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

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WASTING OF CONTROLLED SUBSTANCES Single-unit doses or partial doses remaining after the administration or attempted administration of a portion of a liquid (solution for injection or oral solution) or solid unit dose of a controlled substance may be destroyed beyond reclamation provided that a notation is made on the administration record sheet; and the destruction is witnessed by a second licensed individual (nurse, pharmacist, physician or dentist). Witnesses must visually observe the discard. CONTROLLED SUBSTANCES THAT ARE UNDESIRED, DETRIORATED OR OBSOLETE • Must be returned to the Department of Pharmacy and documented on the disposition record/inventory control form/automated point-of use technology • Only controlled drugs received from the Department of Pharmacy may be returned to the Department of Pharmacy. • Controlled drugs purchased from an outside source (wholesaler, distributor or manufacturer) may be returned to the distributor or manufacturer if the package is in its sealed original state, or Bureau of Controlled Substances. OFFICIAL NEW YORK STATE PRESCRIPTION FORMS (on-site and off-site) • Official New York State prescription forms must be stored securely to ensure adequate safeguards to prevent against the loss, destruction, theft or unauthorized access. • Practitioners will immediately notify the Department of Security, Department of Pharmacy, Police Department and appropriate regulatory agencies of the loss, destruction, theft or unauthorized use of any state prescription form. QUALITY IMPROVEMENT Refer to Montefiore's Institutional QI Plan JQ04.1 in the Administrative Policy and Procedure Manual. Or refer to the PI Tool Kit in the Performance Improvement Resource Center on the QM/RM intranet web page. Quality Management Department 718-920-5026 Rohit Bhalla, MD Brandon Yongue, PhD PERFORMANCE IMPROVEMENT MODEL The Performance Improvement Model is consistent with the philosophy, mission, and goals of Montefiore. All associates are involved in this planned, systematic, and ongoing performance improvement program. It is an interdisciplinary process designed to objectively and systematically monitor and evaluate the quality and safety of care and services, pursue opportunities to improve patient care, strive for service excellence and to address identified problems and vulnerable areas (high risk, high volume, problem prone, high cost). Montefiore is an organization of interdependent parts. The organization seeks to optimize the performance of the entire system. In continual improvement, an organization analyzes the processes that support care delivery to reduce unnecessary variation, improve the quality of its services and provide optimal outcomes. 112
One Quality Improvement Plan exists for the entire Montefiore Network and one committee, The Montefiore Quality Council, has oversight responsibility for performance improvement across the entire Montefiore integrated delivery system. Characteristics of the Performance Improvement Program are that it is customer focused, interdisciplinary, data driven, and outcome oriented. The essence of performance improvement is to work continually to better meet customer expectations, enhance efficiency, and improve the processes of care delivery. Advances are achieved in part through interdisciplinary effort, adoption of “Best Practices” and exploitation of advances in information technology. QUALITY IMPROVEMENT Who is responsible for quality • Each of us What is quality • Montefiore's Vision Statement defines quality in health care: Montefiore is committed to being the best healthcare provider in the Bronx and beyond. Our associates and medical staff provide patient/family-focused care that exceeds customer expectations, embraces academic excellence and achieves quality outcomes in a fiscally responsible manner. • The Institute of Medicine identifies the following as the domains of quality in health care: • Patient Safety • Effectiveness • Timeliness • Efficiency • Equity • Patient Centeredness Who are your customers (Internal and External) • External: patients, families, insurance agencies, JCAHO, NYSDOH referring physicians, Medicare/Medicaid, etc. • Internal: peers, administration, hospital associates, all departments. How do we identify performance improvement (PI) projects • Montefiore prioritizes those processes for improvement that are: • High Risk • High Volume • Problem Prone • High Cost • Sources of information for PI projects include feedback from internal and external customers, community concerns and ongoing indicator monitoring. What is the chosen model for planned, systematic improvements • Plan-Do-Check-Act (PDCA) Model PLAN • Assemble an interdisciplinary workgroup • Review "Best Practices" from Montefiore and elsewhere • Identify critical measures of success • Assess causes of perceived problems DO 113
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Medical Staff House Staff Orientati
