Medical Staff House Staff Orientation Manual - Montefiore Medical ...
Medical Staff House Staff Orientation Manual - Montefiore Medical ...
Medical Staff House Staff Orientation Manual - Montefiore Medical ...
Transform your PDFs into Flipbooks and boost your revenue!
Leverage SEO-optimized Flipbooks, powerful backlinks, and multimedia content to professionally showcase your products and significantly increase your reach.
<strong>Medical</strong> <strong>Staff</strong><br />
<strong>House</strong> <strong>Staff</strong><br />
<strong>Orientation</strong> <strong>Manual</strong><br />
2005<br />
<strong>Montefiore</strong> <strong>Medical</strong> Center<br />
The University Hospital of the Albert Einstein College of Medicine
Welcome to <strong>Montefiore</strong> <strong>Medical</strong> Center, the University Hospital for the Albert Einstein College<br />
of Medicine. As a member of our physician community you will be experiencing one of the most<br />
unique and rewarding human experiences. Our common goal is to deliver the highest quality care<br />
to our patients, their families, and the community. This manual is intended to serve as a ready<br />
reference tool for use during your tenure here.<br />
Congratulations on joining one of the finest health care teams in the world.<br />
Good Luck!<br />
Steven M. Safyer, MD<br />
Senior Vice President<br />
Chief <strong>Medical</strong> Officer<br />
June, 1996<br />
Revised: May, 1997<br />
Revised: March, 1999<br />
Revised: April 2001<br />
Revised: November 2003<br />
Revised: January 2005<br />
2
We would like to take this opportunity to welcome you to <strong>Montefiore</strong> <strong>Medical</strong> Center. This<br />
manual was prepared to assist and guide you through our institution. Since no manual can<br />
possibly contain information on every hospital policy and procedure, please feel free to contact<br />
us if you require clarification or any additional information. We would also welcome your<br />
suggestions on any material that you would like to see in future editions of this manual.<br />
Thank you.<br />
Elaine M. Taylor<br />
Director<br />
<strong>House</strong> <strong>Staff</strong> Office<br />
(718) 920-4091<br />
Michael Dowling<br />
Director<br />
Provider Services and Network Contracting<br />
(914)377-4668<br />
3
MONTEFIORE MEDICAL CENTER - AN OVERVIEW<br />
<strong>Montefiore</strong> <strong>Medical</strong> Center is a large, nonprofit, integrated health system and one of America's<br />
foremost academic medical centers. <strong>Montefiore</strong> seeks to improve health by delivering highquality<br />
patient care, producing superbly trained health professionals, advancing medical<br />
knowledge through imaginative research, and by reaching out to the community with new<br />
approaches to pressing problems that are often considered beyond the traditional medical<br />
mission.<br />
<strong>Montefiore</strong> is the University Hospital and Academic <strong>Medical</strong> Center for the Albert<br />
Einstein College of Medicine and shares with that distinguished institution an outstanding faculty<br />
of clinicians and scientists. These highly skilled professionals, engaged in exciting research<br />
initiatives, bring to patient care and physician training the fruits of their investigations, the most<br />
current scientific knowledge and the most sophisticated medical technologies. Countless patients<br />
have been helped, and their lives extended and enhanced, by innovations that <strong>Montefiore</strong><br />
physicians have conceived, perfected and trained others to use.<br />
<strong>Montefiore</strong> serves the 1.3 million residents of the Bronx, 500,000 neighbors in nearby<br />
Westchester County, and persons referred from across the region and the nation. The medical<br />
center treats people, not just diseases, and offers a full range of services, including preventive,<br />
primary, specialty, acute and long-term care. Serving people of all ages, from newborns to the<br />
elderly, <strong>Montefiore</strong> offers special programs for specific age groups, such as the MontePlus Club,<br />
which provides senior citizens with a wide variety of health and fitness programs, educational<br />
events and discounts on products and services.<br />
<strong>Montefiore</strong> is widely recognized for its distinctive combination of cutting-edge medicine,<br />
caring response to patients and their families and commitment to community needs. Service to<br />
the community at large, not simply to those who come through its doors seeking help, has been a<br />
longstanding <strong>Montefiore</strong> tradition and an explicit component of its mission. This community<br />
commitment has resulted in a major expansion of basic health services in underserved<br />
neighborhoods and national models for combating AIDS, lead poisoning, child abuse and other<br />
intractable problems.<br />
Far more than a collection of services, <strong>Montefiore</strong> is a multilevel, interconnected and<br />
integrated delivery system, accredited with commendation by the Joint Commission on<br />
Accreditation of Healthcare Organizations. At the center of the system are three acute care<br />
hospitals, the 600-bed Henry and Lucy Moses Division and the 106-bed Children’s Hospital at<br />
<strong>Montefiore</strong>, both in the northwest Bronx and the 334-bed Jack D. Weiler Hospital of the Albert<br />
Einstein College of Medicine in the east Bronx. Together they provide nearly 56,000 inpatient<br />
stays annually. More than 3.4 million ambulatory visits are provided annually in <strong>Montefiore</strong>'s<br />
emergency rooms, hospital-based outpatient department and primary and specialty care sites in<br />
the Bronx and Westchester County. <strong>Montefiore</strong> operates the oldest and one of the largest<br />
hospital-based home health agencies in the nation, with 400,000 visits made annually.<br />
Rehabilitation care is provided at the 22-bed Lubin Rehabilitation Center on the Weiler-Einstein<br />
Campus. A hospice program offers palliative care and family support services.<br />
Under the leadership of President Spencer Foreman, MD, <strong>Montefiore</strong> has undertaken a<br />
major expansion of its ambulatory care facilities, which has greatly improved access and<br />
increased patient service. The <strong>Montefiore</strong> <strong>Medical</strong> Group, a network of neighborhood health<br />
centers in the Bronx and southern Westchester County, has grown to more than 20 sites, which<br />
provide more than 600,000 patient visits annually. Specialty centers in Westchester include<br />
4
<strong>Montefiore</strong>’s Institute for Reproductive Medicine and Health in Hartsdale, the Cross County<br />
Women’s Center in Yonkers and the Women's Center in Larchmont.<br />
<strong>Montefiore</strong>’s Centers of Excellence coordinate a full range of care for patients with<br />
highly specialized needs. The internationally recognized Centers of Excellence include: 1)The<br />
Children's Hospital at <strong>Montefiore</strong> (CHAM); completed in 2001, the CHAM is a model for<br />
pediatric care in the 21st century and the hub of a unique family-centered Child Health Network,<br />
2) Women’s Health, which features excellent obstetrical care, a level 3 NICU, care for mothers<br />
with high risk pregnancies, Assisted Reproductive Technology Program for women with fertility<br />
problems, 3) Surgery, which features the <strong>Montefiore</strong> Institute for Minimally Invasive Surgery<br />
(MIMIS), 4) <strong>Montefiore</strong>-Einstein Heart Center treats virtually every type of heart disease or<br />
heart problem and features minimally invasive heart surgery and a designated heart transplant<br />
center, and 5) <strong>Montefiore</strong>-Einstein Cancer Center; designated as elite NCI (National Cancer<br />
Institute) Comprehensive Cancer Center, multidisciplinary teams offer a full range of cancer<br />
prevention, diagnosis and treatment services.<br />
Major new initiatives continue to enhance clinical excellence, customer service and<br />
access to the <strong>Montefiore</strong> system. To speed the flow of information and enhance quality across its<br />
extensive system, <strong>Montefiore</strong> has made major investments in information systems, which link<br />
the entire network through on-line patient care and business databases. Together with the<br />
Contract Management Organization (CMO), <strong>Montefiore</strong> has also been a leader in preparing for<br />
managed care, building an infrastructure that can accept and handle risk and that is widely<br />
recognized as the region's best hospital-based care-managing system.<br />
The Service Excellence initiative promotes a commitment by all <strong>Montefiore</strong> associates to<br />
participate in the creation of an exceptional health care delivery system that consistently meets<br />
and exceeds patients’ and all other customers’ requirements. The Customer Relationship<br />
Management initiative strives to provide easy access to <strong>Montefiore</strong> patients and providers by<br />
offering centralized services for referrals, appointment scheduling and billing inquiry through the<br />
CMO Call Center.<br />
<strong>Montefiore</strong>’s Vision for Service Excellence<br />
Service Excellence is a commitment by all <strong>Montefiore</strong> associates to participate in the creation of<br />
an exceptional health care delivery system that consistently meets and exceeds patients’ and all<br />
other customers’ requirements.<br />
Patients prefer <strong>Montefiore</strong> because they are assured an exceptional experience that promotes<br />
health and healing where:<br />
• Quality clinical outcomes are achieved with a high level of responsiveness to patients’<br />
anxiety, pain, and personal needs.<br />
• They and their families are:<br />
• Valued as partners in the care process,<br />
• Listened to and educated,<br />
• Served by associates that demonstrate our Standards for Service Excellence.<br />
The seven Standards are:<br />
Respect<br />
Effective Communication<br />
Sensitivity<br />
Professionalism<br />
5
Exceeding Expectations<br />
Courtesy<br />
Teamwork<br />
• Services throughout the continuum are superior, coordinated and patient-centered<br />
• The physical and emotional environments are welcoming, professional, and confidenceinspiring.<br />
Associates prefer to work at <strong>Montefiore</strong> because they:<br />
• Make a difference in people’s lives<br />
• Feel listened to and valued for who they are and what they do<br />
• Recognize, respect and thank each other<br />
• Have opportunities for learning, career development, and advancement<br />
• Experience a work environment that has clear expectations and is ethical, equitable, and<br />
appreciates diversity<br />
• Lead and are led in ways that encourage growth, innovation, and outstanding results.<br />
• Have a competitive pay and benefits package<br />
• Celebrate successes and have fun<br />
• Work as a great team<br />
6
TABLE OF CONTENTS<br />
SECTION 1- General Information<br />
Frequently Used Numbers 12<br />
Banking Facilities 19<br />
SECTION 2- <strong>Medical</strong> <strong>Staff</strong> and <strong>House</strong> <strong>Staff</strong><br />
MEDICAL STAFF<br />
Credentialing Office 21<br />
Privileges and Appointment to the <strong>Medical</strong> <strong>Staff</strong> 21<br />
<strong>Medical</strong> <strong>Staff</strong> Reappointment 21<br />
Change of Status 22<br />
Change of Address/Practice Location 22<br />
Provider Relations Office 22<br />
MIPA/CMO 23<br />
MIPA Referral Management Process 23<br />
CMO Important Telephone Numbers 25<br />
HOUSE STAFF<br />
<strong>House</strong> <strong>Staff</strong> Office 27<br />
Committee on Graduate <strong>Medical</strong> Education 27<br />
General Essentials of Accredited Residencies 28<br />
Approval and Accreditation 28<br />
Institutional Requirements 28<br />
Sponsoring Institution 28<br />
Educational Administration 28<br />
Institutional Agreements 30<br />
Accreditation for Patient Care 30<br />
Resident Eligibility and Selection 31<br />
Resident Participation in Educational Activities 32<br />
Resident Support, Benefits and Conditions of Employment 32<br />
Resident Supervision, Duty, Hours and Work Environment 34<br />
Licensing 35<br />
DEA Registration Number 35<br />
Malpractice Insurance 35<br />
Procedures for Evaluation, Supervision, and Due Process 35<br />
The Effects of Leave of Absence from a Program 37<br />
<strong>House</strong> <strong>Staff</strong> Maternity Leave Policy 37<br />
<strong>House</strong> <strong>Staff</strong> Sick Leave Policy 38<br />
<strong>House</strong> <strong>Staff</strong> Vacation Policy 38<br />
<strong>House</strong> <strong>Staff</strong> Benefit Plans 38<br />
Limitation of <strong>House</strong> <strong>Staff</strong> Hours 38<br />
Moonlighting 38<br />
Physician Impairment and Drug Abuse Policy 39<br />
Pre-Appointment and Annual Physical Examinations 39<br />
7
Professional Conduct Reporting Policy 39<br />
Meal Tickets 40<br />
On-Call Rooms 40<br />
Paychecks 40<br />
Voluntary Service on MMC Administrative Committees 40<br />
Admissions, <strong>House</strong> <strong>Staff</strong> 41<br />
Chart Completion Policy for <strong>House</strong> Officers 42<br />
Laundry and Linen Service 42<br />
Parking 42<br />
Shuttle Buses 42<br />
Employee Assistance Program 43<br />
Housing 44<br />
SECTION 3- <strong>Montefiore</strong> <strong>Medical</strong> Group (MMG)<br />
<strong>Montefiore</strong> <strong>Medical</strong> Group (MMG) 48<br />
MMG Administration 48<br />
MMG 1 Sites 48<br />
MMG 2 Sites 50<br />
MMG 3 Sites 52<br />
MMG 4 53<br />
School Health 53<br />
Homeless Program 57<br />
WIC Program 59<br />
SECTION 4- Clinical Departments<br />
Anesthesiology 61<br />
Cardiology 62<br />
Cardiothoracic Surgery 63<br />
Child Psychiatric Outpatient Divisions 64<br />
Dentistry 64<br />
Emergency Medicine 65<br />
Epidemiology and Population Health 65<br />
Family Medicine 66<br />
Medicine 67<br />
Neurology 70<br />
Neurosurgery 70<br />
Nuclear Medicine 71<br />
Obstetrics & Gynecology and Women’s Health 73<br />
Oncology 76<br />
Ophthalmology and Visual Science 78<br />
Orthopedic Surgery 78<br />
Otolaryngology 79<br />
Pathology 79<br />
Pediatrics 80<br />
8
Plastic and Reconstructive Surgery 81<br />
Psychiatry and Behavioral Sciences 81<br />
Radiology 82<br />
Radiation Oncology 85<br />
Rehabilitation Medicine 85<br />
Surgery 86<br />
Urology 88<br />
SECTION 5- Policies and Procedures<br />
Patients’ Bill of Rights 90<br />
Protected Health Information Uses and Disclosures 90<br />
Advanced Directives- Health Care Proxies and Living Wills 92<br />
Brain Death 93<br />
Do Not Resuscitate Orders 95<br />
Do Not Intubate Orders 97<br />
End of Life Care 99<br />
Foregoing Life-Sustaining Treatment 100<br />
Informed Consent and Refusal 101<br />
Verification of Operative Procedure Site and Patient Identification 103<br />
Death Certificates 104<br />
Fire Safety and Prevention 104<br />
Infection Control Program 105<br />
Ethical and Legal Compliance 106<br />
Harassment 107<br />
Drug Free Work Place 108<br />
Smoke Free Policy 108<br />
Equal Opportunity Employer 108<br />
Controlled Substances in the <strong>Medical</strong> Center 109<br />
Quality Improvement 112<br />
SECTION 6- Service Departments<br />
Acute Pain 116<br />
Admitting 116<br />
Bioethics 117<br />
Blood Banks 118<br />
Child Protection Center 119<br />
Clinical Information Systems 119<br />
Continuing <strong>Medical</strong> Education 120<br />
Customer Services 121<br />
Dialysis Center III 121<br />
Division of Education and Organizational Development 121<br />
Environmental Service 122<br />
Food and Nutrition Services 123<br />
9
Gift Shop 124<br />
Health Information Management 124<br />
Home Health Agency 129<br />
The Tishman Learning Center Health Sciences Library 131<br />
Mailroom 133<br />
Office of the <strong>Medical</strong> Director 133<br />
Operating Room 134<br />
Occupational Health Services 134<br />
Palliative Care 135<br />
Patient, Family and Community Health Education Resources 137<br />
Patient Safety 138<br />
Pharmacy Services 139<br />
Quality Management 142<br />
Respiratory Care 143<br />
Risk Management 144<br />
Safety and Security 145<br />
Sleep- Wake Disorders Center 146<br />
Social Work Services 147<br />
<strong>Staff</strong> and Alumni Association 148<br />
Telecommunications 148<br />
Volunteer Services 149<br />
INDEX 150<br />
10
SECTION 1<br />
•<br />
GENERAL INFORMATION<br />
11
FREQUENTLY USED NUMBERS<br />
<strong>Montefiore</strong> <strong>Medical</strong> Center-Moses Division 718-920-4321<br />
Tie line to Einstein Weiler Division 712<br />
Tie line to Fordham Plaza 713<br />
Tie line to Einstein College of Medicine 712-52<br />
Tie line to CHAM 715<br />
Children’s Hospital at <strong>Montefiore</strong> (CHAM) 718-741-2426<br />
Tie line to Moses Division 6<br />
Tie line to Einstein Weiler Division 712<br />
Tie line to Fordham Plaza 713<br />
Tie line to Einstein College of Medicine 712-52<br />
Einstein/Weiler Division 718- 904-2000<br />
Tie line to Moses Division 51<br />
Tie line to Fordham Plaza 51-713<br />
Tie line to Einstein College of Medicine 52<br />
Tie line to CHAM 51-715<br />
Albert Einstein College of Medicine 718-430-2000<br />
Office of Graduate <strong>Medical</strong> Education 718-430-4282<br />
Beth Abraham Hospital 718-881-3000<br />
Jacobi <strong>Medical</strong> Center 718-918-5000<br />
North Central Bronx 718-519-5000<br />
Page Operator<br />
Moses Division<br />
External 718- 920-5321<br />
Internal<br />
X8282<br />
Emergency<br />
X2222<br />
CHAM<br />
External 718-741-2426<br />
Emergency<br />
X2222<br />
Einstein/Weiler Division<br />
External 718-904-4141<br />
Internal<br />
X2711<br />
Emergency<br />
X2222<br />
Prefix Numbers<br />
Moses Division (M)<br />
CHAM (C)<br />
Einstein/Weiler Division (W)<br />
<strong>Montefiore</strong> <strong>Medical</strong> Park (MMP)<br />
Fordham Plaza (F)<br />
Albert Einstein College of Medicine (A)<br />
920+extension<br />
741+extension<br />
904+extension<br />
405+extension<br />
405+extension<br />
430+extension<br />
12
Contract Management Organization (CMO) 914-377+extension<br />
DEPARTMENTS<br />
Administration M 6400 KIau Corridor<br />
W 2985 Room 2-60<br />
Admitting M 5001 Rosenthal Main<br />
W 3286 Room 1-36<br />
AIDS M 5224 Schiff 1<br />
Ambulatory Surgery M 7073 MAP 4th fl<br />
W 2878 3rd Floor<br />
Anesthesia M 4316 North 4-005<br />
W 2872 Room 316<br />
Audiology M 2333<br />
M 4646 MAP<br />
Bacteriology M 4695 North 8<br />
Baumwritter Kidney 597-2255 1325 Morris Ave<br />
Blood Bank M 4786 North 8<br />
W 2868<br />
Blood Donor<br />
M 4810<br />
Rosenthal 2<br />
W 2100<br />
Cardiology M 4116 North 2<br />
W 2927<br />
Cardiac Catheterization<br />
M<br />
W<br />
5413<br />
2071<br />
Central 1<br />
Cardiac non-Invasive<br />
M 4807<br />
North 2<br />
W 2779<br />
Cardiothoracic Surgery M 7000 3316 Rochambeau<br />
MMP 8248<br />
W 405-8373<br />
Central Supply M 4371 North Main<br />
W 2386<br />
Chemistry M 4181<br />
W 3423<br />
Clinical Pathology W 2861 Room 3-33<br />
Clinical Research M 4941 Central 3<br />
Credentialing CMO 4690 100 Corp. Drive<br />
Cytology M 4269 Central 3<br />
Dental M 6266 Centennial Bldg.<br />
Dialysis M 4974 North 4<br />
W 2595 Room W2-60<br />
EEG M 4311 Northwest 3<br />
W 2766 Room 1071<br />
EKG<br />
M 4676<br />
Central 1<br />
W 2779<br />
EMG M 4930 Klau Service Corridor<br />
13
Emergency Room<br />
Emergency Room<br />
M 6295 Northwest Main<br />
M 5731<br />
North 1<br />
W 3333<br />
Emergency Room-Pediatric C 2150<br />
Endocrinology M 4331 Hofhicimer 3<br />
Engineering<br />
M 4868<br />
90 E. 210th Street<br />
W 3284<br />
W 4000 1st. Floor<br />
Environmental Services M 4903 Basement<br />
Garage M 6350 11 E. 210th Street<br />
Geriatrics M 6721 Centennial Bldg.<br />
M 8150 KIau 4<br />
Gift Shop<br />
C<br />
W<br />
2294<br />
2742<br />
Gynecology/Obstetrics M 5157<br />
W 2797<br />
Headache Unit M 4636 3326 Rochambeau<br />
Hematology M 4137 North 8<br />
Holter Monitoring<br />
M 5166<br />
Central 1<br />
W 2390<br />
Home Health Agency F 4400 One Fordham Plaza<br />
<strong>House</strong> <strong>Staff</strong> Office M 4091 150 E. 210th St.<br />
Immunodiagnostic M 5570 Storage Bldg.1<br />
Immunohematology M 4785 Moses 5<br />
Immunology Laboratory M 4695 North 8<br />
Infection Control<br />
M 4562<br />
3341 Steuben<br />
W 3422<br />
Information Desk M 4141 Rosenthal Main<br />
Laundry M 5357 Service Bldg. 1<br />
Library- <strong>Medical</strong> M 4666 North 2<br />
Loeb Center M 4696 Northwest Main<br />
Mail Room M 5382 Moses Basement<br />
W 8963 1st Floor<br />
<strong>Medical</strong> Director M 6791 KIau Corridor<br />
W 2612 Room 2-60<br />
<strong>Medical</strong> Records M 4921 Rosenthal Main<br />
W 2747 Room 2-70<br />
Medicine M 7700 Centennial 4<br />
A 4041 360 Rousso<br />
MRI M 8209/8265 Central Main<br />
Microbiology M 4695 North 8<br />
Morgue M 4264 Hofheimer M<br />
W 2820 Room 1-34<br />
Neonatology W 4105 7 North<br />
Nephrology A 3158 615 Ullman<br />
14
Neurology M 4656 3351 Steuben<br />
A 3166<br />
MMP 405-8259<br />
Neuroradiology M 4640 North Main<br />
W 2736 Room 3-61<br />
Neurosurgery M 4196 3316 Rochambeau<br />
Nuclear Medicine M 5011 North 4<br />
W 2923 Room 1-21<br />
Nursing Department M 4701 Rosenthal Main<br />
W 2951 Room 2-71<br />
Nutrition<br />
M 4691<br />
North Main<br />
W 2731<br />
Occupational Therapy M 4083 Northwest Main<br />
W 2940<br />
Operating Room M 4491 North 3<br />
W 3413 Room 3-105<br />
OR Schedules M 6308 North 3<br />
W 2876 Room 3-104<br />
Ophthalmology M 4609 MAP<br />
Orthopedics M 2060 MAP 6<br />
Otolaryngology M 4646 MAP<br />
Outside Transportation M 5503/4407 NW Basement<br />
Pacemaker M 4881 North 2<br />
Pain Treatment M 5584 DTC<br />
Palliative Care M 6378 3544 Jerome Ave.<br />
Parking<br />
M 6350<br />
3324 Rochambeau<br />
W 8763<br />
Pathology M 4976 Central 3<br />
Patient Information M 4141<br />
W 4151 Main Floor<br />
Patient Relations W 2395 Room 2-52<br />
Pediatrics C 2460 Rosenthal 4<br />
Pharmacy M 4526 Storage Bldg.<br />
W 2838 Room 1-11<br />
Plastic Surgery<br />
M 5551<br />
3331 Bainbridge<br />
MMP 405-8444 Blondell<br />
Podiatry M 5101 DTC 460<br />
Pre-Admission<br />
M 5596<br />
Rosenthal<br />
W 3188<br />
Provider Relations CMO 4477 100 Corp. Drive<br />
Psychiatry M 4813 Klau Basement<br />
W 3467 Room 2S-56<br />
Pulmonary<br />
M<br />
W<br />
6054<br />
2983<br />
Centennial Bldg.<br />
15
Radiation Oncology M 4361 Yellow Zone Main<br />
W 2921 Room 1-21<br />
Radiology M 4861 North Main X-Ray<br />
W 3411 3rd Floor<br />
Receiving<br />
M 5341<br />
Storage Bldg. Main<br />
W 3435<br />
Recovery Room<br />
M 4477<br />
North 3<br />
W 2871<br />
Rehabilitation Medicine M 4844 Northwest Basement<br />
W 2296 Room 2-246<br />
Renal M 5442<br />
Centennial Bldg.<br />
430-3158<br />
Research Administration M 4151 3308 Rochambeau<br />
Respiratory Therapy M 4969 Northwest Main<br />
W 3214 Room W4-080<br />
Rheumatology M 4639<br />
Centennial Bldg.<br />
430-2078<br />
Risk Management M 6340 3328 Rochambeau<br />
Safety M 5104 90 East 210th Street<br />
Security/Transportation M 6131 3324 Rochambeau<br />
W 2800 1st Floor Lobby<br />
Social Service M 4545 Rosenthal C<br />
W 2707 Room 2-198<br />
Surgery<br />
M 6287<br />
MAP 4TH FL.<br />
Telecommunications<br />
W<br />
M<br />
M<br />
W<br />
2260<br />
6262<br />
5601<br />
2701<br />
Hofheimer 2<br />
Hofheimer 2<br />
Room 1-116<br />
Telemetry Triage W 2220<br />
Transplant M 4459 Rosenthal C<br />
Transportation- Patient M 4911 North Main<br />
Ultrasound<br />
M<br />
W<br />
4070<br />
2322<br />
Urinalysis Lab M 4695 North 8<br />
W 3425 Room 349<br />
Urology<br />
M 4531<br />
MAP 5<br />
W 4053<br />
M 5402 MAP 5<br />
Vascular Lab<br />
M 6603<br />
Klau Corridor<br />
W 2290<br />
Vascular Surgery<br />
M 4108<br />
MAP<br />
W 2586<br />
Volunteer<br />
M<br />
W<br />
4191<br />
2934<br />
Blue Zone<br />
16
MOSES NURSING STATIONS<br />
C 741-2377 Pediatric Day Hospital CHAM 3<br />
C 741-2600 Adolescent CHAM 6<br />
C 741-2200 Infants CHAM 8<br />
C 741-2100 Children's CHAM 9<br />
C 741-2000 Pediatric Critical Care CHAM 10<br />
C 741-2055 Epilepsy Inpatient CHAM 10<br />
M 4631 Sickle Cell KIau 3<br />
M 4641/6253 Medicine KIau 4<br />
M 4651/6256 Medicine KIau 5<br />
M 4661/6257 Medicine KIau 6<br />
M 4621 Psychiatry Klau 2<br />
M 4671/6273 Medicine Klau 7<br />
M 4681/6275 Medicine Klau 8<br />
M 6763 Stepdown Unit N7B<br />
M 4413 CCU North 2<br />
M 4411 MICU North 2<br />
M 6136 CSICU North 3<br />
M 5794 SICU North 3<br />
M 4974 Dialysis North 4<br />
M 6660 ICCU North 6AE<br />
M 6660 <strong>Medical</strong>/Surgical North 6B<br />
M 4581 Vascular Surgery North 7A East<br />
M 4611 Orthopedic Surgery North 7A West<br />
M 4601 CT/Plastic Surgery North 7B<br />
M 6551 Oncology Northwest 3<br />
M 4741 Oncology Northwest 4<br />
M 4731 Neurosurgery Northwest 8<br />
M 4731 Neurology Northwest 8<br />
M 5220 NSCU Northwest 8<br />
M 4571 Urology Northwest 8<br />
M 4541 Pulmonary Rosenthal 1<br />
M 5450 Pulmonary Care Unit (PCU) Rosenthal 1<br />
M 5218 Kidney Transplant Rosenthal 4<br />
M 5596 Adult/Same Day Care Center Rosenthal B<br />
M 7441 Family Medicine Rosenthal D<br />
M 4591 General Surgery<br />
M 5045 PACUP<br />
M 6702 LAF<br />
17
WEILER NURSING UNITS<br />
W 2781<br />
2 North<br />
W 2735<br />
2 North<br />
W 2595 Dialysis 2 West<br />
W 3119 ICCU 4 Northwest<br />
W 3415 ICU 4 Northwest<br />
W 4032 NICU 5 North<br />
W 2606<br />
5 South<br />
W 3433 Labor & Delivery 6 North<br />
W 3431<br />
6 South<br />
W 2762<br />
8 North<br />
W 2773<br />
8 South<br />
W 2704<br />
9 North<br />
W 2210<br />
9 South<br />
W 2744<br />
10 North<br />
W 2706<br />
10 South<br />
W 2974<br />
11 North<br />
W 3492<br />
11 South<br />
OUTPATIENT DEPARTMENT- CLINICS - MOSES<br />
M 6304 Administrator<br />
M 5586 Adult #1 and #2<br />
M 273 Adult Walk-In Clinic<br />
M 5584 Allergy<br />
M 5584 Arthritis<br />
M 5949 Cardiology MAP 7<br />
M 7373 Comprehensive Sickle Cell Center Klau 3<br />
M 6266 Dental Centennial 2<br />
M 7763 Dermatology (Primary Care) MAP<br />
M 5101 Diabetic DTC 4<br />
M 5101 Dressing DTC 440<br />
M 5085 E.N.T. (Otolaryngology) MAP 3<br />
M 5101 Endocrinology DTC 3<br />
M 5584 Epilepsy DTC 440<br />
M 4216 Eye MAP<br />
M 5584 Gastroenterology (G.I.) DTC440<br />
M 2273 General <strong>Medical</strong> DTC 320<br />
M 5584 Gold Therapy DTC440<br />
M 5157 Gynecology DTC 360<br />
M 5584 Headache Unit DTC 440<br />
M 5101 Hematology DTC 320<br />
M 8542 Infectious Disease DTC 3<br />
M 6707 Information and Referral DTC 3<br />
18
M 5584 Lupus Clinic<br />
M 5584 Neurology DTC 440<br />
M 7474 Neurosurgery 3316 Rochambeau<br />
M 5594 Nutritionist Schiff 1<br />
M 7541 Oncology (Breast/Chemotherapy) NW3<br />
M 2060 Orthopedics (Adult and Pediatrics) MAP 6<br />
M 7073 Peripheral Vascular Disease (PYD) MAP 4<br />
M 5586 Plastic Surgery DTC360<br />
M 5101 Podiatry DTC4<br />
M 4295 Psychiatry KIau 1<br />
M 5584 Pulmonary DTC3<br />
M 4361 Radiation Oncology Yellow Zone<br />
M 4844 Rehabilitation Northwest Ground<br />
M 7763 Renal Hypertension MAP<br />
M 5586 Renal Transplant DTC3<br />
M 5101 Scoliosis DTC4<br />
M 5445 Speech and Hearing Gold Zone<br />
M 5101 Surgery DTC4<br />
M 4531 Urology MAP<br />
BANKING FACILITIES<br />
MOSES<br />
There are automatic teller machines (ATM) and a postage stamp machine at the Gun Hill Road<br />
Entrance in the Silver Zone.<br />
WEILER<br />
There is an ATM located on 4th floor.<br />
BANKS IN THE AREA<br />
• Chase Bank<br />
Jerome Avenue (3 blocks west of 210th Street entrance and right on Jerome Avenue - east side<br />
of street)<br />
• Citibank<br />
Jerome Avenue (2 blocks west of Gunhill Road entrance and left on Jerome Avenue - west side<br />
of street)<br />
• Washington Mutual<br />
Jerome Avenue (3 blocks west of 210 th Street entrance next to Chase)<br />
19
SECTION II<br />
•<br />
MEDICAL STAFF<br />
&<br />
HOUSE STAFF<br />
20
MEDICAL STAFF CREDENTIALING OFFICE<br />
Director, Provider Services & Network Contracting 914-377-4668<br />
Michael Dowling<br />
914 -377-4794 Fax<br />
Director, Credentialing 914-377-4605<br />
Rose Richter<br />
914-377-4791 Fax<br />
Assistant Director, Provider Information 914-377-6021<br />
Justina Marrone<br />
914-709-0386 Fax<br />
The Credentialing Office is responsible for the Appointment and Reappointment of all attending<br />
physicians and employed allied health professionals for <strong>Montefiore</strong> <strong>Medical</strong> Center and the<br />
<strong>Montefiore</strong> Independent Provider Associations (MIPA).<br />
Privileges and Appointment to the <strong>Medical</strong> <strong>Staff</strong><br />
Applications to the <strong>Medical</strong> <strong>Staff</strong> and <strong>Montefiore</strong> IPA(s) can be obtained through the<br />
Department Chairman’s Office. All <strong>Medical</strong> <strong>Staff</strong> appointments are provisional for one year and<br />
all medical staff are required to be reappointed every two (2) years.<br />
Clinical departments are responsible for assembling the required credentialing documents<br />
necessary for appointment prior to submission of the application package to the Credentialing<br />
Office. Required documents include:<br />
• Current curriculum vitae<br />
• Delineation of Privileges (Completed by applicant and signed by the chairman)<br />
• Current NY State License registration, signed by physician<br />
• NYS Infection Control Certification<br />
• DEA certificate<br />
• Current malpractice insurance certificate<br />
• Recommendation and appointment letter from Department Chairman<br />
• Confidential <strong>Medical</strong> History and Examination<br />
• Completed application signed by the Department Chairman<br />
• Letters of recommendation and verification of education, training and clinical competence<br />
• Health Plan and government programs enrollment forms<br />
The Credentialing Office is responsible for all verifications including sanction checks,<br />
affiliations, state licensure, DEA registration and others as required by regulatory agencies. The<br />
Credentialing Office will be responsible for ensuring that all appropriate signatures are obtained<br />
and that the completed file is processed and approved according to <strong>Montefiore</strong> <strong>Medical</strong> Center’s<br />
<strong>Medical</strong> <strong>Staff</strong> By-Laws, Rules and Regulations.<br />
<strong>Medical</strong> <strong>Staff</strong> Reappointment<br />
<strong>Montefiore</strong> <strong>Medical</strong> Center <strong>Medical</strong> <strong>Staff</strong> members are subject to reappointment every two<br />
years. At the time of reappointment each physician/dentist is asked to:<br />
• review and update a General Information Profile Form which outlines biographical and<br />
practice information<br />
21
• list all continuing medical education credits; minimum of 150 CME credits per three (3)<br />
years are required<br />
• indicate hospital affiliations and any actions regarding licensure, registration and privileges<br />
or sanctions<br />
• complete a malpractice history questionnaire<br />
• complete departmental delineation of clinical privileges and self evaluation forms<br />
• submit documentation of an annual health assessment<br />
• complete authorization to release information<br />
• submit current certificates<br />
• complete other forms and provide other supplemental information as required<br />
Change of Status<br />
All <strong>Medical</strong> <strong>Staff</strong> members and/or clinical departments are required to submit status changes<br />
(e.g. change from Full Time to Voluntary) prior to the effective date of the change in writing.<br />
Information may be faxed to (914)709-0386.<br />
Change of Address/Location<br />
Change of address or practice information must be submitted in writing to Justina Marrone using<br />
the “Provider Change of Address” form. Forms may be faxed to (914)709-0386.<br />
PROVIDER RELATIONS OFFICE<br />
Bill Scesney<br />
Director, Provider Relations<br />
Office 914-377-4701<br />
Fax 914-377-4794<br />
Provider Relations is the communication link between <strong>Montefiore</strong> <strong>Medical</strong> Center, IPA<br />
providers, and contracted health plans. Provider Relations Liaisons offer a variety of services<br />
including orientation and educational sessions for IPA providers and office staff on CMO and<br />
health plan policies and procedures. Along with Network Development, Provider Relations<br />
works closely with the health plans to strengthen the IPA position in the market and grow<br />
provider membership in the network.<br />
22
MONTEFIORE INTEGRATED PROVIDER ASSOCIATION (MIPA) AND THE<br />
CONTRACT MANAGEMENT ORGANIZATION (CMO)<br />
What is Managed Care<br />
Managed care is a broad term that is used to describe the delivery and financing of<br />
health care services to a specific group of people (i.e., those covered under the payer's insurance<br />
plan) across all levels of services. The services may range from a routine physician office visit to<br />
hospital intensive care needs to healthcare provided in a home setting. The goal is to manage all<br />
the levels of care in a way that provides quality care in a cost effective manner. There are a<br />
variety of types of managed care benefits plans such as: Health Maintenance Organizations<br />
(HMOs), Preferred Provider organizations (PPOs), and Point of Service (POS). Each of these<br />
benefit plans pays the provider in a different way – usually a capitated rate or a discounted fee<br />
for service. The patient is responsible for co-payments based on their benefit plan requirements.<br />
MIPA and CMO Overview<br />
The <strong>Montefiore</strong> Independent Provider Associations (MIPA) were formed to provide a<br />
coordinated, integrated health services network (including physicians and hospital services) that<br />
will render comprehensive quality health care in the Bronx and the surrounding communities.<br />
The Contract Management Organization (CMO) employs staff to handle contracting with payers,<br />
medical management activities, credentialing and processing and payment of claims. The<br />
physicians accept the negotiated rates and may only bill patients for copayments or non-covered<br />
services with a signed waiver. Providers send claims to a central location at the CMO for claims<br />
review and processing.<br />
The MIPA is governed by a Board of Directors comprised of physician and hospital<br />
representatives. The board members are charged with broad policy decisions for the MIPA and<br />
approval of recommendations made by specific MIPA committees. Each committee has a<br />
specific area for which they make recommendations to the Board of Directors. In addition, the<br />
specific committees may serve as a monitoring arm of the CMO for its particular area of focus.<br />
The standing committees are Credentialing, <strong>Medical</strong> Management and Finance.<br />
MONTEFIORE IPA REFERRAL MANAGEMENT PROCESS<br />
CareLink<br />
Care Link is an Internet based system that allows providers and office staff direct access to verify<br />
member eligibility, submit referrals and authorizations, and check status of a<br />
referral/authorization in real-time. The features of this application include:<br />
• Verify eligibility for IPA Members<br />
• Submit referrals and authorizations on-line<br />
• View status of referrals and authorizations<br />
• View reports of referrals and authorization activity for a particular office<br />
Primary Care Physician (PCP) Responsibilities<br />
• Initially determines when appropriate for a patient to be referred<br />
23
to a SCP (Specialty Care Physician) for consultation<br />
• Completes an IPA Referral which should provide the following<br />
information to the specialist:<br />
• Specific reason the consultation is being requested<br />
• Information and/or results regarding any tests and/or procedures which may have already<br />
been performed<br />
• Forwards the IPA Referral to the SCP with any pertinent results of previous testing<br />
• Provides a copy of the Referral to the patient<br />
Specialist (SCP) Responsibilities<br />
• Ensures the patient is referred appropriately<br />
• Orders diagnostic tests necessary to complete the requested consultation<br />
• Complies with CMO requirements for notification and authorization<br />
• Determines if additional treatment is necessary and communicates the treatment plan to PCP<br />
• If the PCP is in agreement with the plan, the SCP coordinates<br />
the treatment, including arranging surgery and/or inpatient hospitalization<br />
• If SCP determines that referral to another SCP for cognitive consult<br />
may be appropriate, the SCP must inform the PCP and the PCP coordinates as above<br />
• Provides a follow-up written report to the PCP which outlines:<br />
• Evaluation<br />
• Findings<br />
• Recommended treatment<br />
• For extended course of treatment, the SCP provides a progress report to the PCP at intervals<br />
agreed upon<br />
Contract Management (CMO) Responsibilities<br />
• Verifies network status of the provider<br />
• Verifies member eligibility and coverage<br />
• If the referral requires authorization, the UM Coordinator performs review<br />
• If criteria are met, the CMO generates an authorization number<br />
• Will provide the PCP or SCP office with the authorization number as appropriate<br />
• If criteria are not met, the UM Coordinator refers the case to the CMO Physician Advisor for<br />
review<br />
• If the Physician Advisor denies the request for referral authorization, the provider is notified<br />
of his/her right to appeal the decision through the Appeals Process<br />
Exceptions to the Referral Guidelines<br />
• OB/GYN: Self-referral by patients to OB/GYN providers within the IPA/HMO network is<br />
permitted under state law for:<br />
• Two well women visits per year<br />
• All maternity care<br />
• Follow-up for any abnormal findings detected during a well<br />
woman visit<br />
• Acute gynecological conditions<br />
• Follow – Up to Care Received in the Emergency Department<br />
24
• Referral by the ED physician is permitted to arrange appropriate and timely follow-up to<br />
care provided in the ED for conditions involving trauma.<br />
• Mental Health/Chemical Dependency For Specific Health Plans<br />
• Mental health/Chemical dependency services for IPA patients is coordinated by<br />
University Behavioral Associates (UBA). The PCP or patient should contact UBA<br />
directly to arrange for referral to an appropriate provider. A paper referral is not required.<br />
• UBA: (800)401-4822<br />
• Diagnostic testing performed in IPA participating facilities<br />
• Lab, Optometry, Routine Podiatry (for members with benefit coverage), Influenza and<br />
Pneumococal vaccine visits do not require referrals<br />
Denials<br />
The CMO tracks, monitors and responds to denials associated with inpatient hospitalizations.<br />
