House Staff Manual - Winthrop University Hospital

OFFICE OF ACADEMIC AFFAIRS222 Station Plaza NorthFifth Floor – Room 510516-663-2521Chief Academic OfficerJohn F. Aloia, M.D.Director of Academic AffairsLauren P. Petersen, MSAssistant Director of Medical EducationMaureen C. Regan, MBA, RPA-CGraduate Medical Education CoordinatorAlexandra TomichUndergraduate Medical Education CoordinatorJennifer LiddellMedical Education RepresentativeTara ConsalvoMedical Education Database CoordinatorErica LepreRev. 1/08

Rev. 1/08

Winthrop-University HospitalHouse Staff ManualThe Office of Academic Affairs has developed this manual as a guide andresource for members of Winthrop’s House Staff. It is distributed to allnew House Staff as a component of the resident appointment agreement.It contains a description of benefits accorded our house staff, and policiesthat establish what a resident can expect of Winthrop-University Hospital,and what Winthrop can expect of its residents. It also contains valuablereference material on clinical support services and administrative issues atWinthrop. Residents are expected to become familiar with and complywith all policies set forth in this manual.The term “resident” used in this manual refers to any trainee (resident orsubspecialty resident/fellow) who is enrolled in an accredited graduatemedical education program. This is the accepted definition used by theAccreditation Council for Graduate Medical Education (ACGME) andWinthrop-University Hospital adheres to this usage.This book will be amended and updated as necessary. If new policies aredeveloped by the Graduate Medical Education Committee in the interim,House Staff will be notified through appropriate channels ofcommunication, including, but not limited to the House StaffCommittee.Rev. 1/08

Winthrop-University HospitalStatement of Commitment toGraduate Medical Education“Winthrop-University Hospital was founded more than 100 years ago to serve the needs of acommunity which had no readily accessible hospital facility. Winthrop successfully and consistentlyfulfilled its original patient care mission until soon after WWII, when Winthrop began itsmaturation from community hospital …to community teaching hospital… to the independentacademic medical center it is today. Winthrop’s position as a leading tertiary care institution onLong Island is inextricably grounded in its commitment to graduate medical education. Theinfrastructure which was created to support GME is in large part the infrastructure which supportsexcellence in patient care.Winthrop-University Hospital - its board, its senior administration, and medical staff - is committedto excellence in Graduate Medical Education, as it is to excellence in patient care. We, who beardirect or indirect responsibility for the training of new physicians, hold core values and expectationsfor our diverse training programs: that scholarship and life-long learning be nurtured; thatprofessionalism, academic and clinical discipline be fostered; that ethical and humanistic treatment ofpatients be paramount. Our learners are expected to incorporate these values, and our teachers areexpected to model them.We are committed to providing the resources necessary to meet or exceed the Institutional andProgram Requirements of the Accreditation Council for Graduate Medical Education (ACGME). Thisincludes attracting and retaining a faculty who have the necessary breadth of clinical knowledge andskills, as well as abiding personal commitments to teaching. We are also committed to having theresources available for restructuring and adapting our GME curricula to a rapidly changing healthcare environment. This would include the provision of core competencies, as defined by the ACGME,across all programs. We will ensure that the curriculum provides for residents to develop clinicalcompetencies under appropriate supervision, with graded levels of progressive responsibility.We will also ensure that the GME environment is enriched by an active program of basic and clinicalresearch, thus providing residents with the opportunity to develop the skills of scientific inquiry. Wewill maintain core support services which facilitate clinical and academic growth, such as adequatepatient support services, a state of the art health sciences library, media services and conferencefacilities appropriate to the scope of medical education at Winthrop.We will provide a learning environment in which opportunities for academic growth are maximizedby attention to quality of life. This includes adherence to duty hours limitations; provision ofcompetitive salary, medical and other benefits; provision of counseling services and career guidance;access to affordable housing and meals; and an environment free of harassment of any nature at anytime.Winthrop is committed to maintaining its support of GME administration, such that the evaluation,assessment, monitoring and oversight of GME policies, procedures and programs can be effectivelyaccomplished.Finally Winthrop reinforces the fact that medical education and research stand in complementarypartnership with patient care, as first articulated in the hospital’s 1989 Mission Statement, and asreaffirmed by the Board of Directors in 2000.Approved by Graduate Medical Education Committee:10/30/00Approved by WUH Board of Directors: 11/14/00; Re-approved March 2005Rev. 1/08

WINTHROP-UNIVERSITY HOSPITALHOUSE STAFF MANUALTable of ContentsHouse Staff Benefits and Services1) Academic Affairs2) Arts and Humanities/History of Medicine3) Biostatistical Services4) Conference Time5) Counseling Services6) Coverage on Holidays7) Diplomas8) Educational Media Services9) Employee Health Service10) Family and Medical Leave11) Health Benefits and Life Insurance12) Health Club Membership13) Hollis Health Sciences Library14) Housing15) Laundry16) Liability Insurance17) Meals18) On-Call Rooms19) Pagers20) Parking21) Pre-Employment and Annual Physicals22) Security Services23) Sick Time24) Sponsored Programs25) Student Loan Deferments26) Telephone Service27) Vacation TimeGraduate Medical Education Policies/Procedures28) Academic Probation29) Accommodation for Disabilities30) Core Curriculum31) Disaster PolicyRev. 1/08

32) Disclosure of Program Accreditation Status33) Dismissal Proceedings34) Dress Code35) Dual Employment36) Due Process37) Duty Hours38) Eligibility, Selection, Appointment Procedures39) Escalation Policy40) Evaluations and Advancement41) Faculty/Program Evaluation42) Graduate Medical Education Committee43) House Staff Committee44) Independent Research45) Internal Reviews of GME Programs46) Licensing47) Personnel Files48) Physician Health and Wellness Process49) Prescription Policy50) Presence of Other Learners51) Procedures Credentialing52) Professional Conduct53) Professional Misconduct54) Program Reductions or Closures55) Pharmaceutical Sales and Promotional Activities56) Resident Promotion57) Responsibilities of Resident Physicians58) Responsibilities of Winthrop-University Hospital59) Restrictive CovenantsLegal/Administrative Considerations and Procedures60) Brain Death - Guidelines for61) Certification of Death62) Child Abuse63) Communicable Diseases64) Corporate Compliance65) Death: Notification and Reporting66) Discharge Against Medical Advice67) Do Not Resuscitate (DNR)68) Equal Employment Opportunity69) Health Care Proxy Law70) HIPAA71) Informed ConsentsRev. 1/08

72) Institutional Review Board73) Organ and Tissue Procurement74) Patient Identification Bracelets75) Patient Restraints76) Quality Management77) Refusal of Treatment78) Reportable Incidents79) Risk Management and Insurance Services80) Sentinel Events81) Sexual Harassment82) Utilization ManagementClinical Support Services83).Discharge Planning Services84).Ethics Consultation Services85).Health Information Management86).Hospital Information Systems87).Hospitalists88).Nutrition Support Services89).Pastoral Care90).Pain Management91).Pathology92).Pharmacy93).Psychiatric Liaison94).Physician Assistants& Nurse Practitioners95).Pulmonary Function Laboratory96).Radiology97).Respiratory Care98).Social Work ServicesPatients’ Rights99).AIDS Confidentiality Law100).Patient Relations101).Patient’s Bill of Rights102).Patient ResponsibilitiesSafety103).Accident/Incident Reporting104).Accident Prevention105).Emergency Preparedness PlanRev. 1/08

106).Fire Regulations107).Infection Control108).Medical Waste Disposal109).No Smoking PolicyTelephone DirectoryRev. 1/08

HOUSE STAFF BENEFITSAND SERVICES1. ACADEMIC AFFAIRSThe Office of Academic Affairs is responsible for providing administrative, planning and support servicesto further the Hospital's medical education and research missions. The Office welcomes input from, and iseager to provide assistance to House Staff. Its responsibilities vis a vis Winthrop's House Staff are variedand include:Providing personnel services to House Staff such as payroll and verification of status for deferment ofloansMaintaining central records on procedures credentialingServing as a resource to discuss concerns in a confidential and protected mannerReviewing, at time of appointment, documentation of prior training and credentialsServing as a repository of House Staff recordsServing as registrar for residents rotating through the hospitalMonitoring for compliance with Section 405 of the New York State Codes and ACGME Standards.Biostatistical Services, The Hollis Health Sciences Library and Educational Media Services (all of whichprovide services to House Staff), the Internal Review Board and the Office of Sponsored Programs reportto Administration through the Office of Academic Affairs.Call ext. 2521 or e-mail academicaffairs@winthrop.org for assistance with any of the services describedwithin, or for clarification of GME and Hospital policies and procedures.2. ARTS AND HUMANITIES/HISTORYOF MEDICINEWinthrop-University Hospital sponsors an "Arts and Humanities" series, which is intended to complementthe residents' medical education with exposure to the Humanities through music, literature, history and finearts.Lectures occur twice a month during the academic year. A schedule is available from the InfectiousDisease Division, which organizes the series. A collection of videotapes and books from previousprograms in the series is housed in the Health Sciences Library.The Department of Medicine hosts a History of Medicine Lecture Series. Lectures given throughout theyear and are given by the nationally recognized medical historian.3. BIOSTATISTICAL SERVICESWinthrop-University Hospital has on staff full-time Ph.D. and M.S. biostatisticians who are available toassist faculty, House Staff and other health professionals in the design of studies and experiments and theanalysis of data supporting research and clinical trials. Statistical tutorials on a group or individual basisRev. 1/08

are also available. Consultation with them is strongly encouraged in the design stages of a study to ensureaccurate statistical data collection. Contact ext. 3887 for further information.4. CONFERENCE TIMEHouse Staff are granted five consecutive conference days within each appointment year, beginning withPGY 2. Conference stipends, which are part of an education fund allocated annually to housestaff, withexpense approvals granted by Program Directors, are as follows: PGY 1 $75 PGY 2 $750 PGY 3 $750 PGY 4 $750 PGY 5 and above $500Other educational related expenses that can be charged against ones educational expense account in a givenyear are medical texts, medical software, board review courses, stethoscopes, etc. All reimbursements mustbe accompanied by supporting original documentation.5. COUNSELING SERVICESGraduate medical education places increasing responsibilities on residents and requires sustainedintellectual and physical effort. For some, these demands will cause periodic physical or emotionaldistress.In addition, members of the House Staff are subject to the same stresses which disrupt the lives of allpeople--marital discord, a death or serious illness in the family, financial worries, parenting problems.Free assessment, referral, and brief psychotherapy services are available on a confidential basis to membersof the House Staff and their immediate families by contacting:Steven Birnbaum, Ph.D.Clinical Psychologist(516) 742-2730Information regarding these interventions is in no way communicated to WUH.6. COVERAGE ON HOLIDAYSThere are no set arrangements for coverage on holidays. Ad hoc arrangements for coverage are made bythe Chief of Service, or are delegated to the Chief Resident.7. DIPLOMASAll Winthrop-University Hospital diplomas are issued through the Office of Academic Affairs and aregiven to the Department Chair for distribution on the last day of duty. Residency and subspecialtyresidency diplomas are awarded, and additional diplomas are given to Chief Residents. A separateinternship diploma is awarded to those in Internal Medicine in Preliminary positions.8. EDUCATIONAL MEDIA SERVICESEducational Media Services is a support service which assists clinical, educational, administrative andresearch professionals in the design and production of audio/visual materials. House Staff may useEducational Media Services if they have obtained written approval from their Division Chief, Chairpersonor Course Director. Media Services can be reached at ext. 2665.9. EMPLOYEE HEALTH SERVICERev. 1/08

The New York State Department of Health requires that employees of health facilities be free from healthimpairments which would present a significant risk to patients or which might interfere with theperformance of their duties. A health history and physical assessment is required at the time ofemployment and annually thereafter, along with your annual PPD. This is your responsibility tocomplete. Failure to complete these requirements leaves the hospital non-compliant with Department ofHealth regulations. In addition, employees are required to report any signs or symptoms of personal illnessto their supervisor, and to be referred for evaluation to determine the appropriate care and work limitation.It is also required that there be no discrimination on the basis of disability or handicap consistent withfederal and state statutes.The Employee Health Service provides pre-employment physicals, annual assessments and tuberculosisscreenings, as well as vaccines and health surveillances as required by regulatory agencies or as ordered bythe Director of the Employee Health Service. These services are provided without charge. The office isopen from 7 A.M. to 3 P.M., Monday through Friday.Employees who become ill while at work may make an appointment to be seen by the health care providerwhen available. Employees must present a “Request for Treatment” form, available in all departments. Atall other times, employees who become ill while at work may be seen in theEmergency Department with prior permission from the employee's supervisor. Employees who experienceany cardiac symptoms or acute gynecological problems should go directly to the Emergency Department.For further information on Employee Health Services, contact ext. 2534.10. FAMILY AND MEDICAL LEAVEIn accordance with the Family and Medical Leave Act of 1993, the Hospital will grant an eligible memberof the housestaff unpaid leave or leaves for up to 12 weeks in a 12-month period. Eligibility is one who hasworked a minimum of 1250 hours in the twelve-month period prior to the start date of the requested leave.Leave may be granted for the birth, adoption or acceptance for foster care of a child; for the care of a child,spouse, or parent with a serious health condition; or for the employee’s own serious illness.One should notify the Program Director and/or Chief Resident at least 30 days prior to the anticipated leaveor as soon as possible if 30 days’ notice is not possible. Residents are able to return to their trainingprogram after a leave of absence without loss of training status if their leave does not exceed that allowedby the specialty boards. Leave allowances as described by respective Boards vary greatly amongprograms; residents should contact the applicable specialty boards for current policies or the Officeof Academic Affairs, which will maintain copies of board policies.Accommodation of scheduling due to an intermittent or part-time leave (e.g. reduced hours, modification innight call or rotational schedules, part-time scheduling) is at the discretion of the Program Director and theChief Resident. The purpose of such accommodation is to allow for the maximum continuity of educationwithout creating intolerable increases in other residents’ workloads.A copy of the Hospital’s Family and Medical Leave Policy and Procedure may be obtained from theDepartment of Human Resources. One requests such a leave in writing by completing a “Leave ofAbsence” request form, also available from Human Resources. A leave request is not official unless signedoff accordingly by Program director or designee.11. HEALTH BENEFITS, DISABILITY AND LIFE INSURANCEWinthrop-University Hospital provides a comprehensive benefits program that affords house staff andmembers of their immediate family flexibility in choosing benefits. Candidates to WUH training programsare apprised of these and other benefits in writing at time of interview.Rev. 1/08

