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

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Evening Supervisor, Moses Carolyn Woodley, Pharm D 718-920-8354 Manager, Oncology Pharmacy, Moses 718-920-8540/5778 Royston Browne, BS, RPh Manager, Oncology Pharmacy, Einstein 718-405-8510 James McCarthy 718-904-4173 Ambulatory Pharmacy Manager, Moses 718-920-4934 Steven Tuckman, BS, R.Ph. Specialty Pharmacy Manager Keith Veltri, PharmD, MS, R.Ph. 718-920-4934 QUALITY MANAGEMENT Quality Management Department 718-920-5026 Rohit Bhalla, MD Brandon Yongue, PhD The Quality Management Department is a team of professionals available to provide assistance in quality and performance improvement initiatives. Technical and consultative support is available in the following areas: • Access to statistical and data resources and expert clinical resources • Guidance in appropriate performance improvement tools and methodology • Guidance in regards to regulatory and accreditation standards • Advice/assistance in development and use of information systems in performance improvement • Facilitation of performance improvement groups PERFORMANCE AND QUALITY IMPROVEMENT The provision of safe, high quality, cost-effective care in an atmosphere of service excellence is one of MMC's highest priorities. Performance Improvement is a systematic means of making positive organizational changes to increase patient safety, meet evolving standards of practice, satisfy patient/family needs and expectations, and increase the efficiency with which care is provided. There is a single overall plan for quality management for the medical center and one institution-wide committee, the Montefiore Quality Council, with oversight responsibility for performance and quality improvement. The methodology for Quality Improvement that MMC has adopted is the PDCA, Plan-Do- Check-Act model. This approach allows us to continually strive to meet high standards for safety, quality and cost effective health care and improved outcomes through better design of services and through a reduction in the variation in how care is provided. It is based on the methods of continuous quality improvement, whereby baseline data are collected, best practices identified through literature searches, interventions are designed, piloted, and if determined to be 142
successful, expanded to other areas. At this point, ongoing monitoring and surveillance is done to ensure on-going effectiveness. Some PI initiatives emerge from rigorous peer review. In the peer review process, each department is responsible for the review of all mortality cases, significant complications, readmissions within 3 days, and cases in which a departure from standards of care may have occurred. Performance Improvement Initiatives also emerge from the need to redesign services or to address key patient safety areas. Examples of organization-wide PI initiatives include Service Excellence, Pain Management, Reduction of Medication Errors, Reduction of Hospital Days, CIS and Computerized Physician Order Entry, ICU Physician Staffing, and creating a seamless continuum of care through all levels of acuity. RESPIRATORY CARE Respiratory Care Services are provided to patients based on a written/electronic prescription by the physician responsible for the patient's care. The Director of the service is available Monday - Friday, 9:00AM - 5:00PM and can be reached at (718) 920-5110 or (718) 904-3214. The Shift Supervisors are available Monday - Friday, 7:00 a.m. - 10:00pm. They can be contacted through the Page Operator. If there are no managers on duty and assistance is needed, contact the Page Operator for the Manager On-Call. HOURS 24 hours-per- day, 7 days-per-week There are two tours: Tour I: 6:30AM - 7:00PM Tour II: 6:30PM - 7:00AM Shift report and daily activities are discussed from 6:30 until 7:00 on both tours. The Respiratory Care Supervisors meet with the clinical staff to discuss quality of care rendered and to assure continuity of care to all patients. Therapists have permanent beeper assignments which are posted on each Nursing Unit. They can also be contacted through the Page Operator. MOSES Northwest Building - Blue Zone, 1 st Floor Medical Director Anita Bhola, MD Director Joseph Antonik, RRT 718- 920-5110 917- 646-0337 pager SHIFT SUPERVISORS Yvonne Wigfall, RRT 718-920-2912 143
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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
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ANESTHESIOLOGY Chairman 718-920-280
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Director John Fisher, MD 718-920-42
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Christine Clarke 718-920-5996 PROGR
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SOCIAL PEDIATRICS 3544 Jerome Ave.
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Vladimir Kvetan, MD 718-920-5440 De
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Residency Program Director Eugene S
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No procedure can be performed until
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Bronx, New York 10461 Administrativ
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Director, Education Programs Rasim
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North Central Bronx Hospital 718-51
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Arlene Saunders 718-741-2492 Admini
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printed name of the referring physi
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The radiology department at Jack D.
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Pediatric Surgery 718-920-7200 Burt
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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 and 112: • Practitioners will immediately
Page 113 and 114: One Quality Improvement Plan exists
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: Unified Director of Pharmacy Frank
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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