Notification of denial may be received prior to, during or following<br />
a hospitalization.<br />
In the event a denial is received prior to or during a hospitalization that you are managing, you<br />
may be contacted with a request to contact a <strong>Medical</strong> Director at the health plan issuing the<br />
denial to provide additional clinical information in an effort to reverse the denial. In the event a<br />
denial is received following the hospitalization, you may be contacted to provide additional<br />
clinical information necessary to complete an appeal.<br />
If you should receive verbal notification from a health plan of a denial, please contact the<br />
Director of Denial Management at (914) 377-4678 with information regarding the patient and<br />
health plan involved. If you receive written notification of a denial, please fax to (914) 377-4677.<br />
CONTRACT MANAGEMENT ORGANIZATION (CMO) IMPORTANT<br />
TELEPHONE NUMBERS<br />
CMO Customer Service Line<br />
888- MONTE CMO or 914-377-4400<br />
Monday – Friday: 8:00 am – 6:00 PM<br />
• Confirm a member’s enrollment status, benefits and co-payment information<br />
• Confirm authorization status including all medical management inquiries<br />
• Confirm claim status<br />
• Resolve inquiries regarding complaints, grievances and administrative appeals<br />
• Address any questions or needs related to the CMO<br />
Fax: 914-375-2174<br />
Credentialing<br />
Phone: 914-377-4690<br />
Fax : 914-377-4691<br />
<strong>Medical</strong> Management<br />
Fax 914-377-4798<br />
25
Phone: Oxford Medicare inquiries only 800-876-7455<br />
Fax: Oxford Medicare only 914-476-4362<br />
Provider Relations<br />
Phone: 914-377-4477<br />
Fax: 914-377-4794<br />
University Behavioral Associates (UBA)<br />
Phone: 800-401-4UBA or 914-377-4550<br />
Fax: 914-377-4788<br />
26
HOUSE STAFF OFFICE<br />
150 East 210th Street<br />
Opposite the 210th Street Entrance of the hospital<br />
Phone 718-920-4091<br />
Fax 718-920-8403<br />
Hours<br />
Monday – Friday 8:30AM - 5:00PM<br />
Notary Available: Please call for an appointment 718-920-2341<br />
Director 718-920-4091<br />
Elaine M. Taylor<br />
917-506-5081 Beeper<br />
taylor@montefiore.org<br />
Assistant Director 718-920-4093<br />
Justice Gaba<br />
jgaba@montefiore.org<br />
Credentialing Specialist 718-920-2340<br />
Esther Gonzalez<br />
egonzale@montefiore.org<br />
Credentialing Specialist 718-920-4806<br />
Gladys Velazquez<br />
gvelazqu@montefiore.org<br />
Data Analyst 718-920-2625<br />
Richard Reinoso<br />
rreinoso@montefiore.org<br />
Data Analyst 718-920-2947<br />
Nilsa Sambula<br />
nsambula@montefiore.org<br />
Reception 718-920-2341<br />
Lackragie Singh (Drew)<br />
lsingh@montefiore.org<br />
Please feel free to contact us for any questions or concerns you may have.<br />
COMMITTEE ON GRADUATE MEDICAL EDUCATION<br />
<strong>Montefiore</strong> <strong>Medical</strong> Center’s Residency Programs are sponsored by the Albert Einstein College<br />
of Medicine (AECOM). The Committee on Graduate <strong>Medical</strong> Education (COGME) is an<br />
organized administrative committee of AECOM that oversees all residency programs and has the<br />
responsibility for monitoring and advising the sponsored institution on all aspects of residency<br />
education. The committee has representation of key academic and hospital administrators, as<br />
well as residents. Included in the responsibilities of the COGME are the establishment and<br />
implementation of policies that affect all residency programs regarding the quality of education<br />
and the work environment of the residents in each program. MMC and JMC are active<br />
participants on this committee and strongly support the mandated mission of the committee.<br />
27
Associate Dean of Graduate <strong>Medical</strong> Education<br />
Michael Reichgott, MD, PhD 718-430-4282<br />
Administrator GME<br />
Linda Collazzi 718-430-4283<br />
Administrative Secretary<br />
Vilma Kalten 718-430-4284<br />
GENERAL ESSENTIALS OF ACCREDITED RESIDENCIES<br />
The following are excerpts from the Essentials of Accredited Residencies in Graduate <strong>Medical</strong><br />
Education. The entire text specifying the requirements every residency program must meet to be<br />
accredited may be found in each department in the booklet listing<br />
approved residency and fellowship programs or from: The Secretary, Accreditation Council for<br />
Graduate <strong>Medical</strong> Education, 535 N. Dearborn Street, Chicago, Ill. 60610. A copy is also<br />
available for review in the <strong>House</strong> <strong>Staff</strong> Office.<br />
Approval and Accreditation<br />
For a program to become accredited, the sponsoring institution must demonstrate a commitment<br />
to GME. The sponsoring institution must be in substantial compliance with the Institutional<br />
Requirements and must assume responsibility for the educational quality of its sponsored<br />
program(s). Further information concerning a “sponsoring institution” is provided below.<br />
Institutional Requirements<br />
Institutional Organization and Commitment: The purpose of GME is to provide an organized<br />
educational program with guidance and supervision of the resident, facilitating the resident’s<br />
ethical, professional and personal development while ensuring safe and appropriate care for<br />
patients.<br />
Sponsoring Institution<br />
• A residency program must operate under the authority and control of a sponsoring institution<br />
(see definition for sponsoring institution in the Glossary under "Institution").<br />
• There must be a written statement of institutional commitment to GME that is supported by<br />
the governing authority, the administration, and the teaching staff.<br />
• Sponsoring institutions must be in substantial compliance with the Institutional Requirements<br />
and must ensure that their ACGME accredited programs are in substantial compliance with<br />
the Program Requirements and the applicable Institutional Requirements.<br />
• An institution's failure to comply substantially with the Institutional Requirements may<br />
jeopardize the accreditation of all of its sponsored residency programs.<br />
Educational Administration<br />
There must be an organized administrative system to oversee all residency programs sponsored<br />
by an institution. In addition, there must be a designated institutional official who has the<br />
authority and the responsibility for the oversight and administration of the GME programs.<br />
28
• Institutions must have a GME Committee (GMEC) that has the responsibility for monitoring<br />
and advising on all aspects of residency education. Voting membership on the committee<br />
must include residents nominated by their peers, appropriate program directors, other<br />
members of the faculty, and the accountable institutional official or his or her designee.<br />
• The committee must meet at least quarterly; minutes must be kept and be available for<br />
inspection by accreditation personnel.<br />
• The responsibilities of the committee must include:<br />
• Establishment and implementation of policies that affect all residency programs<br />
regarding the quality of education and the work environment for the residents in each<br />
program.<br />
• Establishment and maintenance of appropriate oversight of and liaison with program<br />
directors and assurance that program directors establish and maintain proper oversight of<br />
and liaison with appropriate personnel of other institutions participating in programs<br />
sponsored by the institutions.<br />
• Regular review of all ACGME letters of accreditation and the monitoring of action plans<br />
for the correction of areas of non-compliance.<br />
• Regular review of all residency programs to assess their compliance with both the<br />
Institutional Requirements and Program and the Program Requirements of the ACGME<br />
Residency Review Committees.<br />
• The review must be conducted by the GMEC or a body designated by the GMEC,<br />
which should include faculty, residents, and administrators, from within the<br />
institution but from programs other than the one that is being reviewed. External<br />
reviewers may also be included on the review body as determined by the GMEC.<br />
The review must follow a written protocol approved by the GMEC.<br />
• Reviews must be conducted approximately at the midpoint between the ACGME<br />
program surveys.<br />
• While assessing the residency program's compliance with each of the program<br />
standards, the review should also appraise the following:<br />
• the educational objectives of each program<br />
• the adequacy of available educational and financial resources to meet these<br />
objectives<br />
• the effectiveness of each program in meeting its objectives<br />
• the effectiveness in addressing citations from previous ACGME letters of<br />
accreditation and previous internal reviews<br />
• the use of dependable measures to assess residents’ competence in patient<br />
care, medical knowledge, practice-based learning and improvement,<br />
interpersonal and communication skills, professionalism and systems-based<br />
practice as defined in the section II.B, and in the Program Requirements<br />
• the effectiveness of each program in implementing a process that links<br />
educational outcomes with program improvement<br />
• Materials and data to be used in the review process must include the following:<br />
• institutional and program requirements from the Essentials of Accredited<br />
Residency Programs<br />
• letters of accreditation from previous ACGME reviews<br />
• reports from previous internal reviews of the program<br />
29
• interviews with the program director, faculty, and residents in the program<br />
and individuals outside the program deemed appropriate by the committee<br />
• There must be a written report of each internal review that is presented to and<br />
reviewed by the GMEC for the monitoring of areas of noncompliance and<br />
appropriate action. In addition, this report or a succinct summary of each report is<br />
required as part of the ACGME institutional review document.<br />
• Although departmental annual reports are often important sources of information<br />
about a residency program, they do not in themselves necessarily meet the<br />
requirement for a periodic review.<br />
• Assurance that each residency program establishes and implements formal written<br />
criteria and processes for the selection, evaluation, promotion, and dismissal of<br />
residents in compliance with both the Institutional and relevant Program<br />
Requirements.<br />
• Assurance of an educational environment in which residents may raise and resolve<br />
issues without fear of intimidation or retaliation. This includes:<br />
• Provision of an organizational system for residents to communicate and<br />
exchange information on their working environment and their educational<br />
programs. This may be accomplished through a resident organization or other<br />
forums in which to address resident issues.<br />
• A process by which individual residents can address concerns in a confidential<br />
and protected manner.<br />
• Establishment and implementation of fair institutional policies and procedures<br />
for academic or other disciplinary actions taken against residents.<br />
• Establishment and implementation of fair institutional policies and procedures<br />
for adjudication of resident complaints and grievances related to actions which<br />
could result in dismissal, nonrenewal of a resident’s contract, or other actions<br />
that could significantly threaten a resident's intended career development.<br />
• Collecting of intra-institutional information and making recommendations on<br />
the appropriate funding for resident positions, including benefits and support<br />
services.<br />
• Monitoring of the programs in establishing an appropriate work environment<br />
and the duty hours of residents.<br />
• Assurance that each program provides a curriculum and an evaluation system<br />
to ensure that residents demonstrate competence in the general areas listed in<br />
II.B, and as defined in each set of Program Requirements.<br />
Institutional Agreements<br />
When resident education occurs in a participating institution, the sponsoring institution continues<br />
to have responsibility for the quality of that educational experience and must retain authority<br />
over the residents' activities. Therefore, current institutional agreements<br />
must exist with all of its major participating institutions.<br />
Accreditation for Patient Care<br />
Institutions sponsoring or participating in GME programs should be accredited by the Joint<br />
Commission on the Accreditation of Healthcare Organizations (JCAHO), if such institutions are<br />
eligible. If an institution is eligible for JCAHO accreditation and chooses not to undergo such<br />
30
accreditation, then the institution should be reviewed by and meet the standards of another<br />
recognized body with reasonably equivalent standards. If the institution is not accredited, it must<br />
provide a satisfactory explanation of why accreditation has not been either granted or sought.<br />
Resident Eligibility and Selection<br />
The sponsoring institution must have written policies and procedures for the recruitment and<br />
appointment of residents that comply with the requirements listed below, and it must monitor the<br />
compliance of each program with these procedures.<br />
RESIDENT ELIGIBILITY<br />
Applicants with one of the following qualifications are eligible for appointment to accredited<br />
residency programs:<br />
• Graduates of medical schools in the United States and Canada, accredited by the Liaison<br />
Committee on <strong>Medical</strong> Education (LCME.<br />
• Graduates of colleges of osteopathic medicine in the United States accredited by the<br />
American Osteopathic Association (AOA)<br />
• Graduates of medical schools outside the United States and Canada who meet one of the<br />
following qualifications:<br />
• Have received a currently valid certificate from the Educational Commission for Foreign<br />
<strong>Medical</strong> Graduates, or<br />
• Have a full and unrestricted license to practice medicine in a US licensing jurisdiction<br />
• Graduates of medical schools outside the United States who have completed a Fifth Pathway<br />
program provided by an LCME-accredited medical school. [Note.- A Fifth Pathway program<br />
is an academic year of supervised clinical education provided by an LCME accredited<br />
medical school to students who meet the following conditions:<br />
• Have completed, in an accredited college or university in the United States,<br />
undergraduate premedical education of the quality acceptable for matriculation in an<br />
accredited United States <strong>Medical</strong> school<br />
• Have studied at a medical school outside the United States and Canada but listed in the<br />
World Health, Organization Directory of <strong>Medical</strong> Schools<br />
• Have completed all of the formal requirements of the foreign medical school except<br />
internship and/or social service<br />
• Have attained a score satisfactory to the sponsoring medical school on a screening<br />
examination<br />
• Have passed either the foreign <strong>Medical</strong> Graduate Examination in the <strong>Medical</strong> Sciences,<br />
Parts I and II of the examination of the National Board of <strong>Medical</strong> Examiners, or Steps 1<br />
and 2 of the United States <strong>Medical</strong> Licensing Examination (USMLE)<br />
RESIDENT SELECTION<br />
The sponsoring institution must ensure that programs select from among eligible applicants on<br />
the basis of the preparedness, ability, aptitude, academic credentials, communication skills, and<br />
personal qualities such as motivation and integrity. Programs must not discriminate with regard<br />
to sex, race, age, religion, color, national origin, disability, or veteran status. In selecting from<br />
among qualified applicants, it is strongly-suggested that institutions and all of their sponsored<br />
programs participate in an organized matching program, where available, such as the National<br />
Resident Matching Program (NRMP).<br />
31
ENROLLMENT OF NON-ELIGIBLES<br />
The enrollment of non-eligible residents may be a cause for withdrawal of accreditation of the<br />
involved program.<br />
Resident Participation in Educational Activities-ACGME Competencies<br />
The residency program must require that its residents obtain competence in the six areas listed<br />
below to the level expected of a new practitioner. Programs must define the specific knowledge,<br />
skills, behaviors, and attitudes required and provide educational experiences as needed in order<br />
for their residents to demonstrate the following:<br />
• Patient care that is compassionate, appropriate, and effective for the treatment of health<br />
problems and promotion of health<br />
• <strong>Medical</strong> knowledge about established and evolving biomedical, clinical, and cognate<br />
sciences and the application of this knowledge to patient care<br />
• Practice-based learning and improvement that involves investigation and evaluation of their<br />
own patient care, appraisal and assimilation of scientific evidence, and improvement in<br />
patient care<br />
• Interpersonal and communication skills that result in effective information exchange and<br />
teaming with patients, their families and other health professionals<br />
• Professionalism, as manifested through a commitment to carrying out professional<br />
responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population<br />
• Systems-based practice, as manifested by actions that demonstrate an awareness of and<br />
responsiveness to the larger context and system for health care and the ability to effectively<br />
call on system resources to provide care that is of optimal value<br />
In addition, institutions must ensure that residents achieve the following:<br />
• Develop a personal program of learning to foster continued professional growth with<br />
guidance from the teaching staff<br />
• Participate fully in the educational and scholarly activities of their program and, as required,<br />
assume responsibility for teaching and supervising other residents and students<br />
• Participate in appropriate institutional committees and councils whose actions affect their<br />
education and/or patient care<br />
• Submit to the program director or to a designated institutional official at least annually<br />
confidential written evaluations of the faculty and of the educational experiences<br />
Resident Support, Benefits and Conditions of Employment<br />
Sponsoring and participating institutions should provide all residents with appropriate financial<br />
support and benefits. Compensation of residents and distribution of resources for the support of<br />
education should be carried out with the advice of the GMEC.<br />
• Financial Support: Adequate financial support of residents is necessary to ensure that<br />
residents are able to fulfill the responsibilities of their educational programs.<br />
• Applicants: Applicants for GME programs must be informed in writing of the terms and<br />
conditions of employment and benefits including financial support, vacations, professional<br />
leave, parental leave, sick leave, professional liability insurance, hospital and health<br />
insurance, disability insurance, and other insurance benefits for the residents and their family,<br />
32
and the conditions under which living quarters, meals and laundry or their equivalents are to<br />
be provided.<br />
• Contracts: Sponsoring institutions must provide residents with a written agreement. or<br />
contract outlining the terms and conditions of their appointment to an educational program,<br />
and the institutions must monitor the implementation of these terms and conditions by the<br />
program directors. The contract must contain or reference at least the following:<br />
• Financial support<br />
• Vacation policies<br />
• Professional liability insurance in conformity with II.C.5<br />
• Disability insurance and other hospital and health benefits for the residents and their<br />
family in conformity with II.C.6<br />
• Professional, parental, and sick-leave benefits in conformity with II.7<br />
• Conditions under which living quarters, meals, and laundry or their equivalents are to<br />
be provided<br />
• Counseling, medical, psychological, and other support services in conformity with<br />
IIC.8<br />
• Institutional policies covering sexual and other forms of harassment<br />
The contract must also delineate or reference specific policies as follows:<br />
• Resident’s duration of appointment and conditions of reappointment<br />
• Professional activities outside the educational program in conformity with II.C.II<br />
• Grievance procedures in conformity with I.B.3.f.4<br />
• Nonrenewal of Contracts: Institutions must ensure that programs provide their residents with<br />
a written notice of intent not to renew a resident’s contract no later than 4 months prior to the<br />
end of the resident’s current contract. However, if the primary reason(s) for the nonrenewal<br />
occurs within the 4 months prior to the end of the contract, institutions must ensure that<br />
programs provide their residents with as much written notice of the intent not to renew as the<br />
circumstances will reasonably allow, prior to the end of the contract. Resident must be<br />
allowed to implement the institution’s grievance procedures as addressed in section I.B.3.F.4,<br />
when they have received a written notice of intent not to renew their contracts.<br />
• Liability Insurance: Residents in GME must be provided with professional liability coverage<br />
for the duration of training. Such coverage must provide legal defense and protection against<br />
awards from claims reported or filed after the completion of GME if the alleged acts or<br />
omissions of the residents are within the scope of the education program. The coverage to be<br />
provided should be consistent with the institution's coverage for other medical/professional<br />
practitioners. Each institution must provide current residents and applicants for residency<br />
with the details of the institution's professional liability coverage for residents.<br />
• Disability Insurance: Institutions sponsoring GME must provide access to insurance, where<br />
available, to all residents for disabilities resulting from activities that are part of the<br />
educational program.<br />
• Leave of Absence: There must be a written institutional policy on leave (with or without pay)<br />
for residents that complies with applicable laws. The institution must provide residents with a<br />
written policy concerning the effect of leaves of absence, for any reason, on satisfying the<br />
criteria for completion of a residency program.<br />
• Counseling Services: GME places increasing responsibilities on residents and requires<br />
sustained intellectual and physical effort. Therefore, institutions should facilitate resident<br />
33
access to appropriate and confidential counseling, medical and psychological support<br />
services.<br />
• Physician Impairment: Institutions must have written policies that describe how physician<br />
impairment, including that due to substance abuse, will be handled. In addition, institutions<br />
should provide an educational program for residents regarding physician impairment,<br />
including substance abuse.<br />
• Residency Closure/Reduction: If an institution intends to reduce the size of a residency<br />
program or to close a residency program, the institution must inform the residents as soon as<br />
possible. In the event of such a reduction or closure, institutions must allow residents already<br />
in the program to complete their education or assist the residents in enrolling in an ACGMEaccredited<br />
program in which they can continue their education.<br />
• Moonlighting: All sponsoring institutions must have a written policy that addresses<br />
professional activities outside the educational program to include moonlighting.<br />
• Restrictive Covenants: ACGME-accredited residencies must not require residents to sign a<br />
non-competition guarantee.<br />
Resident Supervision, Duty, Hours and Work Environment<br />
Institutions must ensure that their GME programs provide appropriate supervision for all<br />
residents, as well as a duty hour schedule and a work environment, that is consistent with proper<br />
patient care, the educational needs of residents, and the applicable Program<br />
Requirements.<br />
• Supervision: There must be sufficient institutional oversight to assure that residents are<br />
appropriately supervised. Residents must be supervised by teaching staff in such a way that<br />
the residents assume progressively increasing responsibility according to their level of<br />
education, ability, and experience. On-call schedules, for teaching staff must be structured to<br />
ensure that Institutional Requirements supervision is readily available to residents on duty.<br />
The level of responsibility accorded to each resident must be determined by the teaching<br />
staff.<br />
• Duty Hours: The sponsoring institution must ensure that each residency program establishes<br />
formal policies governing resident duty hours that foster resident education and facilitate the<br />
care of patients.<br />
• The educational goals of the program and learning objectives of residents must not be<br />
compromised by excessive reliance on residents to fulfill institutional service obligations.<br />
Duty hours, however, must reflect the fact that responsibilities for continuing patient care<br />
are not automatically discharged at specific times. Programs must ensure that residents<br />
are provided appropriate backup support when patient care responsibilities are especially<br />
difficult or prolonged.<br />
• Resident duty hours and on-call time periods must not be excessive. The structuring of<br />
duty hours and on-call schedules must focus on the needs of the patient, continuity of<br />
care, and the educational needs of the resident.<br />
• Work Environment: Sponsoring institutions must provide services and develop systems to<br />
minimize the work of residents that is extraneous to their educational programs,. ensuring<br />
that the following conditions are met:<br />
• Residents on duty in the hospital must be provided adequate and appropriate food<br />
services and sleeping quarters.<br />
34
• Patient support services, such as intravenous services, phlebotomy services, and<br />
laboratory services, as well as messenger and transporter services, must be provided in a<br />
manner appropriate to and consistent with educational objectives and patient care.<br />
• An effective laboratory, medical records, and radiological information retrieval system<br />
must be in place to provide for appropriate conduct of the educational programs and<br />
quality and timely patient care.<br />
• A medical records system that documents the course of each patient’s illness and care<br />
must be available at all times and must be adequate to support the education of residents,<br />
support quality-assurance activities, and provide a resource for scholarly activity.<br />
• Appropriate security and personal safety measures must be provided to residents in all<br />
locations including but not limited to parking facilities, on-call quarters, hospital and<br />
institutional grounds, and related clinical facilities (e.g., medical office building).<br />
Licensing<br />
According to the New York State Education Department, interns and residents participating in an<br />
accredited training program need not be licensed. It is the <strong>Medical</strong> Center's recommendation that<br />
all Clinical/Fellows, chief residents, and senior chief residents at the <strong>Medical</strong> Center be in<br />
possession of a New York State license or limited permit on July 1 of the academic year in<br />
question. Applications for licensure or limited permit are available on the internet at<br />
www.op.nysed.gov or by calling NYS Education @ (518) 474-3841.<br />
DEA Registration Number<br />
In order to prescribe and administer narcotics to Hospital inpatients or outpatients, each member<br />
of the <strong>House</strong> <strong>Staff</strong> will use the nine-digit Hospital DEA number with their own personal threedigit<br />
suffix. The individual three-digit suffix will be assigned by the <strong>House</strong><br />
<strong>Staff</strong> Office (920-4091). A plastic blue card is issued to all <strong>House</strong> <strong>Staff</strong> that write prescriptions<br />
with their name imprinted on it. This card is available through the <strong>House</strong> <strong>Staff</strong> Office.<br />
Malpractice Insurance<br />
Risk Management provides an annual in-service for new residents reflecting the parameters of<br />
their malpractice coverage under <strong>Montefiore</strong> <strong>Medical</strong> Center's Umbrella Malpractice policy. For<br />
more information regarding your coverage, please contact<br />
Risk Management at (718) 920-6733.<br />
Procedures for Evaluation, Supervision and Due Process<br />
EVALUATION<br />
The Director of Service is responsible for evaluating and reviewing each member of the <strong>House</strong><br />
<strong>Staff</strong>. The Director of Service will include consideration of:<br />
• Professional and clinical performance<br />
• Physical and mental health status<br />
• Completion of education and training requirements<br />
• Attendance at departmental conferences, meetings and rounds<br />
• Timely completion of medical records<br />
• Compliance with <strong>Medical</strong> <strong>Staff</strong> By-Laws, Rules and Regulations and with hospital policies<br />
35
Performance evaluation will be kept on file within each department. <strong>House</strong> staff will be apprised<br />
of their performance at least annually.<br />
SUPERVISION<br />
The <strong>House</strong> <strong>Staff</strong> may provide patient care at <strong>Montefiore</strong> <strong>Medical</strong> Center only as part of an<br />
accredited training program. All patient care activities provided by <strong>House</strong> <strong>Staff</strong> will be<br />
supervised by the Attending Physician responsible for the care of the patient. Attending<br />
Physician supervision will be appropriately documented in the medical record.<br />
DELINEATION OF CLINICAL PRIVILEGES<br />
Each Service Director will recommend individual clinical privileges for each member of the<br />
<strong>House</strong> <strong>Staff</strong>. Delineation of privileges is based upon the requirements of the training program in<br />
conjunction with the <strong>House</strong> <strong>Staff</strong> member's periodic performance evaluation.<br />
DUE PROCESS<br />
<strong>Montefiore</strong> <strong>Medical</strong> Center has established a process for resident evaluation and corrective<br />
action, in accordance with ACGME standards. <strong>Montefiore</strong> residents are entitled to due process<br />
to ensure that the resident is afforded the opportunity for fair adjudication of complaints or<br />
grievances which could result in termination or threaten<br />
his or her career development. <strong>Montefiore</strong>'s due process procedure consist of several progressive<br />
steps:<br />
• An informational departmental resolution<br />
• A departmental ad hoc committee review<br />
• A due process hearing consisting of five physicians, at least two of which are residents<br />
• An appeal to the President of the medical center<br />
Please note that due process procedures of the employing institution of the resident govern, and<br />
may vary somewhat from the steps outlined above. Detailed information on due process<br />
procedures are contained in the "Hearing and Appeal Policy and Procedures for Redress of<br />
Adverse Actions and Grievances of Residents," which is available to<br />
Residents through the <strong>House</strong> <strong>Staff</strong> Office. In general, <strong>Montefiore</strong>'s Due Process Policy provides<br />
as follows:<br />
• Applicability: If an adverse action is taken which would prevent the resident from<br />
completing the current training year or residency program, or which would prevent the<br />
resident from achieving admissibility status to take a certification examination of the<br />
American <strong>Medical</strong> Specialty Board, the resident is entitled to due process. Note that<br />
placement on academic probation in and of itself does not entitle the resident to due process.<br />
• Summary or Interim Action: In cases in which a resident's performance or actions are<br />
deemed to endanger the health or safety of others or to threaten the integrity of research, or<br />
when <strong>Montefiore</strong> reasonably believes that the resident engaged in illegal or immoral act(s)<br />
which pertain directly to the practice of medicine, the resident may be suspended or<br />
terminated immediately. In this circumstance, although the resident is entitled to due process,<br />
he or she will remain suspended or terminated until or unless the suspension or termination is<br />
reversed or modified as a result of the due process procedure.<br />
• Step One: Informal Resolution by the Department: In the event an adverse action is<br />
contemplated, the department will first attempt to resolve the underlying issues<br />
informally. Procedures for such informal resolution may include some or all of the<br />
36
following: counseling, appointment of a faculty advisor, development of a program for<br />
remedial training, and the imposition of a term of probation.<br />
• Step Two: Departmental Ad Hoc Committee Review: If the matter cannot be resolved<br />
informally, the department chairperson may, in his or her discretion, convene a<br />
departmental review with written notice to the resident. If a departmental review is<br />
convened, the department chairperson shall appoint a departmental ad hoc committee<br />
consisting of at least three attending physicians from the department who were not<br />
involved in the underlying matters giving rise to the adverse action. The proceedings of<br />
the departmental ad hoc committee consist of interviews with the resident and other<br />
individuals and review of relevant documents. Thereafter, the departmental ad hoc<br />
committee shall issue a report, a copy of which shall be provided to the resident. If no<br />
resolution is achieved, the resident is entitled to request a due process hearing within a<br />
certain time limit. If a hearing is not requested in a timely manner, the resident is deemed<br />
to have waived his or her right to a hearing and to have accepted the adverse action.<br />
• Step Three: Due Process Hearing: When the resident requests a hearing, the Senior Vice<br />
President - Chief <strong>Medical</strong> Officer or designee shall appoint a formal hearing panel<br />
consisting of no more than five physicians, at least two of whom shall be <strong>Montefiore</strong><br />
residents, and the balance of which shall be full-time attending physicians. The<br />
department and the resident may be represented by legal counsel throughout the hearing.<br />
At the hearing, the department and the resident shall have the right to call witnesses and<br />
introduce relevant evidence. Testimony will be taken under oath, and a stenographer will<br />
record the proceedings. Upon conclusion of presentation of the evidence, the hearing<br />
panel will make written findings and render its decision. The party against whom an<br />
adverse decision has been made has the right to appeal the decision of the hearing panel<br />
by giving written notice to the President of <strong>Montefiore</strong>. The President shall undertake an<br />
appellate review of the matter and shall make a final determination.<br />
Please note that <strong>Montefiore</strong>'s Due Process Policy is reviewed annually and may be changed<br />
based on annual review. The version of the policy that is in effect at the time the resident is<br />
given notice of his or her right to due process shall apply. Residents are encouraged to<br />
review <strong>Montefiore</strong>'s Due Process Policy, for further information.<br />
The Effects of Leave of Absence from a Program<br />
Due to the fact that all training programs have different curriculums and training requirement<br />
needs, each department has their own policy entitled Policy on Effect of Leave for Satisfying<br />
Completion of Program. This policy is available through your training program director or<br />
residency coordinator.<br />
<strong>House</strong> <strong>Staff</strong> Maternity Leave Policy<br />
During period of disability resulting from pregnancy the <strong>House</strong> <strong>Staff</strong> Officer will first use all<br />
accrued and unused sick leave. After sick time is exhausted while still within the disability<br />
period, they will then be eligible for NYS Statutory Disability.<br />
The disability period is defined as follows:<br />
• Starts with first day out<br />
• Up to four weeks prior to delivery<br />
• Up to six weeks post-delivery (normal delivery)<br />
• Up to eight weeks post-delivery (C-Section)<br />
37
During the disability period MMC will supplement the disability with a payment to bring the<br />
combination of disability and supplemental payment to 2/3 of their pay.<br />
<strong>House</strong> <strong>Staff</strong> Sick Leave Policy<br />
Each full time <strong>House</strong> <strong>Staff</strong> Officer earns paid sick leave at the rate of one day per month which is<br />
to be used for bonafide illnesses. The <strong>House</strong> <strong>Staff</strong> Office may advance sick time of up to one<br />
year's entitlement during your period of continuous disability or the expiration of your Resident<br />
Agreement, whichever is earlier. Each <strong>House</strong> <strong>Staff</strong> Officer is responsible for notifying the<br />
director of their training program, his/her Chief Resident or the residency coordinator when the<br />
<strong>House</strong> <strong>Staff</strong> Officer is sick. The director of training or residency coordinator will notify the<br />
<strong>House</strong> <strong>Staff</strong> Office in writing of this sick time.<br />
<strong>House</strong> <strong>Staff</strong> Vacation Policy<br />
One of the benefits provided to each full time <strong>House</strong> <strong>Staff</strong> Officer is 4 weeks paid vacation per<br />
contract year. The vacation time off is granted in accordance with the individual training<br />
program's departmental policy.<br />
<strong>House</strong> <strong>Staff</strong> Benefit Plans<br />
<strong>Montefiore</strong> <strong>Medical</strong> Center provides comprehensive benefit programs. You will attend a benefit<br />
orientation wherein materials will be provided to you describing your options under the Choice<br />
and other programs. In order to avail yourselves of these programs, you<br />
