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

More documents

Recommendations

Info

Associate Dean of Graduate Medical Education Michael Reichgott, MD, PhD 718-430-4282 Administrator GME Linda Collazzi 718-430-4283 Administrative Secretary Vilma Kalten 718-430-4284 GENERAL ESSENTIALS OF ACCREDITED RESIDENCIES The following are excerpts from the Essentials of Accredited Residencies in Graduate Medical Education. The entire text specifying the requirements every residency program must meet to be accredited may be found in each department in the booklet listing approved residency and fellowship programs or from: The Secretary, Accreditation Council for Graduate Medical Education, 535 N. Dearborn Street, Chicago, Ill. 60610. A copy is also available for review in the House Staff Office. Approval and Accreditation For a program to become accredited, the sponsoring institution must demonstrate a commitment to GME. The sponsoring institution must be in substantial compliance with the Institutional Requirements and must assume responsibility for the educational quality of its sponsored program(s). Further information concerning a “sponsoring institution” is provided below. Institutional Requirements Institutional Organization and Commitment: The purpose of GME is to provide an organized educational program with guidance and supervision of the resident, facilitating the resident’s ethical, professional and personal development while ensuring safe and appropriate care for patients. Sponsoring Institution • A residency program must operate under the authority and control of a sponsoring institution (see definition for sponsoring institution in the Glossary under "Institution"). • There must be a written statement of institutional commitment to GME that is supported by the governing authority, the administration, and the teaching staff. • Sponsoring institutions must be in substantial compliance with the Institutional Requirements and must ensure that their ACGME accredited programs are in substantial compliance with the Program Requirements and the applicable Institutional Requirements. • An institution's failure to comply substantially with the Institutional Requirements may jeopardize the accreditation of all of its sponsored residency programs. Educational Administration There must be an organized administrative system to oversee all residency programs sponsored by an institution. In addition, there must be a designated institutional official who has the authority and the responsibility for the oversight and administration of the GME programs. 28
• Institutions must have a GME Committee (GMEC) that has the responsibility for monitoring and advising on all aspects of residency education. Voting membership on the committee must include residents nominated by their peers, appropriate program directors, other members of the faculty, and the accountable institutional official or his or her designee. • The committee must meet at least quarterly; minutes must be kept and be available for inspection by accreditation personnel. • The responsibilities of the committee must include: • Establishment and implementation of policies that affect all residency programs regarding the quality of education and the work environment for the residents in each program. • Establishment and maintenance of appropriate oversight of and liaison with program directors and assurance that program directors establish and maintain proper oversight of and liaison with appropriate personnel of other institutions participating in programs sponsored by the institutions. • Regular review of all ACGME letters of accreditation and the monitoring of action plans for the correction of areas of non-compliance. • Regular review of all residency programs to assess their compliance with both the Institutional Requirements and Program and the Program Requirements of the ACGME Residency Review Committees. • The review must be conducted by the GMEC or a body designated by the GMEC, which should include faculty, residents, and administrators, from within the institution but from programs other than the one that is being reviewed. External reviewers may also be included on the review body as determined by the GMEC. The review must follow a written protocol approved by the GMEC. • Reviews must be conducted approximately at the midpoint between the ACGME program surveys. • While assessing the residency program's compliance with each of the program standards, the review should also appraise the following: • the educational objectives of each program • the adequacy of available educational and financial resources to meet these objectives • the effectiveness of each program in meeting its objectives • the effectiveness in addressing citations from previous ACGME letters of accreditation and previous internal reviews • the use of dependable measures to assess residents’ competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice as defined in the section II.B, and in the Program Requirements • the effectiveness of each program in implementing a process that links educational outcomes with program improvement • Materials and data to be used in the review process must include the following: • institutional and program requirements from the Essentials of Accredited Residency Programs • letters of accreditation from previous ACGME reviews • reports from previous internal reviews of the program 29
Page 1 and 2: Medical Staff House Staff Orientati
Page 3 and 4: We would like to take this opportun
Page 5 and 6: Montefiore’s Institute for Reprod
Page 7 and 8: TABLE OF CONTENTS SECTION 1- Genera
Page 9 and 10: Plastic and Reconstructive Surgery
Page 11 and 12: SECTION 1 • GENERAL INFORMATION 1
Page 13 and 14: Contract Management Organization (C
Page 15 and 16: Neurology M 4656 3351 Steuben A 316
Page 17 and 18: MOSES NURSING STATIONS C 741-2377 P
Page 19 and 20: M 5584 Lupus Clinic M 5584 Neurolog
Page 21 and 22: MEDICAL STAFF CREDENTIALING OFFICE
Page 23 and 24: MONTEFIORE INTEGRATED PROVIDER ASSO
Page 25 and 26: • Referral by the ED physician is
Page 27: HOUSE STAFF OFFICE 150 East 210th S
Page 31 and 32: accreditation, then the institution
Page 33 and 34: and the conditions under which livi
Page 35 and 36: • Patient support services, such
Page 37 and 38: following: counseling, appointment
Page 39 and 40: Physician Impairment and Drug Abuse
Page 41 and 42: participants the opportunity to com
Page 43 and 44: WALDO AVENUE SHUTTLE Those resident
Page 45 and 46: First Year Residents: Assignments o
Page 47 and 48: SECTION III • MONTEFIORE MEDICAL
Page 49 and 50: Administrator: Jennifer Ortiz Medic
Page 51 and 52: Medical Director: Marta Rico, MD, A
Page 53 and 54: 2532 Grand Concourse Bronx, New Yor
Page 55 and 56: Briggs Avenue Academy 3010 Briggs A
Page 57 and 58: Nurse: Maria Campos, LPN Sheila Mon
Page 59 and 60: 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 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 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
show all

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?