriously compromise patient care
because the study will not be available to other physicians taking care of the patient. Films must
never be taken from the department unless properly checked out and must always be returned.
The cooperation of every member of the house staff is expected in this regard.
DIRECTORY (Extensions)
Moses (718) 920-xxxx
Silver Zone Reading Room 4879/5547
File Room 4866/4867
Neuroradiology Reading Room 4030/4640
Body CT Reading Room 4396/4397
Ultrasound Reading Room 4070
Vascular/Interventional Reading Room 5729
Mammography
5400 (MIC)
Unified Chairman 5113
Chief of Radiology 4200
Administrator 4848/4135
QC/QI Manager 6694
Residency Coordinator 5506
Business Manager 5730
Chief Tech 2725/2290
Tech Supervisor 2290
File Room Supervisor 5209/4866
US Supervisor 4070
CT/MR Supervisor 5010
Einstein (718) 904-xxxx
Chief of Radiology 2965
Administrator 2964
Chief Tech 2768
Nurses Station 2378
Remote Transcription Access System-RTAS 2679
Radiology Reception (M-F 8am- 7pm) 3411
Front Desk (M-F 8am- 7pm)) 3400
Ultrasound (M-F 8am- 5pm) 2322
CT (M-F 8am- 5pm) 4038
MRI (M-F 8am- 7pm) 2600
File Room 3407
(M-F 8am- 7pm Sat, Sun & Hol 8:00am -4:00pm)
After hours, please call the page operator at 904-2711
84

The radiology department at Jack D. Weiler Hospital at the Albert Einstein College of Medicine,
a division of the Montefiore Medical Center, offer the following: MRI, CT, US, Mammography,
Diagnostic x-rays, Interventional procedures (Invasive and Non-
Invasive), Fluoroscopy studies (e.g. Mod-barium swallows, Upper GI, IVP,
hysterosalpingogram, Voiding Cystourethrogram)
RADIATION ONCOLOGY
Interim Chairman
Jonathan Beitler, MD 718-920-4942
Administrator, Director of Business &
Clinical Service, Medical & Radiation Oncology
Richard Daversa 718-920-4674
Residency Coordinator and Program Director
James Butler, MD 718-904-2921
Senior Physicist
Ravindra Yaparpalvi (Einstein)
Rafael Yankelevich (Moses)
Locations:
Moses Division: 111 East 210th St.
Weiler Division: 1825 Eastchester Rd.
REHABILITATION MEDICINE
Chairman
Avital Fast, MD 718-920-2751
Administrator
Carmela Greco 718-920-4906
Residency Program Director
Mark Thomas, MD 718-920-2753
Rehabilitation Administration 718-920-2751
111 East 210th Street 718-920-5048 Fax
Bronx, New York 10467-9024
CLINICAL TRAINING SITES
Moses Division 718-920-4083
Einstein Division Weiler 718-920-2296
Cardiac Rehabilitation Center - Blondell Avenue 718-405-8471
Jacobi Medical Center 718-918-5545
85

Beth Abraham Hospital 718-519-5831
Jamaica Hospital 718-206-6894
N.Y. Hospital - Queens 718-670-1290
CLINICAL DIRECTORS
Moses Division
Stanley Wainapel, MD 718-920-4938
Einstein-Weiler Division
Jeffrey Nissinoff, MD 718-904-2296
Blondell Avenue Center
Anna Lasak, MD 718-405-8410
OTHER CLINICAL SERVICES
Cardiac Rehabilitation 718-405-8471
Electrodiagnosis
Moses Division 718-920-4083
Blondell Avenue 718-405-8410
Interventional Physiatry & Pain Management 718-405-8410
Pediatric Rehabilitation 718-920-4133
Intraoperative Monitoring (Evoked Potentials) 718-904-4083
Orthotics/Prosthetics
Moses Division 718-920-4083
Weiler Division 718-904-2296
Physical and Occupational Therapy
Moses Division 718-920-2287
Weiler Division 718-904-2785
Speech and Language Pathology 718-904-2786
SURGERY
Chairman 718-920-6287
Thanjavur S. Ravikumar, MD
718-798-1883 Fax
Residency Coordinator 718-920-5411
Jackie Jiminez
718-798-1883 Fax
Medical Student 3rd year Clerkship Director 718-920-5490
Michael Menack, MD
718-798-1883 Fax
MOSES DIVISION
111 East 210th Street
Bronx, New York 10467
MAP 4
Chief of Surgery
Surgical Oncology 718-920-6287
Thanjavur S. Ravikumar, MD
718-798-1883 Fax
86

Pediatric Surgery 718-920-7200
Burton Harris, MD
718-547-2929 Fax
Vascular Surgery 718-920-4108
Takao Ohki, MD
718-231-9811 Fax
Transplant Surgery 718-920-4718
Vivian Tellis, MD
718-547-4773 Fax
Head & Neck Surgery 718-920-4308
Carl Silver, MD
718-798-1883 Fax
Critical Care 718-920-5653
Cordelia Sharma, MD
718-798-1883 Fax
Bariatric Surgery 718-920-6228
Julio Teixeira, MD
718-798-1883 Fax
Medical Student Site Coordinator 718-920-5653
Michael Menack, MD
718-798-1883 Fax
WEILER DIVISION
1825 Eastchester Road, Suite 2S-5
Bronx, New York 10461
Chief of Surgery 718-904-2260
Alan White, MD
718-904-4183 Fax
Surgical Oncology 718-904-3517
Thomas Weber, MD
718-904-3099 Fax
Vascular Surgery 718-405-3230
Reese Wain, MD
718-405-8253 Fax
Pediatric Surgery: 718-405-8241
Gerard Weinberg, MD
718-405-8292 Fax
Medical Student Site Director: 718-405-8239
John Hodgson, MD
718-405-8292 Fax
JACOBI
Bronx Municipal Hospital Center (Jacobi)
Pelham Parkway South and Eastchester Road
Bronx, New York 10461
Chief of Surgery 718-918-5565
87

Harry Delany, MD
718-918-5567 Fax
Trauma Surgery/Critical Care: 718-918-5598
Ronald Simon, MD
718-918-5593 Fax
Breast Center 718-918-5588
Cynthia Jones, MD
718-918-5593 Fax
Pediatric Surgery: 718-405-8241
Gerard Weinberg, MD
718-405-8292 Fax
Medical Student Coordinator 718-918-5588
Cynthia Jones, MD
718-918-5593 Fax
NORTH CENTRAL BRONX
North Center Bronx Hospital NCB
3424 Kossuth Avenue
Bronx, New York 10467
Chief of Surgery: 718-519-3928
Lawrence Bizer, MD
718-519-3022 Fax
UROLOGY
Medical Arts Pavilion - 5th floor
Chairman &
Residency Program Director
Arnold Melman, MD 718-920-5402
Administrator
Phyllis Markic 718-920-6245
88

SECTION V
•
POLICIES AND PROCEDURES
89

PATIENTS’ BILL OF RIGHTS
As a patient in a hospital in New York State, you have the right, consistent with law, to:
1. Understand and use these rights. If for any reason you do not understand or you need help,
the hospital MUST provide assistance, including an interpreter.
2. Receive treatment without discrimination as to race, color, religion, sex, national origin,
disability, sexual orientation or source of payment.
3. Receive considerate and respectful care in a clean and safe environment free of unnecessary
restraints.
4. Receive emergency care if you need it.
5. Be informed of the name and position of the doctor who will be in charge of your care in the
hospital.
6. Know the names, positions and functions of any hospital staff involved in your care and
refuse their treatment, examination or observation.
7. A no smoking room.
8. Receive complete information about your diagnosis, treatment and prognosis.
9. Receive all the information that you need to give informed consent for any proposed
procedure or treatment. This information shall include the possible risks and benefits of the
procedure or treatment.
10. Receive all the information you need to give informed consent for an order not to resuscitate.
You also have the right to designate an individual to give this consent for you if you are too
ill to do so. If you would like additional information, please ask for a copy of the pamphlet
"Do Not Resuscitate Orders -- A Guide for Patients and Families."
11. Refuse treatment and be told what effect this may have on your health.
12. Refuse to take part in research. In deciding whether or not to participate, you have the right
to a full explanation.
13. Privacy while in the hospital and confidentiality of all information and records regarding
your care.
14. Participate in all decisions about your treatment and discharge from the hospital. The hospital
must provide you with a written discharge plan and written description of how you can
appeal your discharge.
15. Review your medical record without charge. Obtain a copy of your medical record for which
the hospital can charge a reasonable fee. You cannot be denied a copy solely because you
cannot afford to pay.
16. Receive an itemized bill and explanation of all charges.
17. Complain without fear of reprisals about the care and services you are receiving and to have
the hospital respond to you and if you request it, a written response. If you are not satisfied
with the hospital's response, you can complain to the New York State Health Department.
The hospital must provide you with the Health Department telephone number.
18. Authorize those family members and other adults who will be given priority to visit
consistent with your ability to receive visitors.
19. Make known your wishes in regard to anatomical gifts. You may document your wishes in
your health care proxy or on a donor card, available from the hospital.
PROTECTED HEALTH INFORMATION USES AND DISCLOSURES
Administrative Policy and Procedure JH41.1
90