must complete and return the appropriate forms to the Benefits Office. The number for Benefits<br />
Office is (718) 405-4670.<br />
Limitation of <strong>House</strong> <strong>Staff</strong> Hours<br />
New York State Hospital Code limits post-graduate trainee working hours to 80 hours per week<br />
averaged over a four-week period. <strong>House</strong> <strong>Staff</strong> will not be scheduled to work more than 24<br />
consecutive hours. An additional 3 hours is permitted beyond the 24-hour limit if the purpose is<br />
for transfer of patient information. The 3 hours may not be used to assign additional patient care<br />
activity and the additional time is included in the 80-hour schedule. Scheduled rotations must be<br />
separated by at least eight non-working hours and at least a 24-hour period of non-working hours<br />
assigned each week. The Accreditation Council on Graduate <strong>Medical</strong> Education requires<br />
scheduled rotations to be separated by at least 10 non-working hours.<br />
Moonlighting<br />
The Program Director must approve any employment outside the training program. <strong>House</strong> <strong>Staff</strong><br />
who have worked the maximum number of hours permitted by the New York State Hospital<br />
Code are prohibited from working additional hours as physicians providing patient care.<br />
Employment outside the training program must be pursuant to a written contract with the<br />
<strong>Medical</strong> Center, approved by the Office of Legal Affairs. Credentialing as a member of the<br />
medical staff with appropriate privileges is required.<br />
Such employment is not permitted within the same clinical department in which the <strong>House</strong> <strong>Staff</strong><br />
member is training, even if the area of employment is outside of the training program. The Office<br />
of Legal Affairs must approve exceptions in advance, based on new developments or<br />
clarifications of the applicable law. The Policy is available in the<br />
<strong>House</strong> <strong>Staff</strong> Office.<br />
38
Physician Impairment and Drug Abuse Policy (Impaired Professionals JH23.1)<br />
This policy governs possible impairment of all licensed professionals who provide direct, skilled<br />
patient care and are employees and/or have clinical privileges at <strong>Montefiore</strong>, including<br />
physicians, registered professional nurses (including nurse practitioners and certified nurse<br />
midwives), licensed practical nurses, pharmacists, physician’s assistants, occupational and<br />
physical therapist and social workers. This policy shall also apply to interns, residents and<br />
fellows enrolled in formal postgraduate training programs at <strong>Montefiore</strong>. A complete copy of<br />
the policy is located in the Administrative Policy and Procedure <strong>Manual</strong> (JH23.1). A copy of<br />
this manual is in the <strong>House</strong> <strong>Staff</strong> Office, 150 East 210th St. or in the Administrator's office of<br />
your individual departments.<br />
Pre-Appointment and Annual Physical Examinations<br />
New York State Hospital Code and Hospital Policy require each <strong>House</strong> <strong>Staff</strong> officer to complete<br />
a pre-employment and annual examination. If you fail to complete the annual physical you will<br />
be subject to probationary or disciplinary procedures. The pre-employment examination provides<br />
required immunizations and skin tests and<br />
includes a urine toxicology examination.<br />
Professional Conduct Reporting Policy<br />
The New York State Department of Health requires all hospitals to report in writing, the denial,<br />
suspension, restriction, termination or curtailment of training, employment, association of<br />
professional privileges or the denial of certification of completion of training of any physician<br />
licensed by New York State for the following reasons:<br />
• Alleged mental or physical impairment, incompetence, malpractice, misconduct or<br />
endangerment of patient safety or welfare<br />
• Voluntary or involuntary resignation or withdrawal of association or of privileges with the<br />
Hospital to avoid the imposition of disciplinary measures<br />
• The receipt of information concerning a criminal conviction of a crime<br />
The Hospital must also report, in writing, to the New York State Department of Education any<br />
change in professional status for any student or participant in a clinical clerkship, fellowship or<br />
residency. The Hospital must report, in writing, to the Department of Health any information<br />
which reasonably appears to show that a physician<br />
is guilty of professional misconduct as defined in the New York State Education Law 6509. As<br />
set forth in Section 6509, professional misconduct includes, but is not limited to, the following:<br />
• Obtaining a <strong>Medical</strong> License Fraudulently<br />
• Practicing the profession fraudulently, beyond his/her authorized scope, with gross<br />
incompetence, with gross negligence on a particular occasion or negligence or incompetence<br />
on more than one occasion<br />
• Practicing the profession while the ability to practice is impaired by alcohol or drugs,<br />
physical disability or mental disability<br />
• Being habitually drunk or being dependent on or a habitual user of narcotics, barbiturates,<br />
amphetamines, hallucinogens, or other drugs having similar effects (Refer to Adm. Pol # JH<br />
23.01on impaired professionals)<br />
39
• Failure to follow universal precautions regarding blood-borne pathogens as mandated by the<br />
Department of Health<br />
• Committing unprofessional conduct, as defined by the Board of Regents in its rules or by the<br />
Commissioner in regulations approved by the Board of Regents<br />
Physicians, the Hospital's <strong>Medical</strong> Director, the President of the <strong>Medical</strong> Board and the Director<br />
of each Service are also required by law to report any information, which reasonably appears to<br />
show that a physician is guilty of professional misconduct. However, a physician is not required<br />
to report any information which the physician<br />
learned solely as a result of rendering treatment to another physician.<br />
Meal Tickets<br />
Residents on MMC payroll or on Jacobi Payroll but doing a rotation at MMC are provided at no<br />
charge with weekly meal tickets for up to three meals a day while they are on duty. The tickets<br />
are given to the residency departmental coordinators for distribution every four weeks. The<br />
coupons can be used at the MMC Food Pavilion (located in Silver Zone on 2nd Fl.), the cafeteria<br />
at Einstein Hospital or the kiosk in the Children’s Hospital at MMC (CHAM).<br />
On-Call Rooms<br />
The hospital will provide each <strong>House</strong> <strong>Staff</strong> Officer with an on-call room, which is cleaned daily,<br />
in good condition and secure. The on-call rooms are located in the Blue Zone - Loeb Building in<br />
the rear of the Activity Room on the first floor (opposite Nurse's Station). To access a room,<br />
please see the Security Officer in the 210th Street Lobby of the Moses site. He will present you<br />
with a key upon checking his copy of the on-call schedule. Please check with your department<br />
for location of additional on-call room sites.<br />
Paychecks<br />
Paychecks are issued every other Thursday and are available to the <strong>House</strong> <strong>Staff</strong>. The checks<br />
may be picked up at the <strong>House</strong> <strong>Staff</strong> Office located at 150 East 210th Street. Residents may<br />
enroll in Direct Deposit to the bank of their choice however, there is a policy they must read and<br />
adhere to before direct deposit is allowed. The applications are available in the <strong>House</strong> <strong>Staff</strong><br />
Office. Direct Deposit Slips will be kept in the <strong>House</strong> <strong>Staff</strong> Office for pick-up or mailed to your<br />
home.<br />
Voluntary Service on -MMC Administrative Committees<br />
The Committee on Graduate <strong>Medical</strong> Education (COGME) is an organized administrative<br />
committee of the Albert Einstein College of Medicine that oversees all residency programs and<br />
has the responsibility for monitoring and advising the sponsored institution on all aspects of<br />
residency education. The committee has representation<br />
of key academic and hospital administrators, as well as residents. Included in the responsibilities<br />
of the COGME are the establishment and implementation of policies that affect all residency<br />
programs regarding the quality of education and the work environment of the residents in each<br />
program. MMC and JMC are active participants on this committee and strongly support the<br />
mandated mission of the committee. It is the intention of MMC that residents have active<br />
participation on important hospital committees that serve to formulate hospital policy. All<br />
residents are invited to provide voluntary service on the administrative committees of this<br />
Institution. The representation of residents on our administrative committees will give the<br />
40
participants the opportunity to communicate and exchange information on their working<br />
environment and their educational programs. Any resident who is interested in providing this<br />
voluntary service<br />
can pick up a form from the <strong>House</strong> <strong>Staff</strong> Office or call Elaine Taylor or Justice Gaba at the<br />
<strong>House</strong> <strong>Staff</strong> office (718) 920-4091 and a form can be faxed to your location.<br />
Admissions, <strong>House</strong> <strong>Staff</strong><br />
<strong>Montefiore</strong> <strong>Medical</strong> Center shall accept patients whose care and treatment are appropriate to an<br />
acute care hospital, based upon accuracy and bed availability, to either a teaching or nonteaching<br />
service, based upon the policies and procedures of each admitting/clinical<br />
department. The hospital shall admit as patients only those persons who require the type of<br />
medical service authorized by the hospitals operating certificate. These services shall include:<br />
medicine, neurology, neurosurgery, ophthalmology, pediatrics, surgery, radiation oncology,<br />
oncology, cardiac surgery, thoracic, vascular, oral surgery, otolaryngology,<br />
plastic surgery, urology, orthopedics, gynecology and psychiatry. Except in emergencies, the<br />
hospital shall not admit any patients to a clinical service which it is not authorized to provide by<br />
the current operating certificate. No person shall be denied admission to the hospital because of<br />
race, creed, color, natural origin, sex, etc. (see policy # EEO statement or Institution) or source of<br />
payment except for fiscal capability thereof. Patients may be admitted only by those physicians<br />
holding active appointments to the <strong>Medical</strong> <strong>Staff</strong>. The responsibility for initiating the admitting<br />
process resides with the attending physician, or his/her designee. Each patient admitted shall<br />
have an attending physician at the time of admission. The attending physician shall be<br />
responsible for the<br />
medical care and treatment of each of his/her patients throughout the hospital stay.<br />
Except in cases of emergency, no patient shall be admitted until a provisional diagnosis has been<br />
stated. In cases of emergency, the provisional diagnoses shall be stated as soon as possible<br />
following admission. Each patient shall be admitted to that service of the hospital appropriate to<br />
the treatment of the condition of the patient. Each intensive and special care unit has a <strong>Medical</strong><br />
Director responsible for managing the care within the unit. Admissions and transfers to/from the<br />
units are the responsibility of the Unit <strong>Medical</strong> Director, or designee in consultation with the<br />
attending physician/house officer and nursing services. No patient on a teaching service shall be<br />
exempt from participation<br />
in a medical student or house staff educational program. Each patient on a teaching service shall:<br />
• Be seen by a house officer on the admitting service promptly following admission (on nonteaching<br />
services, the attending provider or his/her designee will see the patient promptly<br />
following admission).<br />
• Each patient must have a complete history and physical examination including a breast,<br />
uterine cytology and rectal examination, as appropriate, documented in the medical record<br />
within 24 hours of admission.<br />
• The Attending Physician or designee shall be responsible for countersigning the history and<br />
physical examination.<br />
• Qualified oral surgeons who admit patients without medical problems may perform the<br />
history and physical examination on those patient, if the oral surgeon has been granted<br />
privileges.<br />
• If a qualified member of the hospital's medical staff has obtained a complete history or has<br />
performed a complete physical examination within seven (7) days prior to the patient's<br />
41
admission to the hospital, a durable, legible copy of the report may be used in the patient's<br />
medical record, provided that an internal admission note is recorded that includes all<br />
additions to the history and any changes in the physical findings subsequent to the original<br />
report.<br />
• When a patient is readmitted to this hospital within 30 days for the same or related problem,<br />
an interval history and physical examination reflecting subsequent history and changes in<br />
physical findings may be used, provided the original information is readily available.<br />
• A history and physical examination appropriate to the ambulatory surgery patient must be<br />
performed prior to surgery.<br />
Chart Completion Policy for <strong>House</strong> Officers<br />
Purpose: To provide a process by which disciplinary action can be applied to house officers who<br />
fail to comply with chart completion standards.<br />
Mandate: Both NYS and the JCAHO mandate a time frame for completion of medical records.<br />
Failure to meet the requirements of these standards places the <strong>Medical</strong> Center at risk for both<br />
financial and operational hardships.<br />
Authority: Signing of the MMC <strong>House</strong> <strong>Staff</strong> contract indicates that the house officers agree to<br />
comply with the rules and regulations of MMC and its sub-divisions including the completion of<br />
medical records.<br />
Laundry & Linen Service<br />
Residents are required to wear prescribed apparel in training. The lab coats or jackets are cleaned<br />
free of charge when they are dropped off at the laundry office located at the rear of the Food<br />
Pavilion in the North Building (Silver Zone) second floor.<br />
The hours of operation are:<br />
Mon., Wed., Fri. 7:00AM - 3:00PM<br />
Tues., Thurs. 9:00AM - 5:00PM<br />
Uniform Room: (718) 920-5357<br />
Parking<br />
Subsidized garage parking is available to all incoming <strong>House</strong> <strong>Staff</strong> doctors on the Hospital<br />
premises. There is also garage parking available at 3450 Wayne Ave. (MH-II) and 3636 Waldo<br />
Ave. (MH-III) There is an additional charge for parking. Phone Number: (718) 920- 6131<br />
Shuttle Buses<br />
AECOM SHUTTLE<br />
Residents, <strong>Medical</strong> Students and designated faculty are provided with transportation to the East<br />
and West Campuses. (see schedule)<br />
AECOM Shuttle Stop Locations<br />
WAECOM 1600 Tenbroeck Avenue<br />
AECOM in front of Belfer Educational Center Building<br />
BMHC Entrance to outpatient Clinics on Pelham Parkway<br />
MMC <strong>Montefiore</strong> No. Bldg. entrance Gun Hill Rd.<br />
Note: You must show your I.D. Card to use the bus<br />
42
WALDO AVENUE SHUTTLE<br />
Those residents living at 3636 Waldo Avenue in Riverdale have access to a commuter van which<br />
brings them to and from the Moses Campus. The schedules are available in the <strong>House</strong> <strong>Staff</strong><br />
Office or the Housing Office at 3450 Wayne<br />
Avenue, 2nd floor.<br />
Waldo Avenue Shuttle Schedule: Monday - Friday<br />
Departs from Waldo to Monte: 6:30AM, 7:30AM, 8:30AM<br />
Departs from Monte to Waldo: 5:00PM, 6:00PM, 7:00PM<br />
FORDHAM SHUTTLE<br />
The shuttle is located at the 210th Street entrance to <strong>Montefiore</strong>. The shuttle departs from Moses<br />
site every hour beginning at 8:00 AM. The shuttle departs from Fordham Plaza every half-hour<br />
beginning at 8:30 AM.<br />
AECOM- MMC MEDICAL CENTER SHUTTLE SCHEDULE<br />
Buses operate Monday through Friday. Riding time between campuses is 12-15 minutes. Please<br />
wait if it is delayed–the bus will not leave before departure time.<br />
BMHC RHINE WHAE - AECOM MMC BMHC AECOM<br />
COM<br />
8:10am 6:25am 8:15am 6:30am 6:50am 7:03am 7:15am<br />
8:55 6:55 9:00 7:00 7:20 7:40 7:45<br />
9:40 7:10 9:45 7:15 7:35 7:48 7:51<br />
10:25 7:40 10:30 7:45 8:05 8:25 8:30<br />
11:10 8:12 11:15 8:20 8:50 9:03 9:06<br />
11:55 8:57 12:00pm 9:05 9:35 9:55 10:00<br />
12:40pm 12:45 9:50 10:20 10:33 10:36<br />
1:25 1:30 10:35 11:05 11:25 11:30<br />
2:10 2:15 11:20 11:50 12:03pm 12:05pm<br />
2:55 3:00 12:05pm 12:35pm 12:55 1:00<br />
3:40 3:45 12:50 1:20 1:33 1:36<br />
4:25 4:30 1:35 2:05 2:25 2:30<br />
5:10 5:15 2:20 2:50 3:03 3:06<br />
5:55 6:00 3:05 3:35 3:55 4:00<br />
3:50 4:20 4:33 4:36<br />
4:35 5:05 5:25 5:30<br />
5:20 5:50 6:03 6:06<br />
6:05 6:35 6:55 7:00<br />
Employee Assistance Program<br />
The Employee Assistance Program (E.A.P.) is available to assist employees with emotional,<br />
substance abuse and interpersonal problems. All self-referrals are confidential.<br />
(718) 882-5920 (Moses Division)<br />
(718) 518-8107 (Weiler Division)<br />
43
Housing<br />
<strong>Montefiore</strong> <strong>Medical</strong> Center Housing refers to <strong>Montefiore</strong> Hospital Housing Co., Inc.<br />
There are three types of apartments available: One and Two Bedroom units and studios.<br />
• MH-I: 3411 Wayne Avenue, Bronx, N.Y.<br />
Constructed in 1965. The Apartment building has very limited availability. There is 24 hour<br />
security guard service, seven (7) days a week. Each apartment has an intercom and buzzer<br />
system to speak into which connects you to the Security desk in the lobby.<br />
• MH-II: 3450 Wayne Avenue, Bronx, N.Y<br />
Constructed in 1972. The building is a 28 story hi-rise with central air conditioning and all units<br />
have terraces and include utilities (Gas and Electric). There is 24-hour security guard service,<br />
seven (7) days a week. Each apartment has an intercom and buzzer to speak into which connects<br />
you to the Security desk in the lobby.<br />
• MH-III: 3636 Waldo Avenue, Riverdale, N.Y.<br />
Constructed in l991. There is 24-hour security guard service, seven (7) days a week. There is an<br />
intercom and individual security system for each apartment. Shuttle Bus service is available (see<br />
section “Shuttle Buses”).<br />
MONTEFIORE HOUSING POLICIES AND PROCEDURES<br />
Due to increased demand for staff housing the following occupancy and lease policies are<br />
effective as of this date for all <strong>Montefiore</strong> housing:<br />
• The units are available only to those employees of the medical center who are in residency or<br />
fellowship programs approved by the Accreditation Council for Graduate <strong>Medical</strong> Education<br />
or employees who are in the Surgical Physician Assistant Training Program.<br />
• <strong>Montefiore</strong> employees other than house officers, fellows or physician's assistants referred to<br />
above currently residing in staff housing may continue to lease their current apartments as<br />
long as they are employed by the medical center.<br />
• <strong>Montefiore</strong> employees who have terminated or will terminate through retirement or<br />
permanent disability prior to July 1, 1996, while tenants of <strong>Montefiore</strong> staff housing, will be<br />
eligible for lease renewals in accordance with the terms and rents established by <strong>Montefiore</strong>.<br />
• <strong>Montefiore</strong> employees who terminate by reason of retirement or permanent disability after<br />
July 1, 1996, who at the time of termination are tenants of <strong>Montefiore</strong> staff housing, may<br />
remain in their units no longer than six (6) months after the date of termination.<br />
While individuals may request a particular building or size of apartment, no assurance can be<br />
given that such a request can be met. Due to the shortage of apartments, it has been necessary to<br />
establish priorities for the assignment of housing.<br />
First priority for housing will be given to incoming <strong>House</strong> <strong>Staff</strong>- First Year Residents<br />
arriving from long distances. Proof of your current residence must be given to the Housing<br />
Office. Whenever possible, the first year residents will be assigned housing at MH-I, MH-II.<br />
After the needs of these residents have been satisfied, any apartments that may still be available<br />
will be assigned in the following order:<br />
• Second year residents (According to distance)<br />
• Physician Assistants – For internship year only<br />
• Fellowship programs approved by the Accreditation Council for Graduate <strong>Medical</strong><br />
Education.<br />
44
First Year Residents: Assignments of incoming first year residents will be based upon<br />
information provided to the Housing Office. Assignments will be made according to distance.<br />
The farther away he/she is coming, the more likely they are to receive housing. Family<br />
composition is also considered. Proof of the resident's current address (Telephone bill, utility<br />
bill, etc.) must accompany the Housing application. To the extent possible, they will be assigned<br />
apartments according to their preferences and needs. Priority for MH-I and MH-II housing will<br />
be given to first year residents coming long distances. All other applicants will be referred to the<br />
Riverdale apartments (MH-III). Guidelines for Apartment Assignments:<br />
• Studio apts. may be shared by no more than two (2) individuals. Single residents will receive<br />
studios, provided there are no married couples in need of these accommodations. (Proof of<br />
marriage is required).<br />
• One Bedroom Apts. must be shared by a minimum of two (2) individuals. A married couple,<br />
after providing acceptable proof of marriage will receive a one-bedroom apartment when<br />
available.<br />
• Two Bedroom Apts. must be shared by a minimum of three (3) individuals. An employee<br />
may occupy an apartment with spouse and children only.<br />
WAITING LIST<br />
Anyone who is not assigned an apartment in May, will go on a waiting list. All applications are<br />
separated by size of apartment, (2 bedrooms, 1 bedroom, Studio ). Each category is then further<br />
defined by the distance to be traveled by the doctor.<br />
The groups are then further separated as follows: Married with children first; singles who will<br />
share apartments next; married without children; and singles last.<br />
All those doing clinical work will get priority over doctors who will not have direct patient<br />
contact . We will go down the waiting list as apartments open up during the<br />
year.<br />
ADDITIONAL HOUSING POLICIES AND PROCEDURES<br />
• Entering tenants must deposit one month's rent as a security deposit and pay the first month's<br />
rent before obtaining the key to an apartment. Separate checks are required. The security<br />
deposit check must be either a Certified Check or Money Order. Cash is not accepted. The<br />
move-in date for <strong>House</strong> <strong>Staff</strong> residents is July l of each year.<br />
• Eligibility - If a resident leaves <strong>Montefiore</strong> <strong>Medical</strong> Center at any time during the term of<br />
their <strong>House</strong> <strong>Staff</strong> contract, the lease agreement is terminated and the tenant must vacate the<br />
apartment within thirty (30) days.<br />
• <strong>House</strong> <strong>Staff</strong> residents, upon completion of residency must vacate their apartment, even if<br />
continuing in employment with the Hospital under another status, no later than June 30 th of<br />
the year of completion of residency.<br />
• Residents may not sublet their apartments. All rentals must be arranged directly through the<br />
Housing Office. Individuals who abuse this policy will have their leases terminated and will<br />
be subject to eviction.<br />
• Sharing - Each employee in a shared apartment must sign a separate lease agreement. If one<br />
party moves, the remaining tenant will be responsible for the full rent. If the remaining<br />
tenant is occupying a one or two bedroom apartment, the Housing Office will assign a new<br />
co-employee. The original employee will have the option of moving to a studio if one is<br />
45
available. A single remaining employee may not occupy the apartment alone on a continuing<br />
basis.<br />
MOVE-OUT PROCEDURES<br />
• The Housing Office should be notified in writing 30 days prior to your move-out date. Your<br />
forwarding address should be included in order that we may return your security deposit.<br />
• Return your apartment, mailbox and front door keys to the Housing Office. Failure to do so<br />
will result in a $50.00 charge against your security deposit.<br />
REPAIRS AND SERVICES<br />
Maintenance requests must be called into the Housing Office at (718) 920-5088. Repairs will be<br />
performed between the hours of 8:00AM to 4:00PM You must either leave your top lock<br />
unlocked, allowing us permission to enter, or someone must be home.<br />
LAUNDRY ROOMS<br />
The Laundry room is located on the lobby level at MH-I and MHII, and in the basement of MH-<br />
III.<br />
MAILBOXES<br />
When coming to pick up your bulk mail you will be asked for a proper form of identification.<br />
Proper identification will be a driver’s license or a Hospital Identification badge with the same<br />
name as the name on the parcel.<br />
AIR CONDITIONING<br />
The apartments at MH-I, MH-II and MH-III are air-conditioned.<br />
CABLE TV<br />
Cable TV is available at all locations at a nominal charge.<br />
TERRACES<br />
All apartments at MH-II have terraces. There is a limited amount of terraces at MH-I. All other<br />
buildings do not have terraces.<br />
46
SECTION III<br />
•<br />
MONTEFIORE MEDICAL GROUP<br />
47
MONTEFIORE MEDICAL GROUP (MMG)<br />
<strong>Montefiore</strong> <strong>Medical</strong> Group offers a full range of comprehensive primary care services to adults<br />
and pediatrics including OB/GYN, family planning, preventive health care, nutrition and health<br />
education. Employing approximately 1,000 physicians, physician extenders, nurses, medical<br />
technicians, support staff and administrators in 21 sites throughout the Bronx and Southern<br />
Westchester, MMG is committed to improving the health and well-being of the communities<br />
served. Members of the MMG team work in partnership with patients and their families, sharing<br />
in the responsibility and accountability for the maintenance and improvement of their health. In<br />
addition to the core primary care services, MMG offers supplemental targeted programs<br />
including:<br />
• HIV outreach, screening, counseling<br />
• Care for the Homeless Team<br />
• School Health<br />
• Women, Infant, Children (WIC) Program<br />
What makes MMG unique is its relationship to the <strong>Medical</strong> Center. Through its 21<br />
neighborhood offices, MMG gives patients access to primary, obstetric and gynecological care<br />
and provides referrals to the <strong>Medical</strong> Center's specialty services. Information regarding MMG<br />
Administration and the individual sites is listed below.<br />
<strong>Montefiore</strong> <strong>Medical</strong> Groups Administration:<br />
3411 Wayne Avenue, 1st floor<br />
Bronx, NY 10467<br />
Tel: 718-920-4245<br />
Fax: 718-405-2097<br />
Executive Director: Terry Goodwin<br />
Director of Operations: Arnel Tirado<br />
• MMG 2 and 4<br />
Director of Operations: Michael Bookchin<br />
• MMG 1 and 3<br />
<strong>Medical</strong> Directors:<br />
• MMG 1: Arthur Hopkins, MD<br />
• MMG 2: Jonathan Swartz, MD<br />
• MMG 3: Donald Raum, MD<br />
• MMG 4: James Stulman, MD (Internal Medicine)<br />
Andrew Racine, MD (Pediatrics)<br />
MMG 1 SITES:<br />
Astor Avenue Pediatrics<br />
1500 Astor Avenue<br />
Bronx, NY 10469<br />
Tel: 718-881-0100<br />
Fax: 718-881-7752<br />
48
Administrator: Jennifer Ortiz<br />
<strong>Medical</strong> Director: Richard Weiner, MD<br />
Specialty: Pediatrics<br />
Burke Avenue<br />
941 Burke Avenue<br />
Bronx, NY. 10469<br />
Tel: 718-654-5900<br />
Fax: 718-654-0053<br />
Administrator: Laurie Fuentes<br />
<strong>Medical</strong> Director: Michael Bagner, MD<br />
Specialties: Internal Medicine and Pediatrics<br />
Co-Op City (Bay Plaza)<br />
2100 Bartow Avenue<br />
Bronx, New York 10475<br />
Tel: 718-320-5300<br />
Fax: 718-320-1116<br />
Administrator: Camille Costa<br />
<strong>Medical</strong> Director: W. Roy Michaelis, MD<br />
Specialties: Internal Medicine, Pediatrics<br />
Eastchester<br />
685 White Plains Road<br />
Eastchester, NY 10709<br />
Tel: 914-395-1530<br />
Fax: 914-395-1559<br />
Administrator: Rita Punch<br />
<strong>Medical</strong> Director: Howard Garson, MD<br />
Specialties: Internal Medicine, Pediatrics, Allergy, Adolescent Medicine, Endocrinology, Sleep<br />
Disorder<br />
Greene <strong>Medical</strong> Arts Pavilion (MAP)<br />
3400 Bainbridge Avenue<br />
Bronx, New York 10467<br />
Tel: 718-920-8888<br />
Fax: 718-519-1164<br />
Administrator: Angie Mercado<br />
Internal Medicine <strong>Medical</strong> Director: Anna Maria Assevero, MD<br />
Peditric <strong>Medical</strong> Director: Mohini Kaul, MD<br />
Specialties: Internal Medicine, Pediatrics, Infectious Diseases, Endocrinology, and Pediatric<br />
Hemotology.<br />
Riverdale<br />
3510 Johnson Avenue<br />
Bronx, NY 10463<br />
49
Tel: 718-601-8205<br />
Fax: 718-601-8693<br />
Administrator: Joanne Gasparini<br />
<strong>Medical</strong> Director: David Levey, MD<br />
Specialty: Internal Medicine<br />
White Plains Road<br />
2100 White Plains Road<br />
Bronx, NY 10462<br />
Tel: 718-892-1626<br />
Fax: 718-892-7060<br />
Administrator: Laurie Fuentes<br />
<strong>Medical</strong> Director: Michael Bagner, MD<br />
Specialties: Internal Medicine, Pediatrics<br />
MMG 2 SITES<br />
Castle Hill<br />
2175 Westchester Avenue<br />
Bronx, New York 10462<br />
Tel: 718-829-6770<br />
Fax: 718-904-9145<br />
Administrator: Jonas Attuh-Mensah<br />
<strong>Medical</strong> Director: Frank Silagy, MD<br />
Specialties: Family Medicine, OB-GYN, Dental<br />
Comprehensive Health Care Center (CHCC)<br />
305 E. 161st Street<br />
Bronx, New York 10451<br />
Tel: 718-579-2500<br />
Fax: 718-579-2599<br />
Administrator: Donald Velazquez<br />
<strong>Medical</strong> Director: Andrea Rich, MD / Pediatric<br />
<strong>Medical</strong> Director: Joeseph Deluca, MD / Internal Medicine<br />
<strong>Medical</strong> Director: Ronald Dedek, MD / OBGYN<br />
Specialties: Internal Medicine, Pediatrics, OB/GYN, Podiatry, Ophthalmology, Dermatology,<br />
Dental<br />
Comprehensive Family Care Center (CFCC)<br />
1621 Eastchester Road<br />
Bronx, NY 10461<br />
Tel: 718-405-8040<br />
Fax: 718-405-8050<br />
Administrator: Carol Lau, FNP<br />
50
<strong>Medical</strong> Director: Marta Rico, MD, Andrew Racine, MD and Peter Bernstein, MD<br />
Specialties: Internal Medicine, Pediatrics, OB/GYN, Ophthalmology, Surgery, Dental,<br />
Nephrology-Renal, Gastroenterology, Endocrine, Immunology, Allergy, Pulmonary,<br />
Rheumatology, Podiatry, Neonatology-Developmental, HIV/AIDs care.<br />
Family Health Center (FHC)<br />
360 East 193 rd Street<br />
Bronx, NY 10458<br />
Tel: 718-933-2400<br />
Fax: 718-367-8168<br />
Administrator: Jose Delgado<br />
<strong>Medical</strong> Director: Zach Rosen, MD<br />
Specialties: Family Medicine, Podiatry, Cardiology<br />
Fordham Family Practice (FFP)<br />
One Fordham Plaza<br />
Bronx, New York 10458<br />
Tel: 718-405-4010<br />
Fax: 718-405-4058<br />
Administrator: Geraldine Bennett<br />
<strong>Medical</strong> Director: Marion Bobb-McKoy<br />
Specialties: Family Medicine, OB/GYN<br />
Marble Hill (MHFP)<br />
5525 Broadway<br />
Bronx, NY 10463<br />
Tel: 718-884-0279<br />
Fax: 718-548-3867<br />
Administrator: Jean Guilloteau<br />
<strong>Medical</strong> Director: David Savarese, MD<br />
Specialties: Internal Medicine, Pediatrics, OB-GYN, Dental<br />
University Avenue Family Practice<br />
105 West 188th Street<br />
Bronx, NY 10468<br />
Tel: 718-563-0757<br />
Fax: 718-563-0756<br />
Administrator: Gloria Farre-Munoz<br />
<strong>Medical</strong> Director: Robert Clarick, MD<br />
Specialties: Internal Medicine, Pediatrics, OB/GYN<br />
West Farms Family Practice<br />
1055 East Tremont Avenue<br />
Bronx, NY 10460<br />
Tel: 718-842-8040<br />
Fax: 718-842-8394<br />
51
Administrator: Jonas Attuh-Mensah<br />
<strong>Medical</strong> Director: Clement Landanno, MD<br />
Specialties: Family Medicine, OB/GYN<br />
Williamsbridge Family Practice Center (WBFP)<br />
3448 Boston Road<br />
Bronx, New York 10469<br />
Tel: 718-547-6111<br />
Fax: 718-547-4749<br />
Administrator: Blanche Doati<br />
<strong>Medical</strong> Director: Noel Brown, MD<br />
Specialties: Family Medicine, OB/GYN, Cardiology<br />
MMG 3 SITES<br />
Bronx East<br />
2300 Westchester Avenue<br />
Bronx, NY 10462<br />
Tel: 718-829-1900<br />
Fax: 718-409-8023<br />
Administrator: Denise Taylor<br />
<strong>Medical</strong> Director: Donald Raum, MD<br />
Specialties: Internal Medicine, Pediatrics, Ophthalmology, Optometry, Surgery, Urology,<br />
Radiology, Physical Therapy<br />
Co-Op City (Dreiser Loop)<br />
115 Dreiser Loop<br />
Bronx, New York 10475<br />
Tel: 718-320-6300<br />
Fax: 718-379-1688<br />
Administrator: Kathy Raftery<br />
<strong>Medical</strong> Director: Sheila Rabinowitch, MD<br />
Specialty: Internal Medicine<br />
Cross County<br />
1010 Central Park Avenue<br />
Yonkers, N.Y. 10704<br />
Tel: 914-964-4000<br />
Fax: 914-964-4044<br />
Administrator: Linda Woolsey<br />
<strong>Medical</strong> Director: Norbert Wolloch, MD<br />
Specialties: Internal Medicine, Pediatrics, Surgery, Ophthalmology, Optometry, Rehabilitation<br />
Medicine, Radiology<br />
Grand Concourse<br />
52
2532 Grand Concourse<br />
Bronx, New York 10458<br />
Tel: 718-960-1500<br />
Fax: 718-960-1501<br />
Administrator: Kenneth Siegel<br />
<strong>Medical</strong> Director: Arthur Weiner, MD<br />
Specialties: Internal Medicine, Pediatrics, Surgery, OB/GYN, Radiology<br />
MMG 4<br />
Family Care Center<br />
<strong>Montefiore</strong> <strong>Medical</strong> Center<br />
3344 Kossuth Avenue<br />
Bronx, NY 10467<br />
Tel: 718-920-7332/5859<br />
Fax: 718-653-5294<br />
Administrator: Jorge Rodriguez<br />
Internal Medicine <strong>Medical</strong> Director: James Stulman, MD<br />
Pediatrics <strong>Medical</strong> Director: Andrew Racine, MD<br />
Specialties: Internal Medicine, Pediatrics, OB/GYN, Developmental Psych, GI, Podiatry,<br />
Palliative Care, Neurolgy, Hematology, Pulmonary, Endocrinology, Plastic Surgery, Sleep/Wake<br />
Disorders<br />
SCHOOL HEALTH<br />
ADMINISTRATION<br />
3380 Reservoir Oval<br />
Bronx, New York 10467<br />
Fax: 515-7741<br />
David Appel, MD<br />
Director<br />
Phone: 718-696-4070<br />
Shanti Jimenez, MBA<br />
Operations Manager<br />
Phone: 718-696-4071<br />
Megan Charlop<br />
Director of Community Health<br />
Phone: 718-696-4053<br />
Carmen Correa<br />
Office Coordinator<br />
Phone: 718-696-4056<br />
53
Isseline Collazo<br />
Account Representative<br />
Phone: 718-696-4061<br />
Kari Collins, Ph.D.<br />
Director of Mental Health<br />
Phone: 718-696-4065<br />
Annie Dhanraj<br />
Research Assitants<br />
Phone: 718-696-4064<br />
Claire Fong, MPH<br />
Site Administrator<br />
Phone: 718-696-4067<br />
Ennis Jackon<br />
Data Manager<br />
Phone: 718-696-4059<br />
Linda Juszczak<br />
Director of Training and Education<br />
Phone: 718-696-4054<br />
John Leo, MD<br />
<strong>Medical</strong> Director<br />
Phone: 718-696-4069<br />
Michelle Odlum, MPH<br />
Research Program Coordinator<br />
Phone: 718-696-4058<br />
Lynn Reitman, MD<br />
Director of Psychiatry<br />
Phone: 718-696-4068<br />
S. Kenneth Schonberg, MD<br />
Consultant<br />
Phone: 718-696-4062<br />
Mayris Webber, Ph.D.<br />
Director of Research<br />
Phone: 718-655-0037<br />
P.S. 8<br />
54
Briggs Avenue Academy<br />
3010 Briggs Avenue<br />
Bronx, New York 10458<br />
Provider: Amy Hanson, MD<br />
Mental Health Provider:<br />
Leah Murphy, PhD<br />
Arielle Goldklang<br />
Tim Silverman, CSW<br />
Nurse: Practice Collins, LPN<br />
Receptionist: Maggie Martinez<br />
Marie Nieves<br />
Phone: 718-563-5263/584-5014<br />
Fax: 718-295-4587<br />
CES 28<br />
1861 Anthony Avenue<br />
Bronx, New York 10457<br />
Provider: Jackie Kelderhouse, FNP<br />
Mental Health Provider:<br />
Kari Collins, Ph.D.<br />
Annette Zygmunt, PhD<br />
Nurse: Iris Pimentel, LPN<br />
Receptionist: Isseline Collazo, PCT<br />
Phone: 718-901-2849<br />
Fax: 718-583-6453<br />
M.S. 45<br />
2502 Lorillard Place<br />
Bronx, New York 10458<br />
Provider: Glenda Long, FNP<br />
Mental Health Provider:<br />
Chrystal Hurst, CSW<br />
Nurse: Audrey Murphy, LPN<br />
Receptionist: Issabelle Perez<br />
Phone: 718-584-2936/ 718-295-4628<br />
Fax: 718-367-9668<br />
P.S./M.S. 95<br />
3961 Hillman Avenue<br />
Bronx, New York 10463<br />
Provider: Samantha Fuster, FNP<br />
Karen Haddad, FNP<br />
Mental Health Provider:<br />
Jennifer Cleveland, PhD<br />
Nurse: Royrie Larkins, LPN<br />
Receptionist: Lissette Aybar<br />
55
Phone: 718-796-3440<br />
Fax: 718-601-2357<br />
P.S. 105<br />
725 Brady Avenue<br />
Bronx, New York 10462<br />
Provider: Frances Douglass, MD<br />
Lorraine VonEeden, PNP<br />
Mental Health Provider:<br />
Andrea Vaccarriello, CSW<br />
Nurse: Nicole Gomez, LPN<br />
Receptionist: Martha Colon<br />
Phone: 718-828-3235<br />
Fax: 718-828-3235<br />
I.S.216/217<br />
Rafael Hernandez Academy<br />
977 Fox Street<br />
Bronx, New York 10459<br />
Provider: JoAnn Thomas, PNP<br />
Mental Health Provider:<br />
Laura Guy, CSW<br />
Nurse: Joyce Dixon, LPN<br />
Receptionist: Millie Ayala<br />
Phone: 718-617-4449<br />
Fax: 718-617-4756<br />
South Bronx High School<br />
701 St. Ann's Avenue, 3rd Fl<br />
Bronx, New York 10455<br />
Provider: Carla Hundt, MD, FAAP<br />
Mental Health Professional: Kori Eldean, Ph.D.<br />
Nurse: Roseann Alston, LPN<br />
Receptionist: Marta Ramos<br />
Phone: 718-402-7618<br />
Fax: 993-4672<br />
DeWitt Clinton<br />
100 W. Mosholu Parkway<br />
Bronx, New York 10468<br />
Provider: Norma Ellis, FNP<br />
Margee Rogers, FNP<br />
Linda Juszczak, FNP<br />
Neal Hoffman, MD<br />
Mental Health Professional: Rob Diamond, CSW<br />
Christina Lima, CSW<br />
56
Nurse: Maria Campos, LPN<br />