During House Staff Orientation, residents select and enroll in the benefit program(s) of their choice.Benefits begin concurrent with start date (should a resident start mid-month, benefits begin the first of thefollowing month.)The “Benefits in Action” insurance program includes:Health Benefits: The Network plan is free for residents and members of their immediate family.Alternatively, residents may select the Point of Service plan at a modest cost.Dental Benefits: Dental coverage is free for residents and their immediate families. Long Term Disability Insurance: Long term disability insurance is also offered free as incomeprotection for illnesses and injury of prolonged duration. Long term disability provides 70% of yoursalary up to a maximum of $5,000 per month, and begins after the 180th continuous day of disability.Life Insurance: The resident is covered with life insurance in the amount of one time his/her annualsalary. Additional supplemental insurance up to three times one’s annual salary may be purchased.Prescriptions: Prescription coverage for residents and family members is provided with a 25% co-pay.If prescriptions for residents are filled in the Hospital Pharmacy, they are free.Residents may refer to their benefits enrollment form verification statement and their Summary Plandescription for specific information concerning their benefits packages or log ontohttp://benefits.winthrop.org/. For further information and insurance forms contact the Department ofHuman Resources’ Benefits Office at ext. 2913.The Hospital, with appropriate notification, reserves the right to modify or discontinue the plan of benefitsas stated in the Summary Plan description distributed at Orientation.12. HEALTH CLUB MEMBERSHIPWinthrop-University Hospital House Staff are eligible for reimbursement of up to $100.00 each academicyear toward health club membership. A copy of the membership agreement and a receipt of payment mustbe presented to the Office of Academic Affairs between July 1 and December 31 to qualify for thisreimbursement. Acceptable facilities include, but are not limited, to health spas, community pools andracquetball/tennis clubs. Application for reimbursement may be obtained from the Office of AcademicAffairs (ext. 2521).13. HOLLIS HEALTH SCIENCES LIBRARYWinthrop-University Hospital provides library services to all members of the medical, professional andhospital staff. The library is open 8:30 a.m. to 9 p.m. Monday through Thursday, 8:30 a.m. to 6 p.m. onFriday, and 10 a.m. to 5 p.m. on Saturday, and 12 noon to 5 p.m. on Sunday. Current information isavailable on-line at http://www.winthrop.org/departments/education/hollis. In emergencies, the library isaccessible after hours by contacting the Security Office.Books circulate for two weeks, media for one week and both may be renewed. Journals do not circulate butmay be photocopied within copyright law restrictions. Only single photocopies are permitted on the librarycopier. Monographs and journal articles not held at Winthrop can be obtained from other libraries throughinterlibrary loan service. There is also a computer lab for employee use.The library is fully automated, using a library information system called Sirsi. Library users must beassigned a barcode in order to borrow materials. The library online catalog is called WebCat and isaccessible via the Library homepage on the Internet. The Library homepage includes links to otherRev. 1/08

valuable information and resources, such as lists of additions to the book collection, print and electronicjournal holdings and recent faculty publications.Links are provided to search the medical literature using OVIDWeb, which includes MEDLINE back to1966, as well as CINAHL and EBM Reviews. UptoDate, Harrison’s Online, MD Consult and PubMed arealso available from the homepage. OVID is accessible from home using a username and password. Thelibrarians can conduct mediated computer searches on a variety of databases for patrons who need suchreference assistance.Instructional support materials such as slide/tape programs, video and audiocassettes, CD, DVD and acollection of computer-assisted instruction are housed in the Computer Laboratory. The library collectsreview materials in a variety of formats and other educational media programs. Personal software such asword processing, database management and presentation graphics are also available.14. HOUSINGHousing is available at greatly subsidized rents in apartment houses owned by the Hospital (studios, 1bedroom and 2 bedrooms) which are in close proximity to the institution. In addition, there are a number ofone family houses which the Hospital rents to House Staff.The Housing Coordinator (ext. 2036) makes assignment of apartments and houses. Housing is assigned ona need basis prioritized as follows: 1) couples with children; 2) couples; 3) single House Staff. Preferenceis also given to House Staff who are coming from outside of the New York metropolitan area. If a memberof the House Staff requests housing at Winthrop-University Hospital at the beginning of each academicyear and suitable housing cannot be provided, a live-off allowance will be given.There are only a limited number of garages available for the apartment buildings. Garage assignments arebased on House Staff seniority. In the event that there are several residents who have lived in the buildingfor the same length of time, a lottery system is used. Each unit is allocated one parking spot.The security deposit, which is fully refundable if one meets all the stipulations in the rental agreement,amounts to one month's rent. It is deducted in ten monthly installments from one's salary, and is returnedwith interest approximately one month after termination of residence in Winthrop-University Hospitalhousing. Residents are expected to comply with terms of their lease, including prohibition of dogs in allapartments.Questions concerning Housing should be addressed to the Housing Coordinator at ext. 2036.15. LAUNDRYFree Hospital laundry service is provided for lab coats and scrubs. Residents may drop off soiled uniforms,Monday through Friday from 7 A.M. to 3 P.M. Fresh uniforms may be picked up 48 hours later.Lab coats are on loan only. At the conclusion of the training experience, residents are to return lab coats tothe Laundry Department. All lab coats left longer than 2 weeks will be removed from circulation.Exceptions can be made (e.g., vacation, illness) if prior arrangements are made with the LaundryDepartment. All residents whose lab coats are removed from circulation will be required to obtain arequisition form from Academic Affairs for replacement. Note: all lab coats which are reissued arerecycled coats.16. LIABILITY INSURANCEHouse Staff are provided with professional liability coverage for the duration of training through theHospital's self-insurance program, which is in excess of any valid and collectible insurance. CoverageRev. 1/08

provides legal defense and protection against awards from claims reported or filed after the completion ofgraduate medical education if the alleged acts or omissions are within the scope of the education program.As stated under “Dual Employment”, residents are not covered by the Hospital while moonlighting.Further details regarding liability insurance are available through Risk Management and InsuranceServices at ext. 2206.17. MEALSHouse Staff are provided with complimentary meals in the Hospital Cafeteria (or in the Lobby Café whenthe Cafeteria is closed) up to a monetary cap as shown below.Housestaff are eligible for the employee discount on any overages which must be paid at the register atthe time of purchase.Breakfast - $3.75Lunch - $4.75Dinner - $4.75The Hospital Cafeteria is open during the following hours on weekdays only:Breakfast 6:30 A.M. – 9:00 A.M.Coffee Break 9:45 A.M. – 10:45 A.M.Lunch 11:30 A.M. – 1:30 P.M.The Lobby Café is available for the house staff meal allowance only when the Hospital Cafeteria isclosed, during the following hours:Dinner 5:00 P.M. - 7:00 P.M. (daily)Breakfast 6:30 A.M. – 9:00 A.M. (weekends only)Coffee Break 9:45 A.M. – 10:45 A.M. (weekends only)Lunch 11:30 A.M. – 1:30 P.M. (weekends onlyKosher meals are available in the cafeteria and can be requested from the cafeteria staff.18. ON-CALL ROOMSOn-call rooms are available to members of the House Staff who are required to be on-call all night.Housekeeping is routinely provided and Residents are asked to leave the rooms in a presentable conditionas a courtesy to their colleagues.19. PAGERSAll members of the house staff are issued pagers which become their personal responsibility, when theybegin their training at Winthrop during Orientation. They are responsible for the pagers for the duration oftraining and must return them when they graduate, or leave Winthrop, to their Clinical Department. Lostpagers must be reported immediately to the Telecommunication Office, or the responsible office staffwithin your program.20. PARKINGFree parking is available for House Staff in a specifically designated area on the upper level of the Visitors’Lot. Parking cards and stickers are issued by the Security Office during orientation. A valid parking stickermust be displayed in one’s car.Rev. 1/08

25. STUDENT LOAN DEFERMENTSResidents should bring loan deferment forms to the Office of Academic Affairs for certification. It is theresident’s responsibility to request deferment forms from his/her lender. The resident should complete andsign his/her portion of the form by the time he/she brings it to the Office of Academic Affairs, and includethe lender’s address. The Office of Academic Affairs will complete the verification portion of the form,send the original to the lending institution, and place a copy in the resident’s file.26. TELEPHONE SERVICEProfessionalWhen a toll or long distance call is required for business or professional reasons connected with the care ofa patient, notify the Winthrop-University Hospital operator; the operator will then place the call.PersonalHouse Staff are required to make their own arrangements for telephone service within housing units rentedfrom Winthrop-University Hospital.27. VACATION TIMEAll House Staff receive four weeks vacation (20 working days) within their contract year. A writtenrequest must be submitted to and approved by the director of the service to which the resident is assigned.Vacation time cannot be accrued from one year to the next and housestaff will not be paid for unused time.Vacation request forms are available through your department or from Academic Affairs.GRADUATE MEDICAL EDUCATION POLICIES/PROCEDURES28. ACADEMIC PROBATIONThis policy sets forth the procedures for probation and dismissal of a resident from a Winthrop-UniversityHospital training program based on academic or other deficiencies as defined below. The Due Processpolicy, through which a member of the house staff can appeal a program director’s decision through theGraduate Medical Education Committee, is listed separately in this manual.Academic probation and due process is based on the understanding that early recognition of the problemadvantages both the resident and the training program. Early recognition presupposes that trainingprograms have clearly defined clinical and academic goals and objectives by which to identify success andfailure. Early recognition also presupposes that there is an ongoing written evaluation/remediation process,which clearly identifies and documents areas of concern. Whenever possible, being placed on probationshould not come as a surprise to the resident and should be initiated after progressive discipline/counseling.Academic Deficiency: Such deficiencies include (a) an insufficient fund of medical knowledge; (b) aninability to use medical knowledge effectively inpatient care; (c) lack of appropriate technical skills;(d) lack of humanism or professionalism; or (e) any other deficiency which bears on an individual’sacademic performance.If a resident’s performance of duties is below acceptable standards, he/she shall be so informed in ameeting with his/her departmental Chair, and/or the Program Director. After the resident is so informed,the Chair or Program Director shall give written notice of probationary status, including an explanation ofRev. 1/08

• Patient Care – providing care that is compassionate, appropriate and effective for the treatment ofhealth problems and the promotion of health.• Medical Knowledge – demonstrating knowledge about established and evolving biomedical, clinicaland cognate sciences and the application of this knowledge to patient care.• Practice-Based Learning and Improvement – investigating and evaluating their own patient carepractices, appraising and assimilating scientific evidence and improving their patient care practices.• Interpersonal and Communication Skills – demonstrating skills that result in effective informationexchange and teaming with patients, their families, and professional associates.• Professionalism- - demonstrating commitment to carrying out professional responsibilities, adherenceto ethical principles and sensitivity to diverse patient populations.• Systems-Based Practice – demonstrating an awareness of and responsiveness to the larger context ofhealth care and the ability to effectively call on system resources to provide optimal care.House Staff at Winthrop are helping develop and implement the new curriculum through participation onGraduate Medical Education and departmental subcommittees responsible for developing templates forcurricula and evaluation outcome methodologies.31. DISASTER POLICYIn the event that WUH has to suspend or close a residency program(s) due to a disaster, there is a processby which Winthrop maintains communication among housestaff, WUH GME and Administrativeleadership and the accrediting bodies for the purpose of facilitating relocation of residents on either atemporary or permanent basis, consistent with ACGME Policies and Procedures and CMS rulings.The Designated Institutional Official (DIO) is responsible for implementing this policy and relatedprocesses. Program Directors are responsible for coordinating information with their respective RRC’s. Ifapplicable Winthrop’s Director of Reimbursement is responsible for working with his/her counterpart at thereceiving institution regarding the transfer of capped positions and/or funding.If, because of a disaster, WUH cannot provide an adequate educational experience for a resident/fellow,WUH, as the sponsoring institution will• Arrange for temporary transfer to an ACGME accredited program.• Cooperate in and facilitate permanent transfer to another ACGME accreditedprogram as necessary in a manner to cause the least disruption to the time cycleof training. If more than one program is available for temporary/permanenttransfer for a particular resident then the resident’s preference must beconsidered.• Inform each resident of the minimum duration of his/her temporary transfer andcontinue to keep them informed of the duration.32. DISCLOSURE OF PROGRAM ACCREDITATION STATUSAs per ACGME requirements, all current residents, incoming residents and applicants to the program mustbe aware of the accreditation status of their residency or subspecialty residency.When an ACGME accreditation letter is received, WUH residents are to be notified of the accreditationstatus. If the action is “Continued Accreditation” (residencies), “Accreditation” or “Accreditation withWarning” (subspecialty residencies), notification could be done in writing or verbally at the discretion ofRev. 1/08