Note: This summary contains key points of this policy and the related procedures. For a
complete understanding of all the relevant provisions, it is necessary to thoroughly read the full
policy.
WHAT:
Montefiore Medical Center (MMC) will comply with applicable legal and regulatory
requirements the management of Protected Health Information (PHI). The policy establishes
rules, which MMC will follow when using and disclosing the PHI of its patients. All MMC
Associates are required to maintain the confidentiality and privacy of PHI in accordance with the
Health Insurance Portability and Accountability Act of 1996 (HIPAA). MMC will not use or
disclose PHI except as permitted by the privacy regulations.
Protected Health Information (PHI) is generally defined by HIPAA as information in any
form or medium (including oral, written and electronic communications), that:
• Is created or received by a health plan, health care provider, health care clearinghouse
or an employer
• Relates to an individual’s physical or mental health, the provision of health care to an
individual, or the payment for the provision of health care to an individual
• Identifies, or could reasonably expected to be used to identify an individual
Protected Health information includes everything from a patient’s name, address and telephone
number to a patient’s clinical and billing records.
WHO:
This policy applies to all Montefiore Medical Center Staff Associates
WHEN:
The policy applies to all Protected Health Information (PHI) collected, maintained, used and
disclosed by Montefiore Medical Center. MMC may use and disclose protected health
information for purposes of treatment, payment and health care options.
HOW:
• MMC Joint Privacy Notice
All individuals seeking services at MMC have the right to receive an MMC Joint Notice of
Privacy Practices that contains information relating to 1. the uses and disclosures of PHI to be
made by MMC, 2. The individual’s right’s relating to his/her PHI, and 3. MMC’s legal duties
with respect to PHI.
The Privacy Notice will be provided to individuals during their first direct encounter for
service at MMC. Notices will be available at all registration and admission points within MMC,
and posted in clear and prominent locations where it is reasonable to expect individuals seeking
service to be able to read the notice. The notice can also be provided electronically upon
request.
MMC will obtain written acknowledgements from individuals attesting to the fact that a
Privacy Notice has been provided to them.
When MMC has an indirect treatment relationship with its patients, MMC need only make
Privacy Notice available upon request and a signed acknowledgement is not required.
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MMC must permit an individual the right to request restrictions relating to uses or disclosures of
PHI about the individual to carry out treatment, payment or health care operations. When
possible, the request should be submitted in writing.
MMC will accommodate reasonable requests from individuals to receive communications of PHI
by alternative means or alternative locations. Requests should be submitted in writing.
CONTACT
Privacy Officer 718-920-4728
ADVANCED DIRECTIVES- HEALTH CAR PROXIES AND LIVING WILLS
Administrative Policy and Procedure JH41.1
Note: This summary contains the key points of this policy. For a complete understanding of all
the relevant provisions, it is necessary to thoroughly read the full policy.
WHAT:
Advance directives are written or oral health care wishes expressed by a person with decisional
capacity. Providers are legally and ethically bound to refer to advance directives when decisions
must be made for patients without the capacity to make them. Advance directives take two
forms:
• Health care proxy is a person’s legal appointment of another individual (health care agent) to
make health care decisions on the person’s behalf in the event of subsequent incapacity.
• Living will is a list of instructions about interventions the person would consent to or refuse
under specified circumstances.
WHO:
• All patients over 18 years of age, regardless of health status, should be encouraged to appoint
a health care agent.
• Any person 18 years or older may appoint a health care proxy, create a living will and/or be a
health care agent.
• A health care agent is specifically chosen and legally appointed by a capacitated person.
Family, even next-of-kin, may not automatically make many important decisions for their
loved ones unless they are legally appointed health care agents.
• An attending physician makes the clinical determination of decisional incapacity, which
triggers the provisions of an advance directive.
• When a health care agent will make decisions about foregoing life-sustaining treatment, the
determination of patient incapacity must be confirmed by a second attending physician.
WHEN:
Adult patients, even those with advance directives, are presumed able to make their own
decisions unless and until they are clinically determined to lack decisional capacity. Advance
directives take effect only when the patient has temporarily or permanently lost the capacity to
make health care decisions. If and when patients regain capacity, they resume making their own
health care decisions. Advance directives may be created at any time and remain effective until
revoked by the patient or are superseded by new directives from the patient.
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WHERE:
• Advance directives are applicable in any clinical or community setting.
• Federal law requires that, upon admission to any health care facility, patients must be asked
if they have advance directives and, if needed, offered assistance in completing them.
• Copies of advance directives should be placed in the front of the medical record as soon as
available.
HOW:
• If patients do not have advance directives, the directives should be explained and assistance
offered in completing them. The appointment of health care proxy agents and alternate
agents should be encouraged.
• Health care proxy appointments are witnessed by two adults, neither of whom is the patients
health care agent or alternate. Associates or Medical Staff may serve as witnesses.
• Health care proxy forms with instructions are available on every clinical unit, in the
admissions office, through Social Services and the Customer Services Department.
• Referrals to Social Services should be made for additional assistance completing proxy form,
for specific questions about advance directives, and for follow-up of advance directive
documentation not available on admission.
• Complex cases involving advance directives may be referred to Bioethics, Office of the
Medical Director or Palliative Care.
• Copies of Making Health Care Decisions for Others: A Guide to Being a Health Care Proxy
or Surrogate and A Quick Reference for Physicians are also available from Social Services or
Bioethics.
CONTACT:
Social Services 718- 920-4545
Bioethics (Moses) 718- 920-6226
(Weiler) 718- 904-2299
Palliative Care 718-920-6378
Office of the Medical Director 718- 920-7052; 2809l; 6078.
BRAIN DEATH
Summary - Administrative Policy and Procedure # JD01.1
Note: This summary contains the key points of this policy. For a complete understanding of all
the relevant provisions, it is necessary to thoroughly read the full policy.
WHAT:
A person (adult or child) is considered to be physiologically and legally dead when he or she has
sustained either:
• cardiopulmonary death (irreversible cessation of circulatory and respiratory function) or
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• brain death (irreversible cessation of all functions of the entire brain, including the brain
stem).
The brain death protocol provides a process, including criteria, for determining and confirming
brain death and implementing the necessary procedures.
WHO:
• Any adult or pediatric patient who has been determined by clinical examination to have lost
all brain function is an appropriate candidate for a confirmatory brain death protocol.
• The clinical determination of brain death is made by two designated attendings, at least one
of whom is from the Department of Neurology or Neurosurgery. The second attending may
be from the Department of Critical Care Medicine. When the patient is less than one year
old, the clinical determination of brain death is made by a pediatric neurologist or
neurosurgeon.
WHEN:
The brain death protocol applies whenever a patient appears clinically to have lost brain
function.
WHERE:
The brain death protocol is applicable in any inpatient clinical setting and emergency room.
HOW:
The brain death protocol includes:
• discussion with family
• initial assessment by either neurology/neurosurgery or critical care attending
• referral to New York Organ Donor Network
• ancillary studies, if considered indicated by attending
• special observation requirements in pediatric cases
• confirmatory brain death determination by either neurology/neurosurgery or critical care
attending
• pronouncement of death
• medical record documentation
• informing family of patient=s death
• maintaining organs if patient is a potential donor
• withdrawing life-supporting interventions
• assisting and supporting family by provision of Chaplaincy services or through Palliative
Care and/or Bioethics Consults.
• Brain death criteria that must be met include but are not limited to:
• absence of confounding drug levels
• cerebral unresponsiveness
• apnea testing, if appropriate
• electro-cerebral silence (as needed for confirmation or as required when patient is less than
one year)
• Reasonable accommodation in cases of objection to a brain death declaration are appropriate
when
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• family has moral or religious objections to brain death definition or determination.
• clinical staff has conscientious objection to brain death definition or determination.
CONTACT:
Neurology 718- 920-6444
Neurosurgery 718- 920-4196
Medical Director 718- 920-7052; 6078
DO-NOT-RESUSCITATE (DNR) ORDERS
Summary - Administrative Policy and Procedure # JA11.1
Note: This summary contains the key points of this policy. For a complete understanding of all
the relevant provisions, it is necessary to thoroughly read the full policy.
WHAT:
A do-not-resuscitate (DNR) order is a consent to forego all or part of cardiopulmonary
resuscitation in the event of a cardiac and/or respiratory arrest. A DNR order does not affect or
limit any other care and can be consistent with aggressive treatment. In a cardiac and/or
pulmonary arrest, a DNR order permits withholding both intubation and other components of
CPR.
NOTE: Do-not-intubate (DNI) orders are distinct from DNR orders. In a cardio-pulmonary
arrest, a separate DNI order is not needed. Refer to Policy JDO5.1 for complete information on
DNI orders.
WHO:
• Suitable patients for DNR orders are those who are unlikely to survive or benefit from
resuscitation in the event of a cardiopulmonary arrest.
• Suitable patients with capacity should be approached for consent to a DNR order.
• Suitable patients without capacity should have consent to a DNR order given either by an
appointed health care agent or a DNR surrogate (see list of authorized surrogates) based on
one of the four specified medical conditions (see below).
• The patient’s attending physician determines suitability and decisional capacity, obtains
consent and writes the DNR order and notifies the patient or surrogate that the order has been
written.
• A determination by the attending that the patient lacks capacity must be confirmed by a
second attending. The second attending also concurs that an incapacitated patient without a
health care agent meets one of the four specified medical conditions (see below).
• House staff may obtain consent and enter a temporary DNR order after discussion with the
attending, who should countersign the order or enter a standing order on CIS within 24 hours.
• Medical director or designee must review, document and sign a DNR order based on medical
futility for patients who meet one of the two specified criteria, have no advance directives or
known wishes, no willing/available surrogate, and no family objecting to a DNR order.
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Patients for whom a DNR based on medical futility is appropriate must meet, one of the
following criteria:
• the patient will not survive a code, or
• the patient will experience multiple arrests in a short period of time.
WHEN:
DNR applies only at the time of cardiac and/or pulmonary arrest and does not affect or limit any
other care.
WHERE:
• DNR orders are valid in every inpatient clinical setting.
• Non-hospital DNR orders are valid in any community or ambulatory care setting.
• Suspension of a DNR order in the OR or other department must be discussed with a
capacitated patient or the health care agent or DNR surrogate of a patient without capacity.
Before a DNR order is suspended for a procedure in the OR or other department, the reasons
for and duration of the suspension must be discussed with the person giving consent. The
decision must be documented by both the attending surgeon and attending anesthesiologist
and their agreement with patient, agent or surrogate fully communicated to the health care
team.
HOW:
The DNR protocol includes documenting on the appropriate forms (see below)::
• determination of patient suitability
• determination of patient’s decisional capacity
• discussion with patient, health care agent or surrogate
• obtaining verbal or written consent to DNR. Verbal consent must be documented
and witnessed by 2 people.
• entering DNR order in the medical record or on CIS
• notification of patient, health care agent or surrogate
If the patient lacks decisional capacity, a DNR order may only be consented to by a health care
agent or DNR surrogate based on one of the following 4 criteria:
• terminal condition, or
• permanent unconsciousness, or
• medical futility (patient would not survive resuscitation or
• would survive but would have multiple arrests within a short period of time (see
above), or extraordinary burden (CPR would cause more harm than benefit).
DNR forms are available on all clinical units
• OD1091-1 DNR Attending Physician’s Documentation (3 pages-pink)
• OD1091-2 Oral Consent to DNR Order (single page-pink, requires 2 witnesses, one
of whom is a physician)
• OD1091-3 Written Consent to DNR Order (single page-pink- for
patient’s/surrogate’s, in English & Spanish )
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• OD1091-4 Affidavit of Close Friend consenting to DNR (single page-pink-- in
English Spanish )
• OD1091-5 Nonhospital DNR (single page-white--order for ambulatory care and
community settings.
Note: After completing the appropriate forms, the attending physician must enter a written or
electronic DNR order.
Disputes about DNR orders for incapacitated patients trigger a dispute mediation process, during
which the DNR is suspended and resuscitation must be attempted in the event of an arrest. When
the patient’s attending physician has a conscientious objection to issuing a DNR order for a
suitable patient, that physician must transfer the patient to another attending.
CONTACT:
Medical Director’s Office 718- 920-7052
Palliative Care 718- 920-6378
Bioethics (Moses) 718- 920-6226
(Weiler) 718- 904-2299
DO-NOT-INTUBATE (DNI) ORDERS
Summary -Administrative Policy and Procedure #JD05.1
Note: This summary contains the key points of this policy and the related procedures. For a
complete understanding of all the relevant provisions, it is necessary to thoroughly read the
full policy.
WHAT:
• In a cardiopulmonary arrest a DNR order permits withholding both intubation and other
components of CPR. A separate DNI order is not needed.
• In situations other than an arrest, such as acute respiratory distress, a separate DNI order is
necessary to forego intubation.
In practice, many patients will request and will meet the conditions for both DNR and DNI
orders but the criteria for consenting to and implementing them are very different.
NOTE: Do-not-intubate (DNI) orders are distinct from do-not-resuscitate (DNR) orders and,
therefore, are covered under a separate do-not-intubate (DNI) policy.
WHO:
A DNI order may be considered for :
• a capacitated patient whose attending physician determines that a do-not-intubate (DNI)
order is medically indicated and recommends this course, or
• an incapacitated patient whose attending determines that a DNI order is medically
indicated and recommends this course to the health care agent or the family/ surrogate
who knows the patient’s wishes about intubation; or
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• A patient, agent or other family/surrogate who requests that intubation be foregone in
light of the patient’s medical condition and known wishes.
• A capacitated patient, after discussion with the attending physician, may consent to
foregoing intubation or re-intubation for present or future moderate-to-severe respiratory
distress or under any future circumstance.
A DNI order may be written for an incapacitated patient who has been determined by the
attending and concurring attending physicians to lack capacity and for whom a DNI is medically
indicated, in the following circumstances:
• a health care agent for an incapacitated patient may consent to foregoing intubation or reintubation
for present or future moderate-to-severe respiratory distress or under any
future circumstance, or
• a family member or other surrogate who knows the patient’s wishes about intubation
may also consent to foregoing intubation or re-intubation for present or future moderate
to severe respiratory distress. The family/surrogate must have fully discussed the
patient’s prior declared treatment choices and best interests with the attending physician
and agreed to a DNI order.
WHEN:
• The patient’s condition and prognosis are so poor that intubation or re-intubation is likely to
merely prolong dying or increase suffering without providing substantial benefit and
• the capacitated patient chooses to forego intubation, or
• the incapacitated patient’s proxy chooses to forego intubation, or
• the surrogate/family provides evidence of the incapacitated patient’s prior wishes to forego
intubation.
WHERE:
• DNI orders to forego intubation may be appropriate in any clinical setting.
• Efforts will be made to communicate decisions to forego intubation/DNI orders to nonhospital
facilities and providers.
HOW:
Foregoing intubation in situations other than cardiopulmonary arrest requires consent by:
• A capacitated patient or a health care agent or other surrogate for an incapacitated patient
who has had a documented discussion with the attending physician about the patient’s
intubation wishes.
• The attending physician’s DNI Documentation form (OD1080-1) and the Patient’s
/Surrogate’s Consent to DNI form (OD1080-2) are available on all clinical units.
After completing the DNI documentation form, the attending must enter a written or
electronic DNI order.
CONTACT:
Office of the Medical Director 718- 920-7052, -2809, -6078
Palliative Care 718- 920-6378
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Bioethics (Moses) 718- 920-6226
(Weiler) 718- 904-2299
END-OF-LIFE CARE
Summary - Administrative Policy and Procedure # JD04.1
Note: This summary contains the key points of this policy. For a complete understanding of
all the relevant provisions, it is necessary to thoroughly read the full policy.
WHAT:
End-of-life care includes therapeutic interventions that meet the medical, spiritual, socio-cultural
and emotional needs of patients with active, progressive far-advanced disease whose disease is
not responsive to curative treatment. These measures have as their goal maximizing comfort and
function, enhancing the quality of remaining life, and supporting the patient’s family.
WHO:
All members of the health care team are responsible for providing compassionate, skillful and
responsive end-of-life care. In addition, palliative care specialists should be consulted about the
management of pain and other symptoms.
WHEN:
End-of-life care is appropriate whenever cure is no longer the primary goal, and the patient is in
the late stages of incurable illness.
WHERE
End-of-life care is appropriate in any clinical or community setting.
HOW:
Every effort should be made to identify as early as possible those patients who would benefit
from aggressive attention to end-of-life needs. These include but are not limited to:
• facilitating advance care planning
• controlling pain and other symptoms;
• meeting spiritual needs
• providing emotional support to patients and family in coping with progressive illness,
loss of function and the attendant anxiety and stress;
• resolving ethical concerns
• clarifying the goals of care, including all available supportive and comfort care options
• enhancing the quality of the patient’s remaining life and the dying process;
• addressing cultural, spiritual and emotional concerns and decisions related to end-of-life,
including foregoing treatment and organ donation; and
• supporting patients, families and care providers as they face loss and bereavement.
CONTACT:
Palliative Care 718-920-6378
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Bioethics (Moses) 718-920-6226
(Weiler) 718-904-2299
Office of the Medical Director 718-920-7052; 2809; 6078
FOREGOING LIFE-SUSTAINING TREATMENT
Summary - Administrative Policy and Procedure # JA12.1
Note: This summary contains the key points of this policy. For a complete understanding of all
the relevant provisions, it is necessary to thoroughly read the full policy.
WHAT:
This policy delineates the roles of the physician and the members of the health care team in
guiding patients, their health care agents, family or other surrogates in end-of-life decision
making. In recommending and responding to decisions about foregoing (withholding or
withdrawing) life-sustaining treatment, physicians and other clinicians should be guided by the
following principles:
• Physicians and other clinicians have no medical, legal or ethical obligation to offer or
provide treatment(s) that are not medically indicated or to offer or provide treatment that
would increase a patient’s suffering or merely prolong the dying process.
• Any decision to forego life-sustaining or other medically indicated treatment(s) should
trigger a process of discussion about the reasons for the decision, the consequences of
foregoing treatment and the range of appropriate therapeutic options, including palliative
care. A Palliative Care Medicine or a Bioethics consult and/or a family meeting may be
helpful in clarifying the goals and plan of care.
• Physicians caring for a patient who is terminally ill should discuss a palliative care plan or a
time-limited course of supportive treatment (e.g., dialysis) with the capacitated patient or
surrogate. These discussions should include a review of the patient’s condition and
prognosis and the patient’s present (or prior) declared health choices.
WHO:
• The patient, family or anyone on the health care team may initiate a discussion about
foregoing treatment.
• The patient’s attending physician determines when foregoing treatment is medically
indicated and recommends this course to the capacitated patient, or the health care agent or
other surrogate who makes decisions for the incapacitated patient.
WHEN:
Foregoing life-sustaining treatment is appropriate whenever a patient’s condition and prognosis
are such that one or more interventions are likely to merely prolong dying or increase suffering
without providing substantial benefit.
WHERE:
Orders to forego life-sustaining treatment may be appropriate in any clinical setting.
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HOW:
• Capacitated patients may refuse any treatment, including life-sustaining treatment.
• Health care agents for incapacitated patients may customarily refuse life-sustaining treatment
for the incapacitated patient. (See the policy for requirements.)
• Most treatment decisions for incapacitated patients who do not have appointed health care
agents are made by the attending physician in conjunction with the patient’s family or other
surrogate. These include decisions not to initiate specific treatments that would not be
medically indicated based on the patient’s condition and prognosis.
• Family members may also request the foregoing of one or more life-sustaining interventions
that are already underway (in particular, ventilatory support, ventricular assist devices,
dialysis and/or artificial nutrition or hydration). This is done by providing information about
the patient’s prior declared treatment wishes, indicating that the now-incapacitated patient
would have chosen to forego life-sustaining treatment under the current circumstances. The
Office of the Medical Director must be called to review the information provided by the
family and the physician documentation of this process.
• When a patient has no available or willing surrogate, life-sustaining treatment may be
foregone if such interventions(s) would merely prolong the dying process or increase
suffering. A Bioethics, Critical Care and/or Palliative Medicine consult may be helpful in
determining an appropriate plan of care. The Medical Director’s Office must be contacted in
these circumstances to coordinate multi-disciplinary review.
• Parents and legal guardians of minor patients may decide to forego life-sustaining treatments.
Pediatric Ethics, Bioethics, the Chief of Service, Palliative Care and/or the Medical
Director’s Office should be involved. Such decisions are made in the best interest of the
child. Consideration is given to the wishes of the parent and the child. The child is included
in the discussions, as appropriate.
• DNI orders are written to forego intubation in any circumstance other than cardiopulmonary
arrest. (See the Do-not-intubate (DNI) Policy for guidance in entering DNI orders for
decisions to forego intubation or re-intubation for moderate to severe respiratory distress or
any situation other than cardiopulmonary arrest).
CONTACT:
Medical Director 718-920-7052; 6078
Bioethics (Moses) 718-920-6226
(Weiler) 718-904-2299
INFORMED CONSENT AND REFUSAL
Administrative Policy and Procedure JC10.1
Note: This summary contains key points of Montefiore's consent policy. For complete
understanding of all the relevant provisions. it is necessary to thoroughly read the full policy.
WHEN
Informed consent is required for all procedures or treatments that are invasive or have potentially
serious side effects or complications. When a patient is a conscious and mentally capable adult,
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only that person may consent to treatment.
WHO
Obtaining informed consent from a patient is the responsibility of the attending physician
performing the procedure. However, consent may be obtained by house staff or PAs as agents of
the attending.
WHAT
The essential part of informed consent is a discussion that imparts to the patient all information
concerning the procedure or treatment that a reasonably prudent person in the patient's position
would want to know. The following information should be disclosed:
• the nature of the patient's condition
• the nature and purpose of the proposed procedure
• the expected risks, benefits, and alternatives to the procedure. Serious risks, even if rare,
should be disclosed.
HOW
• The informed consent discussion should be held in a language that the patient understands,
using terms that a lay person would understand. If a translator is needed, obtain one from the
MMC Language Bank. Family members should not be used as translators for an informed
consent discussion.
• After the informed consent discussion, the patient should be asked to sign the hospital
consent form and the patient's signature should be witnessed by a hospital employee. The
procedure should be described in terms a layperson can readily understand; no abbreviations
should be used.
• A note summarizing the discussion must then be written to reflect that the informed consent
discussion has taken place. This note may be written in Section II on the consent form or in
the progress notes. On the day of surgery, the attending physician must sign Section III of
the consent form to confirm that it correctly describes the procedure.
• If the patient lacks the capacity to consent, the physician should seek the informed consent of
the patient's health care proxy, legal guardian or next of kin, in that order. However, if the
patient lacks capacity and is actively refusing the procedure, Treatment cannot proceed. Risk
Management (920-6340) must be contacted.
• Administrative Review - In nonemergent situations, where the patient lacks the capacity to
consent and is not refusing treatment but the patient has no known health care proxy, legal
guardian or next of kin the Medical Director's office (920-6078)
must be contacted.
• Refusals - A patient with capacity may refuse any procedure but except for a health care
proxy or legal guardian, no one may refuse necessary treatment on behalf of an incapable
adult patient. Neither a parent nor a legal guardian may refuse lifesaving treatment for a child
or mentally retarded adult. Risk Management should be contacted if these situations arise.
• Emergencies -In an emergency, if the attempt to secure consent would seriously jeopardize
the patient's life or health, the physician may proceed without obtaining consent but must
document the nature of the emergency in the medical record.
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VERIFICATION OF OPERATIVE PROCEDURE SITE AND PATIENT
IDENTIFICATION
Patient Care Manual: Code O-4
Note: This summary contains key points of this policy and the related procedures. For a
complete understanding of all the relevant provisions, it is necessary to thoroughly read the full
policy.
WHAT:
It is the responsibility of all associates involved in the care of the patient undergoing an
operative/invasive procedure to verify the correct patient, procedure and procedure site. It is the
Attending physician’s responsibility to document this verification process on the informed
consent tool on the day of the procedure. This policy ensures that the correct surgery/procedure
is performed at the correct side on the correct patient and eliminates wrong-side, wrong-site,
wrong-patient, wrong-procedure surgery.
WHO:
• This policy applies to patients undergoing operative/invasive procedures
• Attending physicians
• All associates involved in the care of the patient undergoing the procedure
WHEN:
This policy applies to all operative and other invasive procedures that expose patients to more
than minimal risk.
WHERE
This policy includes but is not limited to procedures done in settings other than the operating
room, such as in special procedure units, endoscopy units, and interventional radiology units,
procedures done at the bedside and those performed outside of the operating room (e.g.,
ambulatory sites).
HOW
• Pre-operative/procedure verification process
Prior to the start of the procedure confirm appropriate documents are available, have been
reviewed and are consistent with the staff’s understanding of the patient, procedure and site.
• Marking process
The procedure site will be marked for invasive procedures involving right/left distinction,
multiple structures, or levels. The Attending Physician, or designee will mark the site before the
patient enters the procedure room and prior to the administration of medications with sedative
effects, except in the case of minors or other patients with decision makers.
• Final Verification Process (“Time Out”)
Immediately prior to the start of any surgical/invasive procedure, a final verification “Time Out”
will be conducted to confirm the correct patient, procedure and procedure site. The process will
be initiated by the circulating nurse and take place between the circulating nurse, anesthesiologist
and surgeon. Before the incision is made, each team member will verbally confirm the name of
the patient, the planned procedure and the procedure site. If there are any discrepancies in
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information, or disagreements regarding the procedure, it will be delayed until the issues are
resolved.
DEATH CERTIFICATES
• The Death Certificate has three sections. Section 1, “Medical Certification” and Section 3,
“Physician's Confidential Medical Report” must be completed by the physician. Section 2,
“Funeral Director' s Report”, must be completed by the Funeral Director. The Death
Certificate should be completed in the Health Information Management where assistance for
completion is available *Note: If the patient is a transsexual, the sex at birth is the official sex
of the decedent regardless of sex change operations.
• The Death Certificate must be completed in black ink only. No erasures, write-overs, or
crossing out of information. Any evidence of abbreviation is unacceptable.
• The Death Certificate must be completed with the name of the patient as registered at MMC.
Any corrections to patient's name must be accompanied by written documentation.
FIRE SAFETY AND PREVENTION
In order to ensure safety and security, all associates are required to obey all applicable Center,
City, State and Federal health, safety, and fire laws, rules and regulations. Information on fire
alarm bells is posted throughout the Medical Center adjacent to all fire alarm boxes. Learn where
the fire alarms are located and where the information is posted.
In case of a fire, follow the R.A.C.E. (Rescue, Alarm, Confine, Extinguish) procedure.
Fires can be called in by activating fire alarms or by dialing extension 2222. In order to
safeguard the lives of patients and personnel and to reduce the loss of property, every staff
member must recognize the importance of fire prevention and fire control. Four steps that should
be followed by anyone discovering a fire in the hospital complex: R.A.C.E
R: Remove from immediate danger anyone in close proximity to the fire or smoke
A: Alarm - use one of the manual fire boxes located on each floor. Open the door of the
alarm box. Pull the internal lever down once and release. The alarm should sound within
five seconds. The staff member should dial the hospital's fire emergency number
(X2222). The caller should give the operator the exact location of the fire.
C: Confine the Fire- Close the door to the room which is on fire. Close doors to all other
patient rooms in the area. Insure that all stairwells, laundry chutes and corridor smoke
barrier doors are closed.
E: If possible, steps should be taken to extinguish the fire by using the portable
extinguishers located throughout the hospital. This step should not be attempted until the
first three steps have been completed. To operate a portable extinguisher, you do the
following:
P – Pull the locking pin from the handle
A – Aim the hose at the base of the fire
S – Squeeze the handle
S – Sweep the hose from side-to-side at the base of the fire.
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INFECTION CONTROL PROGRAM
Moses Nurses (718) 920 - 4562
Weiler Nurses (718) 904 – 3422
The goal of the Infection Control Program is to prevent and control the spread of infections
between patients, personnel and visitors. The Infection Control Committee is a standing
multidisciplinary committee of the hospital staff, which meets regularly to discuss problems and
solutions related to controlling infections.
Every department that has direct or indirect patient contact has a manual specific to the
department. House staff Infection Control Handbooks are distributed during house staff
orientation and upon request. It is the responsibility of every associate to become familiar with
the contents of their handbook which contain the standards of infection control practice.
Infection Control Nurses are responsible for establishing, implementing and monitoring infection
control practices throughout the hospital and ambulatory sites. Standard Precautions are
protocols that must be used for every interaction between any patient and health care worker.
These general protocols are designed to prevent the bi-directional transmission of disease
between patients and health care workers.
Fundamental principles of Standard Precautions include proper hand hygiene (using soap and
water, or alcohol based hand rub agents between all patient encounters) and the appropriate
cleaning of patient care areas and equipment between patient encounters. Standard Precautions
also addresses issues related to the potential exposure and transmission of bloodborne pathogens
during patient and health care worker interactions and requires the appropriate use of Personal
Protective Equipment (PPE), and patient equipment use during invasive procedures.
Detailed information regarding infection control practice at Montefiore Medical Center
(restricted antibiotics, protocols for invasive procedures, isolation procedures, etc.) will be
provided to you in a separate House Staff Infection Control Handbook.
NEEDLE STICKS
The following practices may be useful in preventing needle sticks:
• Use and properly dispose of all safety needle stick prevention devices. Activate the safety
mechanism of the device directly after use (if applicable).
• Dispose of needles properly in puncture-resistant containers
• Avoid rushing when using a needle in caring for an uncooperative patient
• Seek assistance when using a needle in caring for an uncooperative patient
• Avoid pulling hard when encountering resistance in withdrawing needles from patients
• Never put needles into your pocket.
• Never try to remove anything from a needle container or force needles into a full container
• Pick up improperly discarded needles with care and dispose of them in puncture-resistant
containers
• Discuss your concerns for prevention with colleagues. This can be useful step toward the
implementation of effective preventive strategies.
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• If you are not already immunized against hepatitis B and are at high risk for needle stick
injury or other exposure to blood and other potentially infectious bodily fluids, get
vaccinated.
What to do if you are stuck
• Wash the injury well with soap and water as soon as possible
• If known, write down the name, site and hospital number of the source patient
• Report the stick to Occupational Health Service. You will be scheduled for assessment, and if
necessary for appropriate counseling, treatment and follow-up procedures. If your injury
occurs during night or weekend hours, you should contact the Emergency Room.
ETHICAL AND LEGAL COMPLIANCE
Employees, House Staff and Medical Staff members are to exercise sound judgment and the
utmost good faith, care and diligence in all matters relating to their duties and responsibilities to
Montefiore, guided by the highest standards of medical and business ethics.
Employees and others performing services for Montefiore are to comply with all legal
requirements in the performance of duties on behalf of Montefiore, as are House Staff members
in the course of their training and medical staff members in their professional activities on the
medical staff. Violations of law and the Montefiore's high ethical standards are unacceptable and
will not be tolerated in any clinical, academic or organizational activities conducted under the
authority or on behalf of Montefiore Medical Center. Accordingly, associate employment, house
staff training programs, and medical staff membership and privileges are conducted in ways that
are consistent with applicable laws and ethical standards.
Montefiore's policy is to prevent, detect and terminate activity that involves fraud or
other violation of law or that otherwise breaches the Montefiore's ethical standards and the
Montefiore Code of Ethics. Violations of Montefiore's ethical standards, including criminal
conduct or other violations of legal requirements, will not be tolerated and will result in
appropriate disciplinary measures. Montefiore's policy is to report violations of criminal laws to
the appropriate law enforcement authorities, and to cooperate with law
enforcement agencies.
Employees, House Staff and members of the Medical Staff should carefully read
educational information provided by Montefiore, and participate in any other training provided
and required by Montefiore, regarding legal requirements applicable to their area of
responsibility or activities. They should be familiar with Montefiore's administrative and
personnel policies and procedures applicable to them and to their activities (including but not
limited to members of the medical staff, the Medical Staff Bylaws and Rules & Regulations and
policies of the Medical Staff) and shall consult these materials as needed in the performance of
their duties to assure that their conduct complies with them.
Montefiore encourages reporting of any activity believed in good faith to constitute an
ethical or legal violation. Reporting may be made to one's training director or supervisor or to a
higher person in his or her chain of command, to the Department of Audit Services, or to others
who may be identified in pertinent Montefiore policies.
Reports will be handled in confidence, and will only be disclosed on a need-to-know basis in
order to investigate and resolve the matter, or as required by law. Montefiore will protect those
who make such reports in good faith from retaliation based on such good faith reporting. Any
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person who feels that he/she may be the subject of such retaliation should immediately contact
the Department of Audit Services or a Vice President in the Department of Human Relations.
Malicious, knowing, false reporting, or making a false report with reckless disregard for the
truth, will result in appropriate disciplinary measures.
HARASSMENT
Montefiore Medical Center is committed to providing a work environment free of discrimination
and unlawful harassment. Actions, words, jokes or comments based on an individual's sex,
sexual orientation, race, ethnicity, age, religion or any other legally protected characteristic will
not be tolerated. Such conduct is demeaning to another person, undermines the integrity of the
employment relationship, and is strictly prohibited. This conduct is unlawful regardless of
whether it is committed by a supervisor or coworker, or a third party vendor, customer,
independent contractor or staff member not employed by the Medical Center.
Sexual harassment is one of the forms of harassment prohibited by this policy.
Specifically, the law defines sexual harassment as any unwelcome sexual advances or requests
for sexual favors or any conduct of a sexual nature when:
• submission to such conduct is made either explicitly or implicitly a term or condition of an
individual's employment
• submission to or rejection of such conduct by an individual is used as the basis of
employment decisions affecting such individual, or
• such conduct has the purpose or effect of substantially interfering with an individual's work
performance or creating an intimidating, hostile or offensive working environment
The first two categories are commonly referred to as "quid pro quo" harassment, and the third
category is referred to as "hostile environment" harassment.
Sexual harassment may include, but is not limited to:
• Repeated offensive or unwelcome touching
• Sexual flirtations or advances
• Verbal abuse or comments of a sexual nature, whether in the form of jokes, innuendoes or
slurs
• Graphic verbal commentaries used to describe a person or about a person's body
• Display of sexually suggestive material in the form of photographs, drawings, graffiti or
computer graphics
• Other offensive physical, verbal or visual conduct
Individuals knowing of or experiencing any form of unlawful harassment are urged to report any
incidents to their supervisor or, if they are not comfortable contacting their supervisor, they
should contact the EEO Officer in the Human Resources Department at (718) 920-4998 or fax
(718) 920-6321.
Reports of harassment may be made without fear of reprisal. Complaints of unlawful harassment
will be investigated by the Medical Center's EEO Officer or his/her designee. All complaints will
be fully and promptly investigated and, where necessary, appropriate
action will be taken. All information disclosed in the procedure will be held in confidence and
will only be disclosed on a need to-know basis in order to investigate and resolve the matter. A
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supervisor or other member of management who has knowledge of a hostile or offensive work
environment resulting from unlawful harassment, either because he/she has observed the
harassment or received a complaint from a victim or observer, must immediately contact the
Medical Center's EEO Officer to inform the EEO Officer
of the complaint and seek assistance on how to proceed. He/she should not undertake a formal
independent investigation of the complaint without first consulting the EEO officer or his/her
designee.
Any associate deemed to have engaged in unlawful harassment against another associate will be
subject to disciplinary action, up to and including termination. Also, any false accusations will
result in appropriate discipline of the accuser, up to and including termination. In the event an
associate is relieved from duty pending investigation of sexual harassment charges and no
misconduct is established, the alleged harasser will return to work with pay retroactive to the
date of suspension.
All Medical Center Human Resources policies and practices are guidelines and may be changed,
modified or discontinued at any time by the Medical Center's senior Human Resources executive
or designee, with or without notice. Exceptions do not invalidate the
basic policy.
DRUG-FREE WORKPLACE
The federal Drug Free Workplace Act of 1988 pertains to Montefiore Medical Center and all of
our associates. The unlawful manufacture, distribution, dispensation, possession or use of a
controlled chemically substance is prohibited in the Medical Center. Any associate who violates
this provision is subject to termination. If you are convicted of any criminal drug offense
(defined as any finding of guilt, plea of no contest or imposition of sentence), you must notify
your department head within 5 days of conviction. The Employee Assistance Program (EAP)
provided by Occupational Health Services is available to you if you need drug counseling or
rehabilitation. The treatment is provided in the strictest confidentially. Participation in EAP does
not exempt you from complying with the above requirements.
SMOKE-FREE POLICY
We are committed to your good health. That is why we are a smoke free hospital. For smoking
cessation programs contact Occupational Health at (718) 920-5406.
EQUAL OPPORTUNITY EMPLOYER
Montefiore Medical Center is an equal employment opportunity employer. It is Montefiore's
policy not to discriminate on the basis of race, creed, color, national origin, gender, age, physical,
or mental disability, veteran status, martial status, sexual orientation, or censorship status, in
employment decisions including, but not limited
to, recruitment, hiring, compensation, training, and apprenticeship, promotion, upgrading,
demotion, downgrading, transfer, layoff, termination, and all other terms and conditions of
employment.
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CONTROLLED SUBSTANCES IN THE MEDICAL CENTER
It is the policy of the Medical Center to comply with federal, state and local regulatory agencies
pertaining to the ordering, receiving, storing, documentation and distribution of all controlled
drugs (CIIV) and to keep accurate records of each transaction. It is expected that all practitioners
who are authorized to administer or prescribe controlled substances in the medical center
conform to the requirements set forth by federal, state and medical center regulations.
The Department of Pharmacy will perform routine inspections and audits of all controlled
substance inventories to insure adherence to medical center policies and procedures and state and
federal regulations.
AUTHORIZED PRESCRIBERS
According to the New York State Department of Health Bureau of Controlled Substances and
MMC policy, the following practitioners are authorized to prescribe controlled substances in the
medical center: Doctors of Medicine, Doctors of Osteopathy, Dentists, Medical
Interns/Residents, Physician Assistants, Midwives, Nurse Practitioners, Optometrists and
Podiatrists.
• Orders for controlled substances written by registered physician assistants must be
countersigned by the collaborating physician within 24 hours.
• Medical students must have their orders countersigned by the resident or attending physician
before the order can be processed and administered to the patient.
• Interns, residents, and foreign physicians are allowed to write controlled substance
prescriptions provided that: 1.) Prescribing is done in the usual course of the practitioner's
professional practice. 2.) The practitioner acts only in the scope of his employment in the
hospital. 3.) The DEA number with a hospital-assigned three-digit suffix is received. Staff
physicians who are qualified to obtain their own DEA numbers may not use a hospital
number.
WRITTEN INPATIENT STANDING AND ROUTINE ORDERS FOR CONTROLLED
SUBSTANCES:
• Must be patient specific and written by an MMC authorized practitioner
• Must state the name of the drug, dose, route and frequency of administration.
• Orders that give a dose range (e.g., 50-100mg) or more than one route (e.g., PO/IM) are not
allowed.
• Preprinted orders are not allowed.
• All orders must have the prescriber signature and countersignature where applicable
• Orders written to be administered PRN without a specific time or frequency (e.g. Ativan lmg
P.O. PRN) are valid only for 72 hours. An order without a specific time may be administered
once only within the 72-hour period. A new order must be written if additional doses are
required.
• Specific orders for controlled substances to be administered at specific times are valid for
seven days and must be rewritten at least every seven days. The specified time may include a
PRN notation to allow the drug to be administered in accordance with the patient's need (e.g
Phenobarbital 15 mg P.O. t.i.d. and H.S.Valium 5 mg P.O. t.i.d. prn and Restoril 30 mg PO.
H.S. prn).
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VERBAL, TELEPHONE, OR FAXED CONTROLLED SUBSTANCE ORDERS
• Are allowed for inpatients in emergency situations only. An emergency is defined as the
immediate administration of the controlled substance is needed for proper treatment and no
alternative treatment is available.
• Are permitted only if it is not possible for the practitioner to provide a written order before
the needed administration of the drug.
• Can only be provided by an attending physician or fellow
• May be continued by house staff, but is restricted to a one time dose
• Must be signed by the physician within 24 hours.
LOSS OR DISCREPANCY OF A CONTROLLED SUBSTANCE
A loss of a controlled substance, including an unresolved discrepancy must be reported to the
Security Department, Department of Pharmacy and chair or manager of the department. An
investigation of the incident and written report, including a list of all individuals who have had
access to controlled substances and their license numbers, must be submitted to the Department
of Pharmacy. The Department of Pharmacy will complete the Report Form for Loss of
Controlled Substances and submit to the New York State Department of Health Bureau of
Controlled Substances Narcotic Enforcement Unit.
DEA NUMBERS
Under the Federal Controlled Substances Act, a practitioner is required to register with the Drug
Enforcement Agency (DEA) in order to prescribe and administer controlled substances. Certain
house staff physicians are not eligible for a federal registration number (interns and certain
residents). Therefore, provisions have been made under federal law to assign a temporary
number (hospital number plus an assigned suffix number), which authorizes the practitioner to
prescribe controlled drugs within the medical center. Interns and residents rotating at Montefiore
from other training programs are not eligible for a temporary Montefiore DEA number and
suffix.
OUT-PATIENT PRESCRIPTION WRITING
• New York State law requires all prescriptions to have a stamp/imprint in addition to the
prescriber's signature.
• The complete DEA number and suffix must be written on the prescription.
• The assigned number can only be used while employed at the medical center and on
prescriptions written for Montefiore patients.
STORAGE AND SECURITY
Controlled substances must be stored in a stationary, secured cabinet with double lock and key to
ensure adequate safeguards and security measures are undertaken to prevent against the loss,
destruction, theft or unauthorized access. Automated point-of-use
technology (Pyxis Medstation System) is an acceptable alternative to a cabinet.
• The cabinet will have inner and outer doors with separate keys. Spring locks or combination
locks are not acceptable.
• When not in use, the keys to the narcotic cabinet must be stored in a secured manner (e.g.,
locked drawer and unavailable to unauthorized personnel).
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• Practitioners will immediately notify the Department of Pharmacy of the loss, destruction,
theft or unauthorized use of any controlled substance.
DAILY INVENTORY
• Change in shift inventories must be performed on all controlled substances each day and
recorded on the inventory control form.
• The inventory must be performed by two licensed individuals (nurse, physician, dentist or
pharmacist) unless the location has received exempt status by the Unified Director of
Pharmacy and sign the inventory control form.
• In patient care areas (i.e., outpatient sites, clinics, and special procedures rooms) where there
is only one nurse or no nurse, the physician(s) or dentist(s) is responsible for the maintenance
of controlled substances and adherence to all policies and procedures.
• In areas that are open for one shift (i.e.,9AM to 5PM) the inventory must be performed by
two licensed individuals and at the open and close of business. The time of the inventory
must be recorded on the inventory record. If the area (clinic, office, procedure room) is
closed on a particular day (Saturday, Sunday or holidays) the word "closed" must be written
on the inventory control form for that date.
• Those areas that have received exempt status by the Unified Director of Pharmacy will have
a controlled drug inventory performed at the open and close of business by one licensed
practitioner and indicate the word “self” in the appropriate space.
• Areas that utilize automated point-of-use dispensing technology are exempt from performing
the change of shift inventory daily. The count must be performed at least once a week on a
designated day.
RECORD KEEPING AND DOCUMENTATION
A separate record will be maintained of the administration of controlled substances indicating the
date and hour of administration, patient's full name (last and first), name and quantity, the
balance on hand after such administration, signature of person administering and name of the
prescriber.
REQUESTING CONTROLLED SUBSTANCES FROM THE PHARMACY BY HOUSE
STAFF
Controlled substances may be picked up from the Pharmacy in cases of emergency by house
staff provided a valid medication order has been written and the patient care area does not stock
the item. Controlled substances will be dispensed to the house staff personnel provided a
Montefiore Medical Center identification badge is shown. Identification badges from other
institutions are not acceptable. Once the proper requirements are confirmed, only one dose of
the controlled substance will be dispensed. The house staff personnel are responsible for
documenting the use and waste of the controlled substance on the disposition form and must
return the form back to the Pharmacy immediately upon completion of the emergency. Any
unused and sealed controlled substance must be returned back to the Pharmacy or given to the
nurse-in-charge in the care area for proper storage and inventory maintenance.
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WASTING OF CONTROLLED SUBSTANCES
Single-unit doses or partial doses remaining after the administration or attempted administration
of a portion of a liquid (solution for injection or oral solution) or solid unit dose of a controlled
substance may be destroyed beyond reclamation provided that a notation is made on the
administration record sheet; and the destruction is witnessed by a second licensed individual
(nurse, pharmacist, physician or dentist). Witnesses must visually observe the discard.
CONTROLLED SUBSTANCES THAT ARE UNDESIRED, DETRIORATED OR OBSOLETE
• Must be returned to the Department of Pharmacy and documented on the disposition
record/inventory control form/automated point-of use technology
• Only controlled drugs received from the Department of Pharmacy may be returned to the
Department of Pharmacy.
• Controlled drugs purchased from an outside source (wholesaler, distributor or manufacturer)
may be returned to the distributor or manufacturer if the package is in its sealed original
state, or Bureau of Controlled Substances.
OFFICIAL NEW YORK STATE PRESCRIPTION FORMS (on-site and off-site)
• Official New York State prescription forms must be stored securely to ensure adequate
safeguards to prevent against the loss, destruction, theft or unauthorized access.
• Practitioners will immediately notify the Department of Security, Department of Pharmacy,
Police Department and appropriate regulatory agencies of the loss, destruction, theft or
unauthorized use of any state prescription form.
QUALITY IMPROVEMENT
Refer to Montefiore's Institutional QI Plan JQ04.1 in the Administrative Policy and Procedure
Manual. Or refer to the PI Tool Kit in the Performance Improvement Resource Center on the
QM/RM intranet web page.
Quality Management Department 718-920-5026
Rohit Bhalla, MD
Brandon Yongue, PhD
PERFORMANCE IMPROVEMENT MODEL
The Performance Improvement Model is consistent with the philosophy, mission, and goals of
Montefiore. All associates are involved in this planned, systematic, and ongoing performance
improvement program. It is an interdisciplinary process designed to objectively and
systematically monitor and evaluate the quality and safety of care and services, pursue
opportunities to improve patient care, strive for service excellence and to address identified
problems and vulnerable areas (high risk, high volume, problem prone, high cost). Montefiore is
an organization of interdependent parts. The organization seeks to optimize the performance of
the entire system. In continual improvement, an organization analyzes the processes that support
care delivery to reduce unnecessary variation, improve the quality of its services and provide
optimal outcomes.
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One Quality Improvement Plan exists for the entire Montefiore Network and one committee, The
Montefiore Quality Council, has oversight responsibility for performance improvement across
the entire Montefiore integrated delivery system. Characteristics of the Performance
Improvement Program are that it is customer focused, interdisciplinary, data driven, and outcome
oriented. The essence of performance improvement is to work continually to better meet
customer expectations, enhance efficiency, and improve the processes of care delivery.
Advances are achieved in part through interdisciplinary effort, adoption of “Best Practices” and
exploitation of advances in information technology.
QUALITY IMPROVEMENT
Who is responsible for quality
• Each of us
What is quality
• Montefiore's Vision Statement defines quality in health care:
Montefiore is committed to being the best healthcare provider in the Bronx and beyond. Our
associates and medical staff provide patient/family-focused care that exceeds customer
expectations, embraces academic excellence and achieves quality outcomes in a fiscally
responsible manner.
• The Institute of Medicine identifies the following as the domains of quality in health care:
• Patient Safety
• Effectiveness
• Timeliness
• Efficiency
• Equity
• Patient Centeredness
Who are your customers (Internal and External)
• External: patients, families, insurance agencies, JCAHO, NYSDOH referring physicians,
Medicare/Medicaid, etc.
• Internal: peers, administration, hospital associates, all departments.
How do we identify performance improvement (PI) projects
• Montefiore prioritizes those processes for improvement that are:
• High Risk
• High Volume
• Problem Prone
• High Cost
• Sources of information for PI projects include feedback from internal and external customers,
community concerns and ongoing indicator monitoring.
What is the chosen model for planned, systematic improvements
• Plan-Do-Check-Act (PDCA) Model
PLAN
• Assemble an interdisciplinary workgroup
• Review "Best Practices" from Montefiore and elsewhere
• Identify critical measures of success
• Assess causes of perceived problems
DO
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• Collect baseline data
• Test the potential solutions that were developed in the planning stage
• Pilot test the solution
• Limit initial implementation
• Minimize risk
• Minimize disruption until process assessed
CHECK
• Assess the success of the changes that were implemented in the testing stage by
recollecting and evaluating pertinent data
• The team determines, using appropriate data analysis, whether there were:
• Significant process improvements
• Reductions in the variation of outcomes
ACT
If the intervention was successful, then implement permanent changes to the process:
• Education and training of all Associates who will be affected by the process revisions
• Changes in the Montefiore Procedure and Policy Manuals, where appropriate
Ongoing monitoring and response to key indicators to 'hold the gain' made by process changes
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SECTION VI
•
SERVICE DEPARTMENTS
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ACUTE PAIN
Interim Medical Director
Albert Saubermann, MD
Administrator
Bettie Jackson
Acute Pain Team:
Linda Dallam, MS, GNP 718-920-6212
917-314-7928
Elissa (Lisa) Davis, MSN, ANP 718-920-5216
917-798-0060
Hours
Monday-Friday 8:00AM - 4:00PM
The Acute Pain Management Team is available for consults. Call for assistance with Intractable
pain, PCA management, Complex pain, Pain in patients with chemical dependency, Undertreated
pain, and Route and dosage conversion. The team is also available to assist with JCAHO
and other pain-related regulatory requirements.
ADMITTING
MOSES
Director
Jodi Yedvab 718-920-2112
Admitting Supervisor
Albert Weiner 718-920-2865
Bed control 718-920-6651/ 6652/ 2196/ 2197/2198
ER Bed control 718-920-2967
Admitting (General) 718-920-5001/ 5002/ 5003/5004
Patient Information 718-920-4141
WEILER
Director
Sandar Kelly
718-904-2597
Admitting Supervisor
Frank Carlisi 718-904-2085
Bed control 718-904-3286
Admitting (General) 718-904-2928
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Legal Certificates 718-904-3456
Financial Counselors 718-904-3552
Cashier 718-904-3448
The admitting office is the center of the medical center. This is the first impression or point of
entry into the hospital for the patient being admitted. The Admitting department is composed of
both management and registration staff:
• Admitting Supervisor: Oversees the admitting process, operations, and related services
pertaining to the department
• Bed control: Coordinate all beds within the hospital, take reservations for patients to be
admitted to the hospital, and oversee all transfers within the hospital
• Admitting Clerks: Interview patients for admission to the hospital, have required paper work
signed by the patient or designee, and place an ID band on the patient for their hospital stay.
• Receptionist: Provide patient information to family and visitors
Within the Admitting department, any physician or designee can call in a reservation to the bed
controller for Ambulatory, Same Day, Elective, or Emergent admissions. Patients may be
admitted from their home, doctor’s office, clinic, or emergency room.
BIOETHICS
When decisions about health care raise ethical issues in the clinical or organizational setting, the
Division of Bioethics, the Bioethics Consultation Service and the Ethics Committee serve as
useful resources to the Montefiore community.
BIOETHICS CONSULTATION SERVICE
Consultations
718-920-6226/4096 Moses
718-904-2299 Weiler
Members of the Division of Bioethics, who compose the consultation service, are available to
meet with patients, families or designated representatives, and caregiving staff to help clarify and
resolve ethical dilemmas. Anyone involved in patient care-patient, family member or proxy
agent, or professional care team with an ethical concern or problem can directly access the
consultation service.
Hours
Monday – Friday 9:00AM - 5:00PM
Outside of regular hours, if the patient care issue does not require immediate attention, a message
left at the offices of the Division of Bioethics will be responded to the next working day. Urgent
consultations outside of regular business hours will be handled by the appropriate the Assistant
Director of Nursing (AND).
ETHICS COMMITTEE
The Ethics Committee is an interdisciplinary body that meets monthly and on an ad hoc basis to
address ethical issues that arise in the clinical and organizational setting. Rather than a decisionmaking
body, the committee is a forum for study, policy review and advice. All deliberations of
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the consultation service and committee are confidential and all information and records are
protected. There is no charge for these services.
BLOOD BANKS
Director
Joan Uehlinger, MD 718-920-4556
718-904-3092
Manager
Leana Serrano-Rahman 718-920-2192
718-904-3377
MOSES DIVISION
Laboratory: North 8 Silver Zone 718-920-4786
Donor Room/Outpatient Services: Rosenthal 2
Manager: Angelina Bonzon-Adelson, RN
Call (718) 920-4810 for Appointment
Blood Donations:
• Autologous
• Directed
• Voluntary
Out-patient transfusions
Therapeutic phlebotomy
Apheresis
EINSTEIN/WEILER DIVISION
Laboratory: 3 rd Floor 718-904-2868
Donor Room/Outpatient Services: Room 2189
Manager: Angelina Bonzon-Adelson, RN
Call (718) 904-2100 for Appointment
Donor Room
Blood Donations:
• Autologous
• Directed
• Voluntary
Out-patient transfusions
Therapeutic phlebotomy
Apheresis
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CHILD PROTECTION CENTER
The Children’s Hospital at Montefiore
3314 Steuben Avenue 718-920-5833
Bronx, NY 10467
718-405-6149 Fax
Executive Director
Karel Amaranth, MA
Medical Director
Linda Cahill, MD
Hours
Monday - Thursday 8:30AM - 7:00PM, Friday 8:30AM - 5:00PM
The Child Protection Center (CPC) is a fully certified Child Advocacy Center dedicated to
breaking the cycle of child abuse. The mission of the center is to minimize the traumas that
afflict children and their families who are victims of sexual and physical abuse and/or neglect.
Through critical medical and psychosocial evaluation, along with community education, the CPC
has intervened to save and restore the lives of thousands of children and families. In addition to
expert evaluation and testimony, the CPC also provides critical services to families in there new
prevention Services building at 3380 Reservoir oval. These services include individual and
family counseling, group therapy and parenting skills classes.
CLINICAL INFORMATION SYSTEMS
Montefiore Medical Center's Clinical Information System (CIS), serves as an on-line medical
record for a number of key elements of the patient’s chart. For all visits across the Montefiore
Integrated Delivery System, the following elements are currently available at CIS Windowsbased
PC workstations located throughout MMC's delivery system:
• Patient demographic and visit information
• Laboratory test results
• Radiology reports
• Nuclear Medicine reports
For all inpatient visits, the following elements are currently available:
• Physician Orders
• Patient Lists
• Nursing medication,
• Vital signs
• Intake and Outputs
• All other flowsheet data
Electronic patient Problem Lists and Prescription writing for all outpatient areas are currently
being rolled out.
ATTENDING PHYSICIANS
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CIS logons are issued after the credentialing process has been completed. To receive your user
number and password, call the Help Desk at (718) 920-4554.
There is a regularly scheduled training class every Tuesday at 4:00 pm in the CIS Training room,
located on the 2 nd floor of the Storage building on the Moses Campus.
HOUSE STAFF
To receive your user number and password, call the Housestaff Office at (718) 920-4091.
Training for house officers is held during the orientation process.
CONTINUING MEDICAL EDUCATION (CME)
Contact
Victor Hatcher, PhD 718-920-6677
Albert Einstein College of Medicine & Montefiore Medical Center are recognized as national
leaders in all three stages within the continuum of medical education; undergraduate, graduate
and continuing medical education. The Einstein & Montefiore Continuing Medical Education
program is among the largest and most respected in the country.
ON CAMPUS AND IN MANHATTAN
Fully accredited to grant Category I CME credit, the Center for Continuing Medical Education
(CCME) accredits approximately 50 Grand Rounds throughout the Medical Center in every
specialty. The CCME sponsors approximately 75 major symposia on-site on the Moses and
Weiler Campuses, and in leading hotels and conference centers in Manhattan.
NATIONAL PROGRAMS
The CCME offers approximately 80 programs in psychiatry, anesthesiology,
neurology and medicine throughout the country. The CCME and the Einstein faculty conduct
educational symposia which attract clinicians from across the country and around the world.
Notably, CCME has presented Einstein & Montefiore symposia at the annual conventions of The
American Academy of Family Physicians, The American College of Physicians, The American
Academy of Pediatrics, The American Geriatric Society, The American Society of Hypertension,
The American Society of Cardiology, and The American College of Rheumatology.
INTERNATIONAL PROGRAMS
Internationally, the CCME has offered programs with the Israel Medical Association in
Jerusalem, an orthopedics hands-on workshop in Geneva, and seminars in Bioethics in Tuscany.
PUBLICATIONS
The CCME also publishes accredited programs in textbook form and in association with Cutis,
The Female Patient, and The Federal Practitioner. Einstein & Montefiore's CCME is one of the
largest of medical school producers of CME materials on audio and video tape. Our educational
programs reach thousands of physicians through CME's national teleconferencing network and
on the Internet.
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CME REQUIREMENTS:
Attending physicians at Montefiore are required to meet the national standard of 50 CME credits
annually, in order to maintain hospital privileges. Since physicians may earn CME credits from
other institutions, specialty societies, consultations, reading and teaching, it is the responsibility
of each physician to maintain his own CME record and to report it to the Attending Staff Office
annually. Residency training is automatically accepted as meeting the national CME standards.
CUSTOMER SERVICES
Director 718-920-4060
Leslie Bank
Main Number 718-920-4943
The Customer Services Department serves as Montefiore's formally established communication
channel and "grievance mechanism" for patients, their families, companions and significant
others. In addition, Customer Services provides access to interpreting services for deaf and hard
of hearing patients and companions, and for LEP (Limited English Proficiency) patients and
companions, all free of charge. (It is a federal and state law that we provide interpreting services.
The use of family members or unqualified staff is strongly discouraged) The Customer Services
Department also measures patient satisfaction, inclusive of satisfaction with physician services.
Customer Services Specialists are available to assist your patients resolve problems, and provide
interpreting resources, Monday through Friday at both Moses and Weiler Divisions. (After
business hours, contact the ADN)
DIALYSIS CENTER III
Baumritter Kidney Center 718-597-2255
1325 Morris Park Avenue
Bronx, New York 10461
Private practice number 718-828-6840
Medical Director
Vaughn W. Folkert, MD
Manager
Maritza Dominguez
Chronic In-Center Hemodialysis & Peritoneal Dialysis
Hours: Monday - Saturday 5:00AM – 11:00PM
DIVISION OF EDUCATION AND ORGANIZATIONAL DEVELOPMENT
Director 718-920-2685
Bettie Jackson
Hours
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Office hours are Monday – Friday: 8:00AM – 5:00PM, however services are provided 24 hours
per day, seven days per week.
CLINICAL CONSULTATIVE SERVICES
DEOD provides consultative services in the areas of Pain Management; Diabetes; Wound,
Ostomy, and Continence Care; Geriatrics; and Bioterrorism preparedness, to name just a few.
Call (718) 920-2685 for further information so our expert clinical and organizational
development faculty can assist you with your learning and patient care needs.
DIABETES
Consultations are provided for patients with Type 1 and Type 2 Diabetes.
Iris Carrisquillo, MSN, CNS
Office (718) 904-2139
Beeper (917) 537-6703
PAIN MANAGEMENT
The Acute Pain Management Team is available for consultation on complex pain management
issues.
Linda Dallam, MS, GNP
Office (718)920-6212
Beeper (917) 314-7928
Elissa (Lisa) Davis, MSN, ANP
Office (718) 920-5216
Beeper (917) 798-0060
WOUND, CONTINENCE & OSTOMY CARE
Clinical Nurse Specialists are available to provide consultation for patients with ostomies and
chronic wounds.
Catherine Badillo, MSN, CNS,
Office (718) 920-8583
Beeper (917) 314-2158
Winifred Hagan, MSN, CNS
Office (718) 904-2889
Beeper (917) 672-4413
Patricia Pellegrino, MSN, CNS
Office (718) 904-3098
Beeper (917) 787-9436
ENVIRONMENTAL SERVICE
(Building Services)
Environmental Services aims to provide a clean and safe environment for the patient, visitor and
health care worker.
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Hours:
Monday - Friday 8:00AM - 5:00PM
MOSES 718-920-4903
Central Building - Kitchen Corridor
After hours, weekends and holidays, the Department Supervisor can be reached through the
page operator (718) 920-8282.
Available Services:
• conference rooms set up
• extermination
• drapery/upholstery repair
• window washing
• moving and storage
• patient TV rental
• vacuum and shampoo carpets
EINSTEIN 718-904-4000
Lobby Entrance - Main Floor
After hours, weekends and holidays, the Department Supervisor can be reached through the page
operator (718) 904-2711.
Available Services:
• conference rooms set up
• extermination
• drapery/upholstery repair
• window washing
• moving and storage
• vacuum and shampoo carpets
FOOD AND NUTRITION SERVICES
Director of Food and Nutrition Services
Chris Trivlis
718-904-2731 Einstein
718-920-4257 Moses
917-424-6221 Beeper
Clinical Nutrition Manager
Miriam Pappo
718-904-2724 Einstein
718-920-4253 Moses
917-641-3736 Beeper
Hours of Operation:
6:30AM - 7:00PM seven days per week
Summary of Department Activity and Services:
• Progressive multi-service department providing food and clinical services to patients,
associates and visitors .
• Nutritional status directly affects patient outcome, therefore early intervention is necessary.
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• All patients at nutritional risk need to be assessed by a Registered Dietitian; Dietitians are
responsible for nutrition care in each Care Center.
• The Dietitian will respond to consults within 24 hours. Consults are CIS generated.
• The nutrition care plan includes goals, recommendations, education and discharge planning.
• Nutrition care is interdisciplinary and ongoing. Dietitians attend IDT rounds.
• Only MD's and PA’s write diet orders including regular and modified diets,
oral supplements, enteral feedings and parenteral nutrition.
• No patient will receive a tray without an active diet order.
• At the Einstein division all meals are prepared in a kitchen under Rabbinical supervision in
accordance with Kosher Jewish dietary laws.
CAFETERIA
Einstein: 4th floor
Hours of Operation: 6:30AM to 7:00PM seven days per week
Moses Food Pavilion: 2nd floor
Hours of Operation: 6:30AM to 7:00PM seven days per week
SCRUBS MAY NOT BE WORN IN THE CAFETERIA UNLESS COVERED BY A LAB
COAT. ANYONE VIOLATING THIS HEALTH CODE WILL NOT BE SERVED.
GIFT SHOP
MOSES
Children’s Hospital at Montefiore (CHAM) Lobby
Managed by Lori’s Hallmark Shop 718-741-2294
Hours:
Monday – Friday 10 –7
Saturday and Sunday 11 – 4
WEILER
Einstein Main Lobby 718-904-2742
Managed by Lori’s Hallmark Shop
Hours:
Monday – Friday 8 – 9
Saturday and Sunday 10 - 8
HEALTH INFORMATION MANAGEMENT (HIM)
THE MEDICAL RECORD
The medical record at MMC is a hybrid of on-line electronic and manually generated
documentation. The Clinical Information System (CIS), at MMC, forms the basis for the
Computerized Patient Record (CPR). Information on each patient is maintained using an
enterprise-wide medical record number, which is used to identify the patient across the MMC
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delivery system. Medical record information maintained online is available to all authorized
users and can be accessed anywhere, at any time, with proper authorization. This includes
documentation entered directly online and those components of the record where there is direct
integration between systems, such as laboratory and radiology information systems.
Components of the record where the caregiver documents on paper or in secondary systems not
interfaced with the CIS, the documentation is stored in hard copy in the paper medical record in
HIM. Various components of the Clinical Information System have been implemented in most
locations in the MMC network. As more elements of the medical record become part of CIS,
more information will be available on line and less in hard copy.
DEPARTMENT SERVICES
The Health Information Management (HIM) Department provides 24- hour/ 7 days-per-week
medical record services at both the Moses and Weiler Divisions.
Location
Moses: Rosenthal South East (RSE) Main Floor -Red Zone
Weiler: 2nd Floor South (2S-70)
Hours
24 hours 7 days a week. (Staff is available at any time)
Telephone Extensions Moses Weiler
File Room Manager 4925 2747
Requests for Medical Records 5315 2901/8109
Medical Record Completion 2219 2149
Medical Information 4921 2748
Death Certificates 2210 3456 (Admitting)
Cancer Registry
(718) 652-5201 Ext.246
Registration Data Quality (718)794-7036
HIM Administration 5108 2330
Retrieval of Medical Records:
For Patient Care: Records needed for immediate patient care can be retrieved 24 hours a day.
The following information is required:
• Valid MMC Identification Card
• Patient Name
• Medical Record Number
• Requester Name/location/telephone number
• Date needed and purpose.
• For Research, Review and other purposes: Advance notice is required for retrieval of records
for reasons other than direct patient care. House staff must show approval of research project
by the supervising attending physician.
• For a data search, for research projects, call ext. 2208 at Moses and 2747 at Einstein
• To retrieve records in bulk discuss volume, time frames, etc with File Room Supervisor or
Manager at the appropriate site.
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Medical Information
If medical information must be sent to or obtained from another health care institution, call ext.
4921 at Moses or 2748 at Weiler for assistance, from Monday to Friday 8:30am to 5:00pm. Call
ext. 5315 at Moses or ext. 8109 at Weiler on weekends and off-hours.
SECURITY AND CONFIDENTIALITY
• Patient Information is confidential and may be disclosed only to the extent authorized or
necessary for patient care
• Refrain from discussing patient information in elevators and other public places.
• Do not share passwords or sign-ons
• Medical records are not to leave MMC's premises
• Medical records must be returned to the file-room no later than 48 hours after being signed
out, except when being used for direct patient care
• Medical records required for review purposes should be reviewed in the HIM department
COMPLETION OF MEDICAL RECORDS
Documentation requirements for the medical record are governed by the JCAHO standards, the
NYS Department of Health regulations, HCFA Medicare Conditions of Participation, and MMC
Medical Staff Bylaws. These regulations/standards provide the requirements of a complete
medical record. Medical records of discharged patients must be completed within 30 days of
discharge.
Each clinical department determines its own guidelines regarding the responsibilities of
house officers for record completion. The following represents general guidelines for
documentation in the medical record and provides some guidelines to assist in reducing the
number of incomplete records.
Entries
• Time and date all entries. Include day, month, year as well as time of day, am vs. pm.
• All entries must be permanent and written in blue or black ink. Do not use a pencil or felt tip
marker.
• Make good entries the first time. Entries should be accurate, timely, objective, specific,
concise, consistent, comprehensive, logical, legible, clear, descriptive and reflective of the
patient's condition and response to treatment.
• Legality: The medical record is a legal document. It should not be used to document
complaints against other staff members or departments.
• Authentication: Sign every entry including addenda. Print your name and professional
designation (PGY 1, MD, PA etc.) with your signature. Never make or sign an entry for
someone else or have another make or sign an entry for you.
• Patient Identification: In the absence of an addressoplate ensure that the patient's name and
medical record number is on every page where there is patient information.
History and Physical
Complete an H&P including a pap smear and breast exam on every female patient 21 years and
over, within 24 hours of admission.
Physician Orders
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All physician orders whether written on paper or entered on-line through Physician Order Entry
must be dated and signed. All sub-intern orders must be countersigned within 3 hours. PA
medication orders must be countersigned within 24 hours. PAs and Sub-interns should ensure
that their orders are counter-signed.
Discharge: Write a discharge order or document circumstances surrounding death,
transfer or AMA status of the patient as appropriate.
Discharge Summary
Complete the Discharge Summary form or dictate a discharge summary on the day of discharge
for all cases with a length of stay of 48 hours or more. All sections of the discharge summary
must be filled out or dictated. A Discharge Note is required on stays of less than 48 hours where
no discharge summary is required. Discharge note should include information regarding the
condition of the patient on discharge and instructions to the patient. A discharge note is required
for all patients who die or who leave AMA. A discharge summary is ALWAYS needed for
expiration cases regardless of length of stay.
Operative Report
Complete the Short Operative Note immediately after surgery. Although the attending physician
is ultimately responsible for the dictation of the operative report the task may be assigned to the
1 st assistant on the surgery. Dictation instructions are below.
DICTATING INSTRUCTIONS
*Please spell all names and unusual medical terms.
Montefiore Medical Center uses a digital voice activated system for dictation of Discharge
Summaries and Operative Reports. The system may be accessed from any touch tone telephone.
The same system is in use at both the Moses and Weiler sites. To obtain your personal ID# to
access the system please contact the Medical Record Completion unit.
• Dial Extension 717 in-house or (718) 920 -6755 for Moses and 3458 in-house or 904-3428
for Einstein.
• Enter your 5 digit attending or house staff physician ID
• Enter the 1-digit work type (e.g. 1=OP Report, 2=Discharge Summary)
• Enter the 8-digit Medical Record Number
• Press:
1 to hold, then "2" to resume dictation
2 Dictate
3 Rewind a few words
4 Go to end of Dictation
5 Go to beginning then "8" to listen
6 End Dictation
7 Fast forward a few words
8 Listen
9 Disconnect
To ensure accurate report tracking when dictating multiple reports, press 6 after each dictation
and then enter the 1 -digit work type and 8-digit patient medical record number for the next case.
FORMAT FOR DICTATION
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Discharge Summary
• Patient Name and Medical Record Number (8 digits)
• Name of Attending and Dictating MD
• Dictation Date, Admission and Discharge Dates.
• Brief History (Chief Complaint)
• Reason for Hospitalization
• Pertinent Physical Findings and Diagnostic Results
• Hospital Course/Significant Findings/Treatment Results
• Discharge Disposition and Final Diagnosis
• Instructions to Patients regarding Physical Activity, Medications, Diet and Follow-up Care.
Operative Report
• Patient Name and Medical Record Number (8 digits)
• Name of Attending Surgeon and Assistants
• Date of Procedure
• Pre and Post Operative Diagnoses
• Name of Operation/Procedure
• Type of Anesthesia
• Name of Anesthesiologists
• Surgical Technique used
• Detailed account of the procedure and findings
• Specimens removed
• Closure & Drains
• Complications
• Fluids Given
• Blood Loss
• Patient Condition at the end of the procedure
Corrections
Make alterations to the medical record very carefully and only when changes are absolutely
necessary. Do not obliterate errors or use whiteout in the medical record. To correct inaccuracies,
follow these procedures:
• Draw a single, thin line through each inaccurate entry, making certain that it is still legible
• Date and initial this line
• Add a note in the margin stating why the entry is being replaced (i.e. error, wrong patient,
etc.)
• Enter the correction in chronological order. If not possible, refer to location of the corrected
material. Date corrected entry with current date.
Addendum
When writing an addendum, indicate that it is an addendum and use the current date. An
addendum is appropriate if the patient requests that a correction be made in the record or if
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additional information is uncovered which may change original information previously recorded
in the medical record.
DEATH CERTIFICATE PROCESSING
Death Certificates are processed in the HIM department at the Moses Division and in the
Admitting department at the Weiler Division. The following documentation is required on every
death:
• Report each death immediately to HIM ext. 2210 at Moses and Admitting ext.3456 at Weiler
• Pronounce patient (unless already pronounced by a PA). Document date, time and
circumstances surrounding death in the patient's medical record. If a PA pronounced the
death, countersign or write the death note.
• Evaluate circumstances of death to ascertain whether Medical Examiner referral is required.
(Name of Medical Examiner, Case Number, and Acceptance/Refusal of the case must be
documented in the medical record.)
• Attempt to obtain autopsy consent for all deaths that do not qualify for medical examiner
referral. (Consent for Autopsy is Page 2 of Death Notification Form NR1625 M/E Rev.
10/99). The pathologist is responsible for completing the death certificate on all autopsied
cases.
• Notify the attending physician.
• Notify the next of kin of the patient's death.
• Notify Pathology Moses ext. 4979. Weiler ext. 2947 and H I M Moses 2210 of pending
autopsy
• Complete the Death Certificate or Medical Examiner Report as required within two (2) hours
of death.
• A license number is required on all death certificates as of January 1, 2003. If the physician
does not yet have a license, then the physician license number of the chief resident or
attending physician of the case will be used.
• Complete all sections of the Notification of Death Form #1625M/E Rev. 10/99 available on
the nursing unit.
HOME HEALTH AGENCY
VP of Clinical Operations
Terry Goodwin 718-405-4401
Administrative Clinical Operations
Pamela Joachim 718-405-4406
The goal of the home care program is to meet the patient's continuing comprehensive health care
needs in the home. Consistent with the Medical Center's objectives, the Home Health Agency's
goal is to provide our patients with continuous quality care, focusing on positive patient
outcomes.
PROGRAMS
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Certified Home Health Agency – Provides professional care in the home during the recuperation
period.
• For patients who require skilled professional care.
• For patients who are under the care of a physician who authorizes home care
services.
• Charges are usually covered by Medicare, Medicaid, and other insurance plans.
Long Term Home Health Care Program- Provides case management and professional care at
home to chronically ill patients who might otherwise require nursing home placement.
• For patients who require ongoing skilled professional care and assistance with
ADL’s.
• For patients who are under the care of a physician who authorizes home care
services.
• Charges are covered by Medicaid.
AIDS Home Care Program- Provides case management and professional care at home to patients
with HIV/AIDS.
• For patients who require skilled care by professionals, trained in this specialty, and
assistance with ADL’s.
SERVICES
Services are provided in the Bronx and Westchester to patients at all stages of life, from
newborns to seniors.
• Services Provided at Home:
• Professional Nursing Care
• Physical Therapy
• Occupational Therapy
• Speech Therapy
• Social Work Services
• Related Support Services: Personal Care
• Specialty Programs:
• Wound Care Management
• Home Infusion Therapy
• Care of New Mothers/Infants
• Pediatrics
• HIV/AIDS
BENEFITS OF MONTEFIORE HOME CARE
• Clinical excellence
• Compassionate care
• Thorough and timely follow-up
• Extensive links to community resources
Referral Process: Call the centralized intake and information line at (718) 405-4532
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THE TISHMAN LEARNING CENTER
HEALTH SCIENCES LIBRARY
Moses, Silver Zone 2 nd Floor 718-920- 4666
HOURS
Monday – Friday: 9:00AM- 8:45PM
Saturday: 9:00AM - 4:45PM (Lunch Break: 12:00PM - 1:00PM)
During the summer months, (July and August) the library is closed on Saturdays.
Sunday Closed
Head, Circulation and Technical Services
Heather Barnabas
Circulation
Yvette LeCointe
Stephanie Spencer
Nicole Symes
Director
Josefina P. Lim
Associate Librarian and Head, Information Technology
Sheigla Smalling
MIS Help Desk
Anca Banciu
ELIGIBLE USERS
All MMC associates, affiliates and NCB medical staff with valid IDs are eligible to use all
library services and privileges. All others have on-site reference use privileges only.
Registration at the Circulation Desk is required.
CIRCULATION
Books circulate for two weeks and are renewable for another two weeks. Bound journals
circulate overnight. Renewals can be made over the telephone. AVs circulate for three days but
are non-renewable.
Non-circulating materials, i.e., unbound journals, reserve and reference items cannot be checked
out of the library.
FINES
There is a charge of $0.10 per day for each item that is overdue. Overdue notices are a
courtesy. Borrowers are responsible for returning and renewing materials on time whether or not
overdue notices reach them.
COMPUTER SERVICES
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A microcomputer study room is equipped with 13 workstations and printers. Internet access,
Microsoft Office Suite and Wordperfect are some of the services available on each PC.
ON-LINE CATALOG
TISH the library’s online catalog provides access to the library's book, audiovisual and journal
collections. The collections at AECOM Library can also be searched through TISH. Both
collections are available through the Web.
ELECTRONIC RESOURCES
Internet access to Medline, MDConsult and other databases is available through Montenet or
AECOM Remote Access. Electronic journals and books are accessible through these networks.
UpToDate is available on designated workstations in the Microcomputer room. Training sessions
for these resources are held at 10:00 am and 2:00 PM Monday through Friday. Mediated
literature searches are conducted at a basic fee of $20 per search. Please call Sheigla Smalling
x4666 for information and registration.
INTERLIBRARY LOANS
Materials not available in the library or online can be obtained through interlibrary loan. Most
journal articles arrive within one to two weeks and most other materials within two weeks to a
month.
AUDIOVISUAL SERVICES
TV/VCR components, slide and LCD projectors are available for circulation and in-house library
use.
PHOTOCOPY SERVICE
Photocopiers are available at $0.10 per page by coins or copy cards.
ARCHIVES
Historical documents about MMC are managed and stored in the Zimmerman Archives located
in the Library. Access to these materials must be arranged by calling 718-920-4666.
RULES FOR USER CONDUCT
These activities are not allowed in the Library:
1. Eating/drinking/bringing in food
2. Solicitations of any kind
3. Unsupervised children/school children
4. Theft and/or misappropriation of Library
or another user's property
5. Interfering with Library staff's performance of their duties
6. Refusing to leave the premises at closing time
7. Vandalism; abuse or misuse of Library equipment or property
8. Violence
If you have any questions or suggestions, please bring them to the
attention of the staff.
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MAILROOM
MOSES
Brown Zone, Moses Basement
Hours
8:00AM - 5:00PM
Supervisor
Joseph Erving 718-920-5382
WEILER
1st Floor
Hours
9:00AM - 5:00PM
Administrator
Henry Makowski 718-904-4000
There is a mail chute opposite the Blue Service elevators for all outgoing, stamped mail.
OFFICE OF THE MEDICAL DIRECTOR
Senior Medical Director and Vice President
Brian Currie, M.D., M.P.H. 718-920-6078
Medical Director and Vice President
Gary Kalkut, M.D., M.P.H. 718-920-2809
The Office of the Medical Director is responsible for a wide range of organizational initiatives
dedicated to improving the quality of medical care and related services provided at the Acute
Care Division, and other components of the medical center. It is involved in initiatives designed
to enhance coordination of medical services across the continuum and promote efficiency and
continuity of care. The Office has oversight of the Quality and Safety Program, the Medical and
House Staff Office and more. It works closely with the Medical School on a variety of clinical
programs and directs the efforts to ensure patient safety and foster excellence in medical care.
Director of Clinical Affairs
Lynn Richmond, NP 718-920-7052
The Director of Clinical Affairs is available to assist physicians with patient care issues and
questions related to the following: Advance Directives, Do-Not-Resuscitate orders, Foregoing
Life-Sustaining Treatment, Do-Not-Intubate orders, Brain Death Protocol, Administrative
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Approval for patients with no next-of-kin, Liaison with the Palliative Care Program as well as
other special projects. .
OPERATING ROOMS
Moses Scheduling 718-920-6308
Weiler Scheduling 718-904-2876
There are 20 operating rooms at the Moses Division and 14 at the Einstein Division including
one lithotripsy and one cystoscopy suite. O.R. time is available to surgeons on a block and
"open-time" basis. Block schedules may be obtained through the O.R. scheduling office at each
site. Block schedules are subject to modification as the
utilization of allocated time is reviewed. 24 hours-per- day, 7 days- per- week coverage of the
operating rooms is provided at each site. Specialty call coverage for specific services is also
available. Patients may be scheduled for surgery by the attending physician's office through the
O.R. scheduling office Monday through Friday between 9 A.M. and 5:30 P.M. When an elective
case is scheduled, complete patient demographic information is required. Emergency cases may
be scheduled through the O.R. charge nurse. At Moses, call ext. 4491 and at Einstein call ext.
2798.
If an elective patient needs to be seen by an anesthesiologist you must request a preadmission
testing appointment at that time. Patients presenting for surgery must have a complete history
and physical within seven days of the planned procedure. The consent tool must be complete
and written in lay terms. The words right and left as well as the spinal levels must be written in
entirety.
On the day of surgery, adult ambulatory surgery and same day admission patients will be
directed to arrive at the Moses 3 North Surgery Center. All pediatric ambulatory and same day
admissions patients will be directed to arrive at the CHAM 3 Day Hospital.
At Weiler, all patients will be instructed to arrive at the surgery center in the Lubin building on
the 2nd floor. Ambulatory surgery patients will be discharged from the respective second stage
recovery areas.
OCCUPATIONAL HEALTH SERVICES
Director
Michela Catalano, M.D.
Moses 718-920-5406
Green Zone - DTC Building - 4th Floor, Room 480
Einstein Division 718-794-7048
1894 Eastchester Road, 2 nd Floor
Occupational Health Services is a unified Department of Montefiore Medical Center. An OHS
clinician is available 24/7 through telecom page.
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The mission of the Occupational Health Services Department is to:
• comply with state, federal and hospital policy regarding initial and interval health
assessments
• determine the ability of all individuals to work in the hospital and its outlying facilities
• treat and/or refer for treatment those individuals who incur work related illnesses or injuries
• engage in the prevention of work-related illnesses by participating in environmental and
personnel monitoring procedures
• promote good health of the work force by promoting preventative health programs
PALLIATIVE CARE
Palliative care is the comprehensive care of patients with advanced and often incurable medical
illnesses. Its goals include the relief of physical, emotional and spiritual suffering as well as the
preservation of psychosocial and physical functioning of the patient and his/her family unit to the
fullest extent possible. The PCARE service provides coordinated interdisciplinary care on both a
consultative and primary care basis to patients with chronic often incurable and life threatening
illnesses.
PALLIATIVE CARE CONSULTATION SERVICE
The Palliative Care Consultation Service (PCARE) provides inpatient consults at Montefiore
Medical Center’s Moses and Weiler divisions. The PCARE service includes full time palliative
care physicians from various departments within the hospital, nurse practitioners, social workers,
bioethicists, and clergy. The PCARE Service does approximately 90 consults per month
including home visits as well as consultative services at several local nursing homes.
The Palliative Care Consultation Service offers:
• Expert treatment of pain and other symptoms of chronic illness
• Care of psychosocial needs of patients and families, including group and individual
counseling
• Pastoral and spiritual care of patients and families
• Assistance with advance care planning, discussion of goals of care, and contingency
planning
• Bereavement services for family members
• Coordinated services across the continuum of care
• Referral to hospice
• Support for professional caregivers and staff
INPATIENT PALLIATIVE CARE SUITE (IPS)
The inpatient Palliative Care Suite (IPS) goal is to provide short-term intervention not requiring
prolonged length of stay. Criteria for admission to IPS:
• Patients with chronic incurable illness requiring acute hospitalization to diagnose and/or
treat newly developed symptoms
• Patients with chronic incurable illness requiring inpatient management of exacerbations
of known symptom, e.g., intensive medication and dose changes requiring close
monitoring, and/or procedures, such as paracentesis or thoracentesis
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• Patients who have been withdrawn from ventilator support or dialysis who can be
anticipated to be symptomatic
• Patients with complex chronic pain
• Patients requiring active treatment to control pain (e.g., radiation therapy, chemotherapy,
nerve block)
• Patients with Hospice coverage
• Actively dying patients requiring short-term hospitalization
• Patients in multiorgan failure who have been evaluated and rejected for admissions to an
intensive care unit.
THE MONTEFIORE ER PALLIATIVE CARE CASE MANAGEMENT PROGRAM FOR
ELDERLY PATIENTS
The program includes two (2) nurse practitioners.
• Elderly and other patients visiting the ED for medical care who need linkage with home
care or hospice
• Patients needing linkage with pharmacy care or specialty services such as geriatric
medicine
• Patients with life-threatening disease
• Patients with complex unrelieved pain
PAIN AND PALLIATIVE CARE OUTPATIENT CLINICS
The Pain and Palliative Care Outpatient clinic is staffed by professionals of the Montefiore
Palliative Care Service. The clinic provides interdisciplinary outpatient pain management and
palliative care service. Patients with the following conditions may benefit from consultation for
pain management and palliative care:
• Patients with cancer and other life-threatening conditions such as advanced congestive
heart failure (CHF), chronic obstructive pulmonary disease (COPD), strokes and other
neurological conditions, for pain, symptom management, psychosocial and spiritual
support.
• Patients suffering from chronic non-malignant pain syndromes, including patients with a
history of chronic pain and substance abuse.
• Pain and Palliative Care Outpatient Clinic is located at 3448 Kossuth Avenue, Bronx,
New York 10467
• Cancer Pain Clinic is located at the Medical Park Pavilion, 1695 Eastchester Road,
Bronx, New York 10461
• HIV Pain Management Clinic is located at 3448 Kossuth Avenue, Bronx, New York
10467
PALLIATIVE CARE IS NEEDED WHEN:
• Patients have been diagnosed with serious illness and pain and other symptoms interfere
in the patient's quality of life
• Help is needed to clarify goals of care of the patient
• Help is needed in end-of life planning and decision-making
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• Families and caregivers need assistance with bereavement and
grief
• Children in the family are affected by the patient's illness
• Emotional or spiritual distress is unrelieved
• Problems arise from advanced illness, and disease-focused treatments
are no longer helping
Palliative care can often be provided in parallel with curative treatment. It is not necessary for
the patient to be in the last days of his or her illness for these needs to be met. The transition to
Palliative Care is a process. As the end of life approaches, the role of Palliative Care increases
subject to patients' and families' approval
and acceptance of the changing goals of care.
THE PROGRAM OFFERS:
• Expert treatment of pain and other symptoms of chronic illness
• Care of psychosocial needs of patients and families, including
group and individual counseling
• Pastoral and spiritual care for patients and families
• Assistance with advance care planning
• Discussion of goals of care
• Bereavement services for family members
• Coordinated services across the continuum of care
• Referral to Hospice and support for professional caregivers and
staff
HOW TO ACCESS SERVICES
In patient consultations and outpatient consultations can be obtained
by contacting the Palliative Care service office at (718) 920-6378 or
paging (917) 729-6232 between 9:00AM and 5:00PM. On nights and weekends,
for urgent matters, page the Palliative Care service at (718) 659-3202.
For appointments for the Outpatient Pain and Palliative Care Clinic call (718) 920-5101 between
the hours of 9am-4:30pm. For appointment for the Cancer Pain Clinic call 718-920-7162; For
appointment for the HIV Pain Management Clinic call 718-920-8542. For non-urgent questions,
please leave a voice mail at the office number above or send an email message to
SOMAHONY@MONTEFIORE.ORG or PSELWYN@MONTEFIORE.ORG.
PATIENT, FAMILY, AND COMMUNITY HEALTH EDUCATION RESOURCES
Director
Josay Laventhol 718-920-6058
North West 5
A broad range of written health education materials in English and Spanish are available from
the Patient/Health Education Department, located at the Moses Division on North West 5.
Materials are developed with multi-disciplinary input and written in layman's language. Topics
include instructions about how to prepare for diagnostic tests, surgical procedures, follow-up
137