Sheila Montegue, LPN<br />
Receptionist: Yocasta Veasquez<br />
Sandy Valoy<br />
Phone: 718-549-8022/549-7934<br />
Fax: 718-549-7977<br />
Martha Neilson/Bronx Regional<br />
979 Rogers Place<br />
Bronx, New York 10459<br />
Provider: Margret Rosenberg, MD<br />
Mental Health Provider:<br />
Tanya Johnson, CSW<br />
Nurse: Angela Chaney, LPN<br />
Receptionist: Romana Moreira<br />
Phone: 718-589-5665<br />
Fax: 718-589-5509<br />
Walton High School<br />
2780 Reservoir Oval<br />
Bronx, New York 10468<br />
Provider: Gail Shafran, FNP<br />
Mental Health Provider: Rachel Sheffet, PhD<br />
Nurse: Millie pabon, LPN<br />
Receptionist: Mari Valentin<br />
Phone: 718-364-2450<br />
Fax: 718-562-4357<br />
HOMELESS PROGRAM<br />
ADMINISTRATION<br />
MMG Family Health Center (FHC)<br />
360 E. 193rd Street<br />
Bronx, NY 10458<br />
718-405-4067<br />
Fax # 718-405-4148<br />
Administrator<br />
Deborah Barrow<br />
MMG FHC Care for the Homeless Program provides comprehensive primary health care<br />
services, health maintenance/preventive care, to adults and pediatric populations residing in<br />
shelters, soup kitchens, assessment shelters, drop in centers and to the street homeless.<br />
JACKSON AVENUE FAMILY RESIDENCE<br />
691 E. 138th Street<br />
Bronx, NY 10454<br />
57
718-993-8900 x51<br />
Fax # 718- 993-1865<br />
Crosby Inman - Director<br />
NELSON AVENUE FAMILY RESIDENCE<br />
1605 Nelson Avenue<br />
Bronx, NY 10453<br />
718-299-5550 x319<br />
Fax # 718- 299-5558<br />
Marjorie Jeamnot – Director<br />
P.O.T.S (PART OF THE SOLUTION)<br />
2763 Webster Avenue<br />
Bronx, NY 10458<br />
718-220-4892<br />
Fax # 718-220-5603<br />
Sr. Mary Alice Hannan - Director<br />
THORPE FAMILY RESIDENCE<br />
2252 Crotona Avenue<br />
Bronx, NY 10457<br />
718-933-7312<br />
Fax # 718-933-7311<br />
Sr. Madeline Cipriano - Director<br />
LIVINGROOM<br />
890 Garrison Avenue<br />
Bronx, NY 10474<br />
718-893-3606<br />
Fax # 718-893-3680<br />
Noel Conception - Director<br />
H.E.L.P. SUPPORTIVE EMPLOYMENT SHELTER PROGRAM<br />
1 Wards Island<br />
New York, NY 10035<br />
212-534-3866 ext. 170 (Provider)<br />
212-534-3866 ext. 171 (RN)<br />
212-534-3866 ext. 170 (<strong>Medical</strong> Assistants)<br />
Fax # 212 -369-3763<br />
Jerry Heaney - Director<br />
LOVE GOSPEL<br />
2315 Grand Concourse<br />
Bronx, NY 10457<br />
718-295-6366<br />
Fax # 718-733-2689<br />
58
Gloria Feliciano – Director<br />
FRANKLIN WOMEN SHELTER<br />
1122 Franlin Avenue<br />
Bronx, NY 10456<br />
718-842-9797<br />
Fax # 718-842-0859<br />
Joan Alston – Director<br />
JAMAICA ASSESSMENT CENTER<br />
175-10 88 th Avenue<br />
Queens, NY 11432<br />
718-262-1288<br />
Fax # 718-298-5439<br />
Franca Okeya – Director<br />
WIC PROGRAM<br />
Manager<br />
Jennifer Klein RD<br />
MMG WIC - SITE 1<br />
22 Westchester Square<br />
Bronx, NY 10461<br />
718-829-4001<br />
Fax # 718-239-2546<br />
Supervisor: Lisa Fermin<br />
MMG WIC - SITE 2<br />
4782 Third Avenue<br />
Bronx, NY 10458<br />
718- 405-4066<br />
Fax # 718-405-4148<br />
Supervisor: Claudette Robinson<br />
MMG WIC - SITE 3<br />
3 05 E. 16 1st (CHCC)<br />
Bronx, NY 10451<br />
718-579-2589<br />
Fax # 718-681-4203<br />
Supervisor: Elaine Jones<br />
59
SECTION IV<br />
•<br />
CLINICAL DEPARTMENTS<br />
60
ANESTHESIOLOGY<br />
Chairman 718-920-2802<br />
Albert J. Saubermann, MD 718-881-2245<br />
Residency Program Director<br />
Allison Spinelli, MD 718-920-4383<br />
Site Directors:<br />
Moses – John Wasnick, MD 718-920-4316<br />
Weiler - Robert Lagasse, MD 718-904-2872<br />
Administrative <strong>Staff</strong>:<br />
Unified Administrator: Samuel Hamilton<br />
Penny Sanchez, Practice Manager<br />
Residency Coordinator: Debbie Rivera<br />
Technical Supervisor: Andrew Nembhard (Moses) – George Davidson (Weiler)<br />
Anesthesiology Departmental Offices at both sites are open from 8:00 AM to 5:00 PM, Monday<br />
through Friday.<br />
MOSES<br />
Main Number 718-920-4316<br />
Control Number 718-920-5268<br />
WEILER<br />
Main Number 718-904-2872<br />
Control Number 718-904-2798<br />
Fax Number 718-822-6180<br />
Graduate <strong>Medical</strong> Education Office 718-920-4383<br />
718-653-2367<br />
Unified Administrator 718-920-4440<br />
OB Anesthesiology - Weiler 718-904-2979<br />
Anesthesiology Technical Support<br />
Moses<br />
Weiler<br />
Billing Services<br />
Penny Sanchez: Practice Manager<br />
Marie Ficarra<br />
Research Services<br />
718-920-5275 Moses<br />
718-904-2875 Weiler<br />
718-920-2409 Moses<br />
718-904-2250 Weiler<br />
718-920-4316 Moses<br />
61
CARDIOLOGY<br />
Interim Division Director<br />
Mark Greenberg, MD<br />
Scott Monrad, MD<br />
Fellowship Directors<br />
James Scheuer, MD (Einstein Cardiology) 718-920-5979<br />
Kevin Ferrick, MD (Bronx-Lebanon Cardiology)<br />
John Fisher, MD<br />
(Electorphysiology)<br />
Scott Monrad, MD (Interventional Cardiology)<br />
The Cardiovascular Division provides comprehensive diagnostic and therapeutic cardiac services<br />
with a commitment to clinical excellence, administrative leadership, educational responsibility<br />
and research development.<br />
CONSULTATIVE SERVICE<br />
Moses Division 718-920- 4116<br />
Weiler Division 718-904-2927<br />
Sophisticated, evidence based consultative cardiological services are provided at both campuses.<br />
NON-INVASIVE CARDIOLOGY<br />
Moses Laboratory Director<br />
Daniel Spevack<br />
Weiler Laboratory Director<br />
Garet Gordon, MD 718-920-7638<br />
The non-invasive laboratories at the Moses and Weiler Divisions provide a full range of services<br />
including echocardiography, transesophageal echocardiography, stress testing, exercise stress<br />
testing, dobutamine echocardiography and holter monitoring<br />
CARDIAC CATHETERIZATION<br />
Moses Director<br />
Mark Greenberg, MD 718-920-4212<br />
Weiler Director<br />
E. Scott Monrad, MD 718-904-2071<br />
The Heart Center has six modern cardiac catheterization laboratories, with three located at the<br />
Moses division and three at the Weiler divisions. They provide a full range of diagnostic and<br />
interventional services. The physician interventionalists are available around the clock through a<br />
24-hour on call system. They are supported by a staff of physician assistants, nurses, x-ray<br />
technicians and cardiovascular technicians.<br />
ELECTROPHYSIOLOGY (EP)/ ARRHYTHMIA<br />
62
Director<br />
John Fisher, MD 718-920-4291<br />
The Electrophysiology/Arrhythmia Service has two EP laboratories, and provide a full range of<br />
diagnostic procedures, including tilt-table testing, signal-averaged EKG, heart-rate variability<br />
studies and ST segmented analysis for ischemia. The arrhythmia specialists are expert in the<br />
implantation of cardiac defibrillators and pacemakers as well as radio frequency ablations. The<br />
program offers pacemaker and defibrillator implants on both campuses, and the other invasive<br />
services at the Moses Campus.<br />
CONGESTIVE HEART FAILURE<br />
Directors<br />
Thierry LeJemtel, MD W 718-904-2193<br />
M 718-920-2248<br />
The Congestive Heart Failure (CHF) Service employs an integrated, multidisciplinary treatment<br />
program. It is a major testing site and research center for treatment innovations. A major focus<br />
of the CHF Service is on helping older patients with heart failure feel better while increasing<br />
their ability to function independently. Services are available on both campuses.<br />
HEART TRANSPLANT<br />
In a coordinated program with Cardiothoracic surgery, the heart transplant service provides stateof-the-art<br />
device based hemodynamic support and cardiac transplantation in patients with endstage<br />
myocardial failure. This service is supported by Dr. LeJemtel<br />
and can be contacted at 920-2483.<br />
HEALTHY HEART PROGRAM<br />
Director<br />
Robert Forman, MD<br />
The Healthy Heart Program reaches out to people in the community, particularly senior citizens,<br />
who are at risk for heart disease through ongoing screenings, education and prevention<br />
initiatives. The Heart Center conducts exciting new research, such as studies of angiogenesis, the<br />
body's natural ability to grow new blood vessels, which may change the way cardiac patients are<br />
treated in the future.<br />
INFORMATION SERVICES<br />
The Cardiovascular Division is committed to the highest standards of patient care, which today<br />
requires immediate, around-the-clock access to all clinical information. This goal is being met<br />
by the integration of the following systems within the practice:<br />
• Phamis LastWord – “spine” system for medical information<br />
• Apollo Cardiology Information System – records cardiology specific information<br />
• MUSE system - manages electrocardiographic information<br />
• MedCon Digital Imaging Archiving System – for recording electrophysiological,<br />
electrocardiographic, and catheter-based angiographic studies<br />
CARDIOTHORACIC SURGERY<br />
Acting-Chairman<br />
63
Steven Keller, MD<br />
Residency Program Director<br />
Jeffrey P. Gold, MD 718-920-7000<br />
Residency Program Coordinator<br />
Jerilyn Moreschi 718-920-7000<br />
Administrator – To be determined 718-920-5381<br />
West Campus: 3400 Bainbridge Ave. 5th Floor<br />
East Campus: 1575 Blondell Avenue. Ste 125 718-920-8248<br />
CHILD PSYCHIATRIC OUTPATIENT DIVISION<br />
<strong>Medical</strong> Director<br />
Carol Hnetila, DO 718-920-7255<br />
Director Child/Adolescent Psychology<br />
Director Adolescent Depression and Suicide Program<br />
Alec Miller, PsyD 718-920-7666<br />
Chairperson Quality Improvement<br />
Carol Hnetila, DO 718-920-7255<br />
Director Consultation Liaison<br />
Ruben Gonzalez, MD 718-920-5463<br />
Intake Coordinator<br />
Margaret Lescher 718-920-5466<br />
DENTISTRY<br />
Chairman<br />
Richard Kraut, DDS 718-920-4984<br />
Administrator<br />
Charles Brockett 718-920-4167<br />
RESIDENCY COORDINATORS<br />
General Practice<br />
Agueda Maldonado 718-405-8193<br />
Oral Surgery<br />
Cathlene Castillo 718-920-5993<br />
Prosthodontics<br />
Christine Clarke 718-920-5996<br />
Orthodontics<br />
Cheri Williams 718-920-5997<br />
Pediatric Dentistry<br />
64
Christine Clarke 718-920-5996<br />
PROGRAM DIRECTORS<br />
General Practice<br />
Julie Kazimiroff 718-920-5142<br />
Oral Surgery<br />
Richard Kraut, DDS 718-920-4984<br />
Orthodontics<br />
Anthony Maganzini, DDS, MSD 718-920-2385<br />
Prosthodontics (Interim Director)<br />
Barry Goldman, DDS 718-920-2381<br />
Pediatric Dentistry<br />
Nuntia Kakanantadilok, DDS 718-519-3304<br />
EMERGENCY SERVICES<br />
Proffessor and Chairman<br />
E. John Gallagher, MD 718-920-7459<br />
Site Residency Director<br />
Lynne Holden, MD 718-920-2066<br />
Moses Division <strong>Medical</strong> Director<br />
Michelle Davitt, MD 718-920-4049<br />
Weiler Chief of Service<br />
Joseph Braverman, MD 718-904-2905<br />
Vice President, Clinical Services<br />
Peter Semczuk, DDS, MPH 718-741-2570<br />
EPIDEMIOLOGY & POPULATION HEALTH<br />
Chairman<br />
Tom Rohan, PhD 718-430-2358<br />
Vice Chairman<br />
Ellie Schoenbaum, MD 718-655-1809<br />
Executive Administrator:<br />
John Cecconi 718-430-3029<br />
Moses Administrator 718-920-6742<br />
Ingrid Symes<br />
718-652-1343 Fax<br />
Moses Division<br />
65
3347 Steuben Avenue<br />
Mail: 111 East 210 th Street<br />
Weiler Division- AECOM 718-430-2281<br />
Belfer 13, 1300 Morris Park<br />
FAMILY MEDICINE<br />
Department Chairman<br />
Peter Selwyn, MD 718-920-2434<br />
3544 Jerome Avenue<br />
Albert Einstein College of Medicine 718-430-2900, 2154<br />
1300 Morris Park Avenue, Belfer 902 718-430-8816 Fax<br />
Chief of Service 718-920-7088<br />
Jonathan Swartz<br />
718-575-5416 Fax<br />
Administrator 718-920-7802<br />
Paul Meissner<br />
718-515-5510 Fax<br />
Secretary<br />
Evelyn Rivera-Lipnicky 718-920-8434<br />
FAMILY PRACTICE<br />
3544 Jerome Ave.<br />
Residency Coordinator<br />
Nicole Lewis 718-920-2815<br />
Residency Program Director<br />
Mary Duggan, MD 718-920-5521<br />
Family Practice has a strong commitment to changing and improving the quality of care for<br />
individuals and families primarily in underserved areas of the inner city. The department's<br />
residents receive inpatient and outpatient training in a wide variety of medical and surgical<br />
general and subspecialty services with additional training in nutrition prenatal care, family<br />
systems psychosocial evaluation and the care of HIV infected patients.<br />
SOCIAL MEDICINE<br />
3544 Jerome Ave.<br />
Residency Program Director<br />
Jerry Paccione, MD 718-920-5521<br />
The Social Internal Medicine residency program emphasizes training in continuity care for innercity<br />
adults. The three year program includes training in inpatient services including subspecialty<br />
electives, a broad spectrum of medical conferences, outpatient clinical experiences and the<br />
innovative primary care curriculum of ambulatory morning rounds, clinical Epidemiology<br />
courses, behavioral medicine, community oriented primary care, and health and human rights.<br />
66
SOCIAL PEDIATRICS<br />
3544 Jerome Ave.<br />
Residency Program Director<br />
Philip Ozuah, MD 718-920-5521<br />
The pediatric residency program emphasizes training in continuity care for inner-city infants and<br />
children. The three year program includes training in inpatient services for newborns, infants,<br />
children and adolescents and outpatient care in emergency services and primary care in a<br />
community practice site.<br />
MEDICINE<br />
The Department of Medicine is the largest department at at <strong>Montefiore</strong> <strong>Medical</strong> Center, the<br />
University Hospital of the Albert Einstein College of Medicine (AECOM). Two campuses<br />
provide a full range of services to patients and are a major teaching and research resource in the<br />
Bronx.<br />
The Moses and Weiler sites train one-half of each AECOM class in Internal Medicine,<br />
and 155 Internal Medicine residents in the categorical, preliminary, primary care, and social<br />
internal medicine residency programs. Strong subspecialty programs contribute to patient care,<br />
provide consultative support to the <strong>House</strong> <strong>Staff</strong>, and provide excellent training for over 100<br />
fellows.<br />
The house staff and fellows also rotate through Jacobi Hospital, and some Fellows rotate<br />
through North Central Bronx hospital, both part of the Health & Hospital Corporations (NYC)<br />
System.<br />
Approximately 230 full-time and a number of voluntary faculty members provide<br />
supervision of the residents and students and participate in the teaching activities of the<br />
programs.<br />
Between them, the Moses and Weiler sites provide care to a daily census of over 400<br />
Internal Medicine inpatients and to an ever-increasing number of outpatient patients around the<br />
Bronx. The Department also provides a wide range of diagnostic and therapeutic services<br />
including: Cardiac Catheterization, Interventional Angioplasty,<br />
Echocardiography, Holter Monitoring, Stress Testing, Renal Dialysis, GI Endoscopy, Pulmonary<br />
Function Studies, Diabetes care, and Diabetes education and consultation.<br />
Chairman 718-430-2906<br />
Victor Schuster, MD 718-920-7701/7710<br />
718-430-8659 Fax<br />
718-515-6103 Fax<br />
Vice Chairman for Clinical Affairs 718-920-6327<br />
Philip D. Lief, MD 718-904-2500<br />
718-515-6103 Fax<br />
718-904-2827 Fax<br />
Vice Chairman for Academic Affairs 718-430-2694<br />
Milford Fulop, MD<br />
Administrator AECOM<br />
67
Shelly Motzkin 718-430-3041<br />
Administrator MMC 718-920-4416<br />
Jonathan Tamir<br />
718-515-6103 Fax<br />
<strong>Medical</strong> Credentialing<br />
Faculty & Hospital Appointments<br />
Vicky Ruiz 718-920-2146<br />
INTERNAL MEDICINE RESIDENCY PROGRAMS<br />
Centennial 3<br />
Program Director<br />
Internal Medicine<br />
Sharon Silbiger, MD 718-920-6098<br />
Program Administrator<br />
Donna Chinea 718-920-4417<br />
Firm I<br />
Marta Rico, MD 718-920-5496<br />
Firm II<br />
Darlene LeFrancois, MD 718-920-2839<br />
Firm III<br />
Joseph DeLuca, MD 718-920-6738<br />
Primary Care<br />
Gerald Paccione, MD 718-920-6097<br />
Social Internal Medicine<br />
Gerald Paccione, MD 718-920-6097<br />
FELLOWSHIP PROGRAM DIRECTORS<br />
Allergy<br />
David Rosenstreich, MD 718-405-8074<br />
Cardiology<br />
James Scheuer , MD 718-920-5979<br />
Scott Monrad, MD 718-904-3216<br />
Cardiac Electrophysiology<br />
John D. Fisher, MD 718-920-4291<br />
Critical Care<br />
68
Vladimir Kvetan, MD 718-920-5440<br />
Dermatology<br />
Michael Fisher, MD 718-918-4272<br />
Endocrinology<br />
Martin Surks, MD 718-920-4331<br />
Gastroenterology<br />
David Greenwald, MD 718-920-4846<br />
Geriatrics<br />
Laurie Jacobs, MD 718-920-6721<br />
Hematology<br />
Shirley Levine, M.D. 718-430-3564<br />
Infectious Diseases<br />
Grace Minamoto, MD 718-920-5224<br />
Nephrology<br />
Vaughn Folkert, MD 718-597-2255<br />
Pulmonary<br />
Andrew Berman, MD 718-405-8300 x 2113<br />
Rheumatology<br />
Chaim Putterman, MD 718-430-4266<br />
DIVISION DIRECTORS<br />
Allergy<br />
David Rosenstreich, MD 718-405-8074<br />
Cardiology<br />
Interim Moses<br />
Mark Greenberg, MD 718-920-4212<br />
Interim Weiler<br />
E. Scott Monrad, MD 718-904-3216<br />
Dermatology<br />
Michael Fisher, MD Van Etten 718-918-4272<br />
Endocrinology<br />
Norman Fleischer, MD Belfer 701 718-430-2908<br />
Gastroenterology<br />
69
Larry Brandt, MD RA 718-920-6032<br />
Geriatrics<br />
Laurie Jacobs, MD Centennial 2 718-920-6122<br />
Hematology<br />
Ronald Nagel, MD Ullmann 718-920-6310<br />
718-430-2186<br />
Infectious Disease<br />
Arturo Casadevall, MD Belfer 610 718-430-3665<br />
Nephrology<br />
Victor Schuster, MD Ullmann 615 718-430-3158<br />
Pulmonary<br />
Thomas Aldrich, MD Centennial 4 718-920-6054<br />
Rheumatology<br />
Chaim Putterman,MD Ullmann 718-430-4081<br />
NEUROLOGY<br />
Chairman<br />
Mark Mehler, MD 718-430-2407<br />
Administrator<br />
Sally Hershkowitz 718-920-4715<br />
Residency Coordinator<br />
Tina Rubano 718-430-3166<br />
Adult Neurology Residency Program Director<br />
Sheryl Haut, MD 718-920-6402<br />
Pediatric Neurology Residency Program Director<br />
Karen Ballaban-Gil, M.D. 718-405-8148<br />
Clinical Neurolophysiology Fellowship Program Director<br />
Fred Lado, M.D.<br />
Neurology produces a 114-Page <strong>Orientation</strong> manual for the Adult<br />
Neurology Program Residents.<br />
East Campus: Albert Einstein College of Medicine<br />
1300 Morris Park Avenue<br />
West Campus: 3351 Steuben Avenue, 3rd Floor<br />
NEUROSURGERY<br />
3316 Rochambeau Avenue 718-920-7400<br />
Chairman &<br />
70
Residency Program Director<br />
Eugene S. Flamm, MD<br />
Administrator &<br />
Residency Coordinator<br />
Rachel Fink 920-7400<br />
NUCLEAR MEDICINE<br />
Chairman<br />
M. Donald Blaufox, MD, PhD<br />
Administrator<br />
Mitchell H. Stromer<br />
Assistant Administrator<br />
Thomas Huvane<br />
Phone: 718-405-8468<br />
Fax: 718-824-1369<br />
Hours<br />
Monday-Friday 8:00am – 9:00pm, Saturday and Sunday 8:00am – 4:00pm<br />
All other times, evening and weekends, emergency scans can be requested through the<br />
Radiology Resident on-call. All inpatient and outpatient procedures are performed in the<br />
Department of Nuclear Medicine located on the 4 th floor in the Silver Zone. No procedures can<br />
be performed until the request and referral form, if necessary, has been received. The request<br />
must be filled out completely and may be submitted by fax to 718-920-2311 or by ordering the<br />
procedure on CIS. If prior Nuclear Medicine or other imaging tests are available from another<br />
institution, it is always helpful if the patient or the referring physician makes these available at<br />
the time of the procedure.<br />
Some categories of illnesses require that the patient be accompanied be a doctor or nurse.<br />
Call the department at (718)920-5011 for any of the following:<br />
• To request a procedure<br />
• To discuss potential procedures with a physician<br />
• To obtain preliminary results<br />
• To discuss any other issues related to Nuclear Medicine<br />
Cardiovascular Nuclear Medicine Stress Test Scheduling 718-920-5144<br />
Positron Emission Topography (PET)<br />
Outpatient Scheduling 718-405-8461<br />
Inpatient Scheduling 718-904-2923<br />
All outpatient Nuclear Medicine and Positron Emission Tomography (PET) procedures are<br />
performed in the <strong>Montefiore</strong> <strong>Medical</strong> Park, 1695A Eastchester Road.<br />
71
Positron Emission Tomograpy (PET) procedures are performed in the <strong>Montefiore</strong> <strong>Medical</strong> Park<br />
Division, 1695 A Eastchester Road.<br />
Weiler/Einstein Division<br />
Chief of Service: David M. Milstein<br />
Supervisor: Philip Paul<br />
Phone: 718-904-2923<br />
Fax: 718-904-2012<br />
MOSES<br />
Vice Chairman and Director<br />
Leonard M. Freeman, MD<br />
Supervisor<br />
Khalid Saleemi 718-920-5013<br />
Hours<br />
Monday - Friday 8:00AM - 5:00PM<br />
All other times, evenings and weekends, emergency scans can be requested through the Weiler<br />
Operator. All inpatient Nuclear Medicine Procedures will be performed in the first floor<br />
Department of Nuclear Medicine.<br />
<strong>Montefiore</strong> <strong>Medical</strong> Park Division<br />
1695A Eastchester Road<br />
Bronx, NY 10461<br />
Chief of Service: David M. Milstein, M D.<br />
Supervisor: Philip Paul<br />
Phone: 718-405-8461<br />
FAX: 718-824-0830<br />
Hours<br />
Monday – Friday 8:00AM to 5:00PM for routine testing. All outpatient Nuclear Medicine<br />
procedures, including PET/CT, will be performed on the first floor. Call the department at 718-<br />
405-8461 for any of the following:<br />
• To request a procedure<br />
• To discuss potential procedures with a physician<br />
• To obtain preliminary results<br />
• To discuss any other issues related to Nuclear Medicine<br />
72
No procedure can be performed until the request has been received. The request must be filled<br />
out completely and may be submitted by fax 718-824-0830. If prior Nuclear Medicine or other<br />
imaging tests are available from another institution, it is always helpful if the patient or the<br />
referring physician makes these available at the time of the procedure.<br />
OBSTETRICS & GYNECOLOGY AND WOMEN'S HEALTH<br />
Chairman<br />
Irwin R. Merkatz, MD 718-430-4192<br />
1300 Morris Park Ave<br />
Belfer Educational Center - Rm 502<br />
Bronx, New York 10461<br />
Senior Administrator<br />
Adrienne Kapel 718-430-8739<br />
Residency Program Director<br />
Brian Cohen, MD 718-430-4031<br />
Residency Coordinator<br />
Kathy Regan 718-430-4031<br />
Undergraduate <strong>Medical</strong> Education<br />
Nadine Katz, MD 718 - 430-3206<br />
Undergraduate <strong>Medical</strong> Education Coordinator<br />
Linda Gillespi 718-430-3205<br />
DIVISION OF MATERNAL FETAL MEDICINE<br />
1300 Morris Park Ave<br />
Belfer 502<br />
Irwin R. Merkatz, MD, Director 718-430-4192<br />
Cynthia Chazotte, MD 718-904-2794<br />
Jack D. Weiler Hospital of the Albert Einstein College of Medicine<br />
Administrative Office 718-904-2794<br />
Patient Referral 718-904-2725<br />
DIVISION OF GYNECOLOGIC ONCOLOGY<br />
Gary L. Goldberg, MD, Director<br />
1695 Eastchester Road - Suite 601<br />
Bronx, New York 10461<br />
Administrative Office 718-904-2893<br />
Patient Referral 718-405-8210<br />
DIVISION OF REPRODUCTIVE ENDOCRINOLOGY<br />
Nanette Santoro, MD, Director - Bronx Site<br />
73
1300 Morris Park Ave - Mazer 301<br />
Bronx, New York 10461<br />
Academic Office 718-430-3152<br />
Administrative Office/Patient Referral 718-997-1060<br />
DIVISION OF REPRODUCTIVE GENETICS<br />
Harold M. Nitowsky, M.D, Co-Director<br />
Susan Gross, MD, Co-Director<br />
Institute for Women's Health, Genetics and<br />
Human Reproduction<br />
1695 Eastchester Road<br />
Bronx, New York 10461<br />
Administrative Office/Patient Referral 718-405-8150<br />
DIVISION OF UROGYNECOLOGY AND RECONSTRUCTIVE<br />
PELVIC SURGERY<br />
Dr. Magdy Mikhail, Division Director<br />
Centennial Women’s Center<br />
3332 Rochambeau Avenue<br />
Bronx, NY 10467<br />
Administrative Office/Patient Referral 718-920-5157<br />
PROGRAM/CLINICAL SITES<br />
MMC - Weiler Division<br />
Ira Karmin, MD<br />
Director, GYN<br />
Patient Referral/Administrative Office 718-904-2797<br />
MMC-Weiler Division<br />
Cynthia Chazotte, MD<br />
Director, OB<br />
Administrative Office 718-904-2794<br />
Patient Referral 718-904-2725<br />
MMC - Moses Division<br />
Mark Levie, M.D.<br />
Director of Obstetrics and Gynecology<br />
Administrative Office 718-920-2864<br />
Patient Referral 718-920-5157<br />
FACULTY PRACTICE OFFICES<br />
Institute for Women’s Health, Genetics and Human Reproduction<br />
1695 Eastchester Road, Suite L2<br />
74
Bronx, New York 10461<br />
Administrative Office/Patient Referral 718-405-8200<br />
Nancy Perugini<br />
Cassandra Duckett Jones<br />
On Site Coordinators<br />
CFCC - OB/GYN and Women's Health<br />
1621 Eastchester Road 718-405-8040<br />
Peter Bernstein, MD - CFCC<br />
Nancy DeVore, CNM Director of Ambulatory Care<br />
Grand Concourse Women’s Center<br />
2532 Grand Concourse<br />
Bronx, NY 10458<br />
Administrative Office/Patient Referral: 718-960-1546<br />
Site Administrator: Annette Mussenden<br />
Maternal/Fetal Assessment Center<br />
1825 Eastchester Road; 2 Floor<br />
Bronx, NY 10461<br />
Cynthia Chazotte, MD 718-904-2725<br />
Centennial Women’s Center<br />
3332 Rochambeau Avenue, Suites A, B, C<br />
Bronx, NY 10467<br />
Patient Referral/Administrative Office 718-920-5157<br />
Ultrasound & Bone Densitometry<br />
Multi-Site<br />
Patient Referral 718-405-8200<br />
WESTCHESTER SITES<br />
Larchmont Women's Center 914-834-0444<br />
Larchmont, New York 10538<br />
Patient Referral/Administrative Office 914-834-4422<br />
Site Administrator: Rose Ghelarducci<br />
<strong>Montefiore</strong>’s Institute for Reproductive Medicine and Health<br />
141 South Central Avenue; Second Floor<br />
Hartsdale, New York 10530<br />
Patient Referral/Administrative Office 914-997-1060<br />
Site Administrator: Piera Graven<br />
Cross County Women’s Center<br />
6 Xavier Drive, Room 610<br />
Yonkers, New York 10704<br />
75
Patient Referral/Administrative Office 914-376-9100<br />
Site Administrator: Susan Weiss<br />
In-Patient Obstetrical Units<br />
Jack D. Weiler Division of the <strong>Montefiore</strong> <strong>Medical</strong> Center<br />
Antepartum 718-904-3431<br />
Labor and Delivery 718-904-3433<br />
Postpartum 718-904-3431<br />
7N Conference Room 718-904-2767<br />
Jacobi <strong>Medical</strong> Center<br />
Antepartum 718-918-6358<br />
Labor and Delivery 718-918-6380<br />
Postpartum 718-918-6358<br />
Perinetal and Genetics Consultants<br />
700 White Plains Road<br />
Scarsdale, NY 10583<br />
Administrative contact: Rose Gheralducci<br />
Administrative Contact Phone: 914-833-2730<br />
Patient Appointment: 914-423-4111<br />
ADDITIONAL PROGRAMS<br />
Midwifery Program<br />
Nancy E. DeVore, CNM, Director 718-405-8039<br />
Patient Education<br />
Margaret Comerford Freda, Consultant 631-423-8600<br />
Office of Community Affairs<br />
Karla Damus, PhD 718-430-2576<br />
ONCOLOGY<br />
Chairman<br />
Roman Perez-Soler, MD 718-920-4001<br />
Director, Cancer Center<br />
I. David Goldman, M.D 718-430-2302<br />
Albert Einstein Cancer Center<br />
Acting Director, Cancer Services<br />
Richard Daversa 718-920-4674<br />
Associate Chairman of Clinical Research<br />
Director, Clinical Trials Office Albert Einstein Cancer Center<br />
Joseph Sparano, M.D. 718-904-2555<br />
76
Director, Education Programs<br />
Rasim Gucalp, M.D. 718-920-7100<br />
Director, Bone Marrow Transplantation<br />
Ira Braunschweig, M.D. 718-920-7100<br />
Director, Oncology Pharmacy<br />
Royston Brown, R.Ph. 718-920-5778<br />
Moses Outpatient Oncology Unit<br />
Northwest 3 718-920-4057<br />
Moses Inpatient/Infusion Oncology Unit<br />
Northwest 4 718-920-4742<br />
<strong>Montefiore</strong> <strong>Medical</strong> Park Outpatient Oncology Unit<br />
1695 Eastchester Road 718-405-8505<br />
<strong>Montefiore</strong> <strong>Medical</strong> Park Infusion Oncology Unit<br />
1695 Eastchester Road 718-405-8520<br />
Weiler Hospital<br />
Inpatient 11 South 718-904-3492<br />
Moses Division Physicians 920-7100<br />
Weiler/Einstein Physicians 904-2900<br />
Bone Marrow Transplant Coordinator<br />
Ruby Yusay 718-920-6322<br />
Nursing Director<br />
Barbara Binder 718-920-4075<br />
Administrative Nurse Manager (Moses)<br />
Peggy Wallace 718-920-4742<br />
Administrative Nurse Manager<br />
<strong>Montefiore</strong> <strong>Medical</strong> Park/Weiler<br />
Marilynn Silverberg, RN 718-405-8513<br />
Research Nurse Moses<br />
Cathy Sarta, RN 718-920-2059<br />
Research Nurse MMP<br />
Una Hopkins, NP 718-405-8520<br />
77
Moses PA 718-920-4933<br />
718-920-2090<br />
Weiler PA 718-904-3492<br />
718-904-3492<br />
OPHTHALMOLOGY & VISUAL SCIENCE<br />
Interim Chairman<br />
Residency Program Director 718-920-7646<br />
Harry M. Engel, MD 718-920-6665<br />
Centennial 3: 3332 Rochambeau Ave.<br />
718-881-5439 Fax<br />
Administrator<br />
Samuel Hamilton<br />
Centennial 3<br />
Practice Manager<br />
Annette Shehu, 718-920-4233<br />
3400 Bainbridge Avenue 718-655-2464<br />
ORTHOPEDIC SURGERY<br />
Chairman<br />
Neil J. Cobelli, MD 718-405-8131<br />
Residency Program Director<br />
I. Martin Levy, MD 718-405-8132<br />
<strong>Montefiore</strong> <strong>Medical</strong> Park<br />
1695 Eastchester Road 2nd Floor<br />
Bronx, New York 10461<br />
Administrator<br />
Lissen Simonsen 718-920-2929<br />
3400 Bainbridge Ave Map 6 718-653-1587 Fax<br />
Bronx, NY 10467<br />
Academic/Residency Coordinator<br />
Tanya Riedl 718-920-2966<br />
3400 Bainbridge Ave-Map 6 718-653-1587 Fax<br />
Bronx, NY 10467<br />
Director<br />
Dean Lorich, MD 718-918-4922<br />
Jacobi <strong>Medical</strong> Center, Room 218<br />
718-918-4914 Fax<br />
Pelham Parkway South & Eastchester Road<br />
Bronx, NY 10461<br />
78
North Central Bronx Hospital 718-519-4946<br />
DeKalb & Kossuth Ave. Room 8C01<br />
Bronx, NY 10467<br />
OTOLARYNGOLOGY<br />
MOSES<br />
3400 Bainbridge Avenue<br />
Map Building, 3rd Floor<br />
Professor and University Chairman 718-920-2991<br />
Residency Program Director<br />
718-405-9014 Fax<br />
Marvin P. Fried, MD<br />
Professor and Vice Chairman 718-920-4267<br />
Director of Head and Neck Services<br />
718-405-9014 Fax<br />
Richard V. Smith, M.D.<br />
Administrator 718-920-8425<br />
Jarrett Stern<br />
718-405-9014 Fax<br />
Appointments/ Information 718-920-4646<br />
The Department of Otolaryngology at <strong>Montefiore</strong> <strong>Medical</strong> Center, the University Hospital for<br />
the Albert Einstein College of Medicine, provides comprehensive patient care for diseases of the<br />
ear, nose and throat. Our multidisciplinary team includes highly specialized physicians,<br />
audiologists, and physiologists, including voice, speech and swallowing therapists. These team<br />
members work directly with other related specialties, forming specialty centers which include the<br />
Center for Voice Disorders, the Speech and Swallowing Disorders Center, Head and Neck<br />
Surgery, Cranial Base and the Craniofacial Center. The department is involved in extensive<br />
research and has received national and international recognition for its significant contributions<br />
to the field of Otolaryngology-Head and Neck Surgery.<br />
Services: Audiology, Head/Neck Surgery, Otology, Neurotology, Pediatric Otolaryngology,<br />
Rhinology- Nasal/Sinus and Diseases/Surgery, and Voice- Speech and Swallow Pathology<br />
PATHOLOGY<br />
Chairman 718-920-2456<br />
Michael B. Prystowsky, MD, Ph.D.<br />
718- 882-8461 Fax<br />
Vice Chairman 718-920-4540<br />
Ira Sussman, MD<br />
718-881-2976 Fax<br />
Senior Administrator 718-920-4523<br />
Vera Solomon<br />
718-881-2976 Fax<br />
79
Associate Administrator<br />
Michele Maimone-Schoen<br />
718-904-3279 Weiler<br />
718-920-4161 Moses<br />
718-881-2976 Fax<br />
Director, Surgical Pathology 718-920-4976<br />
James Pullman, MD<br />
718-920-7611 Fax<br />
Director, Anatomic Pathology 718-904-2174<br />
Kathleen Whitney, MD 718-904-2256<br />
Core Laboratory – Moses: Chemistry, Hematology, Lab Services, Microbiology, Protein<br />
Separation Lab<br />
718-920-4695<br />
718-881-4397 Fax<br />
Rapid Response Laboratory – Weiler: Chemistry, Hematology, Laboratory Services, Phlebotomy<br />
PEDIATRICS<br />
3415 Bainbridge Avenue<br />
Chairman<br />
Gabriel G. Haddad, M.D.<br />
Vice Chairman Research Affairs<br />
Harris Goldstein, M.D.<br />
Vice Chairman Affiliate and Network Affairs<br />
Frederick J. Kaskel, M.D., Ph.D.<br />
Vice Chairman Clinical and Educational Affairs<br />
Philip O. Ozuah, M.D., Ph.D.<br />
Director, Residency Program 718-741-2466<br />
Catherine C. Skae, M.D<br />
718-654-6692 Fax<br />
Education Administrator<br />
Mary McGuire 718-741-2460<br />
Director of Administration 718-741-2490<br />
Mary R. Doncourt<br />
Associate Administrator 718-741-2411<br />
Ann Allowe<br />
Assistant Administrator for Sectional Affairs<br />
80
Arlene Saunders 718-741-2492<br />
Administrative Supervisor<br />
Mary Ellen Watson 718-241-2464<br />
Credentials Coordinator 718-741-2487<br />
Loretta Garin<br />
718-654-6692 Fax<br />
The Department of Pediatrics is dedicated to delivering and teaching pediatric primary care<br />
serving as the mainstay for subspecialty and tertiary care for the children of our region and to<br />
advancing pediatric research efforts. The Department’s faculty and <strong>House</strong> <strong>Staff</strong> deliver care and<br />
teaching at the University Hospital of the Albert Einstein College of Medicine at <strong>Montefiore</strong><br />
<strong>Medical</strong> Center, the Children’s Hospital at <strong>Montefiore</strong> and the Jack. D. Weiler Hospital in<br />
addition to numerous outpatient and community-based venues. The pediatric faculty provides<br />
supervision of the three-year residency and numerous fellowship programs.<br />
PLASTIC AND RECONSTRUCTIVE SURGERY<br />
Chairman<br />
Berish Strauch, MD 718-405-8444<br />
1625 Popular St., Suite 200<br />
Administrative Supervisor<br />
Agneta Gustafsson 718-920-6168<br />
Administrative Office 718-920-6168<br />
Director of Academic Affairs<br />
Dr. Lee Landres 718-920-4449<br />
The departmental offices are open during normal business hours. There is a resident on call inhouse<br />
at all times at both the east and west campus and in the Burn Unit at Jacobi <strong>Medical</strong><br />
Center. The Department provides the full range of Plastic and Reconstructive Surgical Services<br />
including aesthetic surgery, craniofacial surgery, microvascular surgery, reconstructive surgery,<br />
replantation surgery, breast reconstruction, facial paralysis surgery, hand surgery, head and neck<br />
reconstruction, maxillofacial surgery, and burn care.<br />
PSYCHIATRY & BEHAVIORAL SCIENCES<br />
Chairman<br />
T. Byram Karasu, MD 718-920-4813<br />
Exec.Vice Chairman & Clinical Director<br />
Bruce J. Schwartz, MD 718-920-4040<br />
Administrator<br />
George J. Como 718-920-6215<br />
81
Residency Program Director<br />
Peter Buckley, MD 718- 931-7102<br />
Consult Liaison Director (West Campus)<br />
Mary Alice O'Dowd, MD 718-920-4441<br />
Consult Liaison Director (East Campus)<br />
David Preven, MD 718-904-3467<br />
RADIOLOGY<br />
Chairman<br />
E. Stephen Amis, Jr., M.D. 718-920-5113<br />
Chief of Service – Moses<br />
Seymour Sprayregen, M.D. 718-920-4200<br />
Chief of Service – Einstein<br />
Nogah Haramati, M.D. 718-904-2965<br />
Administrator<br />
Richard Alaimo 718-920-4848<br />
Chief Technologist – Moses 718-920-2290<br />
Chief Technologist – Einstein 718-904-2768<br />
Nursing Station – Moses 718-920-4877<br />
Nursing Station – Einstein 718-904-2378<br />
MOSES DIVISION<br />
The Department of Radiology offers complete imaging services and consultation. The<br />
department also performs a wide variety of diagnostic and therapeutic invasive procedures.<br />
Consultation includes review of completed studies and recommendations for the most efficacious<br />
sequencing of imaging studies for diagnosing a particular condition. During normal working<br />
hours, radiologists are available in the reading room in the Silver Zone and in subspecialty<br />
reading areas. After hours, and on weekends and holidays, consultation is available in the<br />
Radiology reading room or by paging the radiology resident through the page operator.<br />
Verbal reports are available as soon as the films have been dictated. Access to the report can be<br />
obtained through the RTAS system by dialing extension 5848 (920-5848 from outside the<br />
hospital) and then entering the patient's medical record number.<br />
SCHEDULING ROUTINE IN-PATIENT EXAMS<br />
All requests for in-patient radiologic exams must be submitted on a <strong>Montefiore</strong> <strong>Medical</strong> Center<br />
x-ray requisition or electronically through the PHAMIS system. The requisition must contain:<br />
the radiologic exam requested, clinical history, demographic information, legible signature and<br />
82
printed name of the referring physician, and beeper or phone number where referring physician<br />
can be reached. Radiologic exams are provided only at the request of referring physicians with<br />
clinical privileges or other practitioners authorized by the medical staff and the governing body<br />
to order radiologic service.<br />
Fax Numbers:<br />
MRI 718-920-7705<br />
CT 718-920-7647<br />
Sonography 718-655-1203<br />
Scheduling 718-655-2142<br />
In-patients 718-920-7799<br />
SCHEDULING PROCEDURES FOR AMBULATORY PATIENTS<br />
During regular work hours, routine radiologic studies can be scheduled by calling the following<br />
extensions:<br />
Sonograms 4070<br />
CT, barium studies, IVP 5492<br />
Mammograms<br />
5400 (MIC)<br />
MRI 4409<br />
Neuroangiograms & myelograms 4640/4630<br />
Angiographic/interventional procedures 5729<br />
Nuclear Medicine 5011<br />
AFTER WORKING HOURS<br />
There is always at least one credentialed radiology resident in the hospital to interpret studies,<br />
assist in determining the appropriate radiologic work up for a patient and to<br />
schedule emergent cases. The resident can be reached through the page operator or at extension<br />
4879.<br />
REVIEW OF CASES<br />
Barium studies are reviewed in the reading area in the Silver zone starting at 2:30 p.m. Monday<br />
Friday. To review neuroradiology cases (head and spine CT and MRI as well as other<br />
neuroradiology procedures), inquiries should be made in the neuroradiology reading room. To<br />
review musculoskeletal cases, inquiries should be made in the musculoskeletal reading room.<br />
Pediatric cases are reviewed in the pediatric reading area. ED cases and plain films of the chest<br />
and abdomen can be reviewed in the Silver Zone reading room. Information about ultrasound<br />
can be obtained at the ultrasound reception desk. Information about CT and MRI scans of the<br />