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We would like to take this opportun
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Montefiore’s Institute for Reprod
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TABLE OF CONTENTS SECTION 1- Genera
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Plastic and Reconstructive Surgery
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SECTION 1 • GENERAL INFORMATION 1
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Contract Management Organization (C
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Neurology M 4656 3351 Steuben A 316
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MOSES NURSING STATIONS C 741-2377 P
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M 5584 Lupus Clinic M 5584 Neurolog
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MEDICAL STAFF CREDENTIALING OFFICE
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MONTEFIORE INTEGRATED PROVIDER ASSO
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• Referral by the ED physician is
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HOUSE STAFF OFFICE 150 East 210th S
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• Institutions must have a GME Co
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accreditation, then the institution
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and the conditions under which livi
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• Patient support services, such
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following: counseling, appointment
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Physician Impairment and Drug Abuse
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participants the opportunity to com
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WALDO AVENUE SHUTTLE Those resident
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First Year Residents: Assignments o
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SECTION III • MONTEFIORE MEDICAL
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Administrator: Jennifer Ortiz Medic
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Medical Director: Marta Rico, MD, A
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2532 Grand Concourse Bronx, New Yor
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Briggs Avenue Academy 3010 Briggs A
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Nurse: Maria Campos, LPN Sheila Mon
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Gloria Feliciano - Director FRANKLI
Page 61 and 62: ANESTHESIOLOGY Chairman 718-920-280
Page 63 and 64: Director John Fisher, MD 718-920-42
Page 65 and 66: Christine Clarke 718-920-5996 PROGR
Page 67 and 68: SOCIAL PEDIATRICS 3544 Jerome Ave.
Page 69 and 70: Vladimir Kvetan, MD 718-920-5440 De
Page 71 and 72: Residency Program Director Eugene S
Page 73 and 74: No procedure can be performed until
Page 75 and 76: Bronx, New York 10461 Administrativ
Page 77 and 78: Director, Education Programs Rasim
Page 79 and 80: North Central Bronx Hospital 718-51
Page 81 and 82: Arlene Saunders 718-741-2492 Admini
Page 83 and 84: printed name of the referring physi
Page 85 and 86: The radiology department at Jack D.
Page 87 and 88: Pediatric Surgery 718-920-7200 Burt
Page 89 and 90: SECTION V • POLICIES AND PROCEDUR
Page 91 and 92: Note: This summary contains key poi
Page 93 and 94: WHERE: • Advance directives are a
Page 95 and 96: • family has moral or religious o
Page 97 and 98: • OD1091-4 Affidavit of Close Fri
Page 99 and 100: Bioethics (Moses) 718- 920-6226 (We
Page 101 and 102: HOW: • Capacitated patients may r
Page 103 and 104: VERIFICATION OF OPERATIVE PROCEDURE
Page 105 and 106: INFECTION CONTROL PROGRAM Moses Nur
Page 107 and 108: person who feels that he/she may be
Page 109 and 110: CONTROLLED SUBSTANCES IN THE MEDICA
Page 111: • Practitioners will immediately
Page 115 and 116: SECTION VI • SERVICE DEPARTMENTS
Page 117 and 118: Legal Certificates 718-904-3456 Fin
Page 119 and 120: CHILD PROTECTION CENTER The Childre
Page 121 and 122: CME REQUIREMENTS: Attending physici
Page 123 and 124: Hours: Monday - Friday 8:00AM - 5:0
Page 125 and 126: delivery system. Medical record inf
Page 127 and 128: All physician orders whether writte
Page 129 and 130: additional information is uncovered
Page 131 and 132: THE TISHMAN LEARNING CENTER HEALTH
Page 133 and 134: MAILROOM MOSES Brown Zone, Moses Ba
Page 135 and 136: The mission of the Occupational Hea
Page 137 and 138: • Families and caregivers need as
Page 139 and 140: The Patient Safety Officer and the
Page 141 and 142: Unified Director of Pharmacy Frank
Page 143 and 144: successful, expanded to other areas
Page 145 and 146: • Professional Misconduct • Pho
Page 147 and 148: Outpatient testing, evaluation and
Page 149 and 150: Office Coordinator Lillian Zambardi
Page 151 and 152: E Educational Administration 28 Eme
Page 153 and 154: Paychecks, House Staff 40 Pediatric
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