care, promoting recovery and preventing complications. Many wellness and prevention flyers are
available. Materials are printed on yellow paper and distributed to Moses and Weiler in/outpatient
areas, including satellites.
A newsletter called "UPDATE" listing over 1,200 patient education sheets can be found on
Montefiore’s Intranet site. New and revised publications are highlighted. Materials may be
ordered in quantity. Topics not listed can be obtained by patients and staff from the department's
library, resource files and Internet searches between 9:00 AM - 5:00 PM. A listing of Support
Groups sponsored throughout the Medical Center, to provide assistance to out-patients/families
and the community, is available upon request. Health Education video programs are shown on
in-patient television sets and in some out patient areas, free-of-charge. A television schedule is
distributed to patients.
PATIENT SAFETY
Patient Safety Officer 718-920-2071
Jason Adelman, MD
jadelman@montefiore.org
The mission of the MMC Patient Safety Program is to continuously improve care systems in
order to minimize the risks posed to patients as a result of exposure to the healthcare system. As
such, the mission of the program is well aligned with MMC’s mission of excellence in patient
care and the MMC strategy of improving organizational performance.
Tenets of the program include:
• Achieving improvement through an emphasis on processes and systems of care over the
identification of individuals
• Drawing upon network-wide surveillance mechanisms as information resources relating
to patient safety
• Enlisting multidisciplinary participation in improving organizational performance
• Learning from adverse events as well as medical errors that may or may not have resulted
in harm
• Valuing patient, family, and staff feedback regarding patient safety
PATIENT SAFETY OFFICER AND COMMITTEE
The primary role of the Patient Safety Officer is to facilitate and enable institutional patient
safety activities and the institutional Patient Safety Program. The Patient Safety Officer reports
to the Vice President, Senior Medical Director.
The Patient Safety Committee serves as an organizational structure to facilitate and enable
patient safety activities and manage the Patient Safety Program. The Patient Safety Committee
is accountable to the Montefiore Quality Council. The Patient Safety Program cannot lead all
activities that relate to improving patient safety at MMC and is not meant to substitute for the
existing institutional activities and structures noted earlier, but to complement them, by focusing
on patient safety related compliance, coordination, and communication.
138