chest and abdomen can be obtained in the Body CT & Chest reading areas. Information about<br />
visceral and peripheral angiograms and interventional procedures can be obtained in the<br />
angiography suite or office. Nuclear Medicine cases are viewed by the Department of Nuclear<br />
Medicine located on the 4th floor of the Silver Zone.<br />
FILM CONTROL<br />
The Department of Radiology is mandated by law to maintain radiographic studies for a period<br />
of seven years for adults and a period of seven years after a pediatric patient reaches the age of<br />
83
21 years. All studies are the property of the Radiology Department. Studies must not be<br />
removed from the department prior to the official interpretation.<br />
When it is necessary to check out films, this should be done only after the films have been<br />
formally interpreted and dictated by a radiologist and after signing the films out of the file room.<br />
The main file room is located in the Yellow Zone. Films must not be<br />
kept in offices or clinics for long periods of time; to do so can seriously compromise patient care<br />
because the study will not be available to other physicians taking care of the patient. Films must<br />
never be taken from the department unless properly checked out and must always be returned.<br />
The cooperation of every member of the house staff is expected in this regard.<br />
DIRECTORY (Extensions)<br />
Moses (718) 920-xxxx<br />
Silver Zone Reading Room 4879/5547<br />
File Room 4866/4867<br />
Neuroradiology Reading Room 4030/4640<br />
Body CT Reading Room 4396/4397<br />
Ultrasound Reading Room 4070<br />
Vascular/Interventional Reading Room 5729<br />
Mammography<br />
5400 (MIC)<br />
Unified Chairman 5113<br />
Chief of Radiology 4200<br />
Administrator 4848/4135<br />
QC/QI Manager 6694<br />
Residency Coordinator 5506<br />
Business Manager 5730<br />
Chief Tech 2725/2290<br />
Tech Supervisor 2290<br />
File Room Supervisor 5209/4866<br />
US Supervisor 4070<br />
CT/MR Supervisor 5010<br />
Einstein (718) 904-xxxx<br />
Chief of Radiology 2965<br />
Administrator 2964<br />
Chief Tech 2768<br />
Nurses Station 2378<br />
Remote Transcription Access System-RTAS 2679<br />
Radiology Reception (M-F 8am- 7pm) 3411<br />
Front Desk (M-F 8am- 7pm)) 3400<br />
Ultrasound (M-F 8am- 5pm) 2322<br />
CT (M-F 8am- 5pm) 4038<br />
MRI (M-F 8am- 7pm) 2600<br />
File Room 3407<br />
(M-F 8am- 7pm Sat, Sun & Hol 8:00am -4:00pm)<br />
After hours, please call the page operator at 904-2711<br />
84
The radiology department at Jack D. Weiler Hospital at the Albert Einstein College of Medicine,<br />
a division of the <strong>Montefiore</strong> <strong>Medical</strong> Center, offer the following: MRI, CT, US, Mammography,<br />
Diagnostic x-rays, Interventional procedures (Invasive and Non-<br />
Invasive), Fluoroscopy studies (e.g. Mod-barium swallows, Upper GI, IVP,<br />
hysterosalpingogram, Voiding Cystourethrogram)<br />
RADIATION ONCOLOGY<br />
Interim Chairman<br />
Jonathan Beitler, MD 718-920-4942<br />
Administrator, Director of Business &<br />
Clinical Service, <strong>Medical</strong> & Radiation Oncology<br />
Richard Daversa 718-920-4674<br />
Residency Coordinator and Program Director<br />
James Butler, MD 718-904-2921<br />
Senior Physicist<br />
Ravindra Yaparpalvi (Einstein)<br />
Rafael Yankelevich (Moses)<br />
Locations:<br />
Moses Division: 111 East 210th St.<br />
Weiler Division: 1825 Eastchester Rd.<br />
REHABILITATION MEDICINE<br />
Chairman<br />
Avital Fast, MD 718-920-2751<br />
Administrator<br />
Carmela Greco 718-920-4906<br />
Residency Program Director<br />
Mark Thomas, MD 718-920-2753<br />
Rehabilitation Administration 718-920-2751<br />
111 East 210th Street 718-920-5048 Fax<br />
Bronx, New York 10467-9024<br />
CLINICAL TRAINING SITES<br />
Moses Division 718-920-4083<br />
Einstein Division Weiler 718-920-2296<br />
Cardiac Rehabilitation Center - Blondell Avenue 718-405-8471<br />
Jacobi <strong>Medical</strong> Center 718-918-5545<br />
85
Beth Abraham Hospital 718-519-5831<br />
Jamaica Hospital 718-206-6894<br />
N.Y. Hospital - Queens 718-670-1290<br />
CLINICAL DIRECTORS<br />
Moses Division<br />
Stanley Wainapel, MD 718-920-4938<br />
Einstein-Weiler Division<br />
Jeffrey Nissinoff, MD 718-904-2296<br />
Blondell Avenue Center<br />
Anna Lasak, MD 718-405-8410<br />
OTHER CLINICAL SERVICES<br />
Cardiac Rehabilitation 718-405-8471<br />
Electrodiagnosis<br />
Moses Division 718-920-4083<br />
Blondell Avenue 718-405-8410<br />
Interventional Physiatry & Pain Management 718-405-8410<br />
Pediatric Rehabilitation 718-920-4133<br />
Intraoperative Monitoring (Evoked Potentials) 718-904-4083<br />
Orthotics/Prosthetics<br />
Moses Division 718-920-4083<br />
Weiler Division 718-904-2296<br />
Physical and Occupational Therapy<br />
Moses Division 718-920-2287<br />
Weiler Division 718-904-2785<br />
Speech and Language Pathology 718-904-2786<br />
SURGERY<br />
Chairman 718-920-6287<br />
Thanjavur S. Ravikumar, MD<br />
718-798-1883 Fax<br />
Residency Coordinator 718-920-5411<br />
Jackie Jiminez<br />
718-798-1883 Fax<br />
<strong>Medical</strong> Student 3rd year Clerkship Director 718-920-5490<br />
Michael Menack, MD<br />
718-798-1883 Fax<br />
MOSES DIVISION<br />
111 East 210th Street<br />
Bronx, New York 10467<br />
MAP 4<br />
Chief of Surgery<br />
Surgical Oncology 718-920-6287<br />
Thanjavur S. Ravikumar, MD<br />
718-798-1883 Fax<br />
86
Pediatric Surgery 718-920-7200<br />
Burton Harris, MD<br />
718-547-2929 Fax<br />
Vascular Surgery 718-920-4108<br />
Takao Ohki, MD<br />
718-231-9811 Fax<br />
Transplant Surgery 718-920-4718<br />
Vivian Tellis, MD<br />
718-547-4773 Fax<br />
Head & Neck Surgery 718-920-4308<br />
Carl Silver, MD<br />
718-798-1883 Fax<br />
Critical Care 718-920-5653<br />
Cordelia Sharma, MD<br />
718-798-1883 Fax<br />
Bariatric Surgery 718-920-6228<br />
Julio Teixeira, MD<br />
718-798-1883 Fax<br />
<strong>Medical</strong> Student Site Coordinator 718-920-5653<br />
Michael Menack, MD<br />
718-798-1883 Fax<br />
WEILER DIVISION<br />
1825 Eastchester Road, Suite 2S-5<br />
Bronx, New York 10461<br />
Chief of Surgery 718-904-2260<br />
Alan White, MD<br />
718-904-4183 Fax<br />
Surgical Oncology 718-904-3517<br />
Thomas Weber, MD<br />
718-904-3099 Fax<br />
Vascular Surgery 718-405-3230<br />
Reese Wain, MD<br />
718-405-8253 Fax<br />
Pediatric Surgery: 718-405-8241<br />
Gerard Weinberg, MD<br />
718-405-8292 Fax<br />
<strong>Medical</strong> Student Site Director: 718-405-8239<br />
John Hodgson, MD<br />
718-405-8292 Fax<br />
JACOBI<br />
Bronx Municipal Hospital Center (Jacobi)<br />
Pelham Parkway South and Eastchester Road<br />
Bronx, New York 10461<br />
Chief of Surgery 718-918-5565<br />
87
Harry Delany, MD<br />
718-918-5567 Fax<br />
Trauma Surgery/Critical Care: 718-918-5598<br />
Ronald Simon, MD<br />
718-918-5593 Fax<br />
Breast Center 718-918-5588<br />
Cynthia Jones, MD<br />
718-918-5593 Fax<br />
Pediatric Surgery: 718-405-8241<br />
Gerard Weinberg, MD<br />
718-405-8292 Fax<br />
<strong>Medical</strong> Student Coordinator 718-918-5588<br />
Cynthia Jones, MD<br />
718-918-5593 Fax<br />
NORTH CENTRAL BRONX<br />
North Center Bronx Hospital NCB<br />
3424 Kossuth Avenue<br />
Bronx, New York 10467<br />
Chief of Surgery: 718-519-3928<br />
Lawrence Bizer, MD<br />
718-519-3022 Fax<br />
UROLOGY<br />
<strong>Medical</strong> Arts Pavilion - 5th floor<br />
Chairman &<br />
Residency Program Director<br />
Arnold Melman, MD 718-920-5402<br />
Administrator<br />
Phyllis Markic 718-920-6245<br />
88
SECTION V<br />
•<br />
POLICIES AND PROCEDURES<br />
89
PATIENTS’ BILL OF RIGHTS<br />
As a patient in a hospital in New York State, you have the right, consistent with law, to:<br />
1. Understand and use these rights. If for any reason you do not understand or you need help,<br />
the hospital MUST provide assistance, including an interpreter.<br />
2. Receive treatment without discrimination as to race, color, religion, sex, national origin,<br />
disability, sexual orientation or source of payment.<br />
3. Receive considerate and respectful care in a clean and safe environment free of unnecessary<br />
restraints.<br />
4. Receive emergency care if you need it.<br />
5. Be informed of the name and position of the doctor who will be in charge of your care in the<br />
hospital.<br />
6. Know the names, positions and functions of any hospital staff involved in your care and<br />
refuse their treatment, examination or observation.<br />
7. A no smoking room.<br />
8. Receive complete information about your diagnosis, treatment and prognosis.<br />
9. Receive all the information that you need to give informed consent for any proposed<br />
procedure or treatment. This information shall include the possible risks and benefits of the<br />
procedure or treatment.<br />
10. Receive all the information you need to give informed consent for an order not to resuscitate.<br />
You also have the right to designate an individual to give this consent for you if you are too<br />
ill to do so. If you would like additional information, please ask for a copy of the pamphlet<br />
"Do Not Resuscitate Orders -- A Guide for Patients and Families."<br />
11. Refuse treatment and be told what effect this may have on your health.<br />
12. Refuse to take part in research. In deciding whether or not to participate, you have the right<br />
to a full explanation.<br />
13. Privacy while in the hospital and confidentiality of all information and records regarding<br />
your care.<br />
14. Participate in all decisions about your treatment and discharge from the hospital. The hospital<br />
must provide you with a written discharge plan and written description of how you can<br />
appeal your discharge.<br />
15. Review your medical record without charge. Obtain a copy of your medical record for which<br />
the hospital can charge a reasonable fee. You cannot be denied a copy solely because you<br />
cannot afford to pay.<br />
16. Receive an itemized bill and explanation of all charges.<br />
17. Complain without fear of reprisals about the care and services you are receiving and to have<br />
the hospital respond to you and if you request it, a written response. If you are not satisfied<br />
with the hospital's response, you can complain to the New York State Health Department.<br />
The hospital must provide you with the Health Department telephone number.<br />
18. Authorize those family members and other adults who will be given priority to visit<br />
consistent with your ability to receive visitors.<br />
19. Make known your wishes in regard to anatomical gifts. You may document your wishes in<br />
your health care proxy or on a donor card, available from the hospital.<br />
PROTECTED HEALTH INFORMATION USES AND DISCLOSURES<br />
Administrative Policy and Procedure JH41.1<br />
90
Note: This summary contains key points of this policy and the related procedures. For a<br />
complete understanding of all the relevant provisions, it is necessary to thoroughly read the full<br />
policy.<br />
WHAT:<br />
<strong>Montefiore</strong> <strong>Medical</strong> Center (MMC) will comply with applicable legal and regulatory<br />
requirements the management of Protected Health Information (PHI). The policy establishes<br />
rules, which MMC will follow when using and disclosing the PHI of its patients. All MMC<br />
Associates are required to maintain the confidentiality and privacy of PHI in accordance with the<br />
Health Insurance Portability and Accountability Act of 1996 (HIPAA). MMC will not use or<br />
disclose PHI except as permitted by the privacy regulations.<br />
Protected Health Information (PHI) is generally defined by HIPAA as information in any<br />
form or medium (including oral, written and electronic communications), that:<br />
• Is created or received by a health plan, health care provider, health care clearinghouse<br />
or an employer<br />
• Relates to an individual’s physical or mental health, the provision of health care to an<br />
individual, or the payment for the provision of health care to an individual<br />
• Identifies, or could reasonably expected to be used to identify an individual<br />
Protected Health information includes everything from a patient’s name, address and telephone<br />
number to a patient’s clinical and billing records.<br />
WHO:<br />
This policy applies to all <strong>Montefiore</strong> <strong>Medical</strong> Center <strong>Staff</strong> Associates<br />
WHEN:<br />
The policy applies to all Protected Health Information (PHI) collected, maintained, used and<br />
disclosed by <strong>Montefiore</strong> <strong>Medical</strong> Center. MMC may use and disclose protected health<br />
information for purposes of treatment, payment and health care options.<br />
HOW:<br />
• MMC Joint Privacy Notice<br />
All individuals seeking services at MMC have the right to receive an MMC Joint Notice of<br />
Privacy Practices that contains information relating to 1. the uses and disclosures of PHI to be<br />
made by MMC, 2. The individual’s right’s relating to his/her PHI, and 3. MMC’s legal duties<br />
with respect to PHI.<br />
The Privacy Notice will be provided to individuals during their first direct encounter for<br />
service at MMC. Notices will be available at all registration and admission points within MMC,<br />
and posted in clear and prominent locations where it is reasonable to expect individuals seeking<br />
service to be able to read the notice. The notice can also be provided electronically upon<br />
request.<br />
MMC will obtain written acknowledgements from individuals attesting to the fact that a<br />
Privacy Notice has been provided to them.<br />
When MMC has an indirect treatment relationship with its patients, MMC need only make<br />
Privacy Notice available upon request and a signed acknowledgement is not required.<br />
91
MMC must permit an individual the right to request restrictions relating to uses or disclosures of<br />
PHI about the individual to carry out treatment, payment or health care operations. When<br />
possible, the request should be submitted in writing.<br />
MMC will accommodate reasonable requests from individuals to receive communications of PHI<br />
by alternative means or alternative locations. Requests should be submitted in writing.<br />
CONTACT<br />
Privacy Officer 718-920-4728<br />
ADVANCED DIRECTIVES- HEALTH CAR PROXIES AND LIVING WILLS<br />
Administrative Policy and Procedure JH41.1<br />
Note: This summary contains the key points of this policy. For a complete understanding of all<br />
the relevant provisions, it is necessary to thoroughly read the full policy.<br />
WHAT:<br />
Advance directives are written or oral health care wishes expressed by a person with decisional<br />
capacity. Providers are legally and ethically bound to refer to advance directives when decisions<br />
must be made for patients without the capacity to make them. Advance directives take two<br />
forms:<br />
• Health care proxy is a person’s legal appointment of another individual (health care agent) to<br />
make health care decisions on the person’s behalf in the event of subsequent incapacity.<br />
• Living will is a list of instructions about interventions the person would consent to or refuse<br />
under specified circumstances.<br />
WHO:<br />
• All patients over 18 years of age, regardless of health status, should be encouraged to appoint<br />
a health care agent.<br />
• Any person 18 years or older may appoint a health care proxy, create a living will and/or be a<br />
health care agent.<br />
• A health care agent is specifically chosen and legally appointed by a capacitated person.<br />
Family, even next-of-kin, may not automatically make many important decisions for their<br />
loved ones unless they are legally appointed health care agents.<br />
• An attending physician makes the clinical determination of decisional incapacity, which<br />
triggers the provisions of an advance directive.<br />
• When a health care agent will make decisions about foregoing life-sustaining treatment, the<br />
determination of patient incapacity must be confirmed by a second attending physician.<br />
WHEN:<br />
Adult patients, even those with advance directives, are presumed able to make their own<br />
decisions unless and until they are clinically determined to lack decisional capacity. Advance<br />
directives take effect only when the patient has temporarily or permanently lost the capacity to<br />
make health care decisions. If and when patients regain capacity, they resume making their own<br />
health care decisions. Advance directives may be created at any time and remain effective until<br />
revoked by the patient or are superseded by new directives from the patient.<br />
92
WHERE:<br />
• Advance directives are applicable in any clinical or community setting.<br />
• Federal law requires that, upon admission to any health care facility, patients must be asked<br />
if they have advance directives and, if needed, offered assistance in completing them.<br />
• Copies of advance directives should be placed in the front of the medical record as soon as<br />
available.<br />
HOW:<br />
• If patients do not have advance directives, the directives should be explained and assistance<br />
offered in completing them. The appointment of health care proxy agents and alternate<br />
agents should be encouraged.<br />
• Health care proxy appointments are witnessed by two adults, neither of whom is the patients<br />
health care agent or alternate. Associates or <strong>Medical</strong> <strong>Staff</strong> may serve as witnesses.<br />
• Health care proxy forms with instructions are available on every clinical unit, in the<br />
admissions office, through Social Services and the Customer Services Department.<br />
• Referrals to Social Services should be made for additional assistance completing proxy form,<br />
for specific questions about advance directives, and for follow-up of advance directive<br />
documentation not available on admission.<br />
• Complex cases involving advance directives may be referred to Bioethics, Office of the<br />
<strong>Medical</strong> Director or Palliative Care.<br />
• Copies of Making Health Care Decisions for Others: A Guide to Being a Health Care Proxy<br />
or Surrogate and A Quick Reference for Physicians are also available from Social Services or<br />
Bioethics.<br />
CONTACT:<br />
Social Services 718- 920-4545<br />
Bioethics (Moses) 718- 920-6226<br />
(Weiler) 718- 904-2299<br />
Palliative Care 718-920-6378<br />
Office of the <strong>Medical</strong> Director 718- 920-7052; 2809l; 6078.<br />
BRAIN DEATH<br />
Summary - Administrative Policy and Procedure # JD01.1<br />
Note: This summary contains the key points of this policy. For a complete understanding of all<br />
the relevant provisions, it is necessary to thoroughly read the full policy.<br />
WHAT:<br />
A person (adult or child) is considered to be physiologically and legally dead when he or she has<br />
sustained either:<br />
• cardiopulmonary death (irreversible cessation of circulatory and respiratory function) or<br />
93
• brain death (irreversible cessation of all functions of the entire brain, including the brain<br />
stem).<br />
The brain death protocol provides a process, including criteria, for determining and confirming<br />
brain death and implementing the necessary procedures.<br />
WHO:<br />
• Any adult or pediatric patient who has been determined by clinical examination to have lost<br />
all brain function is an appropriate candidate for a confirmatory brain death protocol.<br />
• The clinical determination of brain death is made by two designated attendings, at least one<br />
of whom is from the Department of Neurology or Neurosurgery. The second attending may<br />
be from the Department of Critical Care Medicine. When the patient is less than one year<br />
old, the clinical determination of brain death is made by a pediatric neurologist or<br />
neurosurgeon.<br />
WHEN:<br />
The brain death protocol applies whenever a patient appears clinically to have lost brain<br />
function.<br />
WHERE:<br />
The brain death protocol is applicable in any inpatient clinical setting and emergency room.<br />
HOW:<br />
The brain death protocol includes:<br />
• discussion with family<br />
• initial assessment by either neurology/neurosurgery or critical care attending<br />
• referral to New York Organ Donor Network<br />
• ancillary studies, if considered indicated by attending<br />
• special observation requirements in pediatric cases<br />
• confirmatory brain death determination by either neurology/neurosurgery or critical care<br />
attending<br />
• pronouncement of death<br />
• medical record documentation<br />
• informing family of patient=s death<br />
• maintaining organs if patient is a potential donor<br />
• withdrawing life-supporting interventions<br />
• assisting and supporting family by provision of Chaplaincy services or through Palliative<br />
Care and/or Bioethics Consults.<br />
• Brain death criteria that must be met include but are not limited to:<br />
• absence of confounding drug levels<br />
• cerebral unresponsiveness<br />
• apnea testing, if appropriate<br />
• electro-cerebral silence (as needed for confirmation or as required when patient is less than<br />
one year)<br />
• Reasonable accommodation in cases of objection to a brain death declaration are appropriate<br />
when<br />
94
• family has moral or religious objections to brain death definition or determination.<br />
• clinical staff has conscientious objection to brain death definition or determination.<br />
CONTACT:<br />
Neurology 718- 920-6444<br />
Neurosurgery 718- 920-4196<br />
<strong>Medical</strong> Director 718- 920-7052; 6078<br />
DO-NOT-RESUSCITATE (DNR) ORDERS<br />
Summary - Administrative Policy and Procedure # JA11.1<br />
Note: This summary contains the key points of this policy. For a complete understanding of all<br />
the relevant provisions, it is necessary to thoroughly read the full policy.<br />
WHAT:<br />
A do-not-resuscitate (DNR) order is a consent to forego all or part of cardiopulmonary<br />
resuscitation in the event of a cardiac and/or respiratory arrest. A DNR order does not affect or<br />
limit any other care and can be consistent with aggressive treatment. In a cardiac and/or<br />
pulmonary arrest, a DNR order permits withholding both intubation and other components of<br />
CPR.<br />
NOTE: Do-not-intubate (DNI) orders are distinct from DNR orders. In a cardio-pulmonary<br />
arrest, a separate DNI order is not needed. Refer to Policy JDO5.1 for complete information on<br />
DNI orders.<br />
WHO:<br />
• Suitable patients for DNR orders are those who are unlikely to survive or benefit from<br />
resuscitation in the event of a cardiopulmonary arrest.<br />
• Suitable patients with capacity should be approached for consent to a DNR order.<br />
• Suitable patients without capacity should have consent to a DNR order given either by an<br />
appointed health care agent or a DNR surrogate (see list of authorized surrogates) based on<br />
one of the four specified medical conditions (see below).<br />
• The patient’s attending physician determines suitability and decisional capacity, obtains<br />
consent and writes the DNR order and notifies the patient or surrogate that the order has been<br />
written.<br />
• A determination by the attending that the patient lacks capacity must be confirmed by a<br />
second attending. The second attending also concurs that an incapacitated patient without a<br />
health care agent meets one of the four specified medical conditions (see below).<br />
• <strong>House</strong> staff may obtain consent and enter a temporary DNR order after discussion with the<br />
attending, who should countersign the order or enter a standing order on CIS within 24 hours.<br />
• <strong>Medical</strong> director or designee must review, document and sign a DNR order based on medical<br />
futility for patients who meet one of the two specified criteria, have no advance directives or<br />
known wishes, no willing/available surrogate, and no family objecting to a DNR order.<br />
95
Patients for whom a DNR based on medical futility is appropriate must meet, one of the<br />
following criteria:<br />
• the patient will not survive a code, or<br />
• the patient will experience multiple arrests in a short period of time.<br />
WHEN:<br />
DNR applies only at the time of cardiac and/or pulmonary arrest and does not affect or limit any<br />
other care.<br />
WHERE:<br />
• DNR orders are valid in every inpatient clinical setting.<br />
• Non-hospital DNR orders are valid in any community or ambulatory care setting.<br />
• Suspension of a DNR order in the OR or other department must be discussed with a<br />
capacitated patient or the health care agent or DNR surrogate of a patient without capacity.<br />
Before a DNR order is suspended for a procedure in the OR or other department, the reasons<br />
for and duration of the suspension must be discussed with the person giving consent. The<br />
decision must be documented by both the attending surgeon and attending anesthesiologist<br />
and their agreement with patient, agent or surrogate fully communicated to the health care<br />
team.<br />
HOW:<br />
The DNR protocol includes documenting on the appropriate forms (see below)::<br />
• determination of patient suitability<br />
• determination of patient’s decisional capacity<br />
• discussion with patient, health care agent or surrogate<br />
• obtaining verbal or written consent to DNR. Verbal consent must be documented<br />
and witnessed by 2 people.<br />
• entering DNR order in the medical record or on CIS<br />
• notification of patient, health care agent or surrogate<br />
If the patient lacks decisional capacity, a DNR order may only be consented to by a health care<br />
agent or DNR surrogate based on one of the following 4 criteria:<br />
• terminal condition, or<br />
• permanent unconsciousness, or<br />
• medical futility (patient would not survive resuscitation or<br />
• would survive but would have multiple arrests within a short period of time (see<br />
above), or extraordinary burden (CPR would cause more harm than benefit).<br />
DNR forms are available on all clinical units<br />
• OD1091-1 DNR Attending Physician’s Documentation (3 pages-pink)<br />
• OD1091-2 Oral Consent to DNR Order (single page-pink, requires 2 witnesses, one<br />
of whom is a physician)<br />
• OD1091-3 Written Consent to DNR Order (single page-pink- for<br />
patient’s/surrogate’s, in English & Spanish )<br />
96
• OD1091-4 Affidavit of Close Friend consenting to DNR (single page-pink-- in<br />
English Spanish )<br />
• OD1091-5 Nonhospital DNR (single page-white--order for ambulatory care and<br />
community settings.<br />
Note: After completing the appropriate forms, the attending physician must enter a written or<br />
electronic DNR order.<br />
Disputes about DNR orders for incapacitated patients trigger a dispute mediation process, during<br />
which the DNR is suspended and resuscitation must be attempted in the event of an arrest. When<br />
the patient’s attending physician has a conscientious objection to issuing a DNR order for a<br />
suitable patient, that physician must transfer the patient to another attending.<br />
CONTACT:<br />
<strong>Medical</strong> Director’s Office 718- 920-7052<br />
Palliative Care 718- 920-6378<br />
Bioethics (Moses) 718- 920-6226<br />
(Weiler) 718- 904-2299<br />
DO-NOT-INTUBATE (DNI) ORDERS<br />
Summary -Administrative Policy and Procedure #JD05.1<br />
Note: This summary contains the key points of this policy and the related procedures. For a<br />
complete understanding of all the relevant provisions, it is necessary to thoroughly read the<br />
full policy.<br />
WHAT:<br />
• In a cardiopulmonary arrest a DNR order permits withholding both intubation and other<br />
components of CPR. A separate DNI order is not needed.<br />
• In situations other than an arrest, such as acute respiratory distress, a separate DNI order is<br />
necessary to forego intubation.<br />
In practice, many patients will request and will meet the conditions for both DNR and DNI<br />
orders but the criteria for consenting to and implementing them are very different.<br />
NOTE: Do-not-intubate (DNI) orders are distinct from do-not-resuscitate (DNR) orders and,<br />
therefore, are covered under a separate do-not-intubate (DNI) policy.<br />
WHO:<br />
A DNI order may be considered for :<br />
• a capacitated patient whose attending physician determines that a do-not-intubate (DNI)<br />
order is medically indicated and recommends this course, or<br />
• an incapacitated patient whose attending determines that a DNI order is medically<br />
indicated and recommends this course to the health care agent or the family/ surrogate<br />
who knows the patient’s wishes about intubation; or<br />
97
• A patient, agent or other family/surrogate who requests that intubation be foregone in<br />
light of the patient’s medical condition and known wishes.<br />
• A capacitated patient, after discussion with the attending physician, may consent to<br />
foregoing intubation or re-intubation for present or future moderate-to-severe respiratory<br />
distress or under any future circumstance.<br />
A DNI order may be written for an incapacitated patient who has been determined by the<br />
attending and concurring attending physicians to lack capacity and for whom a DNI is medically<br />
indicated, in the following circumstances:<br />
• a health care agent for an incapacitated patient may consent to foregoing intubation or reintubation<br />
for present or future moderate-to-severe respiratory distress or under any<br />
future circumstance, or<br />
• a family member or other surrogate who knows the patient’s wishes about intubation<br />
may also consent to foregoing intubation or re-intubation for present or future moderate<br />
to severe respiratory distress. The family/surrogate must have fully discussed the<br />
patient’s prior declared treatment choices and best interests with the attending physician<br />
and agreed to a DNI order.<br />
WHEN:<br />
• The patient’s condition and prognosis are so poor that intubation or re-intubation is likely to<br />
merely prolong dying or increase suffering without providing substantial benefit and<br />
• the capacitated patient chooses to forego intubation, or<br />
• the incapacitated patient’s proxy chooses to forego intubation, or<br />
• the surrogate/family provides evidence of the incapacitated patient’s prior wishes to forego<br />
intubation.<br />
WHERE:<br />
• DNI orders to forego intubation may be appropriate in any clinical setting.<br />
• Efforts will be made to communicate decisions to forego intubation/DNI orders to nonhospital<br />
facilities and providers.<br />
HOW:<br />
Foregoing intubation in situations other than cardiopulmonary arrest requires consent by:<br />
• A capacitated patient or a health care agent or other surrogate for an incapacitated patient<br />
who has had a documented discussion with the attending physician about the patient’s<br />
intubation wishes.<br />
• The attending physician’s DNI Documentation form (OD1080-1) and the Patient’s<br />
/Surrogate’s Consent to DNI form (OD1080-2) are available on all clinical units.<br />
After completing the DNI documentation form, the attending must enter a written or<br />
electronic DNI order.<br />
CONTACT:<br />
Office of the <strong>Medical</strong> Director 718- 920-7052, -2809, -6078<br />
Palliative Care 718- 920-6378<br />
98
Bioethics (Moses) 718- 920-6226<br />
(Weiler) 718- 904-2299<br />
END-OF-LIFE CARE<br />
Summary - Administrative Policy and Procedure # JD04.1<br />
Note: This summary contains the key points of this policy. For a complete understanding of<br />
all the relevant provisions, it is necessary to thoroughly read the full policy.<br />
WHAT:<br />
End-of-life care includes therapeutic interventions that meet the medical, spiritual, socio-cultural<br />
and emotional needs of patients with active, progressive far-advanced disease whose disease is<br />
not responsive to curative treatment. These measures have as their goal maximizing comfort and<br />
function, enhancing the quality of remaining life, and supporting the patient’s family.<br />
WHO:<br />
All members of the health care team are responsible for providing compassionate, skillful and<br />
responsive end-of-life care. In addition, palliative care specialists should be consulted about the<br />
management of pain and other symptoms.<br />
WHEN:<br />
End-of-life care is appropriate whenever cure is no longer the primary goal, and the patient is in<br />
the late stages of incurable illness.<br />
WHERE<br />
End-of-life care is appropriate in any clinical or community setting.<br />
HOW:<br />
Every effort should be made to identify as early as possible those patients who would benefit<br />
from aggressive attention to end-of-life needs. These include but are not limited to:<br />
• facilitating advance care planning<br />
• controlling pain and other symptoms;<br />
• meeting spiritual needs<br />
• providing emotional support to patients and family in coping with progressive illness,<br />
loss of function and the attendant anxiety and stress;<br />
• resolving ethical concerns<br />
• clarifying the goals of care, including all available supportive and comfort care options<br />
• enhancing the quality of the patient’s remaining life and the dying process;<br />
• addressing cultural, spiritual and emotional concerns and decisions related to end-of-life,<br />
including foregoing treatment and organ donation; and<br />
• supporting patients, families and care providers as they face loss and bereavement.<br />
CONTACT:<br />
Palliative Care 718-920-6378<br />
99
Bioethics (Moses) 718-920-6226<br />
(Weiler) 718-904-2299<br />
Office of the <strong>Medical</strong> Director 718-920-7052; 2809; 6078<br />
FOREGOING LIFE-SUSTAINING TREATMENT<br />
Summary - Administrative Policy and Procedure # JA12.1<br />
Note: This summary contains the key points of this policy. For a complete understanding of all<br />
the relevant provisions, it is necessary to thoroughly read the full policy.<br />
WHAT:<br />
This policy delineates the roles of the physician and the members of the health care team in<br />
guiding patients, their health care agents, family or other surrogates in end-of-life decision<br />
making. In recommending and responding to decisions about foregoing (withholding or<br />
withdrawing) life-sustaining treatment, physicians and other clinicians should be guided by the<br />
following principles:<br />
• Physicians and other clinicians have no medical, legal or ethical obligation to offer or<br />
provide treatment(s) that are not medically indicated or to offer or provide treatment that<br />
would increase a patient’s suffering or merely prolong the dying process.<br />
• Any decision to forego life-sustaining or other medically indicated treatment(s) should<br />
trigger a process of discussion about the reasons for the decision, the consequences of<br />
foregoing treatment and the range of appropriate therapeutic options, including palliative<br />
care. A Palliative Care Medicine or a Bioethics consult and/or a family meeting may be<br />
helpful in clarifying the goals and plan of care.<br />
• Physicians caring for a patient who is terminally ill should discuss a palliative care plan or a<br />
time-limited course of supportive treatment (e.g., dialysis) with the capacitated patient or<br />
surrogate. These discussions should include a review of the patient’s condition and<br />
prognosis and the patient’s present (or prior) declared health choices.<br />
WHO:<br />
• The patient, family or anyone on the health care team may initiate a discussion about<br />
foregoing treatment.<br />
• The patient’s attending physician determines when foregoing treatment is medically<br />
indicated and recommends this course to the capacitated patient, or the health care agent or<br />
other surrogate who makes decisions for the incapacitated patient.<br />
WHEN:<br />
Foregoing life-sustaining treatment is appropriate whenever a patient’s condition and prognosis<br />
are such that one or more interventions are likely to merely prolong dying or increase suffering<br />
without providing substantial benefit.<br />
WHERE:<br />
Orders to forego life-sustaining treatment may be appropriate in any clinical setting.<br />
100
HOW:<br />
• Capacitated patients may refuse any treatment, including life-sustaining treatment.<br />
• Health care agents for incapacitated patients may customarily refuse life-sustaining treatment<br />
for the incapacitated patient. (See the policy for requirements.)<br />
• Most treatment decisions for incapacitated patients who do not have appointed health care<br />
agents are made by the attending physician in conjunction with the patient’s family or other<br />
surrogate. These include decisions not to initiate specific treatments that would not be<br />
medically indicated based on the patient’s condition and prognosis.<br />
• Family members may also request the foregoing of one or more life-sustaining interventions<br />
that are already underway (in particular, ventilatory support, ventricular assist devices,<br />
dialysis and/or artificial nutrition or hydration). This is done by providing information about<br />
the patient’s prior declared treatment wishes, indicating that the now-incapacitated patient<br />
would have chosen to forego life-sustaining treatment under the current circumstances. The<br />
Office of the <strong>Medical</strong> Director must be called to review the information provided by the<br />
family and the physician documentation of this process.<br />
• When a patient has no available or willing surrogate, life-sustaining treatment may be<br />
foregone if such interventions(s) would merely prolong the dying process or increase<br />
suffering. A Bioethics, Critical Care and/or Palliative Medicine consult may be helpful in<br />
determining an appropriate plan of care. The <strong>Medical</strong> Director’s Office must be contacted in<br />
these circumstances to coordinate multi-disciplinary review.<br />
• Parents and legal guardians of minor patients may decide to forego life-sustaining treatments.<br />
Pediatric Ethics, Bioethics, the Chief of Service, Palliative Care and/or the <strong>Medical</strong><br />
Director’s Office should be involved. Such decisions are made in the best interest of the<br />
child. Consideration is given to the wishes of the parent and the child. The child is included<br />
in the discussions, as appropriate.<br />
• DNI orders are written to forego intubation in any circumstance other than cardiopulmonary<br />
arrest. (See the Do-not-intubate (DNI) Policy for guidance in entering DNI orders for<br />
decisions to forego intubation or re-intubation for moderate to severe respiratory distress or<br />
any situation other than cardiopulmonary arrest).<br />
CONTACT:<br />
<strong>Medical</strong> Director 718-920-7052; 6078<br />
Bioethics (Moses) 718-920-6226<br />
(Weiler) 718-904-2299<br />
INFORMED CONSENT AND REFUSAL<br />
Administrative Policy and Procedure JC10.1<br />
Note: This summary contains key points of <strong>Montefiore</strong>'s consent policy. For complete<br />