the program director. Residents should also be informed of the length of accreditation, and be given asummary of any citations and the program’s intended response to and remediation regarding the citations.Should an adverse action occur, i.e. “Probationary Accreditation” or “Withdrawal of Accreditation”,Program Directors must notify all current residents as well as applicants to the program in writing. Copiesof these letters must be kept on file by the program director. The Internal Review Process, a series ofinterviews that takes place mid-cycle in the accreditation timeline with integral members of a specificdepartment, will include questions regarding compliance with this policy.33. DISMISSAL PROCEEDINGSDismissal of House Staff members for unsatisfactory performance and/or professional misconduct isreportable to the New York State Department of Health’s Office of Professional Medical Conduct and insome circumstances, may be reportable to the National Practitioner Data Bank. (See section entitled"Professional Conduct Reporting".)Normally a decision of dismissal will be preceded by verbal counseling and a written warning, a period ofprobation, the recommendation that the resident receive counseling or other actions which will makeabundantly clear the serious nature of the sanction which may be imposed. A decision to dismiss a memberof the House Staff is arrived at after consultation with the resident's faculty supervisors and the ChiefAcademic Officer. Residents always have the opportunity to appeal a dismissal through a Due Processhearing (see below).34. DRESS CODEWinthrop University Hospital House Staff are expected to present an image that is consistent with their role as healthcare professionals, and appropriate to their interactions with patients, colleagues, staff and the public.House Staff are todress and appear in a professional manner at all times when on duty. They should present an appearance which isconsistent with their daily activities and which engenders a sense of confidence, trust and meets customer and patientexpectations.Dress must comply with Center for Disease Control and Joint Commission (JCAHO) standards. Nails must be short (upto 1/4 inch beyond finger is acceptable). Nail polish is acceptable if free of chips or cracks. Artificial nails or nailenhancements are not permitted. Bracelets and ornate rings (which impede effective handwashing) are not permitted.Jewelry, make-up and fragrances must be conservative, and must not interfere with patient care. Sandals and open-toedshoes are not considered acceptable footwear. Visible body piercing, with the exception of non-dangling earrings, isnot permitted. Men are to wear ties in all patient care settings when not wearing scrubs.Scrub suits are to be worn in designated areas only (for example, OR and Labor and Delivery). Faculty practices,private offices and conference rooms are not designated areas. If, in an exceptional situation, a scrub suit must beworn outside a designated area, a long white coat must cover it. In all other clinical settings, a long white coat is to beworn over professional attire. (Exceptions could be made by Program Directors in those situations where a white coatproduces anxiety among the patients being served.) White coats and scrub suits may not be worn innon-hospital related settings.At all times while on duty, house staff must wear their WUH identification badge and/or the identificationbadge of the institution to which they are rotating. The badge must be conspicuously displayed at chestlevel or above with the photo facing out so it is visible and readable to all concerned. Attire must always bein compliance with the dress code of the facility in which the resident is serving.House Staff who do not adhere to this policy will be counseled by their Chief Resident and/or theirProgram Director. Repeated violations will be considered an issue of professionalism, and will be so notedin the individual’s evaluation file.35. DUAL EMPLOYMENTRev. 1/08

As per ACGME requirements, Winthrop does not encourage residents to engage in any moonlightingactivities. Those who choose to do so must first obtain pre-approval from their Program Director foremployment outside the Hospital. They are to use the “House Staff Dual Employment” form availablethrough their Program Director or the Office of Academic Affairs. This form includes the proposed siteand proposed schedule.Housestaff who have worked the maximum number of hours permitted under the Duty Hoursprovisions of the ACGME and New York State Codes are prohibited from working additional hoursas physicians providing professional patient care services. Housestaff who have worked less than themaximum hours permitted may not exceed this maximum in their Winthrop and dual employment(moonlighting) duty hours combined. See below for "Duty Hours" provisions of the Codes. House Staffshould take note of the fact that while moonlighting they are not covered by Winthrop-UniversityHospital’s professional liability insurance and that you must be licensed for unsupervised medical practice.Residents who engage in moonlighting without advance written permission are subject to dismissal.36. DUE PROCESSWinthrop provides a fair and consistent method for review of residents’ grievances, without fear of reprisal.Residents who believe they have been unfairly dismissed or disciplined (e.g. not promoted as scheduled)may appeal to the Graduate Medical Education (GME) Committee. On receiving such an appeal, the Chairof the GME Committee will, within fifteen (15) working days, appoint an ad hoc committee of threepersons to review the case. All evidence on the basis of which the dismissal was recommended will besubmitted to the ad hoc review committee in writing. The person making the appeal will be given anopportunity to review this evidence and to rebut it in front of the ad hoc committee. Also, in considerationof due process, the person making the appeal will be allowed to present additional written evidence and/orwitnesses.The review committee will report its conclusions and recommendations in writing to the next regularlyscheduled GME Committee meeting. The written report, including relevant documentation, shall beavailable to GME Committee members for review prior to that meeting. The Chair of the Department andthe President and Chief Executive Officer of the Hospital will absent themselves from the deliberations ofthe GME Committee concerning the appeal.If the GME Committee recommends to sustain the decision for dismissal, this will be communicated to theresident within 10 working days and the resident will have 15 working days from receipt of thatcommunication to request, in writing, an appeal to the President and Chief Executive Officer of Winthrop-University Hospital, whose decision is final.If the GME Committee recommends that the resident should not be dismissed, the matter will beconsidered and decided within 15 working days by the Chief Executive Officer of the Hospital, whosedecision is final.37. DUTY HOURSResidents and subspecialty residents are required to follow the more stringent of duty hour provisions asmandated by Section 405.4 of the New York State Hospital Codes and the ACGME, as described below.In addition, they are periodically required to complete a self-survey of their duty hours which is used byWinthrop to monitor for compliance. Completing the form when so instructed is mandatory.NEW YORK STATE AND ACGME DUTY HOUR SUMMARY1. The scheduled workweek shall not exceed 80 hours per week over a four-week period.Rev. 1/08

2. Residents shall not be scheduled to work for more than 24 consecutive hours.3. A maximum 3 additional hours for transfer of information about patients is allowed in connection witha consecutive 24-hour shift if 1) the resident assumes no new patient care responsibilities during thistime, and 2) the transition time is included in the 80-hour work week. The 3-hour transition time shallnot be scheduled as part of assigned duties.4. Scheduled activities which count in the 80-hour work week and for the 24-hour consecutive work ruleinclude inpatient assignments, outpatient clinic and ED assignments, required conferences and otherrequired educational activities, and on-site activity/direct patient care which occurs when a resident ison beeper call.5. Scheduled on-duty assignments shall be separated by not less than 10 non-working hours.6. Residents shall have at least one 24-hour period of scheduled, non-working time per week. This meansno scheduled activities including beeper call from home.7. Each resident shall prospectively notify his/her department of any employment outside of assignedprogram duties (i.e., moonlighting). Residents are prohibited from working outside of the trainingprogram if the addition of such hours will exceed the 80-hour maximum workweek or the 24-hourconsecutive work limit. The hours devoted to moonlighting must be added to the training programwork hours and must be reported in the Office of Academic Affairs work hours survey.8. For departments other than Anesthesiology, Family Practice, Medical, Surgical, Obstetrical, Pediatricor other services which have a high volume of acutely ill patients, and where night calls are infrequentand physician rest time is adequate, the department may develop other scheduling arrangements withapproval of the GME Committee.Approved by NYS DOH 6/2/98Approved by Graduate Medical Education CommitteeUpdated and approved by the Graduate Medical Education Committee38. ELIGIBILITY, SELECTION AND APPOINTMENT PROCEDUREAll residents who are selected into residency programs are required to meet the eligibility and selectionrequirements in accordance with the Essentials of the Accreditation Council for Graduate MedicalEducation. Winthrop-University Hospital (WUH) does not discriminate with regard to sex, race, age,religion, color, national origin, disability, or veteran status.RESIDENT ELIGIBILITYApplicants for residency are considered eligible for appointment to an ACGME-accredited residencyprogram if they meet the following qualifications:Graduates of medical schools in the United States and Canada accredited by the Liaison Committee onMedical Education (LCME)Graduates of colleges of osteopathic medicine in the United States accredited by the AmericanOsteopathic Association (AOA)Graduates of medical schools outside the United States and Canada who meet one of the followingqualifications:Have received a currently valid certificate from the Educational Commission for ForeignMedical Graduates orHave a full and unrestricted license to practice medicine in a U.S. licensing jurisdiction.Rev. 1/08

Graduates of medical schools outside the United States who have completed a Fifth Pathway programprovided by an LCME-accredited medical school.Residents who have completed their basic residency and are applicants for residency in subspecialtyprograms shall be graduates of ACGME-accredited programs.SELECTION CRITERIAThe Program Director is responsible for selecting from among eligible applicants on the basis of theirpreparedness, ability, academic credentials, communication skills, personal qualities such as motivation andintegrity and professionalism. Each Program Director has program-specific policies which provide greaterspecificity to the above criteria.APPOINTMENT PROCEDURES/REAPPOINTMENTSThe Program Director reviews applicant credentials and qualifications to determine eligibility forappointment at WUH. Applicants are responsible for providing all the required credentials andemployment eligibility requirements to WUH prior to their appointment.Once the Program Director has selected an applicant for a residency position, the Office of AcademicAffairs reviews all academic credentials to ensure that the eligibility requirements have been met.Contracts are issued for one year.Reappointments are made based on satisfactory completion of the current post-graduate year. Exceptunder extraordinary circumstances, notification of intent not to renew is given no later than four monthsprior to the end of the current contract year.39. ESCALATION POLICYThe following policy delineates the responsibility of the healthcare provider in recognizing and reportingconcerns, problems and emergencies in the health care delivery system that threaten the welfare and safetyof the patient, patient’s family or hospital personnel. It defines the chain of command to be followed forescalation.POLICY1. The following is a list of conditions that might require escalation. It is not totally inclusive of allconditions or situations that require escalation. Each situation must be evaluated independently.Changes in medical condition that need prompt attentionInappropriate or questionable medical or nursing practiceDiscrepancy in medical or nursing judgmentEthical or legal issues needing prompt resolutionEquipment failureFacility emergenciesEnvironmental emergenciesFailure of clinical or ancillary department to respond to defined needsSuspected Terrorism2. It is the responsibility of all healthcare providers to be knowledgeable about the escalation process andto implement it appropriately.3. Implementation of the escalation process will not result in punitive action toward the initiatingindividual.Rev. 1/08

PROCEDUREImmediate Action:1. Clinical judgment must be used in determining what concerns, problems, and emergencies requireescalation, and appropriate time frames for response. Escalation policies exist for clinical andadministrative concerns.2. If the healthcare provider has a concern, problem, or emergency that requires initiation of theescalation process, it is her/his responsibility to escalate the matter to the person to whom theyreport (see Diagram 1 for sample-refer to department specific policy for further clarification).3. If in the judgment of the healthcare provider the appropriate response is not then achieved orobtained in a reasonable amount of time the healthcare provider must escalate the problem,concern or emergency to a higher level in chain of command, and continue the escalation processuntil resolution is achieved.Follow up Reporting/documentation:1. Documentation in the patient record will be factual, objective, complete and accurate. If aproblem or emergency is identified, documentation will reflect date and time matter wasidentified, actions taken to resolve them and the patient’s response and outcome.2. Documentation of a concern, problem, emergency or initiation of the escalation process on anIncident Report must reflect a comprehensive description of the event. Complete documentationmust include specifically the time of the event, time of notification, name of person who wasnotified, the information communicated the response and outcome.3. If the healthcare provider initiating the escalation process does not perceive the resolution of theconcern, problem, or emergency as satisfactory, a request for review should be submitted toQuality Management.ESCALATION FLOWCHART for PATIENT CARE (Diagram 1)Clinical Issue Identified By HealthCare ProfessionalAction Taken to Resolve IssueIssue ResolvedYesNoSenior Resident/Nurse Manager – Notified of IssueIssue ResolvedYesNoRev. 1/08

Chief Resident/Attending MD, Admin ChiefNotifiedIssue ResolvedYesNoChief/ Chairman/ Medical Director NotifiedESCALATION FLOWCHART (cont’d)AdministrativeIssueStaffDepartment Manager/Administrative NursingSupervisorDepartment AdministratorVice President, Administration/AOC40. EVALUATIONS AND ADVANCEMENTRev. 1/08

All House Staff are evaluated in writing at least twice each academic year by the program director andteaching faculty. The resident or subspecialty resident is given an opportunity to review this evaluation,and is provided with verbal feedback. He/she is asked to sign and date the evaluation form, therebyindicating that the review has occurred. House Staff are advanced to positions of higher responsibilityonly if they have achieved the educational goals outlined for that particular year of training.Educational goals, by level of training, are distributed to all House Staff at the beginning of their residencyprogram. Unsatisfactory house staff evaluation can result in required remedial activities, temporarysuspension from duties, or termination of residency education.41. FACULTY/PROGRAM EVALUATIONSEvery residency and fellowship program has a confidential process by which House Staff evaluate facultyand program effectiveness. House Staff are expected to use that process at least yearly as a way toreinforce areas of excellence and to offer constructive criticism regarding aspects of the training which theyfind less than satisfactory.Should a resident wish to discuss programmatic concerns with someone outside his or her department,senior staff in the Office of Academic Affairs (ext. 2521) are available for that purpose.42. GRADUATE MEDICAL EDUCATION COMMITTEEThe Graduate Medical Education Committee (GMEC) is a committee of the Medical Staff, which bearsresponsibility for oversight of all ACGME-accredited training programs at Winthrop.The GMEC comprises department chairpersons, program directors, representatives from Administrationand Academic Affairs, as well as representatives from the House Staff, as full voting members. In addition,a rotating Academic coordinator sits as a non-voting member. Two housestaff representatives are electedby their peers from the membership at large; a third is elected from the House Staff Committee. The HouseStaff Committee representative reports to the GMEC at each of its regularly scheduled meetings, and backto the House Staff Committee re: GMEC activity. The GMEC meets a minimum of four times a year.43. HOUSE STAFF COMMITTEEWinthrop’s House Staff Committee consists of representatives from each of the hospital’s residencyprograms. They are elected to the Committee by a vote of their peers. The Committee meets on aregularly scheduled basis to address matters of concern or interest to the house staff. Among itsresponsibilities, the House Staff Committee:Serves in an advocacy role for the house staff at largeHelps to identify and resolve issues of concern among the house staff relating both to work and livingenvironmentsIdentifies and helps plan core interdisciplinary educational programsServes as a conduit for communication with the house staff44. INDEPENDENT RESEARCHHouse Staff are encouraged to participate in research and investigative studies. Full-time biostatisticians(see "House Staff Benefits and Services") are available for research design and statistical analysisconsultations. Members of the House Staff who wish to engage in research must submit a proposal inwriting to the Department Chair, for written approval. If the project involves human subjects, the proposalmust then be submitted to the Institutional Review Board.Rev. 1/08