The Patient Safety Officer and the Medical Director, Quality Management, co-chair the
institutional Patient Safety Committee. Membership includes representatives of areas within the
delivery system who have oversight for activities that are fundamentally relevant to improving
patient safety. Broad based representation allows for coordination and communication of
activities across the delivery system.
The 3 primary functions of the Patient Safety Officer and Committee can be summarized as:
• Compliance with patient safety related regulations, including JCAHO patient safety
standards and goals
• Coordination and integration of patient safety activities across the institution
• Communication of patient safety related information to leadership, associates, patients
and families
The scope of activities of the Patient Safety Program enabled by the Patient Safety Officer and
Patient Safety Committee, in conjunction with owners of various patient safety related content
areas, include:
• Review and facilitation of institutional activities enhancing patient safety, including
activities relating to:
• Proactive risk reduction activities
• Errors
• Adverse and critical events
• “Near miss” events – variations in healthcare process not affecting outcomes, but
where recurrences carry significant chances of adverse outcomes
• “No-harm” events – unintended acts of omission or commission that do not result in
adverse outcomes
• Facilitating:
• Communication of patient safety related information throughout the organization
• Education of leadership, associates, patients and families with respect to patient
safety
• Annual redesign of at least one high risk process for proactive risk reduction (failure
modes and effects analysis)
• Assessment and refinement of MMC policies and procedures to be in compliance with
regulations, including JCAHO patient safety standards and goals
• Review of information from patients, families and associates to improve patient safety
• An annual report on institutional patient safety activities
PHARMACY SERVICES
MOSES 718-920-4529
The Moses Pharmacy Department is composed of a centralized pharmacy and six satellites or
decentralized pharmacies. The central pharmacy facility and pediatric satellite are open 24 hours
a day, 7 days a week. The central pharmacy is located in the Storage Building, Orange Zone and
can be reached at phone number 920-4103. The pediatric pharmacy is located in the Children’s
Hospital at Montefiore on the sixth floor and can be reached at phone number 741-2626. The
TPN production area can be reached
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at 904-8860 (Weiler Division). The Moses Administrative Pharmacy office hours of operation
are 8:30AM to 5:00PM, Monday through Friday, and are located in the Orange Zone of the
Storage Building. The telephone number is 718-920-8540/5778920-2940.
In addition, six decentralized pharmacy satellites provide pharmaceutical
care services. These are located in the following areas:
Medicine 718-920-5208
8:30AM - 11:30PM
Klau5
Pediatrics 718-741-2626
24 hours per day CHAM 6
Inpatient Oncology 718-920-2329
8:30AM - 5:00PM
NW3
Outpatient Oncology 718-920-5778
8:00AM - 5:00PM
NW4
Med-Surg 718-920-5348
8:30AM - 5:00PM North 6
Critical Care 718-920-5335
8:30AM - ll:00PM Weekdays, 8:30AM - 5:00PM Weekends and Holidays
North 3
An ambulatory pharmacy located in the ground floor of the Family Care Center (FCC)
building fills prescriptions for employees. The employee must present hospital ID when picking
up prescriptions.
A second ambulatory pharmacy, Specialty Pharmacy, provides pharmaceutical services
to patients in the Infectious Diseases Clinic. The Specialty Pharmacy is located in the FCC
Building on the second floor.
WEILER 718-904-3225
A central pharmacy facility is open 24 hours-per-day, 7 days-per- week. The phone number is
904-2838. The TPN production area can be reached at 904-8860. The central pharmacy and the
administrative pharmacy offices are located on the main floor in the service area. In addition, an
Oncology Pharmacy Satellite provides pharmaceutical care services to patients on 11 South and
5 South. The satellite is open 7:30AM - 6:15PM Monday – Friday and from 8:00AM - 4:15PM
on weekends and holidays and can be reached at 904-4173.
An ambulatory pharmacy located in the central pharmacy fills prescriptions
for employees only 8:00AM to 4:00PM Monday - Friday (closed on hospital holidays).
Employees must present hospital ID when picking up prescriptions. An Ambulatory Oncology
Pharmacy provides pharmacy services from the Montefiore Medical Park, Monday – Friday,
8:30AM to 4:45PM. The Ambulatory Oncology Pharmacy can be reached at (718)405-8510.
KEY PERSONNEL
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Unified Director of Pharmacy
Frank Sosnowski, MS, RPh
718-920-4529 Moses
718-904-2369 Weiler
Director, Pharmacy Operations
Ellen Rudnick, MS,RPh 718-920-2943
Director, Clinical and Educational Pharmacy Services
Mark Sinnett, Pharm D, FASHP, RPh 718-920-2944
Director, Pharmacy Operations
Yvonne Gayle, PharmD, MS, RPh 718-904-2825
Director, Pharmacy Finance and Automation
Barney Zaino, MS, RPh 718-920-2949
Evening Supervisor, Weiler 718-904-2838
Day Supervisor, Weiler
Irene Maningas, R.Ph. 718-904-2838
Clinical Pharmacy Manager, OR/Anesthesia
Frank Aroh, PharmD, BS, RPh 718-904-2014
Clinical Pharmacy Manager, Infectious Diseases
Maria Amodio-Groton, Pharm D, RPh 718-920-6433
Clinical Pharmacy Manager, Infectious Diseases 718-920-6433
Yi Guo, Pharm D, RPh
Clinical Pharmacy Manager, Critical Care
Julie Chen, Pharm D, BCPS RPh 718-920-6433
Clinical Pharmacy Manager, Cardiology/NICU
Angela Cheng, Pharm D, RPh 718-920-6433
Clinical Pharmacy Manager, Family Medicine 718-920-6433
Manager, Investigational Drugs
Clemencia Solorzano, BS, RPh 718-920-8354
Production Supervisor, Moses
Ann Brownstein, MS, RPh 718-920-8527
Day Supervisor, Moses
Alla Belovsky, M.S., R.Ph. 718-920-8354
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Evening Supervisor, Moses
Carolyn Woodley, Pharm D 718-920-8354
Manager, Oncology Pharmacy, Moses 718-920-8540/5778
Royston Browne, BS, RPh
Manager, Oncology Pharmacy, Einstein 718-405-8510
James McCarthy 718-904-4173
Ambulatory Pharmacy Manager, Moses 718-920-4934
Steven Tuckman, BS, R.Ph.
Specialty Pharmacy Manager
Keith Veltri, PharmD, MS, R.Ph. 718-920-4934
QUALITY MANAGEMENT
Quality Management Department 718-920-5026
Rohit Bhalla, MD
Brandon Yongue, PhD
The Quality Management Department is a team of professionals available to provide assistance
in quality and performance improvement initiatives. Technical and consultative support is
available in the following areas:
• Access to statistical and data resources and expert clinical resources
• Guidance in appropriate performance improvement tools and methodology
• Guidance in regards to regulatory and accreditation standards
• Advice/assistance in development and use of information systems in performance
improvement
• Facilitation of performance improvement groups
PERFORMANCE AND QUALITY IMPROVEMENT
The provision of safe, high quality, cost-effective care in an atmosphere of service excellence is
one of MMC's highest priorities. Performance Improvement is a systematic means of making
positive organizational changes to increase patient safety, meet evolving standards of practice,
satisfy patient/family needs and expectations, and increase the efficiency with which care is
provided. There is a single overall plan for quality management for the medical center and one
institution-wide committee, the Montefiore Quality Council, with oversight responsibility for
performance and quality improvement.
The methodology for Quality Improvement that MMC has adopted is the PDCA, Plan-Do-
Check-Act model. This approach allows us to continually strive to meet high standards for
safety, quality and cost effective health care and improved outcomes through better design of
services and through a reduction in the variation in how care is provided. It is based on the
methods of continuous quality improvement, whereby baseline data are collected, best practices
identified through literature searches, interventions are designed, piloted, and if determined to be
142