understanding of all the relevant provisions. it is necessary to thoroughly read the full policy.<br />
WHEN<br />
Informed consent is required for all procedures or treatments that are invasive or have potentially<br />
serious side effects or complications. When a patient is a conscious and mentally capable adult,<br />
101
only that person may consent to treatment.<br />
WHO<br />
Obtaining informed consent from a patient is the responsibility of the attending physician<br />
performing the procedure. However, consent may be obtained by house staff or PAs as agents of<br />
the attending.<br />
WHAT<br />
The essential part of informed consent is a discussion that imparts to the patient all information<br />
concerning the procedure or treatment that a reasonably prudent person in the patient's position<br />
would want to know. The following information should be disclosed:<br />
• the nature of the patient's condition<br />
• the nature and purpose of the proposed procedure<br />
• the expected risks, benefits, and alternatives to the procedure. Serious risks, even if rare,<br />
should be disclosed.<br />
HOW<br />
• The informed consent discussion should be held in a language that the patient understands,<br />
using terms that a lay person would understand. If a translator is needed, obtain one from the<br />
MMC Language Bank. Family members should not be used as translators for an informed<br />
consent discussion.<br />
• After the informed consent discussion, the patient should be asked to sign the hospital<br />
consent form and the patient's signature should be witnessed by a hospital employee. The<br />
procedure should be described in terms a layperson can readily understand; no abbreviations<br />
should be used.<br />
• A note summarizing the discussion must then be written to reflect that the informed consent<br />
discussion has taken place. This note may be written in Section II on the consent form or in<br />
the progress notes. On the day of surgery, the attending physician must sign Section III of<br />
the consent form to confirm that it correctly describes the procedure.<br />
• If the patient lacks the capacity to consent, the physician should seek the informed consent of<br />
the patient's health care proxy, legal guardian or next of kin, in that order. However, if the<br />
patient lacks capacity and is actively refusing the procedure, Treatment cannot proceed. Risk<br />
Management (920-6340) must be contacted.<br />
• Administrative Review - In nonemergent situations, where the patient lacks the capacity to<br />
consent and is not refusing treatment but the patient has no known health care proxy, legal<br />
guardian or next of kin the <strong>Medical</strong> Director's office (920-6078)<br />
must be contacted.<br />
• Refusals - A patient with capacity may refuse any procedure but except for a health care<br />
proxy or legal guardian, no one may refuse necessary treatment on behalf of an incapable<br />
adult patient. Neither a parent nor a legal guardian may refuse lifesaving treatment for a child<br />
or mentally retarded adult. Risk Management should be contacted if these situations arise.<br />
• Emergencies -In an emergency, if the attempt to secure consent would seriously jeopardize<br />
the patient's life or health, the physician may proceed without obtaining consent but must<br />
document the nature of the emergency in the medical record.<br />
102
VERIFICATION OF OPERATIVE PROCEDURE SITE AND PATIENT<br />
IDENTIFICATION<br />
Patient Care <strong>Manual</strong>: Code O-4<br />
Note: This summary contains key points of this policy and the related procedures. For a<br />
complete understanding of all the relevant provisions, it is necessary to thoroughly read the full<br />
policy.<br />
WHAT:<br />
It is the responsibility of all associates involved in the care of the patient undergoing an<br />
operative/invasive procedure to verify the correct patient, procedure and procedure site. It is the<br />
Attending physician’s responsibility to document this verification process on the informed<br />
consent tool on the day of the procedure. This policy ensures that the correct surgery/procedure<br />
is performed at the correct side on the correct patient and eliminates wrong-side, wrong-site,<br />
wrong-patient, wrong-procedure surgery.<br />
WHO:<br />
• This policy applies to patients undergoing operative/invasive procedures<br />
• Attending physicians<br />
• All associates involved in the care of the patient undergoing the procedure<br />
WHEN:<br />
This policy applies to all operative and other invasive procedures that expose patients to more<br />
than minimal risk.<br />
WHERE<br />
This policy includes but is not limited to procedures done in settings other than the operating<br />
room, such as in special procedure units, endoscopy units, and interventional radiology units,<br />
procedures done at the bedside and those performed outside of the operating room (e.g.,<br />
ambulatory sites).<br />
HOW<br />
• Pre-operative/procedure verification process<br />
Prior to the start of the procedure confirm appropriate documents are available, have been<br />
reviewed and are consistent with the staff’s understanding of the patient, procedure and site.<br />
• Marking process<br />
The procedure site will be marked for invasive procedures involving right/left distinction,<br />
multiple structures, or levels. The Attending Physician, or designee will mark the site before the<br />
patient enters the procedure room and prior to the administration of medications with sedative<br />
effects, except in the case of minors or other patients with decision makers.<br />
• Final Verification Process (“Time Out”)<br />
Immediately prior to the start of any surgical/invasive procedure, a final verification “Time Out”<br />
will be conducted to confirm the correct patient, procedure and procedure site. The process will<br />
be initiated by the circulating nurse and take place between the circulating nurse, anesthesiologist<br />
and surgeon. Before the incision is made, each team member will verbally confirm the name of<br />
the patient, the planned procedure and the procedure site. If there are any discrepancies in<br />
103
information, or disagreements regarding the procedure, it will be delayed until the issues are<br />
resolved.<br />
DEATH CERTIFICATES<br />
• The Death Certificate has three sections. Section 1, “<strong>Medical</strong> Certification” and Section 3,<br />
“Physician's Confidential <strong>Medical</strong> Report” must be completed by the physician. Section 2,<br />
“Funeral Director' s Report”, must be completed by the Funeral Director. The Death<br />
Certificate should be completed in the Health Information Management where assistance for<br />
completion is available *Note: If the patient is a transsexual, the sex at birth is the official sex<br />
of the decedent regardless of sex change operations.<br />
• The Death Certificate must be completed in black ink only. No erasures, write-overs, or<br />
crossing out of information. Any evidence of abbreviation is unacceptable.<br />
• The Death Certificate must be completed with the name of the patient as registered at MMC.<br />
Any corrections to patient's name must be accompanied by written documentation.<br />
FIRE SAFETY AND PREVENTION<br />
In order to ensure safety and security, all associates are required to obey all applicable Center,<br />
City, State and Federal health, safety, and fire laws, rules and regulations. Information on fire<br />
alarm bells is posted throughout the <strong>Medical</strong> Center adjacent to all fire alarm boxes. Learn where<br />
the fire alarms are located and where the information is posted.<br />
In case of a fire, follow the R.A.C.E. (Rescue, Alarm, Confine, Extinguish) procedure.<br />
Fires can be called in by activating fire alarms or by dialing extension 2222. In order to<br />
safeguard the lives of patients and personnel and to reduce the loss of property, every staff<br />
member must recognize the importance of fire prevention and fire control. Four steps that should<br />
be followed by anyone discovering a fire in the hospital complex: R.A.C.E<br />
R: Remove from immediate danger anyone in close proximity to the fire or smoke<br />
A: Alarm - use one of the manual fire boxes located on each floor. Open the door of the<br />
alarm box. Pull the internal lever down once and release. The alarm should sound within<br />
five seconds. The staff member should dial the hospital's fire emergency number<br />
(X2222). The caller should give the operator the exact location of the fire.<br />
C: Confine the Fire- Close the door to the room which is on fire. Close doors to all other<br />
patient rooms in the area. Insure that all stairwells, laundry chutes and corridor smoke<br />
barrier doors are closed.<br />
E: If possible, steps should be taken to extinguish the fire by using the portable<br />
extinguishers located throughout the hospital. This step should not be attempted until the<br />
first three steps have been completed. To operate a portable extinguisher, you do the<br />
following:<br />
P – Pull the locking pin from the handle<br />
A – Aim the hose at the base of the fire<br />
S – Squeeze the handle<br />
S – Sweep the hose from side-to-side at the base of the fire.<br />
104
INFECTION CONTROL PROGRAM<br />
Moses Nurses (718) 920 - 4562<br />
Weiler Nurses (718) 904 – 3422<br />
The goal of the Infection Control Program is to prevent and control the spread of infections<br />
between patients, personnel and visitors. The Infection Control Committee is a standing<br />
multidisciplinary committee of the hospital staff, which meets regularly to discuss problems and<br />
solutions related to controlling infections.<br />
Every department that has direct or indirect patient contact has a manual specific to the<br />
department. <strong>House</strong> staff Infection Control Handbooks are distributed during house staff<br />
orientation and upon request. It is the responsibility of every associate to become familiar with<br />
the contents of their handbook which contain the standards of infection control practice.<br />
Infection Control Nurses are responsible for establishing, implementing and monitoring infection<br />
control practices throughout the hospital and ambulatory sites. Standard Precautions are<br />
protocols that must be used for every interaction between any patient and health care worker.<br />
These general protocols are designed to prevent the bi-directional transmission of disease<br />
between patients and health care workers.<br />
Fundamental principles of Standard Precautions include proper hand hygiene (using soap and<br />
water, or alcohol based hand rub agents between all patient encounters) and the appropriate<br />
cleaning of patient care areas and equipment between patient encounters. Standard Precautions<br />
also addresses issues related to the potential exposure and transmission of bloodborne pathogens<br />
during patient and health care worker interactions and requires the appropriate use of Personal<br />
Protective Equipment (PPE), and patient equipment use during invasive procedures.<br />
Detailed information regarding infection control practice at <strong>Montefiore</strong> <strong>Medical</strong> Center<br />
(restricted antibiotics, protocols for invasive procedures, isolation procedures, etc.) will be<br />
provided to you in a separate <strong>House</strong> <strong>Staff</strong> Infection Control Handbook.<br />
NEEDLE STICKS<br />
The following practices may be useful in preventing needle sticks:<br />
• Use and properly dispose of all safety needle stick prevention devices. Activate the safety<br />
mechanism of the device directly after use (if applicable).<br />
• Dispose of needles properly in puncture-resistant containers<br />
• Avoid rushing when using a needle in caring for an uncooperative patient<br />
• Seek assistance when using a needle in caring for an uncooperative patient<br />
• Avoid pulling hard when encountering resistance in withdrawing needles from patients<br />
• Never put needles into your pocket.<br />
• Never try to remove anything from a needle container or force needles into a full container<br />
• Pick up improperly discarded needles with care and dispose of them in puncture-resistant<br />
containers<br />
• Discuss your concerns for prevention with colleagues. This can be useful step toward the<br />
implementation of effective preventive strategies.<br />
105
• If you are not already immunized against hepatitis B and are at high risk for needle stick<br />
injury or other exposure to blood and other potentially infectious bodily fluids, get<br />
vaccinated.<br />
What to do if you are stuck<br />
• Wash the injury well with soap and water as soon as possible<br />
• If known, write down the name, site and hospital number of the source patient<br />
• Report the stick to Occupational Health Service. You will be scheduled for assessment, and if<br />
necessary for appropriate counseling, treatment and follow-up procedures. If your injury<br />
occurs during night or weekend hours, you should contact the Emergency Room.<br />
ETHICAL AND LEGAL COMPLIANCE<br />
Employees, <strong>House</strong> <strong>Staff</strong> and <strong>Medical</strong> <strong>Staff</strong> members are to exercise sound judgment and the<br />
utmost good faith, care and diligence in all matters relating to their duties and responsibilities to<br />
<strong>Montefiore</strong>, guided by the highest standards of medical and business ethics.<br />
Employees and others performing services for <strong>Montefiore</strong> are to comply with all legal<br />
requirements in the performance of duties on behalf of <strong>Montefiore</strong>, as are <strong>House</strong> <strong>Staff</strong> members<br />
in the course of their training and medical staff members in their professional activities on the<br />
medical staff. Violations of law and the <strong>Montefiore</strong>'s high ethical standards are unacceptable and<br />
will not be tolerated in any clinical, academic or organizational activities conducted under the<br />
authority or on behalf of <strong>Montefiore</strong> <strong>Medical</strong> Center. Accordingly, associate employment, house<br />
staff training programs, and medical staff membership and privileges are conducted in ways that<br />
are consistent with applicable laws and ethical standards.<br />
<strong>Montefiore</strong>'s policy is to prevent, detect and terminate activity that involves fraud or<br />
other violation of law or that otherwise breaches the <strong>Montefiore</strong>'s ethical standards and the<br />
<strong>Montefiore</strong> Code of Ethics. Violations of <strong>Montefiore</strong>'s ethical standards, including criminal<br />
conduct or other violations of legal requirements, will not be tolerated and will result in<br />
appropriate disciplinary measures. <strong>Montefiore</strong>'s policy is to report violations of criminal laws to<br />
the appropriate law enforcement authorities, and to cooperate with law<br />
enforcement agencies.<br />
Employees, <strong>House</strong> <strong>Staff</strong> and members of the <strong>Medical</strong> <strong>Staff</strong> should carefully read<br />
educational information provided by <strong>Montefiore</strong>, and participate in any other training provided<br />
and required by <strong>Montefiore</strong>, regarding legal requirements applicable to their area of<br />
responsibility or activities. They should be familiar with <strong>Montefiore</strong>'s administrative and<br />
personnel policies and procedures applicable to them and to their activities (including but not<br />
limited to members of the medical staff, the <strong>Medical</strong> <strong>Staff</strong> Bylaws and Rules & Regulations and<br />
policies of the <strong>Medical</strong> <strong>Staff</strong>) and shall consult these materials as needed in the performance of<br />
their duties to assure that their conduct complies with them.<br />
<strong>Montefiore</strong> encourages reporting of any activity believed in good faith to constitute an<br />
ethical or legal violation. Reporting may be made to one's training director or supervisor or to a<br />
higher person in his or her chain of command, to the Department of Audit Services, or to others<br />
who may be identified in pertinent <strong>Montefiore</strong> policies.<br />
Reports will be handled in confidence, and will only be disclosed on a need-to-know basis in<br />
order to investigate and resolve the matter, or as required by law. <strong>Montefiore</strong> will protect those<br />
who make such reports in good faith from retaliation based on such good faith reporting. Any<br />
106
person who feels that he/she may be the subject of such retaliation should immediately contact<br />
the Department of Audit Services or a Vice President in the Department of Human Relations.<br />
Malicious, knowing, false reporting, or making a false report with reckless disregard for the<br />
truth, will result in appropriate disciplinary measures.<br />
HARASSMENT<br />
<strong>Montefiore</strong> <strong>Medical</strong> Center is committed to providing a work environment free of discrimination<br />
and unlawful harassment. Actions, words, jokes or comments based on an individual's sex,<br />
sexual orientation, race, ethnicity, age, religion or any other legally protected characteristic will<br />
not be tolerated. Such conduct is demeaning to another person, undermines the integrity of the<br />
employment relationship, and is strictly prohibited. This conduct is unlawful regardless of<br />
whether it is committed by a supervisor or coworker, or a third party vendor, customer,<br />
independent contractor or staff member not employed by the <strong>Medical</strong> Center.<br />
Sexual harassment is one of the forms of harassment prohibited by this policy.<br />
Specifically, the law defines sexual harassment as any unwelcome sexual advances or requests<br />
for sexual favors or any conduct of a sexual nature when:<br />
• submission to such conduct is made either explicitly or implicitly a term or condition of an<br />
individual's employment<br />
• submission to or rejection of such conduct by an individual is used as the basis of<br />
employment decisions affecting such individual, or<br />
• such conduct has the purpose or effect of substantially interfering with an individual's work<br />
performance or creating an intimidating, hostile or offensive working environment<br />
The first two categories are commonly referred to as "quid pro quo" harassment, and the third<br />
category is referred to as "hostile environment" harassment.<br />
Sexual harassment may include, but is not limited to:<br />
• Repeated offensive or unwelcome touching<br />
• Sexual flirtations or advances<br />
• Verbal abuse or comments of a sexual nature, whether in the form of jokes, innuendoes or<br />
slurs<br />
• Graphic verbal commentaries used to describe a person or about a person's body<br />
• Display of sexually suggestive material in the form of photographs, drawings, graffiti or<br />
computer graphics<br />
• Other offensive physical, verbal or visual conduct<br />
Individuals knowing of or experiencing any form of unlawful harassment are urged to report any<br />
incidents to their supervisor or, if they are not comfortable contacting their supervisor, they<br />
should contact the EEO Officer in the Human Resources Department at (718) 920-4998 or fax<br />
(718) 920-6321.<br />
Reports of harassment may be made without fear of reprisal. Complaints of unlawful harassment<br />
will be investigated by the <strong>Medical</strong> Center's EEO Officer or his/her designee. All complaints will<br />
be fully and promptly investigated and, where necessary, appropriate<br />
action will be taken. All information disclosed in the procedure will be held in confidence and<br />
will only be disclosed on a need to-know basis in order to investigate and resolve the matter. A<br />
107
supervisor or other member of management who has knowledge of a hostile or offensive work<br />
environment resulting from unlawful harassment, either because he/she has observed the<br />
harassment or received a complaint from a victim or observer, must immediately contact the<br />
<strong>Medical</strong> Center's EEO Officer to inform the EEO Officer<br />
of the complaint and seek assistance on how to proceed. He/she should not undertake a formal<br />
independent investigation of the complaint without first consulting the EEO officer or his/her<br />
designee.<br />
Any associate deemed to have engaged in unlawful harassment against another associate will be<br />
subject to disciplinary action, up to and including termination. Also, any false accusations will<br />
result in appropriate discipline of the accuser, up to and including termination. In the event an<br />
associate is relieved from duty pending investigation of sexual harassment charges and no<br />
misconduct is established, the alleged harasser will return to work with pay retroactive to the<br />
date of suspension.<br />
All <strong>Medical</strong> Center Human Resources policies and practices are guidelines and may be changed,<br />
modified or discontinued at any time by the <strong>Medical</strong> Center's senior Human Resources executive<br />
or designee, with or without notice. Exceptions do not invalidate the<br />
basic policy.<br />
DRUG-FREE WORKPLACE<br />
The federal Drug Free Workplace Act of 1988 pertains to <strong>Montefiore</strong> <strong>Medical</strong> Center and all of<br />
our associates. The unlawful manufacture, distribution, dispensation, possession or use of a<br />
controlled chemically substance is prohibited in the <strong>Medical</strong> Center. Any associate who violates<br />
this provision is subject to termination. If you are convicted of any criminal drug offense<br />
(defined as any finding of guilt, plea of no contest or imposition of sentence), you must notify<br />
your department head within 5 days of conviction. The Employee Assistance Program (EAP)<br />
provided by Occupational Health Services is available to you if you need drug counseling or<br />
rehabilitation. The treatment is provided in the strictest confidentially. Participation in EAP does<br />
not exempt you from complying with the above requirements.<br />
SMOKE-FREE POLICY<br />
We are committed to your good health. That is why we are a smoke free hospital. For smoking<br />
cessation programs contact Occupational Health at (718) 920-5406.<br />
EQUAL OPPORTUNITY EMPLOYER<br />
<strong>Montefiore</strong> <strong>Medical</strong> Center is an equal employment opportunity employer. It is <strong>Montefiore</strong>'s<br />
policy not to discriminate on the basis of race, creed, color, national origin, gender, age, physical,<br />
or mental disability, veteran status, martial status, sexual orientation, or censorship status, in<br />
employment decisions including, but not limited<br />
to, recruitment, hiring, compensation, training, and apprenticeship, promotion, upgrading,<br />
demotion, downgrading, transfer, layoff, termination, and all other terms and conditions of<br />
employment.<br />
108
CONTROLLED SUBSTANCES IN THE MEDICAL CENTER<br />
It is the policy of the <strong>Medical</strong> Center to comply with federal, state and local regulatory agencies<br />
pertaining to the ordering, receiving, storing, documentation and distribution of all controlled<br />
drugs (CIIV) and to keep accurate records of each transaction. It is expected that all practitioners<br />
who are authorized to administer or prescribe controlled substances in the medical center<br />
conform to the requirements set forth by federal, state and medical center regulations.<br />
The Department of Pharmacy will perform routine inspections and audits of all controlled<br />
substance inventories to insure adherence to medical center policies and procedures and state and<br />
federal regulations.<br />
AUTHORIZED PRESCRIBERS<br />
According to the New York State Department of Health Bureau of Controlled Substances and<br />
MMC policy, the following practitioners are authorized to prescribe controlled substances in the<br />
medical center: Doctors of Medicine, Doctors of Osteopathy, Dentists, <strong>Medical</strong><br />
Interns/Residents, Physician Assistants, Midwives, Nurse Practitioners, Optometrists and<br />
Podiatrists.<br />
• Orders for controlled substances written by registered physician assistants must be<br />
countersigned by the collaborating physician within 24 hours.<br />
• <strong>Medical</strong> students must have their orders countersigned by the resident or attending physician<br />
before the order can be processed and administered to the patient.<br />
• Interns, residents, and foreign physicians are allowed to write controlled substance<br />
prescriptions provided that: 1.) Prescribing is done in the usual course of the practitioner's<br />
professional practice. 2.) The practitioner acts only in the scope of his employment in the<br />
hospital. 3.) The DEA number with a hospital-assigned three-digit suffix is received. <strong>Staff</strong><br />
physicians who are qualified to obtain their own DEA numbers may not use a hospital<br />
number.<br />
WRITTEN INPATIENT STANDING AND ROUTINE ORDERS FOR CONTROLLED<br />
SUBSTANCES:<br />
• Must be patient specific and written by an MMC authorized practitioner<br />
• Must state the name of the drug, dose, route and frequency of administration.<br />
• Orders that give a dose range (e.g., 50-100mg) or more than one route (e.g., PO/IM) are not<br />
allowed.<br />
• Preprinted orders are not allowed.<br />
• All orders must have the prescriber signature and countersignature where applicable<br />
• Orders written to be administered PRN without a specific time or frequency (e.g. Ativan lmg<br />
P.O. PRN) are valid only for 72 hours. An order without a specific time may be administered<br />
once only within the 72-hour period. A new order must be written if additional doses are<br />
required.<br />
• Specific orders for controlled substances to be administered at specific times are valid for<br />
seven days and must be rewritten at least every seven days. The specified time may include a<br />
PRN notation to allow the drug to be administered in accordance with the patient's need (e.g<br />
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.<br />
H.S. prn).<br />
109
VERBAL, TELEPHONE, OR FAXED CONTROLLED SUBSTANCE ORDERS<br />
• Are allowed for inpatients in emergency situations only. An emergency is defined as the<br />
immediate administration of the controlled substance is needed for proper treatment and no<br />
alternative treatment is available.<br />
• Are permitted only if it is not possible for the practitioner to provide a written order before<br />
the needed administration of the drug.<br />
• Can only be provided by an attending physician or fellow<br />
• May be continued by house staff, but is restricted to a one time dose<br />
• Must be signed by the physician within 24 hours.<br />
LOSS OR DISCREPANCY OF A CONTROLLED SUBSTANCE<br />
A loss of a controlled substance, including an unresolved discrepancy must be reported to the<br />
Security Department, Department of Pharmacy and chair or manager of the department. An<br />
investigation of the incident and written report, including a list of all individuals who have had<br />
access to controlled substances and their license numbers, must be submitted to the Department<br />
of Pharmacy. The Department of Pharmacy will complete the Report Form for Loss of<br />
Controlled Substances and submit to the New York State Department of Health Bureau of<br />
Controlled Substances Narcotic Enforcement Unit.<br />
DEA NUMBERS<br />
Under the Federal Controlled Substances Act, a practitioner is required to register with the Drug<br />
Enforcement Agency (DEA) in order to prescribe and administer controlled substances. Certain<br />
house staff physicians are not eligible for a federal registration number (interns and certain<br />
residents). Therefore, provisions have been made under federal law to assign a temporary<br />
number (hospital number plus an assigned suffix number), which authorizes the practitioner to<br />
prescribe controlled drugs within the medical center. Interns and residents rotating at <strong>Montefiore</strong><br />
from other training programs are not eligible for a temporary <strong>Montefiore</strong> DEA number and<br />
suffix.<br />
OUT-PATIENT PRESCRIPTION WRITING<br />
• New York State law requires all prescriptions to have a stamp/imprint in addition to the<br />
prescriber's signature.<br />
• The complete DEA number and suffix must be written on the prescription.<br />
• The assigned number can only be used while employed at the medical center and on<br />
prescriptions written for <strong>Montefiore</strong> patients.<br />
STORAGE AND SECURITY<br />
Controlled substances must be stored in a stationary, secured cabinet with double lock and key to<br />
ensure adequate safeguards and security measures are undertaken to prevent against the loss,<br />
destruction, theft or unauthorized access. Automated point-of-use<br />
technology (Pyxis Medstation System) is an acceptable alternative to a cabinet.<br />
• The cabinet will have inner and outer doors with separate keys. Spring locks or combination<br />
locks are not acceptable.<br />
• When not in use, the keys to the narcotic cabinet must be stored in a secured manner (e.g.,<br />
locked drawer and unavailable to unauthorized personnel).<br />
110
• Practitioners will immediately notify the Department of Pharmacy of the loss, destruction,<br />
theft or unauthorized use of any controlled substance.<br />
DAILY INVENTORY<br />
• Change in shift inventories must be performed on all controlled substances each day and<br />
recorded on the inventory control form.<br />
• The inventory must be performed by two licensed individuals (nurse, physician, dentist or<br />
pharmacist) unless the location has received exempt status by the Unified Director of<br />
Pharmacy and sign the inventory control form.<br />
• In patient care areas (i.e., outpatient sites, clinics, and special procedures rooms) where there<br />
is only one nurse or no nurse, the physician(s) or dentist(s) is responsible for the maintenance<br />
of controlled substances and adherence to all policies and procedures.<br />
• In areas that are open for one shift (i.e.,9AM to 5PM) the inventory must be performed by<br />
two licensed individuals and at the open and close of business. The time of the inventory<br />
must be recorded on the inventory record. If the area (clinic, office, procedure room) is<br />
closed on a particular day (Saturday, Sunday or holidays) the word "closed" must be written<br />
on the inventory control form for that date.<br />
• Those areas that have received exempt status by the Unified Director of Pharmacy will have<br />
a controlled drug inventory performed at the open and close of business by one licensed<br />
practitioner and indicate the word “self” in the appropriate space.<br />
• Areas that utilize automated point-of-use dispensing technology are exempt from performing<br />
the change of shift inventory daily. The count must be performed at least once a week on a<br />
designated day.<br />
RECORD KEEPING AND DOCUMENTATION<br />
A separate record will be maintained of the administration of controlled substances indicating the<br />
date and hour of administration, patient's full name (last and first), name and quantity, the<br />
balance on hand after such administration, signature of person administering and name of the<br />
prescriber.<br />
REQUESTING CONTROLLED SUBSTANCES FROM THE PHARMACY BY HOUSE<br />
STAFF<br />
Controlled substances may be picked up from the Pharmacy in cases of emergency by house<br />
staff provided a valid medication order has been written and the patient care area does not stock<br />
the item. Controlled substances will be dispensed to the house staff personnel provided a<br />
<strong>Montefiore</strong> <strong>Medical</strong> Center identification badge is shown. Identification badges from other<br />
institutions are not acceptable. Once the proper requirements are confirmed, only one dose of<br />
the controlled substance will be dispensed. The house staff personnel are responsible for<br />
documenting the use and waste of the controlled substance on the disposition form and must<br />
return the form back to the Pharmacy immediately upon completion of the emergency. Any<br />
unused and sealed controlled substance must be returned back to the Pharmacy or given to the<br />
nurse-in-charge in the care area for proper storage and inventory maintenance.<br />
111
WASTING OF CONTROLLED SUBSTANCES<br />
Single-unit doses or partial doses remaining after the administration or attempted administration<br />
of a portion of a liquid (solution for injection or oral solution) or solid unit dose of a controlled<br />
substance may be destroyed beyond reclamation provided that a notation is made on the<br />
administration record sheet; and the destruction is witnessed by a second licensed individual<br />
(nurse, pharmacist, physician or dentist). Witnesses must visually observe the discard.<br />
CONTROLLED SUBSTANCES THAT ARE UNDESIRED, DETRIORATED OR OBSOLETE<br />
• Must be returned to the Department of Pharmacy and documented on the disposition<br />
record/inventory control form/automated point-of use technology<br />
• Only controlled drugs received from the Department of Pharmacy may be returned to the<br />
Department of Pharmacy.<br />
• Controlled drugs purchased from an outside source (wholesaler, distributor or manufacturer)<br />
may be returned to the distributor or manufacturer if the package is in its sealed original<br />
state, or Bureau of Controlled Substances.<br />
OFFICIAL NEW YORK STATE PRESCRIPTION FORMS (on-site and off-site)<br />
• Official New York State prescription forms must be stored securely to ensure adequate<br />
safeguards to prevent against the loss, destruction, theft or unauthorized access.<br />
• Practitioners will immediately notify the Department of Security, Department of Pharmacy,<br />
Police Department and appropriate regulatory agencies of the loss, destruction, theft or<br />
unauthorized use of any state prescription form.<br />
QUALITY IMPROVEMENT<br />
Refer to <strong>Montefiore</strong>'s Institutional QI Plan JQ04.1 in the Administrative Policy and Procedure<br />
<strong>Manual</strong>. Or refer to the PI Tool Kit in the Performance Improvement Resource Center on the<br />
QM/RM intranet web page.<br />
Quality Management Department 718-920-5026<br />
Rohit Bhalla, MD<br />
Brandon Yongue, PhD<br />
PERFORMANCE IMPROVEMENT MODEL<br />
The Performance Improvement Model is consistent with the philosophy, mission, and goals of<br />
<strong>Montefiore</strong>. All associates are involved in this planned, systematic, and ongoing performance<br />
improvement program. It is an interdisciplinary process designed to objectively and<br />
systematically monitor and evaluate the quality and safety of care and services, pursue<br />
opportunities to improve patient care, strive for service excellence and to address identified<br />
problems and vulnerable areas (high risk, high volume, problem prone, high cost). <strong>Montefiore</strong> is<br />
an organization of interdependent parts. The organization seeks to optimize the performance of<br />
the entire system. In continual improvement, an organization analyzes the processes that support<br />
care delivery to reduce unnecessary variation, improve the quality of its services and provide<br />
optimal outcomes.<br />
112
One Quality Improvement Plan exists for the entire <strong>Montefiore</strong> Network and one committee, The<br />
<strong>Montefiore</strong> Quality Council, has oversight responsibility for performance improvement across<br />
the entire <strong>Montefiore</strong> integrated delivery system. Characteristics of the Performance<br />
Improvement Program are that it is customer focused, interdisciplinary, data driven, and outcome<br />
oriented. The essence of performance improvement is to work continually to better meet<br />
customer expectations, enhance efficiency, and improve the processes of care delivery.<br />
Advances are achieved in part through interdisciplinary effort, adoption of “Best Practices” and<br />
exploitation of advances in information technology.<br />
QUALITY IMPROVEMENT<br />
Who is responsible for quality<br />
• Each of us<br />
What is quality<br />
• <strong>Montefiore</strong>'s Vision Statement defines quality in health care:<br />
<strong>Montefiore</strong> is committed to being the best healthcare provider in the Bronx and beyond. Our<br />
associates and medical staff provide patient/family-focused care that exceeds customer<br />
expectations, embraces academic excellence and achieves quality outcomes in a fiscally<br />
responsible manner.<br />
• The Institute of Medicine identifies the following as the domains of quality in health care:<br />
• Patient Safety<br />
• Effectiveness<br />
• Timeliness<br />
• Efficiency<br />
• Equity<br />
• Patient Centeredness<br />
Who are your customers (Internal and External)<br />
• External: patients, families, insurance agencies, JCAHO, NYSDOH referring physicians,<br />
Medicare/Medicaid, etc.<br />
• Internal: peers, administration, hospital associates, all departments.<br />
How do we identify performance improvement (PI) projects<br />
• <strong>Montefiore</strong> prioritizes those processes for improvement that are:<br />
• High Risk<br />
• High Volume<br />
• Problem Prone<br />
• High Cost<br />
• Sources of information for PI projects include feedback from internal and external customers,<br />
community concerns and ongoing indicator monitoring.<br />
What is the chosen model for planned, systematic improvements<br />
• Plan-Do-Check-Act (PDCA) Model<br />
PLAN<br />
• Assemble an interdisciplinary workgroup<br />
• Review "Best Practices" from <strong>Montefiore</strong> and elsewhere<br />
• Identify critical measures of success<br />
• Assess causes of perceived problems<br />
DO<br />
113
• Collect baseline data<br />
• Test the potential solutions that were developed in the planning stage<br />
• Pilot test the solution<br />
• Limit initial implementation<br />
• Minimize risk<br />
• Minimize disruption until process assessed<br />
CHECK<br />
• Assess the success of the changes that were implemented in the testing stage by<br />
recollecting and evaluating pertinent data<br />
• The team determines, using appropriate data analysis, whether there were:<br />
• Significant process improvements<br />
• Reductions in the variation of outcomes<br />
ACT<br />
If the intervention was successful, then implement permanent changes to the process:<br />
• Education and training of all Associates who will be affected by the process revisions<br />
• Changes in the <strong>Montefiore</strong> Procedure and Policy <strong>Manual</strong>s, where appropriate<br />
Ongoing monitoring and response to key indicators to 'hold the gain' made by process changes<br />
114
SECTION VI<br />
•<br />
SERVICE DEPARTMENTS<br />
115
ACUTE PAIN<br />