48. PHYSICIAN HEALTH AND WELLNESS PROCESSThe following process on physician health, wellness and impairment, is a policy of Winthrop’s MedicalStaff which also applies to its House Staff.PURPOSETo ensure physician wellness and assist in matters of individual physician health (including addictive,psychiatric and emotional disorders) that is confidentialTo provide education about health and prevention of physical, psychiatric or emotional illness.To facilitate confidential referral, diagnosis, treatment and rehabilitation of physicians who suffer froma potentially impairing condition consistent with services provided by the Medical Society of NewYork State’s Committee for Physician Health (CPH) with the goal of restoring the physician to his/herability to provide safe and competent patient care.MEDICAL STAFF COMMITMENT TO PHYSICIAN HEALTH AND WELLNESSThe Medical Staff through its By-Laws, Rules and Regulations, is committed to providing safe, effective,timely and respectful medical care to patients while fostering an environment which promotes physicianhealth and wellness. The Medical Staff affirms that substance abuse and other behavioral health disordersare treatable illnesses and after treatment, physicians (house staff) may be considered for return to the safepractice of medicine (and training) with appropriate monitoring.COMMITTEE FOR PHYSICIAN’S HEALTH (CPH)CPH is authorized by Section 230-11 of Public Health Law to confidentially contact and refer to treatmentphysicians who are troubled with behavioral health concerns including substance abuse and otherpsychiatric disorders. CPH activities are confidential, its records not discoverable, and the law providesimmunity for those who make referrals. They have a very positive success rate.CPH is a division of the Medical Society of the State of New York and not part of any government agency.CPH accepts referrals for all behavioral health disorders including substance abuse disorders; obsessivecompulsive disorders; other addictive conditions such as eating, gambling, and sexual compulsivedisorders; psychiatric disorders including depression, bipolar disorder and personality disorders; anddisruptive behaviors.CPH representatives may be contacted at:Voice: 800-338-1833Email: info@mssnycph.orgREGULATORY REQUIREMENTSPublic Health Law of New York, Section 230-11, requires that physicians and hospital chief executiveofficers report to the New York State Office of Professional Medical Conduct (OPMC) any informationwhich reasonably appears to show that a physician may be guilty of professional misconduct as defined inSections 6530 and 6531 of New York State Education Law (for house staff, see section 49 for regulatoryreporting requirements). In the absence of such information, physician health matters may beconfidentially referred to the CPH with no requirement for an OPMC report.PROCESSThe process that follows and actions to be taken are intended to provide over-all guidance and direction onhow to proceed when confronted with a potentially impaired physician, recognizing that they will not beRev. 1/08

appropriate in every circumstance. Medical Staff leadership and Hospital leaders educate physicians aboutrecognizing physician health issues, and address prevention strategies for physical and emotional illness.REFERRAL MECHANISM FOR EVALUATION OF COMPLAINT, ALLEGATION, OR CONCERNIt is the obligation of anyone within the organization to report concerns if a physician is affected by acondition that creates the likelihood that unsafe patient treatment may be provided.1. Physician Self-ReferralPhysicians are encouraged to contact CPH to obtain confidential assistance for themselves and theircolleagues. Physicians and staff members observing signs and symptoms that may be indicative of apotentially impairing condition may make referrals confidentially to CPH. CPH clinical staff willassess the credibility of the referral and coordinate the intervention and risk assessment. If the referralis credible, CPH will arrange for a confidential clinical evaluation at the physician’s cost by aspecialist approved by the Medical Society. If the evaluation results in no diagnosis, no further actionwill be taken.If a condition is diagnosed, CPH staff will obtain the physician’s approval to contact appropriatemedical staff leaders, preferably the Chief Academic Officer, Medical Director and DepartmentalChairperson to maintain confidentiality. To promote assistance and rehabilitation rather thandiscipline, physicians requiring time away from the training program will be granted a medical leave ofabsence. Time may need to be made up as per respective Licensing Board.(See Section 10 – Family and Medical Leave – re impact of leave on training status and applicablespecial board requirements).2. Hospital Staff ReferralIf an individual working in the Hospital has reasonable suspicion that a clinician may be impaired, thefollowing steps should be taken:An oral or written report shall be given to the President and Chief Executive Officer, the MedicalDirector, the Vice President of Administration responsible for Medical Staff Affairs, or theChairperson of a clinical department. (In the case of House Staff, the Chief Academic Officer willalso be notified.) The report shall include a description of the incident(s) that led to the belief thatthe physician may be impaired. The report does not need to give proof of the impairment, butmust state the facts leading to the suspicion.If, after discussion with the individual who filed the report, there is enough information to warrantan investigation, the CEO or his designee shall direct that an investigation be instituted andappoint the Medical Director to form an investigative committee.If, after investigation, it is found that sufficient evidence does exist, the Medical Director andother members of the investigative committee, if warranted, shall meet with the physician. Thephysician shall be told that the results of the investigation indicate that the physician may sufferfrom an impairment, that affects, or may affect his/her practice and be encouraged to seektreatment.Depending on the severity of the problem and the nature of the impairment, the Hospital may takethe following actions:• Require that the physician undergo a rehabilitation program as a condition of continuedappointment or clinical privileges;• Impose appropriate restrictions on the physician’s practice;Rev. 1/08

• Immediately suspend the physician’s privileges until rehabilitation has been accomplished ifthe physician does not agree to discontinue practice voluntarily.If the physician does not accept the suggestions and findings of the Medical Director, the mattermay be referred to the Executive Committee of the Medical Staff for appropriate disposition.Voluntary request for a leave of absence from the medical staff and acceptance of a plan of actionwould not require further reporting and is consistent with the confidential and supportive role ofthis program.If the matter cannot be handled internally, or jeopardizes the safety of the physician or others, theHospital may seek the advice of Hospital counsel to determine whether any conduct must bereported to law enforcement authorities or other governmental agencies.The original report and a description of the actions taken will be included in a confidentialpersonnel file. If the investigation reveals that there may be some merit to the report but notenough to warrant immediate action, the report shall be included in the confidential file and thephysician’s activities and practice shall be monitored until it can be established that there is, or isnot, an impairment problem.Throughout this process, all parties shall be reminded to avoid speculation, conclusions, gossipand nay discussions of the matter with anyone outside those described in this process.REHABILITATION AND REINSTATEMENT TO HOUSE STAFF DUTIESCPH will coordinate appropriate treatment and notify Hospital Administration, the Medical Director andthe Chief Academic Officer when the resident is medically cleared for duty and appropriate monitoring inplace. Upon request, CPH will conference with Hospital representatives to facilitate reentry into theworkplace. Once back on duty, CPH will monitor the physician to assure continued engagement intreatment and investment in recovery. The Hospital, at it’s discretion, may request periodic reports fromCPH and may institute it’s own monitoring as it deems necessary.Physicians determined incapable of safely performing their clinical privileges should be referred to GMEStaff leadership and Administration for action consistent with Public Health Law and GME Policies. CPHshall also be notified.HOUSESTAFF EDUCATIONAL PROGRAMMembers of the Housestaff shall be oriented to recognize indicators of impairment in physicians and otherhealth professionals and shall receive an educational brochure from the Medical Society of New YorkState’s Committee on Physician Health.Periodically, the CPH will present education programs on physician impairment, intervention andconfidential assessment to the Executive Committee of the Medical Staff, clinical and nursingdepartments and other interested departments in the Hospital.The Medical Director or his designee will present information about the Physician Health andWellness Process at the Annual Medical Staff Meeting.CONFIDENTIALITYPhysician health assessments are confidential medical records and will be maintained with restrictedaccess separate from discipline or credential files. To promote confidentiality during house staffreappointment, only designated medical staff and administrative representatives will review physicianhealth assessments.Rev. 1/08

Delegating professional responsibilities to a person when the practitioner knows he/she is notcompetent to perform them or permitting, aiding or abetting an unlicensed person to performactivities requiring a licenseRefusing to provide professional services because of a person’s race, creed, color or ethnic originAbandoning or neglecting a patient in need of immediate professional carePerforming professional services which have not been authorized by the patient or his/herrepresentativeWillfully harassing, abusing or intimidating a patient, either physically or verballyAltering or falsifying medical records in such a way that needed information for patient care isomitted or falsifiedExercising undue influence on the patient, including the promotion of the sale of services, goods,appliances or drugs in such a manner as to exploit the patient for financial gainRevealing personally identifiable facts, data or information obtained in a professional capacitywithout the prior consent of the patient, except as authorized or required by lawGuaranteeing that satisfaction or a cure will result from the performance of professional servicesOrdering of excessive tests, treatment or use of treatment facilities not warranted by the conditionof the patientFailing to wear identifiable badge, conspicuously displayed and legibleThe Office of Professional Medical Conduct (OPMC) of the New York Sate Department of Health(http://www.health.state.ny.us/nysdoh/opmc/faq.htm) investigates professional misconduct by physicians,physician assistants and specialist assistants. For unlicensed medical residents, a report must also be sent toThe Office of Professional Discipline of the State Education Department (OPD) if the resident’semployment, clinical privileges or association with the hospital is curtailed or terminated (see below).While anyone may report possible professional misconduct by physicians to the appropriate New York SateOffice, Public Health Law, Section 230 (11) requires that physicians who have a reasonable degree ofsuspicion, report suspected cases of physician misconduct. Reporting through the hospital’s RiskManagement or Chief Academic Officer or reporting directly to OPMC will satisfy this obligation. Failureto report suspicions of misconduct can result in action being taken by OPMC against the individual whofailed to report.A resident who is concerned about professional misconduct on the part of another health care provider isencouraged to report concerns to the Department Chair or the Chief Academic Officer.If misconduct is suspected on the part of a resident, the Residency Program Director, Department Chair andChief Academic Officer will investigate and determine appropriate disciplinary action, if warranted, whichwill be communicated to the resident in writing. The resident shall have the right to appeal termination ornon-promotion, as described in the Due Process Policy included in this manual.If it is determined that a medical resident is guilty of misconduct as described above, the Chief AcademicOfficer will report such misconduct to OPMC and to OPD, if the resident is not licensed. The ChiefAcademic Officer will report within 30 days to OPMC and OPD, as applicable, any of the followingoccurrences:Rev. 1/08

1. The denial, suspension, restriction, termination or curtailment of the training, employment,association or professional privileges related in any way to: Alleged mental or physical impairment Incompetence Malpractice Misconduct Endangerment of patient safety or welfare2. The denial or withholding of certification of completion of training for reasons related to thoselisted in 1.3. The voluntary or involuntary resignation or withdrawal of association, employment, or ofprivileges, to avoid the imposition of disciplinary measures.4. The receipt of information that indicates a resident has been convicted of a crime.54. PROGRAM REDUCTIONS OR CLOSURESIn the event that a GME program is downsized or eliminated, residents will be informed of any action assoon as possible. Every effort will be made to allow residents already in the program to complete theireducation. If residents are to be displaced by either reductions or closure, the program director and otherinstitutional members will make every effort to assist the residents in identifying programs where they cancontinue their education. In addition, should there be any adverse accreditation actions taken by theAccreditation Council for Graduate Medical Education, the hospital will inform the house staff in areasonable period of time.55. PHARMACEUTICAL SALES AND PROMOTIONAL ACTIVITIESThe GMEC has guidelines for interactions between House Staff and Faculty with pharmaceutical andhealth-related companies. They are based on the premise that pharmaceutical and other detailing shouldnot bias physician practice, and that the primary mission of Winthrop’s training programs is to preparephysicians to order patient-focused, competent, evidence-based and responsible clinical care. Theseguidelines are distributed and discussed at Orientation. It is expected that House Staff will adhere to themin concept and practice.56. RESIDENT PROMOTION AND RENEWALResidents shall be advanced to the next level of training upon satisfactorily meeting the goals andobjectives for that year of training. Promotion shall not be automatic. It shall be based upon cumulativeevaluation of residents, by core competencies, and other criteria as defines by the Program Directors intheir respective curricula.Residents whose contracts are not being renewed, or residents who will not be promoted to the next level oftraining, shall be given written notice of intent four months prior to the end of the resident’s currentcontract. If the primary reason for non-renewal is within four months prior to the end of the currentagreement, the Program Director is to provide the resident with as much notice as possible. At the time ofnotification of non-renewal or non-promotion, residents have the right to grieve the decision through theGMEC’s Due Process Policy.57. RESPONSIBILITIES OF RESIDENT PHYSICIANSGENERALAs a member of Winthrop’s House Staff, residents and subspecialty residents will:Rev. 1/08