successful, expanded to other areas. At this point, ongoing monitoring and surveillance is done to
ensure on-going effectiveness.
Some PI initiatives emerge from rigorous peer review. In the peer review process, each
department is responsible for the review of all mortality cases, significant complications, readmissions
within 3 days, and cases in which a departure from standards of care may have
occurred. Performance Improvement Initiatives also emerge from the need to redesign services
or to address key patient safety areas. Examples of organization-wide PI initiatives include
Service Excellence, Pain Management, Reduction of Medication Errors, Reduction of Hospital
Days, CIS and Computerized Physician Order Entry, ICU Physician Staffing, and creating a
seamless continuum of care through all levels of acuity.
RESPIRATORY CARE
Respiratory Care Services are provided to patients based on a written/electronic prescription by
the physician responsible for the patient's care.
The Director of the service is available Monday - Friday, 9:00AM - 5:00PM and can be reached
at (718) 920-5110 or (718) 904-3214. The Shift Supervisors are available Monday - Friday, 7:00
a.m. - 10:00pm. They can be contacted through the Page Operator. If there are no managers on
duty and assistance is needed, contact the Page Operator for the Manager On-Call.
HOURS
24 hours-per- day, 7 days-per-week
There are two tours:
Tour I: 6:30AM - 7:00PM
Tour II: 6:30PM - 7:00AM
Shift report and daily activities are discussed from 6:30 until 7:00 on both tours. The Respiratory
Care Supervisors meet with the clinical staff to discuss quality of care rendered and to assure
continuity of care to all patients. Therapists have permanent beeper assignments which are
posted on each Nursing Unit. They can also be contacted
through the Page Operator.
MOSES
Northwest Building - Blue Zone, 1 st Floor
Medical Director
Anita Bhola, MD
Director
Joseph Antonik, RRT 718- 920-5110
917- 646-0337 pager
SHIFT SUPERVISORS
Yvonne Wigfall, RRT 718-920-2912
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917-457-8256 pager
Merlean Clarke, RRT 718- 920-2128
917- 787-7698 pager
Scott Dabbene, RRT 718- 920-5248
917- 537-4652
WEILER
Medical Director
Manoj Karwa,MD
Director
Joseph Antonik,RRT 718- 904-3214
SHIFT SUPERVISORS
Richard Verrette,RRT 718-904-2006
917-672-4398 pager
Nancy Torres,RRT 718-904-2339
917-672-4356 pager
Cliff Dryden,RRT 718-904-3215
917-762-5066 pager
RISK MANAGEMENT
3328 Rochambeau Avenue, 2nd floor 718-920-6340/6733
The Risk Management Department seeks to promote safety and prevent and minimize the
Medical Center's financial losses associated with patient/visitor injury, medical malpractice
claims and other liabilities. All levels of staff are encouraged to report accidents, actual or
potential claims, medical errors and untoward events promptly to Risk Management. The
Department is available 24 hours-per-day, 7 days-per-week to assist with the management of
difficult cases involving medical-legal problems, liability issues, consents, refusals of treatment,
and disputes/conflicts concerning patient care issues. During the evening, at night or on
weekends, Risk Management consultation may be accessed for urgent matters through the
Administrative Nursing Supervisor.
During non-office hours, non-emergent messages may be left at the above numbers.
Please contact Risk Management for any questions or concerns regarding these Administrative
Policies/Procedures:
• Informed Consent
• Disclosure of Unanticipated Events
• Occurrence Reports
• Safe Medical Devices
144