Interim <strong>Medical</strong> Director<br />
Albert Saubermann, MD<br />
Administrator<br />
Bettie Jackson<br />
Acute Pain Team:<br />
Linda Dallam, MS, GNP 718-920-6212<br />
917-314-7928<br />
Elissa (Lisa) Davis, MSN, ANP 718-920-5216<br />
917-798-0060<br />
Hours<br />
Monday-Friday 8:00AM - 4:00PM<br />
The Acute Pain Management Team is available for consults. Call for assistance with Intractable<br />
pain, PCA management, Complex pain, Pain in patients with chemical dependency, Undertreated<br />
pain, and Route and dosage conversion. The team is also available to assist with JCAHO<br />
and other pain-related regulatory requirements.<br />
ADMITTING<br />
MOSES<br />
Director<br />
Jodi Yedvab 718-920-2112<br />
Admitting Supervisor<br />
Albert Weiner 718-920-2865<br />
Bed control 718-920-6651/ 6652/ 2196/ 2197/2198<br />
ER Bed control 718-920-2967<br />
Admitting (General) 718-920-5001/ 5002/ 5003/5004<br />
Patient Information 718-920-4141<br />
WEILER<br />
Director<br />
Sandar Kelly<br />
718-904-2597<br />
Admitting Supervisor<br />
Frank Carlisi 718-904-2085<br />
Bed control 718-904-3286<br />
Admitting (General) 718-904-2928<br />
116
Legal Certificates 718-904-3456<br />
Financial Counselors 718-904-3552<br />
Cashier 718-904-3448<br />
The admitting office is the center of the medical center. This is the first impression or point of<br />
entry into the hospital for the patient being admitted. The Admitting department is composed of<br />
both management and registration staff:<br />
• Admitting Supervisor: Oversees the admitting process, operations, and related services<br />
pertaining to the department<br />
• Bed control: Coordinate all beds within the hospital, take reservations for patients to be<br />
admitted to the hospital, and oversee all transfers within the hospital<br />
• Admitting Clerks: Interview patients for admission to the hospital, have required paper work<br />
signed by the patient or designee, and place an ID band on the patient for their hospital stay.<br />
• Receptionist: Provide patient information to family and visitors<br />
Within the Admitting department, any physician or designee can call in a reservation to the bed<br />
controller for Ambulatory, Same Day, Elective, or Emergent admissions. Patients may be<br />
admitted from their home, doctor’s office, clinic, or emergency room.<br />
BIOETHICS<br />
When decisions about health care raise ethical issues in the clinical or organizational setting, the<br />
Division of Bioethics, the Bioethics Consultation Service and the Ethics Committee serve as<br />
useful resources to the <strong>Montefiore</strong> community.<br />
BIOETHICS CONSULTATION SERVICE<br />
Consultations<br />
718-920-6226/4096 Moses<br />
718-904-2299 Weiler<br />
Members of the Division of Bioethics, who compose the consultation service, are available to<br />
meet with patients, families or designated representatives, and caregiving staff to help clarify and<br />
resolve ethical dilemmas. Anyone involved in patient care-patient, family member or proxy<br />
agent, or professional care team with an ethical concern or problem can directly access the<br />
consultation service.<br />
Hours<br />
Monday – Friday 9:00AM - 5:00PM<br />
Outside of regular hours, if the patient care issue does not require immediate attention, a message<br />
left at the offices of the Division of Bioethics will be responded to the next working day. Urgent<br />
consultations outside of regular business hours will be handled by the appropriate the Assistant<br />
Director of Nursing (AND).<br />
ETHICS COMMITTEE<br />
The Ethics Committee is an interdisciplinary body that meets monthly and on an ad hoc basis to<br />
address ethical issues that arise in the clinical and organizational setting. Rather than a decisionmaking<br />
body, the committee is a forum for study, policy review and advice. All deliberations of<br />
117
the consultation service and committee are confidential and all information and records are<br />
protected. There is no charge for these services.<br />
BLOOD BANKS<br />
Director<br />
Joan Uehlinger, MD 718-920-4556<br />
718-904-3092<br />
Manager<br />
Leana Serrano-Rahman 718-920-2192<br />
718-904-3377<br />
MOSES DIVISION<br />
Laboratory: North 8 Silver Zone 718-920-4786<br />
Donor Room/Outpatient Services: Rosenthal 2<br />
Manager: Angelina Bonzon-Adelson, RN<br />
Call (718) 920-4810 for Appointment<br />
Blood Donations:<br />
• Autologous<br />
• Directed<br />
• Voluntary<br />
Out-patient transfusions<br />
Therapeutic phlebotomy<br />
Apheresis<br />
EINSTEIN/WEILER DIVISION<br />
Laboratory: 3 rd Floor 718-904-2868<br />
Donor Room/Outpatient Services: Room 2189<br />
Manager: Angelina Bonzon-Adelson, RN<br />
Call (718) 904-2100 for Appointment<br />
Donor Room<br />
Blood Donations:<br />
• Autologous<br />
• Directed<br />
• Voluntary<br />
Out-patient transfusions<br />
Therapeutic phlebotomy<br />
Apheresis<br />
118
CHILD PROTECTION CENTER<br />
The Children’s Hospital at <strong>Montefiore</strong><br />
3314 Steuben Avenue 718-920-5833<br />
Bronx, NY 10467<br />
718-405-6149 Fax<br />
Executive Director<br />
Karel Amaranth, MA<br />
<strong>Medical</strong> Director<br />
Linda Cahill, MD<br />
Hours<br />
Monday - Thursday 8:30AM - 7:00PM, Friday 8:30AM - 5:00PM<br />
The Child Protection Center (CPC) is a fully certified Child Advocacy Center dedicated to<br />
breaking the cycle of child abuse. The mission of the center is to minimize the traumas that<br />
afflict children and their families who are victims of sexual and physical abuse and/or neglect.<br />
Through critical medical and psychosocial evaluation, along with community education, the CPC<br />
has intervened to save and restore the lives of thousands of children and families. In addition to<br />
expert evaluation and testimony, the CPC also provides critical services to families in there new<br />
prevention Services building at 3380 Reservoir oval. These services include individual and<br />
family counseling, group therapy and parenting skills classes.<br />
CLINICAL INFORMATION SYSTEMS<br />
<strong>Montefiore</strong> <strong>Medical</strong> Center's Clinical Information System (CIS), serves as an on-line medical<br />
record for a number of key elements of the patient’s chart. For all visits across the <strong>Montefiore</strong><br />
Integrated Delivery System, the following elements are currently available at CIS Windowsbased<br />
PC workstations located throughout MMC's delivery system:<br />
• Patient demographic and visit information<br />
• Laboratory test results<br />
• Radiology reports<br />
• Nuclear Medicine reports<br />
For all inpatient visits, the following elements are currently available:<br />
• Physician Orders<br />
• Patient Lists<br />
• Nursing medication,<br />
• Vital signs<br />
• Intake and Outputs<br />
• All other flowsheet data<br />
Electronic patient Problem Lists and Prescription writing for all outpatient areas are currently<br />
being rolled out.<br />
ATTENDING PHYSICIANS<br />
119
CIS logons are issued after the credentialing process has been completed. To receive your user<br />
number and password, call the Help Desk at (718) 920-4554.<br />
There is a regularly scheduled training class every Tuesday at 4:00 pm in the CIS Training room,<br />
located on the 2 nd floor of the Storage building on the Moses Campus.<br />
HOUSE STAFF<br />
To receive your user number and password, call the <strong>House</strong>staff Office at (718) 920-4091.<br />
Training for house officers is held during the orientation process.<br />
CONTINUING MEDICAL EDUCATION (CME)<br />
Contact<br />
Victor Hatcher, PhD 718-920-6677<br />
Albert Einstein College of Medicine & <strong>Montefiore</strong> <strong>Medical</strong> Center are recognized as national<br />
leaders in all three stages within the continuum of medical education; undergraduate, graduate<br />
and continuing medical education. The Einstein & <strong>Montefiore</strong> Continuing <strong>Medical</strong> Education<br />
program is among the largest and most respected in the country.<br />
ON CAMPUS AND IN MANHATTAN<br />
Fully accredited to grant Category I CME credit, the Center for Continuing <strong>Medical</strong> Education<br />
(CCME) accredits approximately 50 Grand Rounds throughout the <strong>Medical</strong> Center in every<br />
specialty. The CCME sponsors approximately 75 major symposia on-site on the Moses and<br />
Weiler Campuses, and in leading hotels and conference centers in Manhattan.<br />
NATIONAL PROGRAMS<br />
The CCME offers approximately 80 programs in psychiatry, anesthesiology,<br />
neurology and medicine throughout the country. The CCME and the Einstein faculty conduct<br />
educational symposia which attract clinicians from across the country and around the world.<br />
Notably, CCME has presented Einstein & <strong>Montefiore</strong> symposia at the annual conventions of The<br />
American Academy of Family Physicians, The American College of Physicians, The American<br />
Academy of Pediatrics, The American Geriatric Society, The American Society of Hypertension,<br />
The American Society of Cardiology, and The American College of Rheumatology.<br />
INTERNATIONAL PROGRAMS<br />
Internationally, the CCME has offered programs with the Israel <strong>Medical</strong> Association in<br />
Jerusalem, an orthopedics hands-on workshop in Geneva, and seminars in Bioethics in Tuscany.<br />
PUBLICATIONS<br />
The CCME also publishes accredited programs in textbook form and in association with Cutis,<br />
The Female Patient, and The Federal Practitioner. Einstein & <strong>Montefiore</strong>'s CCME is one of the<br />
largest of medical school producers of CME materials on audio and video tape. Our educational<br />
programs reach thousands of physicians through CME's national teleconferencing network and<br />
on the Internet.<br />
120
CME REQUIREMENTS:<br />
Attending physicians at <strong>Montefiore</strong> are required to meet the national standard of 50 CME credits<br />
annually, in order to maintain hospital privileges. Since physicians may earn CME credits from<br />
other institutions, specialty societies, consultations, reading and teaching, it is the responsibility<br />
of each physician to maintain his own CME record and to report it to the Attending <strong>Staff</strong> Office<br />
annually. Residency training is automatically accepted as meeting the national CME standards.<br />
CUSTOMER SERVICES<br />
Director 718-920-4060<br />
Leslie Bank<br />
Main Number 718-920-4943<br />
The Customer Services Department serves as <strong>Montefiore</strong>'s formally established communication<br />
channel and "grievance mechanism" for patients, their families, companions and significant<br />
others. In addition, Customer Services provides access to interpreting services for deaf and hard<br />
of hearing patients and companions, and for LEP (Limited English Proficiency) patients and<br />
companions, all free of charge. (It is a federal and state law that we provide interpreting services.<br />
The use of family members or unqualified staff is strongly discouraged) The Customer Services<br />
Department also measures patient satisfaction, inclusive of satisfaction with physician services.<br />
Customer Services Specialists are available to assist your patients resolve problems, and provide<br />
interpreting resources, Monday through Friday at both Moses and Weiler Divisions. (After<br />
business hours, contact the ADN)<br />
DIALYSIS CENTER III<br />
Baumritter Kidney Center 718-597-2255<br />
1325 Morris Park Avenue<br />
Bronx, New York 10461<br />
Private practice number 718-828-6840<br />
<strong>Medical</strong> Director<br />
Vaughn W. Folkert, MD<br />
Manager<br />
Maritza Dominguez<br />
Chronic In-Center Hemodialysis & Peritoneal Dialysis<br />
Hours: Monday - Saturday 5:00AM – 11:00PM<br />
DIVISION OF EDUCATION AND ORGANIZATIONAL DEVELOPMENT<br />
Director 718-920-2685<br />
Bettie Jackson<br />
Hours<br />
121
Office hours are Monday – Friday: 8:00AM – 5:00PM, however services are provided 24 hours<br />
per day, seven days per week.<br />
CLINICAL CONSULTATIVE SERVICES<br />
DEOD provides consultative services in the areas of Pain Management; Diabetes; Wound,<br />
Ostomy, and Continence Care; Geriatrics; and Bioterrorism preparedness, to name just a few.<br />
Call (718) 920-2685 for further information so our expert clinical and organizational<br />
development faculty can assist you with your learning and patient care needs.<br />
DIABETES<br />
Consultations are provided for patients with Type 1 and Type 2 Diabetes.<br />
Iris Carrisquillo, MSN, CNS<br />
Office (718) 904-2139<br />
Beeper (917) 537-6703<br />
PAIN MANAGEMENT<br />
The Acute Pain Management Team is available for consultation on complex pain management<br />
issues.<br />
Linda Dallam, MS, GNP<br />
Office (718)920-6212<br />
Beeper (917) 314-7928<br />
Elissa (Lisa) Davis, MSN, ANP<br />
Office (718) 920-5216<br />
Beeper (917) 798-0060<br />
WOUND, CONTINENCE & OSTOMY CARE<br />
Clinical Nurse Specialists are available to provide consultation for patients with ostomies and<br />
chronic wounds.<br />
Catherine Badillo, MSN, CNS,<br />
Office (718) 920-8583<br />
Beeper (917) 314-2158<br />
Winifred Hagan, MSN, CNS<br />
Office (718) 904-2889<br />
Beeper (917) 672-4413<br />
Patricia Pellegrino, MSN, CNS<br />
Office (718) 904-3098<br />
Beeper (917) 787-9436<br />
ENVIRONMENTAL SERVICE<br />
(Building Services)<br />
Environmental Services aims to provide a clean and safe environment for the patient, visitor and<br />
health care worker.<br />
122
Hours:<br />
Monday - Friday 8:00AM - 5:00PM<br />
MOSES 718-920-4903<br />
Central Building - Kitchen Corridor<br />
After hours, weekends and holidays, the Department Supervisor can be reached through the<br />
page operator (718) 920-8282.<br />
Available Services:<br />
• conference rooms set up<br />
• extermination<br />
• drapery/upholstery repair<br />
• window washing<br />
• moving and storage<br />
• patient TV rental<br />
• vacuum and shampoo carpets<br />
EINSTEIN 718-904-4000<br />
Lobby Entrance - Main Floor<br />
After hours, weekends and holidays, the Department Supervisor can be reached through the page<br />
operator (718) 904-2711.<br />
Available Services:<br />
• conference rooms set up<br />
• extermination<br />
• drapery/upholstery repair<br />
• window washing<br />
• moving and storage<br />
• vacuum and shampoo carpets<br />
FOOD AND NUTRITION SERVICES<br />
Director of Food and Nutrition Services<br />
Chris Trivlis<br />
718-904-2731 Einstein<br />
718-920-4257 Moses<br />
917-424-6221 Beeper<br />
Clinical Nutrition Manager<br />
Miriam Pappo<br />
718-904-2724 Einstein<br />
718-920-4253 Moses<br />
917-641-3736 Beeper<br />
Hours of Operation:<br />
6:30AM - 7:00PM seven days per week<br />
Summary of Department Activity and Services:<br />
• Progressive multi-service department providing food and clinical services to patients,<br />
associates and visitors .<br />
• Nutritional status directly affects patient outcome, therefore early intervention is necessary.<br />
123
• All patients at nutritional risk need to be assessed by a Registered Dietitian; Dietitians are<br />
responsible for nutrition care in each Care Center.<br />
• The Dietitian will respond to consults within 24 hours. Consults are CIS generated.<br />
• The nutrition care plan includes goals, recommendations, education and discharge planning.<br />
• Nutrition care is interdisciplinary and ongoing. Dietitians attend IDT rounds.<br />
• Only MD's and PA’s write diet orders including regular and modified diets,<br />
oral supplements, enteral feedings and parenteral nutrition.<br />
• No patient will receive a tray without an active diet order.<br />
• At the Einstein division all meals are prepared in a kitchen under Rabbinical supervision in<br />
accordance with Kosher Jewish dietary laws.<br />
CAFETERIA<br />
Einstein: 4th floor<br />
Hours of Operation: 6:30AM to 7:00PM seven days per week<br />
Moses Food Pavilion: 2nd floor<br />
Hours of Operation: 6:30AM to 7:00PM seven days per week<br />
SCRUBS MAY NOT BE WORN IN THE CAFETERIA UNLESS COVERED BY A LAB<br />
COAT. ANYONE VIOLATING THIS HEALTH CODE WILL NOT BE SERVED.<br />
GIFT SHOP<br />
MOSES<br />
Children’s Hospital at <strong>Montefiore</strong> (CHAM) Lobby<br />
Managed by Lori’s Hallmark Shop 718-741-2294<br />
Hours:<br />
Monday – Friday 10 –7<br />
Saturday and Sunday 11 – 4<br />
WEILER<br />
Einstein Main Lobby 718-904-2742<br />
Managed by Lori’s Hallmark Shop<br />
Hours:<br />
Monday – Friday 8 – 9<br />
Saturday and Sunday 10 - 8<br />
HEALTH INFORMATION MANAGEMENT (HIM)<br />
THE MEDICAL RECORD<br />
The medical record at MMC is a hybrid of on-line electronic and manually generated<br />
documentation. The Clinical Information System (CIS), at MMC, forms the basis for the<br />
Computerized Patient Record (CPR). Information on each patient is maintained using an<br />
enterprise-wide medical record number, which is used to identify the patient across the MMC<br />
124
delivery system. <strong>Medical</strong> record information maintained online is available to all authorized<br />
users and can be accessed anywhere, at any time, with proper authorization. This includes<br />
documentation entered directly online and those components of the record where there is direct<br />
integration between systems, such as laboratory and radiology information systems.<br />
Components of the record where the caregiver documents on paper or in secondary systems not<br />
interfaced with the CIS, the documentation is stored in hard copy in the paper medical record in<br />
HIM. Various components of the Clinical Information System have been implemented in most<br />
locations in the MMC network. As more elements of the medical record become part of CIS,<br />
more information will be available on line and less in hard copy.<br />
DEPARTMENT SERVICES<br />
The Health Information Management (HIM) Department provides 24- hour/ 7 days-per-week<br />
medical record services at both the Moses and Weiler Divisions.<br />
Location<br />
Moses: Rosenthal South East (RSE) Main Floor -Red Zone<br />
Weiler: 2nd Floor South (2S-70)<br />
Hours<br />
24 hours 7 days a week. (<strong>Staff</strong> is available at any time)<br />
Telephone Extensions Moses Weiler<br />
File Room Manager 4925 2747<br />
Requests for <strong>Medical</strong> Records 5315 2901/8109<br />
<strong>Medical</strong> Record Completion 2219 2149<br />
<strong>Medical</strong> Information 4921 2748<br />
Death Certificates 2210 3456 (Admitting)<br />
Cancer Registry<br />
(718) 652-5201 Ext.246<br />
Registration Data Quality (718)794-7036<br />
HIM Administration 5108 2330<br />
Retrieval of <strong>Medical</strong> Records:<br />
For Patient Care: Records needed for immediate patient care can be retrieved 24 hours a day.<br />
The following information is required:<br />
• Valid MMC Identification Card<br />
• Patient Name<br />
• <strong>Medical</strong> Record Number<br />
• Requester Name/location/telephone number<br />
• Date needed and purpose.<br />
• For Research, Review and other purposes: Advance notice is required for retrieval of records<br />
for reasons other than direct patient care. <strong>House</strong> staff must show approval of research project<br />
by the supervising attending physician.<br />
• For a data search, for research projects, call ext. 2208 at Moses and 2747 at Einstein<br />
• To retrieve records in bulk discuss volume, time frames, etc with File Room Supervisor or<br />
Manager at the appropriate site.<br />
125
<strong>Medical</strong> Information<br />
If medical information must be sent to or obtained from another health care institution, call ext.<br />
4921 at Moses or 2748 at Weiler for assistance, from Monday to Friday 8:30am to 5:00pm. Call<br />
ext. 5315 at Moses or ext. 8109 at Weiler on weekends and off-hours.<br />
SECURITY AND CONFIDENTIALITY<br />
• Patient Information is confidential and may be disclosed only to the extent authorized or<br />
necessary for patient care<br />
• Refrain from discussing patient information in elevators and other public places.<br />
• Do not share passwords or sign-ons<br />
• <strong>Medical</strong> records are not to leave MMC's premises<br />
• <strong>Medical</strong> records must be returned to the file-room no later than 48 hours after being signed<br />
out, except when being used for direct patient care<br />
• <strong>Medical</strong> records required for review purposes should be reviewed in the HIM department<br />
COMPLETION OF MEDICAL RECORDS<br />
Documentation requirements for the medical record are governed by the JCAHO standards, the<br />
NYS Department of Health regulations, HCFA Medicare Conditions of Participation, and MMC<br />
<strong>Medical</strong> <strong>Staff</strong> Bylaws. These regulations/standards provide the requirements of a complete<br />
medical record. <strong>Medical</strong> records of discharged patients must be completed within 30 days of<br />
discharge.<br />
Each clinical department determines its own guidelines regarding the responsibilities of<br />
house officers for record completion. The following represents general guidelines for<br />
documentation in the medical record and provides some guidelines to assist in reducing the<br />
number of incomplete records.<br />
Entries<br />
• Time and date all entries. Include day, month, year as well as time of day, am vs. pm.<br />
• All entries must be permanent and written in blue or black ink. Do not use a pencil or felt tip<br />
marker.<br />
• Make good entries the first time. Entries should be accurate, timely, objective, specific,<br />
concise, consistent, comprehensive, logical, legible, clear, descriptive and reflective of the<br />
patient's condition and response to treatment.<br />
• Legality: The medical record is a legal document. It should not be used to document<br />
complaints against other staff members or departments.<br />
• Authentication: Sign every entry including addenda. Print your name and professional<br />
designation (PGY 1, MD, PA etc.) with your signature. Never make or sign an entry for<br />
someone else or have another make or sign an entry for you.<br />
• Patient Identification: In the absence of an addressoplate ensure that the patient's name and<br />
medical record number is on every page where there is patient information.<br />
History and Physical<br />
Complete an H&P including a pap smear and breast exam on every female patient 21 years and<br />
over, within 24 hours of admission.<br />
Physician Orders<br />
126
All physician orders whether written on paper or entered on-line through Physician Order Entry<br />
must be dated and signed. All sub-intern orders must be countersigned within 3 hours. PA<br />
medication orders must be countersigned within 24 hours. PAs and Sub-interns should ensure<br />
that their orders are counter-signed.<br />
Discharge: Write a discharge order or document circumstances surrounding death,<br />
transfer or AMA status of the patient as appropriate.<br />
Discharge Summary<br />
Complete the Discharge Summary form or dictate a discharge summary on the day of discharge<br />
for all cases with a length of stay of 48 hours or more. All sections of the discharge summary<br />
must be filled out or dictated. A Discharge Note is required on stays of less than 48 hours where<br />
no discharge summary is required. Discharge note should include information regarding the<br />
condition of the patient on discharge and instructions to the patient. A discharge note is required<br />
for all patients who die or who leave AMA. A discharge summary is ALWAYS needed for<br />
expiration cases regardless of length of stay.<br />
Operative Report<br />
Complete the Short Operative Note immediately after surgery. Although the attending physician<br />
is ultimately responsible for the dictation of the operative report the task may be assigned to the<br />
1 st assistant on the surgery. Dictation instructions are below.<br />
DICTATING INSTRUCTIONS<br />
*Please spell all names and unusual medical terms.<br />
<strong>Montefiore</strong> <strong>Medical</strong> Center uses a digital voice activated system for dictation of Discharge<br />
Summaries and Operative Reports. The system may be accessed from any touch tone telephone.<br />
The same system is in use at both the Moses and Weiler sites. To obtain your personal ID# to<br />
access the system please contact the <strong>Medical</strong> Record Completion unit.<br />
• Dial Extension 717 in-house or (718) 920 -6755 for Moses and 3458 in-house or 904-3428<br />
for Einstein.<br />
• Enter your 5 digit attending or house staff physician ID<br />
• Enter the 1-digit work type (e.g. 1=OP Report, 2=Discharge Summary)<br />
• Enter the 8-digit <strong>Medical</strong> Record Number<br />
• Press:<br />
1 to hold, then "2" to resume dictation<br />
2 Dictate<br />
3 Rewind a few words<br />
4 Go to end of Dictation<br />
5 Go to beginning then "8" to listen<br />
6 End Dictation<br />
7 Fast forward a few words<br />
8 Listen<br />
9 Disconnect<br />
To ensure accurate report tracking when dictating multiple reports, press 6 after each dictation<br />
and then enter the 1 -digit work type and 8-digit patient medical record number for the next case.<br />
FORMAT FOR DICTATION<br />
127
Discharge Summary<br />
• Patient Name and <strong>Medical</strong> Record Number (8 digits)<br />
• Name of Attending and Dictating MD<br />
• Dictation Date, Admission and Discharge Dates.<br />
• Brief History (Chief Complaint)<br />
• Reason for Hospitalization<br />
• Pertinent Physical Findings and Diagnostic Results<br />
• Hospital Course/Significant Findings/Treatment Results<br />
• Discharge Disposition and Final Diagnosis<br />
• Instructions to Patients regarding Physical Activity, Medications, Diet and Follow-up Care.<br />
Operative Report<br />
• Patient Name and <strong>Medical</strong> Record Number (8 digits)<br />
• Name of Attending Surgeon and Assistants<br />
• Date of Procedure<br />
• Pre and Post Operative Diagnoses<br />
• Name of Operation/Procedure<br />
• Type of Anesthesia<br />
• Name of Anesthesiologists<br />
• Surgical Technique used<br />
• Detailed account of the procedure and findings<br />
• Specimens removed<br />
• Closure & Drains<br />
• Complications<br />
• Fluids Given<br />
• Blood Loss<br />
• Patient Condition at the end of the procedure<br />
Corrections<br />
Make alterations to the medical record very carefully and only when changes are absolutely<br />
necessary. Do not obliterate errors or use whiteout in the medical record. To correct inaccuracies,<br />
follow these procedures:<br />
• Draw a single, thin line through each inaccurate entry, making certain that it is still legible<br />
• Date and initial this line<br />
• Add a note in the margin stating why the entry is being replaced (i.e. error, wrong patient,<br />
etc.)<br />
• Enter the correction in chronological order. If not possible, refer to location of the corrected<br />
material. Date corrected entry with current date.<br />
Addendum<br />
When writing an addendum, indicate that it is an addendum and use the current date. An<br />
addendum is appropriate if the patient requests that a correction be made in the record or if<br />
128
additional information is uncovered which may change original information previously recorded<br />
in the medical record.<br />
DEATH CERTIFICATE PROCESSING<br />
Death Certificates are processed in the HIM department at the Moses Division and in the<br />
Admitting department at the Weiler Division. The following documentation is required on every<br />
death:<br />
• Report each death immediately to HIM ext. 2210 at Moses and Admitting ext.3456 at Weiler<br />
• Pronounce patient (unless already pronounced by a PA). Document date, time and<br />
circumstances surrounding death in the patient's medical record. If a PA pronounced the<br />
death, countersign or write the death note.<br />
• Evaluate circumstances of death to ascertain whether <strong>Medical</strong> Examiner referral is required.<br />
(Name of <strong>Medical</strong> Examiner, Case Number, and Acceptance/Refusal of the case must be<br />
documented in the medical record.)<br />
• Attempt to obtain autopsy consent for all deaths that do not qualify for medical examiner<br />
referral. (Consent for Autopsy is Page 2 of Death Notification Form NR1625 M/E Rev.<br />
10/99). The pathologist is responsible for completing the death certificate on all autopsied<br />
cases.<br />
• Notify the attending physician.<br />
• Notify the next of kin of the patient's death.<br />
• Notify Pathology Moses ext. 4979. Weiler ext. 2947 and H I M Moses 2210 of pending<br />
autopsy<br />
• Complete the Death Certificate or <strong>Medical</strong> Examiner Report as required within two (2) hours<br />
of death.<br />
• A license number is required on all death certificates as of January 1, 2003. If the physician<br />
does not yet have a license, then the physician license number of the chief resident or<br />
attending physician of the case will be used.<br />
• Complete all sections of the Notification of Death Form #1625M/E Rev. 10/99 available on<br />
the nursing unit.<br />
HOME HEALTH AGENCY<br />
VP of Clinical Operations<br />
Terry Goodwin 718-405-4401<br />
Administrative Clinical Operations<br />
Pamela Joachim 718-405-4406<br />
The goal of the home care program is to meet the patient's continuing comprehensive health care<br />
needs in the home. Consistent with the <strong>Medical</strong> Center's objectives, the Home Health Agency's<br />
goal is to provide our patients with continuous quality care, focusing on positive patient<br />
outcomes.<br />
PROGRAMS<br />
129
Certified Home Health Agency – Provides professional care in the home during the recuperation<br />
period.<br />
• For patients who require skilled professional care.<br />
• For patients who are under the care of a physician who authorizes home care<br />
services.<br />
• Charges are usually covered by Medicare, Medicaid, and other insurance plans.<br />
Long Term Home Health Care Program- Provides case management and professional care at<br />
home to chronically ill patients who might otherwise require nursing home placement.<br />
• For patients who require ongoing skilled professional care and assistance with<br />
ADL’s.<br />
• For patients who are under the care of a physician who authorizes home care<br />
services.<br />
• Charges are covered by Medicaid.<br />
AIDS Home Care Program- Provides case management and professional care at home to patients<br />
with HIV/AIDS.<br />
• For patients who require skilled care by professionals, trained in this specialty, and<br />
assistance with ADL’s.<br />
SERVICES<br />
Services are provided in the Bronx and Westchester to patients at all stages of life, from<br />
newborns to seniors.<br />
• Services Provided at Home:<br />
• Professional Nursing Care<br />
• Physical Therapy<br />
• Occupational Therapy<br />
• Speech Therapy<br />
• Social Work Services<br />
• Related Support Services: Personal Care<br />
• Specialty Programs:<br />
• Wound Care Management<br />
• Home Infusion Therapy<br />
• Care of New Mothers/Infants<br />
• Pediatrics<br />
• HIV/AIDS<br />
BENEFITS OF MONTEFIORE HOME CARE<br />
• Clinical excellence<br />
• Compassionate care<br />
• Thorough and timely follow-up<br />
• Extensive links to community resources<br />
Referral Process: Call the centralized intake and information line at (718) 405-4532<br />
130
THE TISHMAN LEARNING CENTER<br />
HEALTH SCIENCES LIBRARY<br />
Moses, Silver Zone 2 nd Floor 718-920- 4666<br />
HOURS<br />
Monday – Friday: 9:00AM- 8:45PM<br />
Saturday: 9:00AM - 4:45PM (Lunch Break: 12:00PM - 1:00PM)<br />
During the summer months, (July and August) the library is closed on Saturdays.<br />
Sunday Closed<br />
Head, Circulation and Technical Services<br />
Heather Barnabas<br />
Circulation<br />
Yvette LeCointe<br />
Stephanie Spencer<br />
Nicole Symes<br />
Director<br />
Josefina P. Lim<br />
Associate Librarian and Head, Information Technology<br />
Sheigla Smalling<br />
MIS Help Desk<br />
Anca Banciu<br />
ELIGIBLE USERS<br />
All MMC associates, affiliates and NCB medical staff with valid IDs are eligible to use all<br />
library services and privileges. All others have on-site reference use privileges only.<br />
Registration at the Circulation Desk is required.<br />
CIRCULATION<br />
Books circulate for two weeks and are renewable for another two weeks. Bound journals<br />
circulate overnight. Renewals can be made over the telephone. AVs circulate for three days but<br />
are non-renewable.<br />
Non-circulating materials, i.e., unbound journals, reserve and reference items cannot be checked<br />
out of the library.<br />
FINES<br />
There is a charge of $0.10 per day for each item that is overdue. Overdue notices are a<br />
courtesy. Borrowers are responsible for returning and renewing materials on time whether or not<br />
overdue notices reach them.<br />
COMPUTER SERVICES<br />
131
A microcomputer study room is equipped with 13 workstations and printers. Internet access,<br />
Microsoft Office Suite and Wordperfect are some of the services available on each PC.<br />
ON-LINE CATALOG<br />
TISH the library’s online catalog provides access to the library's book, audiovisual and journal<br />
collections. The collections at AECOM Library can also be searched through TISH. Both<br />
collections are available through the Web.<br />
ELECTRONIC RESOURCES<br />
Internet access to Medline, MDConsult and other databases is available through Montenet or<br />
AECOM Remote Access. Electronic journals and books are accessible through these networks.<br />
UpToDate is available on designated workstations in the Microcomputer room. Training sessions<br />
for these resources are held at 10:00 am and 2:00 PM Monday through Friday. Mediated<br />
literature searches are conducted at a basic fee of $20 per search. Please call Sheigla Smalling<br />
x4666 for information and registration.<br />
INTERLIBRARY LOANS<br />
Materials not available in the library or online can be obtained through interlibrary loan. Most<br />
journal articles arrive within one to two weeks and most other materials within two weeks to a<br />
month.<br />
AUDIOVISUAL SERVICES<br />
TV/VCR components, slide and LCD projectors are available for circulation and in-house library<br />
use.<br />
PHOTOCOPY SERVICE<br />
Photocopiers are available at $0.10 per page by coins or copy cards.<br />
ARCHIVES<br />
Historical documents about MMC are managed and stored in the Zimmerman Archives located<br />
in the Library. Access to these materials must be arranged by calling 718-920-4666.<br />
RULES FOR USER CONDUCT<br />
These activities are not allowed in the Library:<br />
1. Eating/drinking/bringing in food<br />
2. Solicitations of any kind<br />
3. Unsupervised children/school children<br />
4. Theft and/or misappropriation of Library<br />
or another user's property<br />
5. Interfering with Library staff's performance of their duties<br />
6. Refusing to leave the premises at closing time<br />
7. Vandalism; abuse or misuse of Library equipment or property<br />
8. Violence<br />
If you have any questions or suggestions, please bring them to the<br />
attention of the staff.<br />
132
MAILROOM<br />
MOSES<br />
Brown Zone, Moses Basement<br />
Hours<br />
8:00AM - 5:00PM<br />
Supervisor<br />
Joseph Erving 718-920-5382<br />
WEILER<br />
1st Floor<br />
Hours<br />
9:00AM - 5:00PM<br />
Administrator<br />
Henry Makowski 718-904-4000<br />
There is a mail chute opposite the Blue Service elevators for all outgoing, stamped mail.<br />
OFFICE OF THE MEDICAL DIRECTOR<br />
Senior <strong>Medical</strong> Director and Vice President<br />
Brian Currie, M.D., M.P.H. 718-920-6078<br />
<strong>Medical</strong> Director and Vice President<br />
Gary Kalkut, M.D., M.P.H. 718-920-2809<br />
The Office of the <strong>Medical</strong> Director is responsible for a wide range of organizational initiatives<br />
dedicated to improving the quality of medical care and related services provided at the Acute<br />
Care Division, and other components of the medical center. It is involved in initiatives designed<br />
to enhance coordination of medical services across the continuum and promote efficiency and<br />
continuity of care. The Office has oversight of the Quality and Safety Program, the <strong>Medical</strong> and<br />
<strong>House</strong> <strong>Staff</strong> Office and more. It works closely with the <strong>Medical</strong> School on a variety of clinical<br />
programs and directs the efforts to ensure patient safety and foster excellence in medical care.<br />
Director of Clinical Affairs<br />
Lynn Richmond, NP 718-920-7052<br />
The Director of Clinical Affairs is available to assist physicians with patient care issues and<br />
questions related to the following: Advance Directives, Do-Not-Resuscitate orders, Foregoing<br />
Life-Sustaining Treatment, Do-Not-Intubate orders, Brain Death Protocol, Administrative<br />
133
Approval for patients with no next-of-kin, Liaison with the Palliative Care Program as well as<br />
other special projects. .<br />
OPERATING ROOMS<br />
Moses Scheduling 718-920-6308<br />
Weiler Scheduling 718-904-2876<br />
There are 20 operating rooms at the Moses Division and 14 at the Einstein Division including<br />
one lithotripsy and one cystoscopy suite. O.R. time is available to surgeons on a block and<br />
"open-time" basis. Block schedules may be obtained through the O.R. scheduling office at each<br />
site. Block schedules are subject to modification as the<br />
utilization of allocated time is reviewed. 24 hours-per- day, 7 days- per- week coverage of the<br />
operating rooms is provided at each site. Specialty call coverage for specific services is also<br />
available. Patients may be scheduled for surgery by the attending physician's office through the<br />
O.R. scheduling office Monday through Friday between 9 A.M. and 5:30 P.M. When an elective<br />
case is scheduled, complete patient demographic information is required. Emergency cases may<br />
be scheduled through the O.R. charge nurse. At Moses, call ext. 4491 and at Einstein call ext.<br />
2798.<br />
If an elective patient needs to be seen by an anesthesiologist you must request a preadmission<br />
testing appointment at that time. Patients presenting for surgery must have a complete history<br />
and physical within seven days of the planned procedure. The consent tool must be complete<br />
and written in lay terms. The words right and left as well as the spinal levels must be written in<br />
entirety.<br />
On the day of surgery, adult ambulatory surgery and same day admission patients will be<br />
directed to arrive at the Moses 3 North Surgery Center. All pediatric ambulatory and same day<br />
admissions patients will be directed to arrive at the CHAM 3 Day Hospital.<br />
At Weiler, all patients will be instructed to arrive at the surgery center in the Lubin building on<br />
the 2nd floor. Ambulatory surgery patients will be discharged from the respective second stage<br />
recovery areas.<br />
OCCUPATIONAL HEALTH SERVICES<br />
Director<br />
Michela Catalano, M.D.<br />
Moses 718-920-5406<br />