TREATMENT OF EMERGENCY DEPARTMENT PATIENTSAll members of the House Staff on rotation in the Emergency Department are supervised by andresponsible to the ER attending physician on duty and through him or her, to the Chair of AmbulatoryCare.All House Staff members must discuss cases with the attending physician on duty. The attending isresponsible for countersigning the record, affirming his/her supervision.All House Staff members must discuss their cases with the attending physician as soon as they havecompleted a pertinent history, physical and have developed a differential diagnosis. The plan of carewill be developed in collaboration with the attending physician. This will include but not be limited todiagnosis, treatment plan and disposition. When the work-up is complete, the resident must againdiscuss the patient with the ED attending for final disposition. At that time, the ED attending willcountersign the chart. No patient should leave the ED before the ED attending discusses the finaldisposition and countersigns the ED chart.All PGY-1’s are to participate in an orientation to the ED with the Chair of Ambulatory Care or hisdesignee prior to starting their rotation.ATTENDANCE AT AMBULATORY TEACHING PRACTICEHouse Staff must attend an assigned ambulatory teaching practice on time according to the schedule. Eachhouse officer is directly responsible to the attending physician supervising the resident’s teaching practicesession.Absence from ambulatory teaching practice duties will be approved only under the followingcircumstances: vacation, sick leave, violation with duty hour requirements and special situations at thediscretion of the teaching faculty. The house officer will be responsible for notifying the teachingpractice.If housestaff are delayed in getting to their Ambulatory Practice on time, due to the need to provideemergent/urgent care in the inpatient units or the Emergency Department, they are to notify the ChiefResident who will attempt to get coverage. They should also notify the teaching practice and estimatethe delay in getting there. House Staff are expected to plan their patient care activities so that they canattend the teaching practice on time.TREATMENT OF HOSPITAL EMPLOYEES AND OUTPATIENTSHouse Staff are permitted to treat outpatients and hospital employees only within the ambulatory teachingpractices and the Emergency Departments, always under the direct supervision of an attending.ADMINISTRATIVE RESPONSIBILITIESAll members of the House Staff have professional, graded responsibilities as follows: All members of the House Staff on each service are directly responsible to the Senior Resident on thatservice and are responsible for any students on the service. Residents in turn, are responsible to theChief Resident and attending physician, and ultimately, to the Chairperson of the department.In administrative matters, members of the House Staff are responsible to the Chairperson of theirclinical department and the President of the Hospital.58. RESPONSIBILITIES OF WINTHROP-UNIVERSITY HOSPITAL TO HOUSE STAFFWinthrop-University Hospital has the following obligations:To provide a stipend and benefits to the House Staff as outlined in the Resident Agreement and in thisHouse Staff Manual.Rev. 1/08

To provide an educational training program that meets ACGME accreditation standards, includingteaching and evaluation of the core curriculum competencies of Patient Care, Medical Knowledge,Practice-Based Learning and Improvement, Interpersonal & Communications Skills, Professionalismand Systems-Based Practice.To provide the House Staff with adequate and appropriate support staff and facilities in accordancewith federal, state, local and ACGME requirements.To orient the House Staff to the facilities, philosophies, rules, regulations, and policies of the Hospitaland the Institutional and Program Requirements of the ACGME.To provide the House Staff with appropriate and adequate faculty and Medical Staff supervision for alleducational and clinical activities.To maintain an environment conducive to the health and well-being of the House Staff.To provide the following services: food and sleeping quarters for House Staff on duty in the Hospital;patient and information support services; security; as well as housing, uniforms, laundry, and parkingas set forth in this House Staff Manual.To evaluate, through the Program Director or his/her designee and program faculty, the educationaland professional progress and achievement of the House Staff on a regular and periodic basis. TheProgram Director shall present to and discuss with the Resident a written summary of the evaluationsat least once during each six-month period of training and/or more frequently if needed.To provide a fair and consistent method for review of the resident’s concerns and/or grievances,without the fear of reprisal.To provide resources necessary to comply with accreditation and regulatory standards.Upon satisfactory completion of the program and the Resident’s responsibilities contained herein, tofurnish to the Resident a Certificate of Completion of the Program.59. RESTRICTIVE COVENANTSAs per ACGME Institutional Requirements, ACGME accredited training programs must not requireresidents to sign any non-competition guarantees. Winthrop may not and will not impose any restrictivecovenants as a condition of residency.LEGAL/ ADMINISTRATIVE CONSIDERATIONS ANDPROCEDURES60. BRAIN DEATH GUIDELINESThe determination of brain death shall be made in accordance with the Hospital policy, "Determination ofBrain Death." (See Hospital Policy P-10-5.)Brain death is defined as irreversible cessation of all functions of the entire brain, including the brain stem.An attending neurologist or neurosurgeon can only make the determination of brain death. Underno circumstances shall post-graduate trainees make the determination or declaration of brain death.Rev. 1/08

The commencement of brain death criteria testing, as outlined in the Hospital's policy, is to be at thedirection of the attending physician.Any questions regarding brain death should be referred to Risk Management and InsuranceServices (ext. 2206).61. CERTIFICATION OF DEATHThe Admitting Department is responsible for obtaining the Attending’s signature on the death certificate. Ifthe Attending is unable to come to the Admitting Department within four hours of notification, theAttending must arrange for a member of the House Staff to sign. See Hospital Policy D-10-2 for furtherdetails.62. CHILD ABUSENew York State requires that any physician having reasonable cause to suspect that a child has receivedserious physical or mental injury or neglect by other than accidental means must report such a case.Winthrop's Department of Social Work ext. 2341, must be advised of all suspected or actual child abusecases and will provide guidance in submitting an abuse report. For further details, see Hospital Policy C-10-1.63. COMMUNICABLE DISEASESThe New York State Health Code requires all physicians to report cases, carriers or persons with any of thecommunicable diseases listed below. Reporting forms are available in the ED or Pediatrics and, on request,from Infection Control. Infection Control acts as a liaison between the Hospital and the Department ofHealth. Infection Control must be notified of all communicable diseases (ext. 2724)AmebiasisAnimal Bites (rabies prophylaxis only)ANTHRAXBabesiosisBOTULISMBrucellosisCampylobacterosisChancroidChlamydia trachomatisCHOLERACryptoporidoiosisCyclosporiasisDIPHTHERIAE. Coli 0157:1-17EncephalitisEnterococcus (vancomycin resistant)*FOODBORNE ILLNESS (specify agent)-including allvibrio speciesGiardiasisGLANDERSGonoccal InfectionHantavirus DiseaseHemolytic Uremic SyndromeH. INFLUENZAEHepatitis A, B, C (acute infection only)HEPATITIS IN A FOOD HANDLERHepatitis B Carrier (pregnant only)Human Immunodeficiency Virus (HIV)**HOSPITAL ASSOCIATED INFECTION(increasedincidence or outbreak)LegionellosisListeriosisLymphogranuloma VenereumLyme DiseaseMalariaMEASLESMELIODOSISMeningitis: Aeseptic HAEMOPHILUS MENINGOCOCCAL Other (specify type)MENINGOCOCCEMIAMonkey PoxMumpsPertussisPLAGUEPOLIOMYELITISPsittacosisQ FEVERRABIESRocky Mountain Spotted FeverRUBELLACongenital Rubella SyndromeSalmonellosisSARS (Severe Acute Respiratory Syndrome)ShigellosisShigiatoxin Producing InfectionSMALL POXStaphylococcus Aureus (vancyomycin resistant only)*Staphylococcal Entero Toxin B PoisoningStreptococcal Group A (invasive disease)Rev. 1/08

Streptococcal Group B (invasive disease)Streptococcus Pneumoniae (invasive disease)SYPHILISTetanusToxic Shock SyndromeTrichinosisTUBERCULOSISTularemiaTYPHOIDYellow FeverYersinosisVIRAL HEMORRHAGIC FEVERRev. 1/08

Diseases in all capital letters require immediate telephone notification*Labs report new cases or increased incidence only**Report Cases Directly to the NYSDOH64. CORPORATE COMPLIANCE PROGRAMMembers of the House Staff are required to adhere to the Hospital’s Corporate Compliance Program and its“Code of Conduct” which supports the Hospital’s commitment to the highest business and ethicalstandards. The program oversees compliance with regulations dealing with, but not limited to, physiciandocumentation, coding and billing, conflict of interest and competitive pricing. House Staff may berequired to participate in additional in-service training to ensure compliance. The Code of Conduct isdistributed at House Staff Orientation.65. DEATH: NOTIFICATION AND REPORTINGNOTIFICATION OF DEATHWhen called to the floor to pronounce a patient dead, the resident should notify the attending physicianimmediately and inquire as to whether the attending or the resident should inform the family, and requestan autopsy.DEATH CERTIFICATESUpon receiving the chart of an expired patient, the Admitting Department is responsible for calling theattending to notify him/her that the certificate is ready for signature. If the attending is unable to come tothe Admitting Departmentwithin four hours, it is the attending’s responsibility to request a licensed member of the House Staffto sign. If after four hours the certificate is still unsigned, the Admitting Department notifies the chief ofthe respective service. This procedure is followed up to 11:00 PM. After this time, unless there is a reasonfor immediate removal, the physician is notified to sign the certificate by 8:00 AM the following morning.DEATHS REPORTABLE TO THE MEDICAL EXAMINER'S OFFICEThe pronouncing physician must identify and report all cases which fall under the established criteria to theMedical Examiner’s (ME) Office. These include:Death by homicide or suspicion of homicide including automobile homicides and cases of criminalnegligence or violence.Deaths due wholly or in part to accidental injuries including industrial accidents (falls, motor vehicleaccidents, explosions, burns, cave-ins, drownings, asphyxia secondary to aspirated materials, etc.)Death by suicide (hanging, shooting, carbon monoxide, slashing, etc.)Death by criminal abortion or suspected abortion.Maternal deaths associated with delivery or abortion.Death by poison or suspicion of poison, including chemical and bacterial food poisoning and industrialpoisoning (In such cases, you are requested to save the stomach washings during life for examinationby the toxicologist. Also save all containers of pills, etc.)Sudden death when in apparent health or unattended by a physician.Rev. 1/08

Death by any suspicious or unusual manner.Death occurring in the institution less than 24 hours after admission, where diagnosis cannot be made.This includes deaths while a patient is in a coma. (Where the diagnosis is unquestioned and the causeof death is a natural one, a death certificate may be issued).Death occurring while on operating table.Death occurring in the Emergency Department (in such cases, you are requested to save bloodsamples that were obtained during life saving measures).Cases in the institution which are dead on arrival and unattended by a physician.Deaths while in legal custody.Fractures of bone (not pathological). Such cases are to be reported even when the fracture is otprimarily responsible for death.Deaths associated with suspected child abuse.Perioperative or peritherapeutic death which is unexpected or unexplained.If the case meets the above criteria, the physician completes a Medical Examiner Referral Form, calls theME Office for a case number, documents in the progress notes that the case was referred to the ME, and thedisposition of the case. If it is known by Winthrop that the deceased opposed an autopsy, this informationmust be given to the ME. If there is any question as to whether the individual case should come under thejurisdiction of the Medical Examiner’s Office, the pronouncing physician should telephone the ME Officefor clarification. For detailed procedures, see Admitting Department Policy No. D-5.66. DISCHARGE AGAINST MEDICAL ADVICECompetent adult patients who wish to leave the Hospital against medical advice are permitted to do so. Ifthe patient insists on leaving, he or she must be asked to complete the form entitled “Discharge fromHospital Against Medical Advice.” If a resident anticipates that a patient may sign out against medicaladvice, the resident must notify the attending physician immediately. The resident or physician must informthe patient of possible risks to his/her condition and advise the patient as to what would be in the patient'sbest interest. The physician/resident must document this discussion in the medical record. In addition, it isadvisable to call in a representative from Social Work (ext. 2341 to speak with the patient. (see Policy D-30-1.)Minor or incompetent patients are not permitted to leave the Hospital unless discharged by aphysician. Call Risk Management and Insurance Services (ext. 2206) for guidance.67. DO NOT RESUSCITATE (DNR)Every patient admitted to the Hospital is presumed to have consented to CPR unless a DNR order isrequested and an order is written in the patient's medical record. Consent for a DNR order must beobtained by an attending physician from the patient, after discussing the diagnosis and prognosis, the rangeof available resuscitation measures, the reasonably foreseeable risks and benefits of CPR and theconsequences of the DNR order. Renewal of DNR orders can be done by housestaff. In the event that thepatient lacks capacity and has not previously assigned a health care proxy, a person on the surrogate list canconsent. (See Hospital Policy P-30-3.)The DNR order must be written in the patient's medical record and the consent must be documented onthe appropriate documentation sheet.Rev. 1/08

Either the patient or person consenting to the DNR order either verbally or in writing at any time canrevoke the consent for the DNR order.The physician must renew the DNR order every seven days.If a patient is transferred to Winthrop-University Hospital from another health care facility, and a validDNR order was signed in the transferring facility, the DNR order shall remain in effect until thephysician examines the patient. Thereafter either a DNR order should be issued (no further consent isrequired from the patient, surrogate or health care agent) or the DNR order should be canceledprovided the physician immediately notifies the person who consented to the DNR order and thehospital staff directly responsible for the patient's care. If the physician fails to take an affirmative actto renew or revoke, the DNR order should remain in effect.68. EQUAL EMPLOYMENT OPPORTUNITYThe Hospital is committed to providing equal employment opportunity, in accordance with all applicablefederal, state and local civil rights laws. The Hospital does not discriminate with respect to hiring,promotion or any other terms or condition of employment on the basis of race, color, religion, nationalorigin, marital status, age, sex, disability, sexual orientation, status as a disabled veteran, or veteran of theVietnam War era. Discrimination is not condoned in any of the Hospital’s activities.69. HEALTH CARE PROXY LAWWinthrop-University Hospital respects the rights of each adult patient to participate in health care decisionmaking to the maximum extent of his or her ability and respects the rights consistent with Federal and NewYork State law (See Hospital Policy P-30-4.)Each adult patient (18 and over) has the right to appoint another adult (18 and over) to make health caredecisions in the event that patient is unable to do so. This appointment is made through a Health CareProxy.A physician could be designated as a health care proxy agent but under those circumstances, the physiciancan no longer act as the patient’s physician.APPOINTING A HEALTH CARE PROXYInformation regarding how to appoint a health care agent is provided to each patient on admission. Thepatient can designate any adult to be the health care agent except a hospital employee unless that individualis a relative or was designated prior to the patient's admission. The patient may also appoint an alternateagent in the event the primary agent is not reasonably available, willing or capable to serve as the patient’shealth care agent.COMPLETION OF HEALTH CARE PROXY FORMPatients are encouraged to use the form provided on admission, but other forms may be accepted. In orderfor the health care proxy to be valid, the following elements must be included on the form:Name of adult who creates proxy (the principal)Name of agentStatement that the patient (principal) intends the agent to make health care decisions for him/herPatient's (principal's) signature and date ofsignatureRev. 1/08