• Professional Misconduct
• Photography
• Equipment Malfunction
In addition, contact Risk Management for:
• Receipt of summonses, subpoenas, court orders, legal documents
requests or inquiries from attorneys
• Insurance claims, including theft, fire, flood, general liability and
other claims against MMC's insurance policies
• Questions concerning professional liability and other insurance
coverage
• Requests from third parties for certificates demonstrating insurance
coverage for MMC employees
Risk Management is committed to staff education and conducts departmental in-service
programs on a variety of medical-legal and risk related topics including documentation, informed
consent, and malpractice prevention/mitigation for physicians and other staff.
SAFETY AND SECURITY
Director of Safety & Security
Peter Kennelly 718-920-4113
Manager of Fire & Safety
Edward Fominyam
(For information on Fire Safety and Prevention, refer to the Policies and Procedures section of
the manual).
Security 718-920-5104
Emile Provencher 718-904-2750
Security Questions/Concerns 718-920-6131
Emergencies Dial 4357
The Security Department serves to provide a safe and secure environment for all patients, staff
and visitors. We strive to provide prompt, courteous, helpful and caring service, as well as
immediate and effective response to all emergencies. Security Officers are present in the
hospital 24 hours each day.
DISASTER CODES
Code 7: External
Code 4: Internal
Code 5: Security
Code ADAM is the hospital term for Pediatric Abduction. Every Associate has a responsibility
during a Code ADAM. All associates should be alert and report anyone attempting to leave with
145