Green Zone - DTC Building - 4th Floor, Room 480<br />
Einstein Division 718-794-7048<br />
1894 Eastchester Road, 2 nd Floor<br />
Occupational Health Services is a unified Department of <strong>Montefiore</strong> <strong>Medical</strong> Center. An OHS<br />
clinician is available 24/7 through telecom page.<br />
134
The mission of the Occupational Health Services Department is to:<br />
• comply with state, federal and hospital policy regarding initial and interval health<br />
assessments<br />
• determine the ability of all individuals to work in the hospital and its outlying facilities<br />
• treat and/or refer for treatment those individuals who incur work related illnesses or injuries<br />
• engage in the prevention of work-related illnesses by participating in environmental and<br />
personnel monitoring procedures<br />
• promote good health of the work force by promoting preventative health programs<br />
PALLIATIVE CARE<br />
Palliative care is the comprehensive care of patients with advanced and often incurable medical<br />
illnesses. Its goals include the relief of physical, emotional and spiritual suffering as well as the<br />
preservation of psychosocial and physical functioning of the patient and his/her family unit to the<br />
fullest extent possible. The PCARE service provides coordinated interdisciplinary care on both a<br />
consultative and primary care basis to patients with chronic often incurable and life threatening<br />
illnesses.<br />
PALLIATIVE CARE CONSULTATION SERVICE<br />
The Palliative Care Consultation Service (PCARE) provides inpatient consults at <strong>Montefiore</strong><br />
<strong>Medical</strong> Center’s Moses and Weiler divisions. The PCARE service includes full time palliative<br />
care physicians from various departments within the hospital, nurse practitioners, social workers,<br />
bioethicists, and clergy. The PCARE Service does approximately 90 consults per month<br />
including home visits as well as consultative services at several local nursing homes.<br />
The Palliative Care Consultation Service offers:<br />
• Expert treatment of pain and other symptoms of chronic illness<br />
• Care of psychosocial needs of patients and families, including group and individual<br />
counseling<br />
• Pastoral and spiritual care of patients and families<br />
• Assistance with advance care planning, discussion of goals of care, and contingency<br />
planning<br />
• Bereavement services for family members<br />
• Coordinated services across the continuum of care<br />
• Referral to hospice<br />
• Support for professional caregivers and staff<br />
INPATIENT PALLIATIVE CARE SUITE (IPS)<br />
The inpatient Palliative Care Suite (IPS) goal is to provide short-term intervention not requiring<br />
prolonged length of stay. Criteria for admission to IPS:<br />
• Patients with chronic incurable illness requiring acute hospitalization to diagnose and/or<br />
treat newly developed symptoms<br />
• Patients with chronic incurable illness requiring inpatient management of exacerbations<br />
of known symptom, e.g., intensive medication and dose changes requiring close<br />
monitoring, and/or procedures, such as paracentesis or thoracentesis<br />
135
• Patients who have been withdrawn from ventilator support or dialysis who can be<br />
anticipated to be symptomatic<br />
• Patients with complex chronic pain<br />
• Patients requiring active treatment to control pain (e.g., radiation therapy, chemotherapy,<br />
nerve block)<br />
• Patients with Hospice coverage<br />
• Actively dying patients requiring short-term hospitalization<br />
• Patients in multiorgan failure who have been evaluated and rejected for admissions to an<br />
intensive care unit.<br />
THE MONTEFIORE ER PALLIATIVE CARE CASE MANAGEMENT PROGRAM FOR<br />
ELDERLY PATIENTS<br />
The program includes two (2) nurse practitioners.<br />
• Elderly and other patients visiting the ED for medical care who need linkage with home<br />
care or hospice<br />
• Patients needing linkage with pharmacy care or specialty services such as geriatric<br />
medicine<br />
• Patients with life-threatening disease<br />
• Patients with complex unrelieved pain<br />
PAIN AND PALLIATIVE CARE OUTPATIENT CLINICS<br />
The Pain and Palliative Care Outpatient clinic is staffed by professionals of the <strong>Montefiore</strong><br />
Palliative Care Service. The clinic provides interdisciplinary outpatient pain management and<br />
palliative care service. Patients with the following conditions may benefit from consultation for<br />
pain management and palliative care:<br />
• Patients with cancer and other life-threatening conditions such as advanced congestive<br />
heart failure (CHF), chronic obstructive pulmonary disease (COPD), strokes and other<br />
neurological conditions, for pain, symptom management, psychosocial and spiritual<br />
support.<br />
• Patients suffering from chronic non-malignant pain syndromes, including patients with a<br />
history of chronic pain and substance abuse.<br />
• Pain and Palliative Care Outpatient Clinic is located at 3448 Kossuth Avenue, Bronx,<br />
New York 10467<br />
• Cancer Pain Clinic is located at the <strong>Medical</strong> Park Pavilion, 1695 Eastchester Road,<br />
Bronx, New York 10461<br />
• HIV Pain Management Clinic is located at 3448 Kossuth Avenue, Bronx, New York<br />
10467<br />
PALLIATIVE CARE IS NEEDED WHEN:<br />
• Patients have been diagnosed with serious illness and pain and other symptoms interfere<br />
in the patient's quality of life<br />
• Help is needed to clarify goals of care of the patient<br />
• Help is needed in end-of life planning and decision-making<br />
136
• Families and caregivers need assistance with bereavement and<br />
grief<br />
• Children in the family are affected by the patient's illness<br />
• Emotional or spiritual distress is unrelieved<br />
• Problems arise from advanced illness, and disease-focused treatments<br />
are no longer helping<br />
Palliative care can often be provided in parallel with curative treatment. It is not necessary for<br />
the patient to be in the last days of his or her illness for these needs to be met. The transition to<br />
Palliative Care is a process. As the end of life approaches, the role of Palliative Care increases<br />
subject to patients' and families' approval<br />
and acceptance of the changing goals of care.<br />
THE PROGRAM OFFERS:<br />
• Expert treatment of pain and other symptoms of chronic illness<br />
• Care of psychosocial needs of patients and families, including<br />
group and individual counseling<br />
• Pastoral and spiritual care for patients and families<br />
• Assistance with advance care planning<br />
• Discussion of goals of care<br />
• Bereavement services for family members<br />
• Coordinated services across the continuum of care<br />
• Referral to Hospice and support for professional caregivers and<br />
staff<br />
HOW TO ACCESS SERVICES<br />
In patient consultations and outpatient consultations can be obtained<br />
by contacting the Palliative Care service office at (718) 920-6378 or<br />
paging (917) 729-6232 between 9:00AM and 5:00PM. On nights and weekends,<br />
for urgent matters, page the Palliative Care service at (718) 659-3202.<br />
For appointments for the Outpatient Pain and Palliative Care Clinic call (718) 920-5101 between<br />
the hours of 9am-4:30pm. For appointment for the Cancer Pain Clinic call 718-920-7162; For<br />
appointment for the HIV Pain Management Clinic call 718-920-8542. For non-urgent questions,<br />
please leave a voice mail at the office number above or send an email message to<br />
SOMAHONY@MONTEFIORE.ORG or PSELWYN@MONTEFIORE.ORG.<br />
PATIENT, FAMILY, AND COMMUNITY HEALTH EDUCATION RESOURCES<br />
Director<br />
Josay Laventhol 718-920-6058<br />
North West 5<br />
A broad range of written health education materials in English and Spanish are available from<br />
the Patient/Health Education Department, located at the Moses Division on North West 5.<br />
Materials are developed with multi-disciplinary input and written in layman's language. Topics<br />
include instructions about how to prepare for diagnostic tests, surgical procedures, follow-up<br />
137
care, promoting recovery and preventing complications. Many wellness and prevention flyers are<br />
available. Materials are printed on yellow paper and distributed to Moses and Weiler in/outpatient<br />
areas, including satellites.<br />
A newsletter called "UPDATE" listing over 1,200 patient education sheets can be found on<br />
<strong>Montefiore</strong>’s Intranet site. New and revised publications are highlighted. Materials may be<br />
ordered in quantity. Topics not listed can be obtained by patients and staff from the department's<br />
library, resource files and Internet searches between 9:00 AM - 5:00 PM. A listing of Support<br />
Groups sponsored throughout the <strong>Medical</strong> Center, to provide assistance to out-patients/families<br />
and the community, is available upon request. Health Education video programs are shown on<br />
in-patient television sets and in some out patient areas, free-of-charge. A television schedule is<br />
distributed to patients.<br />
PATIENT SAFETY<br />
Patient Safety Officer 718-920-2071<br />
Jason Adelman, MD<br />
jadelman@montefiore.org<br />
The mission of the MMC Patient Safety Program is to continuously improve care systems in<br />
order to minimize the risks posed to patients as a result of exposure to the healthcare system. As<br />
such, the mission of the program is well aligned with MMC’s mission of excellence in patient<br />
care and the MMC strategy of improving organizational performance.<br />
Tenets of the program include:<br />
• Achieving improvement through an emphasis on processes and systems of care over the<br />
identification of individuals<br />
• Drawing upon network-wide surveillance mechanisms as information resources relating<br />
to patient safety<br />
• Enlisting multidisciplinary participation in improving organizational performance<br />
• Learning from adverse events as well as medical errors that may or may not have resulted<br />
in harm<br />
• Valuing patient, family, and staff feedback regarding patient safety<br />
PATIENT SAFETY OFFICER AND COMMITTEE<br />
The primary role of the Patient Safety Officer is to facilitate and enable institutional patient<br />
safety activities and the institutional Patient Safety Program. The Patient Safety Officer reports<br />
to the Vice President, Senior <strong>Medical</strong> Director.<br />
The Patient Safety Committee serves as an organizational structure to facilitate and enable<br />
patient safety activities and manage the Patient Safety Program. The Patient Safety Committee<br />
is accountable to the <strong>Montefiore</strong> Quality Council. The Patient Safety Program cannot lead all<br />
activities that relate to improving patient safety at MMC and is not meant to substitute for the<br />
existing institutional activities and structures noted earlier, but to complement them, by focusing<br />
on patient safety related compliance, coordination, and communication.<br />
138
The Patient Safety Officer and the <strong>Medical</strong> Director, Quality Management, co-chair the<br />
institutional Patient Safety Committee. Membership includes representatives of areas within the<br />
delivery system who have oversight for activities that are fundamentally relevant to improving<br />
patient safety. Broad based representation allows for coordination and communication of<br />
activities across the delivery system.<br />
The 3 primary functions of the Patient Safety Officer and Committee can be summarized as:<br />
• Compliance with patient safety related regulations, including JCAHO patient safety<br />
standards and goals<br />
• Coordination and integration of patient safety activities across the institution<br />
• Communication of patient safety related information to leadership, associates, patients<br />
and families<br />
The scope of activities of the Patient Safety Program enabled by the Patient Safety Officer and<br />
Patient Safety Committee, in conjunction with owners of various patient safety related content<br />
areas, include:<br />
• Review and facilitation of institutional activities enhancing patient safety, including<br />
activities relating to:<br />
• Proactive risk reduction activities<br />
• Errors<br />
• Adverse and critical events<br />
• “Near miss” events – variations in healthcare process not affecting outcomes, but<br />
where recurrences carry significant chances of adverse outcomes<br />
• “No-harm” events – unintended acts of omission or commission that do not result in<br />
adverse outcomes<br />
• Facilitating:<br />
• Communication of patient safety related information throughout the organization<br />
• Education of leadership, associates, patients and families with respect to patient<br />
safety<br />
• Annual redesign of at least one high risk process for proactive risk reduction (failure<br />
modes and effects analysis)<br />
• Assessment and refinement of MMC policies and procedures to be in compliance with<br />
regulations, including JCAHO patient safety standards and goals<br />
• Review of information from patients, families and associates to improve patient safety<br />
• An annual report on institutional patient safety activities<br />
PHARMACY SERVICES<br />
MOSES 718-920-4529<br />
The Moses Pharmacy Department is composed of a centralized pharmacy and six satellites or<br />
decentralized pharmacies. The central pharmacy facility and pediatric satellite are open 24 hours<br />
a day, 7 days a week. The central pharmacy is located in the Storage Building, Orange Zone and<br />
can be reached at phone number 920-4103. The pediatric pharmacy is located in the Children’s<br />
Hospital at <strong>Montefiore</strong> on the sixth floor and can be reached at phone number 741-2626. The<br />
TPN production area can be reached<br />
139
at 904-8860 (Weiler Division). The Moses Administrative Pharmacy office hours of operation<br />
are 8:30AM to 5:00PM, Monday through Friday, and are located in the Orange Zone of the<br />
Storage Building. The telephone number is 718-920-8540/5778920-2940.<br />
In addition, six decentralized pharmacy satellites provide pharmaceutical<br />
care services. These are located in the following areas:<br />
Medicine 718-920-5208<br />
8:30AM - 11:30PM<br />
Klau5<br />
Pediatrics 718-741-2626<br />
24 hours per day CHAM 6<br />
Inpatient Oncology 718-920-2329<br />
8:30AM - 5:00PM<br />
NW3<br />
Outpatient Oncology 718-920-5778<br />
8:00AM - 5:00PM<br />
NW4<br />
Med-Surg 718-920-5348<br />
8:30AM - 5:00PM North 6<br />
Critical Care 718-920-5335<br />
8:30AM - ll:00PM Weekdays, 8:30AM - 5:00PM Weekends and Holidays<br />
North 3<br />
An ambulatory pharmacy located in the ground floor of the Family Care Center (FCC)<br />
building fills prescriptions for employees. The employee must present hospital ID when picking<br />
up prescriptions.<br />
A second ambulatory pharmacy, Specialty Pharmacy, provides pharmaceutical services<br />
to patients in the Infectious Diseases Clinic. The Specialty Pharmacy is located in the FCC<br />
Building on the second floor.<br />
WEILER 718-904-3225<br />
A central pharmacy facility is open 24 hours-per-day, 7 days-per- week. The phone number is<br />
904-2838. The TPN production area can be reached at 904-8860. The central pharmacy and the<br />
administrative pharmacy offices are located on the main floor in the service area. In addition, an<br />
Oncology Pharmacy Satellite provides pharmaceutical care services to patients on 11 South and<br />
5 South. The satellite is open 7:30AM - 6:15PM Monday – Friday and from 8:00AM - 4:15PM<br />
on weekends and holidays and can be reached at 904-4173.<br />
An ambulatory pharmacy located in the central pharmacy fills prescriptions<br />
for employees only 8:00AM to 4:00PM Monday - Friday (closed on hospital holidays).<br />
Employees must present hospital ID when picking up prescriptions. An Ambulatory Oncology<br />
Pharmacy provides pharmacy services from the <strong>Montefiore</strong> <strong>Medical</strong> Park, Monday – Friday,<br />
8:30AM to 4:45PM. The Ambulatory Oncology Pharmacy can be reached at (718)405-8510.<br />
KEY PERSONNEL<br />
140
Unified Director of Pharmacy<br />
Frank Sosnowski, MS, RPh<br />
718-920-4529 Moses<br />
718-904-2369 Weiler<br />
Director, Pharmacy Operations<br />
Ellen Rudnick, MS,RPh 718-920-2943<br />
Director, Clinical and Educational Pharmacy Services<br />
Mark Sinnett, Pharm D, FASHP, RPh 718-920-2944<br />
Director, Pharmacy Operations<br />
Yvonne Gayle, PharmD, MS, RPh 718-904-2825<br />
Director, Pharmacy Finance and Automation<br />
Barney Zaino, MS, RPh 718-920-2949<br />
Evening Supervisor, Weiler 718-904-2838<br />
Day Supervisor, Weiler<br />
Irene Maningas, R.Ph. 718-904-2838<br />
Clinical Pharmacy Manager, OR/Anesthesia<br />
Frank Aroh, PharmD, BS, RPh 718-904-2014<br />
Clinical Pharmacy Manager, Infectious Diseases<br />
Maria Amodio-Groton, Pharm D, RPh 718-920-6433<br />
Clinical Pharmacy Manager, Infectious Diseases 718-920-6433<br />
Yi Guo, Pharm D, RPh<br />
Clinical Pharmacy Manager, Critical Care<br />
Julie Chen, Pharm D, BCPS RPh 718-920-6433<br />
Clinical Pharmacy Manager, Cardiology/NICU<br />
Angela Cheng, Pharm D, RPh 718-920-6433<br />
Clinical Pharmacy Manager, Family Medicine 718-920-6433<br />
Manager, Investigational Drugs<br />
Clemencia Solorzano, BS, RPh 718-920-8354<br />
Production Supervisor, Moses<br />
Ann Brownstein, MS, RPh 718-920-8527<br />
Day Supervisor, Moses<br />
Alla Belovsky, M.S., R.Ph. 718-920-8354<br />
141
Evening Supervisor, Moses<br />
Carolyn Woodley, Pharm D 718-920-8354<br />
Manager, Oncology Pharmacy, Moses 718-920-8540/5778<br />
Royston Browne, BS, RPh<br />
Manager, Oncology Pharmacy, Einstein 718-405-8510<br />
James McCarthy 718-904-4173<br />
Ambulatory Pharmacy Manager, Moses 718-920-4934<br />
Steven Tuckman, BS, R.Ph.<br />
Specialty Pharmacy Manager<br />
Keith Veltri, PharmD, MS, R.Ph. 718-920-4934<br />
QUALITY MANAGEMENT<br />
Quality Management Department 718-920-5026<br />
Rohit Bhalla, MD<br />
Brandon Yongue, PhD<br />
The Quality Management Department is a team of professionals available to provide assistance<br />
in quality and performance improvement initiatives. Technical and consultative support is<br />
available in the following areas:<br />
• Access to statistical and data resources and expert clinical resources<br />
• Guidance in appropriate performance improvement tools and methodology<br />
• Guidance in regards to regulatory and accreditation standards<br />
• Advice/assistance in development and use of information systems in performance<br />
improvement<br />
• Facilitation of performance improvement groups<br />
PERFORMANCE AND QUALITY IMPROVEMENT<br />
The provision of safe, high quality, cost-effective care in an atmosphere of service excellence is<br />
one of MMC's highest priorities. Performance Improvement is a systematic means of making<br />
positive organizational changes to increase patient safety, meet evolving standards of practice,<br />
satisfy patient/family needs and expectations, and increase the efficiency with which care is<br />
provided. There is a single overall plan for quality management for the medical center and one<br />
institution-wide committee, the <strong>Montefiore</strong> Quality Council, with oversight responsibility for<br />
performance and quality improvement.<br />
The methodology for Quality Improvement that MMC has adopted is the PDCA, Plan-Do-<br />
Check-Act model. This approach allows us to continually strive to meet high standards for<br />
safety, quality and cost effective health care and improved outcomes through better design of<br />
services and through a reduction in the variation in how care is provided. It is based on the<br />
methods of continuous quality improvement, whereby baseline data are collected, best practices<br />
identified through literature searches, interventions are designed, piloted, and if determined to be<br />
142
successful, expanded to other areas. At this point, ongoing monitoring and surveillance is done to<br />
ensure on-going effectiveness.<br />
Some PI initiatives emerge from rigorous peer review. In the peer review process, each<br />
department is responsible for the review of all mortality cases, significant complications, readmissions<br />
within 3 days, and cases in which a departure from standards of care may have<br />
occurred. Performance Improvement Initiatives also emerge from the need to redesign services<br />
or to address key patient safety areas. Examples of organization-wide PI initiatives include<br />
Service Excellence, Pain Management, Reduction of Medication Errors, Reduction of Hospital<br />
Days, CIS and Computerized Physician Order Entry, ICU Physician <strong>Staff</strong>ing, and creating a<br />
seamless continuum of care through all levels of acuity.<br />
RESPIRATORY CARE<br />
Respiratory Care Services are provided to patients based on a written/electronic prescription by<br />
the physician responsible for the patient's care.<br />
The Director of the service is available Monday - Friday, 9:00AM - 5:00PM and can be reached<br />
at (718) 920-5110 or (718) 904-3214. The Shift Supervisors are available Monday - Friday, 7:00<br />
a.m. - 10:00pm. They can be contacted through the Page Operator. If there are no managers on<br />
duty and assistance is needed, contact the Page Operator for the Manager On-Call.<br />
HOURS<br />
24 hours-per- day, 7 days-per-week<br />
There are two tours:<br />
Tour I: 6:30AM - 7:00PM<br />
Tour II: 6:30PM - 7:00AM<br />
Shift report and daily activities are discussed from 6:30 until 7:00 on both tours. The Respiratory<br />
Care Supervisors meet with the clinical staff to discuss quality of care rendered and to assure<br />
continuity of care to all patients. Therapists have permanent beeper assignments which are<br />
posted on each Nursing Unit. They can also be contacted<br />
through the Page Operator.<br />
MOSES<br />
Northwest Building - Blue Zone, 1 st Floor<br />
<strong>Medical</strong> Director<br />
Anita Bhola, MD<br />
Director<br />
Joseph Antonik, RRT 718- 920-5110<br />
917- 646-0337 pager<br />
SHIFT SUPERVISORS<br />
Yvonne Wigfall, RRT 718-920-2912<br />
143
917-457-8256 pager<br />
Merlean Clarke, RRT 718- 920-2128<br />
917- 787-7698 pager<br />
Scott Dabbene, RRT 718- 920-5248<br />
917- 537-4652<br />
WEILER<br />
<strong>Medical</strong> Director<br />
Manoj Karwa,MD<br />
Director<br />
Joseph Antonik,RRT 718- 904-3214<br />
SHIFT SUPERVISORS<br />
Richard Verrette,RRT 718-904-2006<br />
917-672-4398 pager<br />
Nancy Torres,RRT 718-904-2339<br />
917-672-4356 pager<br />
Cliff Dryden,RRT 718-904-3215<br />
917-762-5066 pager<br />
RISK MANAGEMENT<br />
3328 Rochambeau Avenue, 2nd floor 718-920-6340/6733<br />
The Risk Management Department seeks to promote safety and prevent and minimize the<br />
<strong>Medical</strong> Center's financial losses associated with patient/visitor injury, medical malpractice<br />
claims and other liabilities. All levels of staff are encouraged to report accidents, actual or<br />
potential claims, medical errors and untoward events promptly to Risk Management. The<br />
Department is available 24 hours-per-day, 7 days-per-week to assist with the management of<br />
difficult cases involving medical-legal problems, liability issues, consents, refusals of treatment,<br />
and disputes/conflicts concerning patient care issues. During the evening, at night or on<br />
weekends, Risk Management consultation may be accessed for urgent matters through the<br />
Administrative Nursing Supervisor.<br />
During non-office hours, non-emergent messages may be left at the above numbers.<br />
Please contact Risk Management for any questions or concerns regarding these Administrative<br />
Policies/Procedures:<br />
• Informed Consent<br />
• Disclosure of Unanticipated Events<br />
• Occurrence Reports<br />
• Safe <strong>Medical</strong> Devices<br />
144
• Professional Misconduct<br />
• Photography<br />
• Equipment Malfunction<br />
In addition, contact Risk Management for:<br />
• Receipt of summonses, subpoenas, court orders, legal documents<br />
requests or inquiries from attorneys<br />
• Insurance claims, including theft, fire, flood, general liability and<br />
other claims against MMC's insurance policies<br />
• Questions concerning professional liability and other insurance<br />
coverage<br />
• Requests from third parties for certificates demonstrating insurance<br />
coverage for MMC employees<br />
Risk Management is committed to staff education and conducts departmental in-service<br />
programs on a variety of medical-legal and risk related topics including documentation, informed<br />
consent, and malpractice prevention/mitigation for physicians and other staff.<br />
SAFETY AND SECURITY<br />
Director of Safety & Security<br />
Peter Kennelly 718-920-4113<br />
Manager of Fire & Safety<br />
Edward Fominyam<br />
(For information on Fire Safety and Prevention, refer to the Policies and Procedures section of<br />
the manual).<br />
Security 718-920-5104<br />
Emile Provencher 718-904-2750<br />
Security Questions/Concerns 718-920-6131<br />
Emergencies Dial 4357<br />
The Security Department serves to provide a safe and secure environment for all patients, staff<br />
and visitors. We strive to provide prompt, courteous, helpful and caring service, as well as<br />
immediate and effective response to all emergencies. Security Officers are present in the<br />
hospital 24 hours each day.<br />
DISASTER CODES<br />
Code 7: External<br />
Code 4: Internal<br />
Code 5: Security<br />
Code ADAM is the hospital term for Pediatric Abduction. Every Associate has a responsibility<br />
during a Code ADAM. All associates should be alert and report anyone attempting to leave with<br />
145
a pediatric patient or any type of package large enough to contain an infant to the security stat<br />
line HELP 4357. Associates with specific<br />
responsibilities will be informed of their duties during their departmental orientation.<br />
ALL ASSOCIATES:<br />
• Must display photo ID at all times at work. If ID is lost, a replacement may be obtained from<br />
the Security Office.<br />
• Should lock personal items of value in a secure place.<br />
• Call HELP- x. 4357 if there is an emergency.<br />
Certain work locations require additional security information and training (i.e. panic buttons,<br />
alarms). Individual departments are responsible for departmental orientation.<br />
WEILER<br />
Security Office Hours<br />
Monday - Friday: 7:30AM - 6:00PM<br />
ID Badges and Parking Validations 718-904-2750<br />
Main Office (located on the first floor across from the Pharmacy)<br />
The Main Lobby post is always manned and the telephone extension is 2800.<br />
The Main Parking Lot is open from 6:30AM. - 1:00AM. Vehicles must have an authorized<br />
Parking Sticker and access card to gain access. This system also allows Security to contact you<br />
in case of any problem (i.e.: flat tire, lights on, keys in the door, etc.).<br />
MOSES<br />
Administrative Office 718-920-6131<br />
Monday - Friday 8:00AM - 5:00PM<br />
Security Control Station (24 hrs) 718-920-5668<br />
ID Badges, and Lost and Found<br />
Monday - Wednesday, and Friday<br />
8:00AM - 12:00PM and 1:00PM - 4:00PM<br />
SLEEP-WAKE DISORDERS CENTER<br />
Director<br />
Michael J. Thorpy, MD<br />
3411 Wayne Avenue<br />
Bronx, New York 10467<br />
Referrals: 718-920-4841<br />
718-798-4352 Fax<br />
146
Outpatient testing, evaluation and diagnosis of all Sleep Disorders for adult and pediatric<br />
patients.<br />
SOCIAL WORK SERVICES<br />
Management Team:<br />
Dolores C. Jackson 718-920-4402<br />
Rhonda Lieberman 718-741-2290<br />
Services Provided:<br />
• Discharge Planning<br />
• Counseling<br />
• Obtain Home Care Services<br />
• Coordinate Placement in appropriate facilities (SNF, Rehab, etc.)<br />
• Community Resource Planning<br />
• Coordinate transportation upon discharge<br />
• Information and Referral Program<br />
MOSES 718-920-4545<br />
Hours:<br />
Monday – Friday 8:30AM - 5:00PM<br />
Emergency Room<br />
Monday – Friday 8:30AM - 10:00PM, Weekend 2:00PM - 10:00PM<br />
Inpatient Worker<br />
8:30AM - 5:00PM Weekends<br />
Covers all inpatient units and the ER as needed until 2:00PM<br />
WEILER 718-904-2707<br />
Hours<br />
Monday - Friday 9:00AM - 5:00PM<br />
Emergency Room<br />
Monday - Friday 9:00AM - 9:00PM<br />
Saturday 1:00PM - 9:00PM, Sunday 2:00PM – 10:00PM<br />
Inpatient Worker<br />
9:00AM - 5:00PM Weekends<br />
Covers all inpatient units and the ER as needed until 12:00PM<br />
Weekends and After Hours<br />
Weekend Social Workers can be reached through the page operators. After hours, Social Work<br />
Managers can also be reached through the page operator for emergencies.<br />
147
STAFF AND ALUMNI ASSOCIATION<br />
3306 Rochambeau Avenue, 2nd floor 718-920-5260<br />
President<br />
Manash Dasgupta, MD<br />
Executive Director 718-920-5260<br />
Margaret Pinsker<br />
718-515-7083 Fax<br />
The mission of the <strong>Montefiore</strong> <strong>Staff</strong> and Alumni Association is to enhance and strengthen the<br />
relationship between <strong>Montefiore</strong> <strong>Medical</strong> Center (MMC) and its medical staff and alumni<br />
through the development of programs that foster education, fellowship and service. Founded by<br />
a group of attending physicians in 1914, the Association has always been involved with patient<br />
and community needs and has acted as a strong advocate for the rights of house staff.<br />
The <strong>Staff</strong> and Alumni Association sponsors the following programs<br />
and services:<br />
• Annual Dinner Dance and Awards Night<br />
• Receptions at medical meetings<br />
• Annual Career Night program for medical center house staff<br />
• Support of a medical center archivist<br />
• Publication of bi-annual Newsletter<br />
• Scholarship Prize given annually to an AECOM graduate<br />
• Support of the Health Science Library of the Tishman Learning Center<br />
• Sponsorship of the annual outstanding <strong>House</strong> Officer Award and the Henry L. Moses Prize<br />
for basic science and clinical research<br />
• Biennial symposia on medical trends and technology<br />
• Membership Directories<br />
• Emergency Loan Fund for physicians in need<br />
• Memorial portrait project<br />
Membership is open to MMC: 1) graduates of medical, dental and physician assistant training<br />
programs, 2) current and former members of the attending staff and 3) PhD's in the Behavioral<br />
and Basic Sciences. The membership year is from<br />
July I - June 30.<br />
All programs, activities and benefits offered by the Association are underwritten by membership<br />
dues. Dues are $60 per year; $30 per year for junior members who are less than five years out of<br />
training. Graduating house staff are offered a one-year complimentary membership which<br />
entitles them to all member benefits.<br />
A Life Membership for payment of $1,000 is also available, which provides all member benefits<br />
in perpetuity. Life members are recognized on a plaque in the <strong>Staff</strong> and Alumni Conference<br />
Room.<br />
TELECOMMUNICATIONS<br />
Administrator<br />
Mary Bishel<br />
718-920-6262 Moses<br />
718-904-2701 Einstein<br />
148
Office Coordinator<br />
Lillian Zambardino<br />
718 920-5601 Moses<br />
The Telecommunications Department provides operations and maintenance of all aspects of<br />
voice communication throughout the <strong>Medical</strong> Center. This includes all areas of telephone<br />
service; incoming and outgoing calls, paging, information service, planning equipment service<br />
and repairs, new installations, moves and/or changes to existing telephone system, distribution of<br />
voice and digital pagers, preparation of in-house pocket directories, monitoring of billings related<br />
to telecommunications, participation in planning and implementation of capital projects.<br />
VOLUNTEER SERVICES<br />
Unified Director<br />
Margaret Hamer<br />
718-920-6654 Moses<br />
718-904-2934 Einstein<br />
MOSES<br />
Program Supervisor<br />
Elizabeth Ambert<br />
Main Building Blue Zone<br />
Loeb Corridor-1 st Floor 718-920-4191/4192<br />
Monday-Friday, 8:30AM - 4:30PM<br />
WEILER<br />
Secretary<br />
Cynthia Rivera<br />
Second Floor Einstein Hospital 718-904-2934<br />
Monday-Friday, 9:00AM – 5:00PM<br />
The Volunteer Services Department directs and oversees all programmatic work throughout the<br />
<strong>Medical</strong> Center, the Children’s Hospital at <strong>Montefiore</strong> (CHAM) and the Children's Mobile Unit<br />
located on 64th St. In addition, the Department develops and implements volunteer recruitment<br />
strategies, conducts community needs assessments, build relationships with community agencies<br />
and oversees a comprehensive volunteer outreach program while helping to retain a diverse and<br />
knowledgeable corps of volunteers. Providing high quality volunteer services while giving the<br />
volunteer a satisfying experience and appropriate support, the Department coordinates<br />
internships, summer programs and school/adult work experience programs. It provides all<br />
resources necessary to meet departmental needs and to provide a conducive environment to<br />
volunteer/staff growth and productivity.<br />
Interviews by appointment only.<br />
149
INDEX<br />
A<br />
Accreditation for Patient Care, <strong>House</strong> <strong>Staff</strong> 30<br />
Acute Pain Service 116<br />
Admissions, <strong>House</strong> <strong>Staff</strong> 41<br />
Admitting 116<br />
Advanced Directives- Health Care Proxies and Living Wills 92<br />
Anesthesiology 61<br />
Approval and Accreditation, <strong>House</strong> <strong>Staff</strong> 28<br />
B<br />
Banking Facilities 19<br />
Bioethics 117<br />
Blood Banks 118<br />
Brain Death 93<br />
C<br />
Cardiology 62<br />
Cardiothoracic Surgery 63<br />
Change of Address/Practice Location, <strong>Medical</strong> <strong>Staff</strong> 22<br />
Change of Status, <strong>Medical</strong> <strong>Staff</strong> 22<br />
Chart Completion Policy for <strong>House</strong> Officers 42<br />
Child Protection Center 119<br />
Child Psychiatric Outpatient Divisions 64<br />
Clinical Information Systems 119<br />
CMO Important Telephone Numbers 25<br />
Committee on Graduate <strong>Medical</strong> Education 27<br />
Continuing <strong>Medical</strong> Education 120<br />
Controlled Substances in the Work Place 109<br />
Credentialing Office 21<br />
Customer Services 121<br />
D<br />
DEA Registration, <strong>House</strong> <strong>Staff</strong> 35<br />
Death Certificates 104<br />
Dentistry 64<br />
Dialysis Center III 121<br />
Division of Education and Organizational Development 121<br />
Do Not Intubate 97<br />
Do Not Resuscitate 95<br />
Drug Free Work Place 108<br />
150
E<br />
Educational Administration 28<br />
Emergency Medicine 65<br />
Employee Assistance Program 43<br />
End of Life Care 99<br />
Environmental Service 122<br />
Epidemiology and Population Health 65<br />
Equal Opportunity Employer 108<br />
Ethical and Legal Compliance 106<br />
F<br />
Family Medicine 66<br />
Fire Safety and Prevention 104<br />
Food and Nutrition 123<br />
Forgoing Life Sustaining Treatment 100<br />
Frequently Used Numbers 12<br />
G<br />
General Essentials of Accredited Residencies 28<br />
Gift Shop 124<br />
H<br />
Harassment 107<br />
Health Information Management 124<br />
Home Health Agency 129<br />
Homeless Program 57<br />
<strong>House</strong> <strong>Staff</strong> Benefits Plans 38<br />
Hours, Limitation of <strong>House</strong> <strong>Staff</strong> 38<br />
<strong>House</strong> <strong>Staff</strong> Office 27<br />
Housing 44<br />
I<br />
Infection Control Program 105<br />
Informed Consent and Refusal 101<br />
Institutional Agreements ` 30<br />
Institutional Requirements, <strong>House</strong> <strong>Staff</strong> 28<br />
L<br />
Laundry and Linen, <strong>House</strong> <strong>Staff</strong> 42<br />
Leave of Absence, <strong>House</strong> <strong>Staff</strong> 37<br />
Library, Tishman Learning Center Health Sciences 131<br />
151
M<br />
Mailroom 133<br />
Malpractice Insurance, <strong>House</strong> <strong>Staff</strong> 35<br />
Maternity Leave, <strong>House</strong> <strong>Staff</strong> 37<br />
Meal Tickets 40<br />
<strong>Medical</strong> Director, Office of 133<br />
<strong>Medical</strong> <strong>Staff</strong> 20<br />
Medicine 67<br />
MIPA/CMO 23<br />
MIPA Referral Management 23<br />
MMG Administration 48<br />
MMG1 Sites 48<br />
MMG 2 Sites 50<br />
MMG 3 Sites 52<br />
MMG 4 53<br />
<strong>Montefiore</strong> <strong>Medical</strong> Group 48<br />
Moonlighting, <strong>House</strong> <strong>Staff</strong> 38<br />
N<br />
Neurology 70<br />
Neurosurgery 70<br />
Nuclear Medicine 71<br />
O<br />
Obstetrics and Gynecology and Women’s Health 73<br />
Occupational Health Services 134<br />
On-call Room 40<br />
Oncology 76<br />
Operating Room 134<br />
Ophthalmology and Visual Science 78<br />
Orthopedic Surgery 78<br />
Otolaryngology 79<br />
P<br />
Palliative Care 135<br />
Parking 42<br />
Pathology 79<br />
Patient, Family, and Community Health Education Resources 138<br />
Patient Safety 137<br />
Patients’ Bill of Rights 90<br />
152
Paychecks, <strong>House</strong> <strong>Staff</strong> 40<br />
Pediatrics 80<br />
Pharmacy Services 139<br />
Physical Exams, Pre-Appointment and Annual, <strong>House</strong> <strong>Staff</strong> 39<br />
Physician Impairment and Drug Abuse Policy 39<br />
Plastic and Reconstructive Surgery 81<br />
Privileges and Appointment to the <strong>Medical</strong> <strong>Staff</strong> 21<br />
Procedures for Evaluation, Supervision and Due Process- <strong>House</strong> <strong>Staff</strong> 35<br />
Professional Conduct Reporting Policy 39<br />
Protected Health Information Uses and Disclosures 90<br />
Provider Relations Office 22<br />
Psychiatry and Behavioral Sciences 81<br />
Q<br />
Quality Improvement 112<br />
Quality Management 142<br />
R<br />
Radiation Oncology 85<br />
Radiology 82<br />
Reappointment, <strong>Medical</strong> <strong>Staff</strong> 21<br />
Rehabilitation Medicine 85<br />
Resident Eligibility and Selection 31<br />
Resident Participation in Educational Activities 32<br />
Resident Supervision, Duty, Hours and Work Environment 34<br />
Resident Support, Benefits and Conditions of Employment 32<br />
Respiratory Care 143<br />
Risk Management 144<br />
S<br />
Safety and Security 145<br />
School Health 53<br />
Sick Leave, <strong>House</strong> <strong>Staff</strong> 38<br />
Shuttle Buses 42<br />
Sleep- Wake Disorders Center 146<br />
Smoke Free Policy 108<br />
Social Work Services 147<br />
<strong>Staff</strong> and Alumni Association 148<br />
Surgery 86<br />
T<br />
Telecommunications 148<br />
153
U<br />
Urology 88<br />
V<br />
Vacation Policy, <strong>House</strong> <strong>Staff</strong> 38<br />
Verification of Operative Procedure Site and Patient Identification 103<br />
Voluntary Service on MMC Administrative Committees 40<br />
Volunteer Services 149<br />
W<br />
WIC Program 59<br />
INDEX 150<br />
154