Signature of two witnesses, neither of whom is the named proxy or physician, date and statement bywitnesses that the patient (principal) appeared to execute the proxy willingly.The patient may choose to specify his/her wishes with regards to specific treatments. The completed formor a copy of the form is to be placed in the patient's medical record, under the tab, Advance Directives; theproxy remains in effect indefinitely unless it is revoked or contains an expiration date. The form does notneed to be reissued in the event of any future admissions.Any questions regarding Health Care Proxies should be referred to Risk Management and InsuranceServices (ext. 2206) or Patient Relations (ext. 2058).AGENT IN HEALTH CARE DECISIONSThe agent may make health care decisions during the time when the patient lacks capacity to make thesedecisions.The determination of lack of capacity may be made by the attending physician except when lack ofcapacity is due to primary mental illness (which must be confirmed by a board-certified psychiatrist). Thedetermination of lack of capacity is to be documented in the medical record and is to include the cause,nature, extent and probable duration of the incapacity. The patient must be given oral and written notice ofthe determination if he/she is capable of understanding. If the patient objects to the determination or to theagent's decision, the patient's objection prevails unless a court determines that the patient lacks capacity. Iftreatment is life-sustaining, lack of capacity must be confirmed by another physician.The consent of the agent is necessary for the issuance of a DNR order and the appropriate DNRforms should be completed.The agent may make any health care decisions on the patient’s behalf except those involving nutrition orhydration, which may not be discontinued unless there is "reasonable knowledge" of the patient's wishes.Unless otherwise limited, the agent's authority takes priority over any other decision-maker, including nextof-kin.In accordance with hospital policy, the agent has access to all medical information and medical recordsnormally available to the patient.Prior to the commencement of action or inaction under the health care proxy, the Director of RiskManagement or Administrator-On-Call must be notified to determine the scope and/or limitations of theagent's authority in conjunction with the physician.The appointment is not valid for decisions after death (autopsy, organ donation); at that point authorityreverts to next-of-kin.REVOCATION OF PROXYThe proxy can be revoked at any time, either orally or in writing. A staff member who is informed of apatient's wish to revoke/change agent shall immediately notify the physician in charge of the patient's care,sign and date the proxy form, and note the revocation of the proxy. The physician shall note the revocationin the medical record and shall inform the agent and the medical staff involved in the patient's care.DISPUTE REGARDING AGENT AUTHORITYAny questions or disputes over the agent's authority to make decisions should be referred to the RiskManagement and Insurance Services (days) or Administrator On-Call (evenings/weekends).LIVING WILLSRev. 1/08

If a patient has a living will, it will provide guidance to the agent and/or health care provider about thepatient's health care wishes. However, a proxy form must be executed to appoint the agent.A living will is a document which contains specific instructions concerning all individual's wishes aboutthe type of health care choices and treatment that he or she does or does not want to receive, but which doesnot designate an agent to make health care decisions. A Living Will is not a health care proxy but canserve as clear and convincing evidence of an individual's wishes.All documents expressing patients’ wishes regarding health care should be referred to RiskManagement and Insurance Services for review prior to commencement of action or inaction.70. HIPAAThe Health Insurance Portability and Accountability Act (HIPAA) is a Federal law which creates uniformstandards for payment-related transactions (e.g., claims submissions) and creates minimum standards forthe privacy and security of patient information.All House Staff are required to complete HIPAA training at Winthrop and to sign a certification that theyhave done so, and that they agree to abide by the Hospital’s HIPAA policies. HIPAA training is providedduring Orientation. Alternative opportunities will be available should a resident miss Orientation for goodand sufficient reasons.HIPAA Policies and Procedures are in the Hospital’s Administrative Policy and Procedure Manual.Questions or concerns about HIPAA compliance should be directed to:Barbara Kohart-KleineWUH Privacy Officer663-220471. INFORMED CONSENTSAUTOPSY CONSENTThe autopsy percentage is a recognized gauge of the quality of medical care in a hospital. Both physiciansand hospital personnel should strive to obtain autopsy consents on as many expirations as possible. Theattending physician is primarily responsible for obtaining consent for autopsy from the next-of-kin. Thisresponsibility may be delegated to the House Staff on the case. Before obtaining consent for autopsy, thecase should be evaluated as to whether it falls under the jurisdiction of the Medical Examiner's Office. Ifthis is the case, it is advisable for the pronouncing physician or his/her designee to notify the ME In theevent that the ME is willing to release the body to the hospital, permission may then be obtained from thenext of kin for autopsy.Reasonable efforts must be made to determine whether the patient would have objected to an autopsy. If itis determined that the patient would have objected, an autopsy cannot be performed despite consent by aperson on the priority list. Autopsy permission must be obtained from authorized persons as prescribed bythe laws of the State of New York. The order of priority is spouse; next of kin; friend. See Hospital PolicyD-10-1 for priority ranking within these categories.Reasonable efforts to obtain the consent from the person in order of priority must be made and documentedin the patient's medical record.In the case where there are no living relatives, friends responsible for burial can give the consent forautopsy. However, the attending physician (or his/her designee) and the Admitting Office should usereasonable care to determine that the deceased is not survived by any living relatives."Authorization for Autopsy" and "Death Certificate" forms are kept at the nursing stations. Regulationsconcerning legal permission for autopsy are outlined on the back of the authorization form.Rev. 1/08

The following is the procedure for obtaining autopsy consent:The attending physician or resident is responsible for ensuring that the “Authorization for Autopsy” isproperly completed by the person authorizing the autopsy. Any limitations or restrictions should beclearly indicated in the appropriate space on the form. If consent is given for biopsy only, it should beindicated whether the biopsy is by percutaneous needle or by incision.The nursing personnel will bring the patient’s Medical Record to the Admitting Office at the time ofdeath. The Death Certificate and the completed Authorization for Autopsy should be attached to theMedical Record.The Admitting Office will notify the Department of Pathology that an autopsy is to be performed. Theattending physician and House Staff are encouragedto communicate with the Pathologist who will perform the autopsy concerning any specific problemsor concerns regarding the case and may attend the autopsy. The responsible physician will be notifiedwhen the autopsy is about to be performed. The back page of the autopsy consent form should becompletely filled out indicating pertinent clinical data and specific questions to be addressed during theautopsy.In the event that a written consent cannot be obtained, the following are acceptable substitutes: Telegram consent Fax consent Telephone consentThe telephone consent must be witnessed and signed by at least two members of the hospital staff, onebeing a physician. Any limitations must be listed. The routine consent form is to be filled out and is toinclude the time, date, family member authorizing the autopsy, whether all members of equal kinshipauthorize the autopsy and the reason why written consent was not obtained.PATIENT PHOTOGRAPHS, VIDEOTAPING, OR SOUND RECORDING CONSENTIf photographs, videotaping or sound recording are done for research and medical education, consentform #55-018NS must be used. It is available at nursing stations or from Educational Media Services (ext.2665) and upon completion is made a part of the patients chart.If photographs (etc.) are for publicity purposes, consent forms from the Department of External Affairs(ext. 2706) are to be used. (Please note that permission from the Vice President for External Affairs isrequired before talking to representatives of the Press, as per Hospital Policy P-50-1.) Both types of consentmust be obtained in writing, in advance, and a copy should be placed in the patient's chart.PROCEDURES OR TREATMENT CONSENTBefore any non-emergency operation, procedure or treatment, all patients must give written informedconsent. The "General Consent for Procedure/Treatment" (Medical) and "Consent to Operation" (Surgery)must be signed by adult patients, and by the parents or guardian for minors. (Additional informed consentforms are described in Hospital Policy H-10-5).If the patient is incompetent, the health care agent or next-of-kin needs to give written permission. If apatient is incompetent and no next-of-kin or health care agent is available and the procedure is neededemergently, this should be clearly stated in the progress notes. This note should include the procedureplanned and the emergent nature of the patient's condition.In order for consent to be considered "informed consent", a physician must disclose to the patient the natureand purpose of the proposed procedure, the reasonable appropriate alternatives and the reasonablyforeseeable risks and benefits involved, in a manner permitting the patient to make a knowledgeableevaluation. A note of the explanation given must be entered into the patient's medical record. The caseRev. 1/08

should be referred to Risk Management and Insurance Services (ext. 2206) if the next-of-kin or health careagent refuses the recommended surgery or treatment.CONSENT FOR RESEARCH PARTICIPATIONPatients or any subjects who are invited to participate in a research protocol at Winthrop must sign aconsent form officially approved by Winthrop’s Institutional Review Board prior to being enrolled in astudy.72. INSTITUTIONAL REVIEW BOARDThe Institutional Review Board is a federally-mandated committee which reviews all proposed and activeHospital research programs involving human subjects. This shall include all investigational drugs andexperimental new devices, experimental non-therapeutic studies as well as those behavioral orpsychological studies which may incur significant risk. All projects, both externally funded as well asinvestigator-initiated must be submitted for IRB review and approval prior to inception.The primary responsibility of the IRB is to inquire into and fully evaluate the moral and ethicalconsiderations of proposed projects in order to guard the human rights of the involved subjects. In thisregard, among the responsibilities of the IRB are:• to insure that adequate and proper informed consent is obtained and is freely given by the researchsubjects.• to insure that the possible risk to the subjects is balanced by the potential benefits to the subjects and/orto society.• to insure that periodic reporting of the progress of research studies to the IRB is established andmaintained.Members of the House Staff may call the IRB administrative office at ext. 2552 for guidance, materials andassistance with the submission of a new project.73. ORGAN AND TISSUE PROCUREMENTBy New York State Law, when a patient dies in the hospital the New York Organ Donor Network must benotified immediately. Notification is done by Nursing, but House Staff play an important initial role incases where patients are on ventilators in the ICU. If the patient has been declared brain dead, or is beingevaluated under Brain Death criteria, the Donor Network must be notified immediately. House Staffshould be aware of the need for timeliness and of communicating the patient’s status to nursing personnel.The Uniform Anatomical Gift Law includes all patients, ages newborn to 86, excluding those with knownHIV. A Donor Network representative will call back to screen the patient for potential donation, based onchart information. If the patient is deemed a suitable candidate, the representative makes the request of thefamily, and coordinates with the appropriate retrieval organizations.74. PATIENT IDENTIFICATION BRACELETSAccurate and consistent patient identification is essential to the delivery of patient care services. Patientidentification is the responsibility of every member of the hospital staff who interacts with patients orintervenes in their care.Hospital policy requires that prior to any encounter or procedure, hospital personnel (including HouseStaff) verify the identification bracelet by asking the patient to state his/her name (if able) and then check tobe sure that the stated name coincides with the name on the bracelet. If it coincides, House Staff shouldRev. 1/08

then cross check the bracelet with the voucher for test or procedure, prescribed medication, menu, chart,etc. If there is any discrepancy, it should be brought immediately to the attention of the patient's nurse.Identification bracelets should not be cut when performing tests or procedures. If the circumstances areacute, and cutting is unavoidable, the nurse should be advised so that a replacement bracelet can bereapplied immediately.75. PATIENT RESTRAINTSBased on JCAHO Standards, restraint usage is to be discouraged and may be used on a temporary basisafter alternatives have been attempted and found unsuccessful. Research has demonstrated that restraintusage can be detrimental to patient care, negatively affecting may body systems and patient outcomes.A Restraint is defined as the direct application of physical force to a patient, with or without the patient’spermission, to restrict his or her freedom of movement. The physical force may be human, mechanicaldevices or a combination thereof. (See Patient Care Manual Policy # P-30-5). Restraints are time limitedfor a maximum of 24 hours. Each new episode of restraint requires a face to face assessment by thepractitioner before reordering. Order is completed using the Restraint Doctor’s Order sheet.76. QUALITY MANAGEMENTThe Joint Commission on Accreditation of Health Care Organizations, as well as the New York StateDepartment of Health (405.6), mandates that all hospitals establish and maintain a Quality ManagementProgram. Clinical departments and Medical Staff committees are responsible to the Executive Committeeof the Medical Staff and the Board of Directors for assuring the implementation of a planned and systemicprocess for monitoring, evaluating and improving patient care. This process is accomplished via regularreview of at least the following:- Mortalities - Re-admissions- Morbidities - Infections- Complications - Drug Usage- Unplanned Surgery - Transfusions- Incidents - Patient RelationsReviews focus on specific indicators or referrals, defining the cause and scope of the event, resolving issuesat the lowest institutional level possible, and monitoring the effectiveness of corrective actions. Issues aretrended according to event, as well as practitioner, in order to determine patterns of care.Clinical department chairpersons are responsible for conducting and coordinating the Quality Managementactivities of their departments. Quality Management issues are addressed regularly at monthlydepartmental meetings, during which time representatives of the House Staff, traditionally chief residents,have an opportunity to observe and participate in the process. Subsequently, the chiefs educate their housestaff accordingly. Further House Staff participation on a peer review level is at the discretion of theDepartment Chair.The Quality Management staff is available for further questions at ext. 2510 and may be contacted if thereis a question concerning quality management policy in general.77. REFUSAL OF TREATMENTA competent adult has a right to refuse any and all treatment on his or her own behalf. In the event apatient refuses treatment, the patient must be clearly and completely informed of the potential risk tohis/her health and welfare. The physician must document in the patient's medical record the discussionwith the patient of the risks and alternatives of the contemplated treatment. This will protect the physicianagainst any claims by patients that they would not have refused treatment had they been aware of thepotential consequences.Rev. 1/08