a pediatric patient or any type of package large enough to contain an infant to the security stat
line HELP 4357. Associates with specific
responsibilities will be informed of their duties during their departmental orientation.
ALL ASSOCIATES:
• Must display photo ID at all times at work. If ID is lost, a replacement may be obtained from
the Security Office.
• Should lock personal items of value in a secure place.
• Call HELP- x. 4357 if there is an emergency.
Certain work locations require additional security information and training (i.e. panic buttons,
alarms). Individual departments are responsible for departmental orientation.
WEILER
Security Office Hours
Monday - Friday: 7:30AM - 6:00PM
ID Badges and Parking Validations 718-904-2750
Main Office (located on the first floor across from the Pharmacy)
The Main Lobby post is always manned and the telephone extension is 2800.
The Main Parking Lot is open from 6:30AM. - 1:00AM. Vehicles must have an authorized
Parking Sticker and access card to gain access. This system also allows Security to contact you
in case of any problem (i.e.: flat tire, lights on, keys in the door, etc.).
MOSES
Administrative Office 718-920-6131
Monday - Friday 8:00AM - 5:00PM
Security Control Station (24 hrs) 718-920-5668
ID Badges, and Lost and Found
Monday - Wednesday, and Friday
8:00AM - 12:00PM and 1:00PM - 4:00PM
SLEEP-WAKE DISORDERS CENTER
Director
Michael J. Thorpy, MD
3411 Wayne Avenue
Bronx, New York 10467
Referrals: 718-920-4841
718-798-4352 Fax
146

