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

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Performance evaluation will be kept on file within each department. House staff will be apprised of their performance at least annually. SUPERVISION The House Staff may provide patient care at Montefiore Medical Center only as part of an accredited training program. All patient care activities provided by House Staff will be supervised by the Attending Physician responsible for the care of the patient. Attending Physician supervision will be appropriately documented in the medical record. DELINEATION OF CLINICAL PRIVILEGES Each Service Director will recommend individual clinical privileges for each member of the House Staff. Delineation of privileges is based upon the requirements of the training program in conjunction with the House Staff member's periodic performance evaluation. DUE PROCESS Montefiore Medical Center has established a process for resident evaluation and corrective action, in accordance with ACGME standards. Montefiore residents are entitled to due process to ensure that the resident is afforded the opportunity for fair adjudication of complaints or grievances which could result in termination or threaten his or her career development. Montefiore's due process procedure consist of several progressive steps: • An informational departmental resolution • A departmental ad hoc committee review • A due process hearing consisting of five physicians, at least two of which are residents • An appeal to the President of the medical center Please note that due process procedures of the employing institution of the resident govern, and may vary somewhat from the steps outlined above. Detailed information on due process procedures are contained in the "Hearing and Appeal Policy and Procedures for Redress of Adverse Actions and Grievances of Residents," which is available to Residents through the House Staff Office. In general, Montefiore's Due Process Policy provides as follows: • Applicability: If an adverse action is taken which would prevent the resident from completing the current training year or residency program, or which would prevent the resident from achieving admissibility status to take a certification examination of the American Medical Specialty Board, the resident is entitled to due process. Note that placement on academic probation in and of itself does not entitle the resident to due process. • Summary or Interim Action: In cases in which a resident's performance or actions are deemed to endanger the health or safety of others or to threaten the integrity of research, or when Montefiore reasonably believes that the resident engaged in illegal or immoral act(s) which pertain directly to the practice of medicine, the resident may be suspended or terminated immediately. In this circumstance, although the resident is entitled to due process, he or she will remain suspended or terminated until or unless the suspension or termination is reversed or modified as a result of the due process procedure. • Step One: Informal Resolution by the Department: In the event an adverse action is contemplated, the department will first attempt to resolve the underlying issues informally. Procedures for such informal resolution may include some or all of the 36
following: counseling, appointment of a faculty advisor, development of a program for remedial training, and the imposition of a term of probation. • Step Two: Departmental Ad Hoc Committee Review: If the matter cannot be resolved informally, the department chairperson may, in his or her discretion, convene a departmental review with written notice to the resident. If a departmental review is convened, the department chairperson shall appoint a departmental ad hoc committee consisting of at least three attending physicians from the department who were not involved in the underlying matters giving rise to the adverse action. The proceedings of the departmental ad hoc committee consist of interviews with the resident and other individuals and review of relevant documents. Thereafter, the departmental ad hoc committee shall issue a report, a copy of which shall be provided to the resident. If no resolution is achieved, the resident is entitled to request a due process hearing within a certain time limit. If a hearing is not requested in a timely manner, the resident is deemed to have waived his or her right to a hearing and to have accepted the adverse action. • Step Three: Due Process Hearing: When the resident requests a hearing, the Senior Vice President - Chief Medical Officer or designee shall appoint a formal hearing panel consisting of no more than five physicians, at least two of whom shall be Montefiore residents, and the balance of which shall be full-time attending physicians. The department and the resident may be represented by legal counsel throughout the hearing. At the hearing, the department and the resident shall have the right to call witnesses and introduce relevant evidence. Testimony will be taken under oath, and a stenographer will record the proceedings. Upon conclusion of presentation of the evidence, the hearing panel will make written findings and render its decision. The party against whom an adverse decision has been made has the right to appeal the decision of the hearing panel by giving written notice to the President of Montefiore. The President shall undertake an appellate review of the matter and shall make a final determination. Please note that Montefiore's Due Process Policy is reviewed annually and may be changed based on annual review. The version of the policy that is in effect at the time the resident is given notice of his or her right to due process shall apply. Residents are encouraged to review Montefiore's Due Process Policy, for further information. The Effects of Leave of Absence from a Program Due to the fact that all training programs have different curriculums and training requirement needs, each department has their own policy entitled Policy on Effect of Leave for Satisfying Completion of Program. This policy is available through your training program director or residency coordinator. House Staff Maternity Leave Policy During period of disability resulting from pregnancy the House Staff Officer will first use all accrued and unused sick leave. After sick time is exhausted while still within the disability period, they will then be eligible for NYS Statutory Disability. The disability period is defined as follows: • Starts with first day out • Up to four weeks prior to delivery • Up to six weeks post-delivery (normal delivery) • Up to eight weeks post-delivery (C-Section) 37
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 and 28: HOUSE STAFF OFFICE 150 East 210th S
Page 29 and 30: • Institutions must have a GME Co
Page 31 and 32: accreditation, then the institution
Page 33 and 34: and the conditions under which livi
Page 35: • Patient support services, such
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
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SECTION V • POLICIES AND PROCEDUR
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Note: This summary contains key poi
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WHERE: • Advance directives are a
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• family has moral or religious o
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• OD1091-4 Affidavit of Close Fri
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Bioethics (Moses) 718- 920-6226 (We
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HOW: • Capacitated patients may r
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VERIFICATION OF OPERATIVE PROCEDURE
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INFECTION CONTROL PROGRAM Moses Nur
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person who feels that he/she may be
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CONTROLLED SUBSTANCES IN THE MEDICA
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• Practitioners will immediately
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One Quality Improvement Plan exists
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SECTION VI • SERVICE DEPARTMENTS
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Legal Certificates 718-904-3456 Fin
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CHILD PROTECTION CENTER The Childre
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CME REQUIREMENTS: Attending physici
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Hours: Monday - Friday 8:00AM - 5:0
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delivery system. Medical record inf
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All physician orders whether writte
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additional information is uncovered
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THE TISHMAN LEARNING CENTER HEALTH
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MAILROOM MOSES Brown Zone, Moses Ba
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The mission of the Occupational Hea
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• Families and caregivers need as
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The Patient Safety Officer and the
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Unified Director of Pharmacy Frank
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successful, expanded to other areas
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• Professional Misconduct • Pho
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Outpatient testing, evaluation and
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Office Coordinator Lillian Zambardi
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E Educational Administration 28 Eme
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Paychecks, House Staff 40 Pediatric
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