Refusal of treatment on behalf of a minor or an incompetent adult, by a family member, legal guardian, orhealth care agent must be reported immediately to Risk Management and Insurance Services (ext. 2206).78. REPORTABLE INCIDENTS: NEW YORK STATE DEPARTMENT OF HEALTHThe New York State Department of Health requires telephone reporting within 24 hours certain incidents,which did or could have caused harm to the patients or the staff in the hospital. Under the law thefollowing types of incidents are considered reportable:Patient deaths or injuries and impairments of bodily functions in circumstances other than those relatedto the natural course of illness, disease or proper treatment in accordance with generally acceptedmedical standards.This category of incidents to be reported should be limited to those events or occurrences which havecaused or contributed to actual harm to patients, including those incidents which prolonghospitalization, which cause greater complications in the patient's treatment regime, which are of along-term or lasting nature, which are life-threatening, or which require transfer to a facility or unitproviding a more intense level of care.The following examples represent a few of the incidents which would fit this category if they occur inthe Hospital:Anesthesia incidents resulting in coma, permanent disabilities, or death.Patient arrests during surgery due to improper intubation.Medication or blood error resulting in coma, permanent disabilities, serious allergic reactions,death.Adverse medication reaction resulting in anaphylactic shock or other serious consequences.Patient falls resulting in fractures or requiring sutures.Rapes, molestations, or assaults to patients (including child abuse) in the hospital.Suicides and attempted suicides.Pneumothoraxes secondary to central venous line insertion that require chest tube placement(pneumothoraxes secondary to needle biopsies are not reportable incidents).Unplanned re-operations occurring within 24 hours of initial surgery.Expirations within 24 hours of admission.Fires or internal disasters in the facility which disrupt the provision of patient care services or causeharm to patients or personnel.Equipment malfunction or equipment user error during treatment or diagnosis of a patient which did orcould have adversely affected a patient or personnel. The incidents which require reporting under thiscategory involve harm to patients or failure to provide needed services on a timely basis to patientsbecause of equipment malfunction.Types of equipment which might malfunction and adversely affect patients and would be reportedunder this category of incidents are:Automatic medication administration machinesRespiratorsRev. 1/08

Patient monitoring equipmentDialysis equipmentAnesthesia equipmentPoisoning occurring within the facility. This category of reportable incidents involves contaminated(bacteriological or chemical) water supply, food and drugs, as well as lethal medication errors, whichwould also be reportable under the first category of incidents.Patient elopements and kidnappings.When a reportable incident occurs, House Staff should notify the attending physician and appropriate nursemanager immediately. Typically the nurse manager completes the report form and delivers it to RiskManagement and Insurance Services, which then notifies the New York State Department of Health. Ifthere is any question as to whether an incident fits the criteria specified, it should be referred to RiskManagement and Insurance Services (ext. 2206)79. RISK MANAGEMENT AND INSURANCE SERVICESThe Department of Risk Management and Insurance Services has the responsibility to reduce and/orcontrol risks to patients and visitors through a system of tracking occurrences and identifying preventativeand corrective measures. All occurrences are reviewed in a blame-free environment with an emphasis onimproving processes as opposed to focusing on individuals.The department coordinates and manages malpractice case files and legal affairs that relate to patient careissues (professional liability), visitor and site-related issues (general liability). In addition, the departmenthas the responsibility for maintaining compliance with various state and federal regulations.House Staff should immediately notify the Risk Management and Insurance Services (ext. 2206) under thefollowing circumstances:Any treatment that results in patient harm or injuryDevices that have been used for the purpose of diagnosis or treatment that have caused patient harm orinjuryWritten or verbal claims of malpracticeContact from anyone purporting to be an attorney, including a representative from the county districtattorney's office, police or any governmental representativeAll legal documents received relating to the resident's duties at Winthrop-University HospitalAny questions or issues relating to patient consent to treatment, patient refusal of treatment,withdrawal or withholding of life supportAll residents employed by Winthrop-University Hospital engaging in professional activities, within thescope of that employment are included in the hospital's self-insurance program, which is in excess of anyvalid and collectible insurance. All residents must participate in the defense of any litigation onrequest by the Hospital.The Risk Management and Insurance Services is available to offer guidance and assistance with any and alllegal issues.80. SENTINEL EVENTSRev. 1/08

Sentinel events are considered unexpected occurrences involving the death or serious physical orpsychological injury to a patient or visitor, or the risk thereof. Serious injury specifically includes loss oflimb or function. The phrase “or the risk thereof” includes any process variation for which a recurrencewould carry a significant chance of serious adverse outcome. Such events are called “sentinel” becausethey sound a signal for the need for immediate investigation and response.Sentinel events include, but are not limited to, the following: suicide; infant abduction or discharge towrong family; rape (including assault, homicide, or other crime resulting in patient death or majorpermanent loss of function); hemolytic transfusion reaction; surgery on wrong patient, wrong body part,or wrong side of body; intrapartum maternal death (related to birth process); any perinatal death unrelatedto a congenital condition in an infant having a birth weight of greater than, or equal to, 1000 grams.In the event you become aware of an actual or potential sentinel event, you must immediately notify RiskManagement, or the Administrator on call during nights, weekends and holidays. You must also notify thepatient’s attending physician and faculty responsible for the clinical area involving the patient. Uponnotification of a possible or actual sentinel event, a root cause analysis team will be convened and facts willbe reviewed to determine whether the situation is in fact a sentinel event. All cases referred through theincident reporting process are addressed through the quality improvement program to identify process andsystem weaknesses and improve patient safety (see Policy/Procedure APPM I-10-1).81. SEXUAL HARASSMENTThe following is Winthrop-University Hospital's policy on sexual harassment, which is a violation of TitleVII of the Civil Rights Act.Sexual harassment is a form of misconduct which undermines respect for individual dignity. By definition,unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexualnature constitute sexual harassment when:Submission to such conduct is made either explicitly or implicitly a term or condition of an individual'semployment;Submission to or rejection of such conduct by an individual is used as the basis of employmentdecisions affecting such individual;Such conduct has the purpose or effect of substantially interfering with an individual's workperformance or creating an intimidating, hostile or offensive working environment (EPOCH).Individuals who believe they have been sexually harassed may obtain redress through the establishedinformal and formal procedures of the institution. Complaints about sexual harassment will be respondedto promptly and equitably. The right to confidentiality of employees/residents of Winthrop-UniversityHospital will be respected in both informal and formal procedures, insofar as possible. This policyexplicitly prohibits retaliation against individuals for bringing complaints of sexual harassment. Violationof this policy may subject the violator to appropriate disciplinary action, up to and including termination ofemployment.If you believe that you are experiencing sexual harassment in any form, contact the Hospital's HumanResources Department (ext. 2353). An Employee Relations representative will help you to resolve theproblem in a prompt and confidential manner.82. UTILIZATION MANAGEMENTState and Federal law require every hospital to carry out an approved "Utilization Management Plan". Theutilization plan is designed to assure effective utilization of hospital services and to maintain quality carethrough the analysis, review and evaluation of clinical practices within the Hospital.Rev. 1/08

At Winthrop, Case Managers initiate review of medical records of all patients within 1 working day ofadmission and continue until discharge using established written criteria. If these criteria are not met, thecase is referred to a Physician Advisor who discusses the case with the attending physician. Issues relatingto length of stay are critical. In order to assist the utilization staff in making appropriate and timelydecisions, House Staff is requested to:Write comprehensive progress notes with specific documentation describing the patient's condition,symptoms, management and treatment plans.Refer patients with potential discharge problems immediately, even before admission if possible, to theCase Management Department.Diagnostic studies, procedures and consultations must be ordered and completed in a timely manner;extra hospital days are costly.Telephone for test results, etc., and record same in progress notes. This will prevent unnecessarydelays, which could result in extra hospital days.Always include documentation, which clearly reflects the patient's continued acute status. "Stable","Doing Well", unaccompanied by documentation of acute conditions, will result in an insurancereimbursement denial, as the documentation implies that the patient is ready for discharge.Record the medical reasons for any pre-op day. Avoid unnecessary pre-op days, which will result incostly extra hospital days.Avoid discharge delays. Patient must be discharged immediately when medically ready for discharge.Extra days generate reimbursement denials and are costly.When Medicare or Medicaid patients are medically ready for discharge, and have a skilled nursingneed but cannot leave the hospital because they are awaiting post-acute care facility placement, or needHomecare services, the progress note must state that "patient at alternate level of care (ALC)," andstate the level of care and/or facility to which the patient will be discharged.Whenever possible, give a patient 24 hours notice of impending discharge.Please make every effort to write legibly. Errors and conflicts are often due to the fact that notescannot be read.For more information on the Utilization Management process, contact the Department at ext. 2732.CLINICAL SUPPORT SERVICES83. DISCHARGE PLANNING SERVICESThe Case Management Department provides for continuity of care to all patients, as needed, to the home,rehabilitation or skilled nursing setting. All discharge plans are developed and implemented in consultationwith the patient, family and physician.The Case Managers who perform discharge planning screen all patient admissions via established screeningcriteria, assess patients’ meeting of these criteria, assist patients and family with insurance information anddevelop appropriate discharge plans.Team conferences for patients with complex discharge needs are held as needed where patients arereviewed, discharge-planning options discussed, and plans initiated.Rev. 1/08

Discharge plans are made based on patients need, physician direction, and available insurance coverageand/or private payment by the patient and family. Patients unable to return home after acute care areassisted with placement to the appropriate rehabilitation, skilled nursing, terminal care, or adult homefacility dependent upon patient need.The Hospital has its own certified home health agency: "Winthrop-University Hospital Home HealthAgency". Many of the Hospital's home care patients are referred to it, if appropriate. This provides foradded continuity of care and communication. Home Care is able to provide physical, occupational andspeech therapy, paraprofessional services, social work and nursing services at home on an intermittentbasis. The attending physician of record must direct the plan of care.Referrals are accepted from all sources including medical staff, nursing, allied health professionals, family,patient, community agencies and institutions. The attending physician is consulted prior to initiation of anydischarge planning.For further information, contact Discharge Planning at ext. 2075 or the Home Health Agency at ext. 6338.84. ETHICS CONSULTATION SERVICEThe Ethics Case Consultation Service is designed to assist patients, family members, attendings, HouseStaff and other hospital staff in making ethical decisions related to patient care. The consultants, who aremembers of Winthrop’s Bioethics Committee, identify and examine the ethical problem by reviewing themedical record and meeting with the patient/family and health care team. The consultants may offer adviceor recommendations but the patient/family and health care team remains responsible for their owndecisions.An Ethics Case Consultation can be arranged by calling ext. 0333 and asking for the Ethics ConsultationService. If one is unclear as to whether a consultation is needed, that should not deter one from calling.The consultants will help to define the issues, and triage the case as needed. One may call the service withassurance of total impunity.85. HEALTH INFORMATION MANAGEMENTCONFIDENTIALITYMedical records containing the clinical histories of the patients are hospital property and containconfidential communications from patient to doctor. No report or other communication, discussion withnews media, lawyers or insurance companies, etc., concerning patients treated in the Hospital shall bereleased, published, or discussed by members of the House Staff under any circumstances.Documents you are discarding that have any patient information ion on them should be shredded.LEGIBILITYAs a legal document and a source on patient care information used by many personnel involved in the careof the patient, all entries into the medical record should be logical and legible. Every order written by amember of the houstaff should be signed as well as stamped with pre-printed information containing nameand contact info. Using the pre-printed information in addition to your signature when writing progress,operative, procedure, delivery notes and discharge summaries is strongly recommended.HISTORY AND PHYSICAL DOCUMENTATION1. Histories and physical examinations are to be completed and written on the record by the admittingresident within 24 hours after admission of the patient. The original history and physical must beplaced on the chart immediately after completion. Please do not hold the forms.It is the responsibility of the supervising resident to see that the history and physical of each patient iscompleted within the 24-hour time period.Rev. 1/08

The supervising resident will be responsible for completion of any history or physical forms thatremain grossly incomplete or are missing 24 hours post admission. Such completion will beimmediately required.2. Please document all pertinent items on the history and physical including breast, pelvic, and rectalassessments as indicated. If any portion of the examination is not completed, it is required that thereason be documented.3. A PGY-1 admitting a patient while substituting for another PGY-1 is responsible for the history andphysical examination.4. A history and physical completed by a medical student must be co-signed by the supervising resident orfellow before it is placed on the chart.5. No patient is to be taken to the Operating Room until the history and physical examination has beenwritten and all pre-op testing results have been done and charted.6. When using the two-page short form, complete both pages and separate the history from the physical.PROGRESS NOTES1. The admitting note should only state the reason for admission and the plan of treatment. Please do notduplicate the history and physical. Documenting "see H&P" is not acceptable as the admittingnote.2. Progress notes should be written at least daily, and whenever there has been a change in the patient’scondition. The content of the progress notes must include assessment of the patient’s condition,treatment plan and patient’s response to the treatment. Include all complications and co-morbidities,which are being treated. Treatment plans must be discussed with the attending physician anddocumentation of this discussion must be included in the progress note. All entries in the medicalrecord shall contain the printed name of the practitioner, contact number (telephone extension orbeeper number), date, time and signature.3. A progress note should be written after all treatments, operations, and diagnostic procedures.4. The Operative Progress note is to be completed immediately following any operativeprocedure.5. Indicate date of discharge summary dictation on the last progress note. If a student has dictated, theresident should have the student indicate date of dictation on the last progress note.6. Document the word “addendum” to the progress note and date, time and sign at the time of entry.OFF-SERVICE NOTES1. Off-service notes are to be written on the progress sheets in the event of a service transfer from onegroup of House Staff to another on the same service.2. The off-service note is to summarize the condition of the patient on the day of transfer, and shouldbriefly describe his or her course in the hospital.ORDERS1. House Staff shall enter orders with printed name, contact number (telephone number,extension or beeper number), date, time and signature.Rev. 1/08