Outpatient testing, evaluation and diagnosis of all Sleep Disorders for adult and pediatric
patients.
SOCIAL WORK SERVICES
Management Team:
Dolores C. Jackson 718-920-4402
Rhonda Lieberman 718-741-2290
Services Provided:
• Discharge Planning
• Counseling
• Obtain Home Care Services
• Coordinate Placement in appropriate facilities (SNF, Rehab, etc.)
• Community Resource Planning
• Coordinate transportation upon discharge
• Information and Referral Program
MOSES 718-920-4545
Hours:
Monday – Friday 8:30AM - 5:00PM
Emergency Room
Monday – Friday 8:30AM - 10:00PM, Weekend 2:00PM - 10:00PM
Inpatient Worker
8:30AM - 5:00PM Weekends
Covers all inpatient units and the ER as needed until 2:00PM
WEILER 718-904-2707
Hours
Monday - Friday 9:00AM - 5:00PM
Emergency Room
Monday - Friday 9:00AM - 9:00PM
Saturday 1:00PM - 9:00PM, Sunday 2:00PM – 10:00PM
Inpatient Worker
9:00AM - 5:00PM Weekends
Covers all inpatient units and the ER as needed until 12:00PM
Weekends and After Hours
Weekend Social Workers can be reached through the page operators. After hours, Social Work
Managers can also be reached through the page operator for emergencies.
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STAFF AND ALUMNI ASSOCIATION
3306 Rochambeau Avenue, 2nd floor 718-920-5260
President
Manash Dasgupta, MD
Executive Director 718-920-5260
Margaret Pinsker
718-515-7083 Fax
The mission of the Montefiore Staff and Alumni Association is to enhance and strengthen the
relationship between Montefiore Medical Center (MMC) and its medical staff and alumni
through the development of programs that foster education, fellowship and service. Founded by
a group of attending physicians in 1914, the Association has always been involved with patient
and community needs and has acted as a strong advocate for the rights of house staff.
The Staff and Alumni Association sponsors the following programs
and services:
• Annual Dinner Dance and Awards Night
• Receptions at medical meetings
• Annual Career Night program for medical center house staff
• Support of a medical center archivist
• Publication of bi-annual Newsletter
• Scholarship Prize given annually to an AECOM graduate
• Support of the Health Science Library of the Tishman Learning Center
• Sponsorship of the annual outstanding House Officer Award and the Henry L. Moses Prize
for basic science and clinical research
• Biennial symposia on medical trends and technology
• Membership Directories
• Emergency Loan Fund for physicians in need
• Memorial portrait project
Membership is open to MMC: 1) graduates of medical, dental and physician assistant training
programs, 2) current and former members of the attending staff and 3) PhD's in the Behavioral
and Basic Sciences. The membership year is from
July I - June 30.
All programs, activities and benefits offered by the Association are underwritten by membership
dues. Dues are $60 per year; $30 per year for junior members who are less than five years out of
training. Graduating house staff are offered a one-year complimentary membership which
entitles them to all member benefits.
A Life Membership for payment of $1,000 is also available, which provides all member benefits
in perpetuity. Life members are recognized on a plaque in the Staff and Alumni Conference
Room.
TELECOMMUNICATIONS
Administrator
Mary Bishel
718-920-6262 Moses
718-904-2701 Einstein
148

Office Coordinator
Lillian Zambardino
718 920-5601 Moses
The Telecommunications Department provides operations and maintenance of all aspects of
voice communication throughout the Medical Center. This includes all areas of telephone
service; incoming and outgoing calls, paging, information service, planning equipment service
and repairs, new installations, moves and/or changes to existing telephone system, distribution of
voice and digital pagers, preparation of in-house pocket directories, monitoring of billings related
to telecommunications, participation in planning and implementation of capital projects.
VOLUNTEER SERVICES
Unified Director
Margaret Hamer
718-920-6654 Moses
718-904-2934 Einstein
MOSES
Program Supervisor
Elizabeth Ambert
Main Building Blue Zone
Loeb Corridor-1 st Floor 718-920-4191/4192
Monday-Friday, 8:30AM - 4:30PM
WEILER
Secretary
Cynthia Rivera
Second Floor Einstein Hospital 718-904-2934
Monday-Friday, 9:00AM – 5:00PM
The Volunteer Services Department directs and oversees all programmatic work throughout the
Medical Center, the Children’s Hospital at Montefiore (CHAM) and the Children's Mobile Unit
located on 64th St. In addition, the Department develops and implements volunteer recruitment
strategies, conducts community needs assessments, build relationships with community agencies
and oversees a comprehensive volunteer outreach program while helping to retain a diverse and
knowledgeable corps of volunteers. Providing high quality volunteer services while giving the
volunteer a satisfying experience and appropriate support, the Department coordinates
internships, summer programs and school/adult work experience programs. It provides all
resources necessary to meet departmental needs and to provide a conducive environment to
volunteer/staff growth and productivity.
Interviews by appointment only.
149

INDEX
A
Accreditation for Patient Care, House Staff 30
Acute Pain Service 116
Admissions, House Staff 41
Admitting 116
Advanced Directives- Health Care Proxies and Living Wills 92
Anesthesiology 61
Approval and Accreditation, House Staff 28
B
Banking Facilities 19
Bioethics 117
Blood Banks 118
Brain Death 93
C
Cardiology 62
Cardiothoracic Surgery 63
Change of Address/Practice Location, Medical Staff 22
Change of Status, Medical Staff 22
Chart Completion Policy for House Officers 42
Child Protection Center 119
Child Psychiatric Outpatient Divisions 64
Clinical Information Systems 119
CMO Important Telephone Numbers 25
Committee on Graduate Medical Education 27
Continuing Medical Education 120
Controlled Substances in the Work Place 109
Credentialing Office 21
Customer Services 121
D
DEA Registration, House Staff 35
Death Certificates 104
Dentistry 64
Dialysis Center III 121
Division of Education and Organizational Development 121
Do Not Intubate 97
Do Not Resuscitate 95
Drug Free Work Place 108
150

E
Educational Administration 28
Emergency Medicine 65
Employee Assistance Program 43
End of Life Care 99
Environmental Service 122
Epidemiology and Population Health 65
Equal Opportunity Employer 108
Ethical and Legal Compliance 106
F
Family Medicine 66
Fire Safety and Prevention 104
Food and Nutrition 123
Forgoing Life Sustaining Treatment 100
Frequently Used Numbers 12
G
General Essentials of Accredited Residencies 28
Gift Shop 124
H
Harassment 107
Health Information Management 124
Home Health Agency 129
Homeless Program 57
House Staff Benefits Plans 38
Hours, Limitation of House Staff 38
House Staff Office 27
Housing 44
I
Infection Control Program 105
Informed Consent and Refusal 101
Institutional Agreements ` 30
Institutional Requirements, House Staff 28
L
Laundry and Linen, House Staff 42
Leave of Absence, House Staff 37
Library, Tishman Learning Center Health Sciences 131
151

M
Mailroom 133
Malpractice Insurance, House Staff 35
Maternity Leave, House Staff 37
Meal Tickets 40
Medical Director, Office of 133
Medical Staff 20
Medicine 67
MIPA/CMO 23
MIPA Referral Management 23
MMG Administration 48
MMG1 Sites 48
MMG 2 Sites 50
MMG 3 Sites 52
MMG 4 53
Montefiore Medical Group 48
Moonlighting, House Staff 38
N
Neurology 70
Neurosurgery 70
Nuclear Medicine 71
O
Obstetrics and Gynecology and Women’s Health 73
Occupational Health Services 134
On-call Room 40
Oncology 76
Operating Room 134
Ophthalmology and Visual Science 78
Orthopedic Surgery 78
Otolaryngology 79
P
Palliative Care 135
Parking 42
Pathology 79
Patient, Family, and Community Health Education Resources 138
Patient Safety 137
Patients’ Bill of Rights 90
152

Paychecks, House Staff 40
Pediatrics 80
Pharmacy Services 139
Physical Exams, Pre-Appointment and Annual, House Staff 39
Physician Impairment and Drug Abuse Policy 39
Plastic and Reconstructive Surgery 81
Privileges and Appointment to the Medical Staff 21
Procedures for Evaluation, Supervision and Due Process- House Staff 35
Professional Conduct Reporting Policy 39
Protected Health Information Uses and Disclosures 90
Provider Relations Office 22
Psychiatry and Behavioral Sciences 81
Q
Quality Improvement 112
Quality Management 142
R
Radiation Oncology 85
Radiology 82
Reappointment, Medical Staff 21
Rehabilitation Medicine 85
Resident Eligibility and Selection 31
Resident Participation in Educational Activities 32
Resident Supervision, Duty, Hours and Work Environment 34
Resident Support, Benefits and Conditions of Employment 32
Respiratory Care 143
Risk Management 144
S
Safety and Security 145
School Health 53
Sick Leave, House Staff 38
Shuttle Buses 42
Sleep- Wake Disorders Center 146
Smoke Free Policy 108
Social Work Services 147
Staff and Alumni Association 148
Surgery 86
T
Telecommunications 148
153

U
Urology 88
V
Vacation Policy, House Staff 38
Verification of Operative Procedure Site and Patient Identification 103
Voluntary Service on MMC Administrative Committees 40
Volunteer Services 149
W
WIC Program 59
INDEX 150
154