2. Telephone orders are limited to emergencies only and are one time orders. If, of necessity, ordersare given over the telephone to a licensed practitioner who is required to write down the telephoneorder and read it back to you. The telephone communication must be signed at the earliest possiblemoment with a maximum time limit of 24 hours.3. Narcotic orders: a member of the House Staff may not write a narcotic order for a patient withoutpersonally evaluating and documenting this assessment in the medical record.4. Pathology orders: standing orders for Laboratory procedures must have a stop date included on thechart with the original order.5. Patient allergies and current medication must be listed on the first order sheet by the physician whohas completed the history and physical.6. Residents must immediately co-sign orders written by students.7. Orders are only to be written using WUH accepted medical abbreviations.DISCHARGE PROCEDURES1. The principal diagnosis (the diagnosis established after study to be chiefly responsible for admission)and secondary diagnoses are to be recorded on the summary sheet of the chart when the diagnoses areestablished, and must be on the chart at the time of discharge.2. In the event that the principal diagnosis has not been established at discharge, due to pending testresults, etc., write this information on the summary sheet at the time of discharge.3. The Discharge Order and Instruction Sheet is to be completed prior to discharge. Complete allsections in full, date, time and sign.4. The medical record must be completed by the House Staff as prescribed by Hospital policy to avoidthe accrual of delinquent charts.The Discharge Summary is the responsibility of the resident who has had on-going responsibility forthe patient. Should a resident be covering a patient for less than 48 hours at the time the patientexpires, is transferred or discharged, then the Discharge Summary is dictated by the previous resident.Dictation of the discharge summary is to be completed upon discharge or expiration. Disciplinaryaction will be taken if the discharge summary remains undictated following discharge.During dictation of the discharge summary, give the first and last name of the attending physicianresponsible for the case, to facilitate mailing procedures. Dictate according to discharge summary formatas follows below.DISCHARGE SUMMARY DICTATION PROCEDURESThe summary should be a concise overview of the case. When required, additional details will be found inthe chart.1. Discharge Summary Outline:Identify yourself as the person dictating.First and last name of attending physician must be included.Give patient's name and spell it.Give patient medical record number (6 digits)Give admission and discharge dates.Then continue with the following format:Speak slowly and clearly when dictating.Rev. 1/08

2. History/Physical/Lab Findings:Give brief summary of significant points in the history and physical findings. The date of onset ofsymptoms and circumstances are particularly important. Where, when and how injury or illnessoccurred should be clearly stated.Give relevant findings as briefly as possible.Give brief summary of all significant/abnormal lab and x-ray findings.3. Condition on Discharge/Disposition:State the in-hospital course including treatment and patient's response to treatment, operations, specialexaminations, consultations, recommendations, etc. Indicate follow-up plan, discharge medications,immunizations and vaccines given during hospitalization, activity level and condition on discharge.4. Final Diagnoses:List principal diagnosis and all other diagnoses co-existing or complicating this admission. UseStandard Nomenclature terminology.CURTAILMENT POLICY: INCOMPLETE RECORDSAll physicians are responsible for complete and timely documentation of medical care given to any patienttreated at Winthrop-University Hospital. Failure to comply with charting regulations will result indisciplinary action. New York State Code 405.10 mandates medical records be completed within 30 daysof discharge. After 30 days, any record incomplete will be considered “Delinquent”.1. The appropriate chiefs of service will be notified of all House Staff with delinquent records anddisciplinary action will be taken.2. If any charts become delinquent, a notice will be given to the Chief of the Department, the ChiefResident, and the delinquent resident. A record of all action taken will be kept in the resident'spermanent file.GENERAL NOTES1. All entries in the medical record shall be written in permanent ink and contain the printed name of thepractitioner, contact number (telephone extension or beeper number), date, time and signature.2. Erasures or blacked out alterations are illegal and render the entry valueless to the patient or to theHospital in the event of litigation. If an error in documentation occurs in the medical record, draw onestraight line through the statement, print the word “error” above the cross-out, verify correction –initial and date after cross-out and document the correct narrative.3. Abbreviations are to be avoided when assigning final diagnosis, and are to be used only if onWinthrop’s Standardized List of Abbreviations.4. Records may not be taken from the Health Information Management Services Department unlessapproved by the Director.5. No records are to be taken from the main hospital building for any reason.6. Operative reports shall be dictated in detail immediately after surgery (JCAHO regulation).7. Requests for records or patient lists for studies to be used for research must be cleared and reviewed bythe Institutional Review Board (IRB). The IRB can be contacted at 516 663-2552.Rev. 1/08

8. The Heath Information Management Services Director requests that during the first week of duty,members of the House Staff visits the Department for orientation to become familiar with theregulations of the Department and proper use of the dictation system throughout the hospital.86. HOSPITAL INFORMATION SYSTEMSThe Hospital Information System is the SMS Invision System. The applications which are currently on lineinclude ADT (Admission, Discharge and Transfer), Order Entry and Results Reporting.Before using the SMS Invision System, House Staff must attend a training class, at which point they aregiven a sign-on number and password. They must also sign a confidentiality statement. All WUHpersonnel have a responsibility to protect Patient information. Access to information, including the SMSInvision System, is limited to appropriate personnel with a legitimate need.In using the Hospital Information System House Staff must:1. Protect their sign-on numbers and personal passwords. The password is equivalent to an electronicsignature and it holds one legally responsible for all ordering done under that password.2. All orders must be written in the patient’s medical record as well as entered into the SMS System.Failure to do so places the institution at risk.3. Write each order number generated by the Invision System into the medical chart. This avoidsduplicative ordering.4. Be sure to access the correct patient, by consistently checking the header information for the patient’sname.5. Include adequate clinical information as to why tests are being ordered. This information assists theancillary departments in providing appropriate care; it is also essential for reimbursement. Signs,symptoms or abnormal findings must be indicated on all –ray requests.6. Always sign-off when finished. This will protect patient confidentiality, and it will protect you so thatno one else can use your sign-on to process orders.7. Do not give your password to students or others.For problems related to the use of the Hospital Information System, call the “Help Desk” at ext. 4357(“help”).87. HOSPITALISTSWinthrop-University Hospital integrates Hospitalists into patient care initiatives as well as utilizing themon several hospital-wide committees. They are also integrally involved in student and house staffeducation and evaluation. In addition to activities dedicated to house staff education, a HospitalistResidency Elective incorporating inpatient issues with medical economics, liability issues, and hospitalistmanagement concepts, is offered to residents interested in concentrating on inpatient issues or a hospitalistcareer.Since its inception in 1996, the Hospitalist Program has evolved into a full-integrated academic division ofthe Department of Medicine composed of faculty physicians who provide full-time inpatient medical carefor patients referred by primary care and specialty physicians I the community. The group also directs thecare of patients whose physicians are not on staff, and for patients who require inpatient medicalconsultation. Emphasis is on coordinating quality inpatient care with appropriate resource utilization andrisk management in an exceptional educational setting.Rev. 1/08

88. NUTRITION SUPPORT SERVICESThe Nutrition Support Team is available to aid in the diagnosis and treatment of inpatient nutrition-relatedproblems. This multidisciplinary team consists of a nutrition support physician, gastroenterology fellow,nutrition support dietitian, nutrition support nurse and pharmacist.For the routine nutritional assessment of patients, selection of p.o. diet or for tube feeding, a staff dietitianfrom the Hospital's dietary department should be consulted. The Nutrition Support Team, an entirelyseparate entity from the Hospital's dietary department, should be called for difficult tube feeding cases,problems with peripheral parenteral nutrition (PPN), diagnostic dilemmas, or if the patient is beingconsidered for Total Parenteral Nutrition (TPN).If TPN is desired for a patient, it is mandatory that the Nutrition Support Team be consulted to evaluate thispatient. The Team must be consulted before a surgical consult is submitted to place the central venouscatheter for TPN access. Once TPN is initiated, the Nutrition Support Team will continue to follow thepatient and provide medical record documentation as necessary to guide the housestaff in managing thepatient’s ongoing nutrition support.89. PASTORAL CAREThe Department of Pastoral Care and Education offers pastoral care and spiritual support to all patients,family members and staff members. Pastoral care ranges from celebrating the birth of a newborn tosupporting a patient and family to find strength, comfort and guidance in their spiritual tradition during thedying process. The basic goal is to offer patients, families and staff a trustworthy, spiritually andemotionally knowledgeable and well-educated companion, with whom the pain and concerns connectedwith the hospital stay can be shared. This sharing usually leads to a deeper acceptance of reality, healthiercoping and supports the healing process, even when there is no cure. This sharing helps the patientcelebrate life up to the last minute and end it in dignity, in tune with the best wisdom of his or her spiritualtradition.Indicators to involve pastoral care: patient in the dying process; after receiving a severe diagnosis; patientor family depressed, upset, worried, alone, has little support; specific religious or cultural concerns.How to reach pastoral care: write a request in the chart; call the Pastoral Care Department at ext. 4749; inan emergency call the operator (24-hour on call service available).90. PAIN MANAGEMENTThe Winthrop Pain Management Center offers a multidisciplinary approach to diagnosis, evaluation andtreatment of pain in an inpatient and outpatient setting. Under the direction a Board-certifiedAnesthesiologist and Pain Management Specialist, the Center is staffed with a physician and a painmanagement clinical nurse specialist, who employ the most advanced techniques to ensure optimaltreatment.Pain Management is a responsibility of all clinicians. If, after initial intervention, a patients’ conditionwarrants insight from a specialist or the patient is a complex situation, the Pain Management Service shouldbe contacted at (516) 739-9771, ext. 11.The institution also offers a Palliative Care Service, available to all patients in need. This Service isavailable every regular business day by calling the operator and requesting a Palliative Care consult.91. PATHOLOGYThe following describes essential policies and procedures of the Department of Pathology. House Staffshould take the time to familiarize themselves with the complete procedures, as contained in the LaboratoryRev. 1/08

Manual kept at each nursing station. Please use the manual as a reference for critical values, profiles andpackages and proper completion of the Laboratory Requisitions.The Department of Pathology is responsible for and has specific procedures regarding the performance ofautopsies at WUH. Autopsy policies and procedures are included in this manual in the "Legal-Administrative " section under "Informed Consents: Autopsy."ANATOMIC PATHOLOGYThe divisions of Surgical Pathology and sections of Immunopathology, Immuno-histochemistry andCytopathology are located on the sixth floor of the Professional Building, 222 Station Plaza North. TheDepartment maintains a refrigerator for specimen drop-off located in the corridor outside the UrologicSurgery suite on 4 Main. All specimens are to be placed in the refrigerator or delivered directly to Suite618.Fluid specimens for cytology must be immediately mixed with an equal volume of 50% ethyl alcohol forcellular preservation. Pre-filled specimen containers are available on 4 Main near the specimenrefrigerator. All specimens for surgical pathology must be placed in pre-filled containers containingbuffered formalin. Bone marrow biopsies are also to be placed in buffered formalin.All specimens for either cytology or surgical pathology must be accompanied by the following:The specimen container must be properly labeled with the patient's addressograph label.A "Surgical Pathology Requisition" or “Cytopathology Requisition” form or the computerized on-lineversion must be properly filled out indicating pertinent clinical history and findings. All bone marrowbiopsies must indicate the time the specimen was obtained.Surgical Pathology and Cytopathology reports will be placed on the chart daily.information, or for uncharted results, call:For additionalSurgical Pathology: ext. 2475Cytopathology: ext. 4561The House Staff is encouraged to review cases of interest with the staff Pathologists and Pathologyresidents.CLINICAL PATHOLOGY1. Identification of SpecimensProper specimen identification is essential. The most dangerous "Laboratory errors" are caused byspecimen mix-up. Therefore, we require that all specimens sent to the Laboratory be labeled with thepatient's full name, medical record number, account number, date and time of collection, and the identity ofthe individual collecting the specimen (drawing the blood, etc.). The Laboratory will refuse specimenslacking proper identification. All capillary specimens are to be wrapped with either a computer label or alabel prepared with the patient's ID plate. Specimens must also be accompanied by a requisition generatedby the hospital information system (SMS). Specimen requests are entered into SMS and a requisition isautomatically printed. Hand written vouchers will only be accepted in the event of SMS downtime.Unlabeled blood, urine, and sputum specimens will be discarded. Other specimens will be held, withoutprocessing, until identified by responsible nursing personnel. Likewise, our phlebotomists will not drawblood from a patient lacking an identifying wristband until absolute and positive identification isestablished with the cooperation of the responsible nursing personnel.The following is the Laboratory policy for positive patient identification and will be adhered to with allphlebotomies:Rev. 1/08

All patients should have an identifying wrist or ankle tag with full name and medical record number.This information will be matched exactly with the information on the requisition and labels.When the tag is attached to the bed, the phlebotomist will require positive identification by nursingstaff and place that nursing staff person's initials on the requisition.Phlebotomists will further confirm patient's identification by asking coherent patients their names.Patient name bands must also be checked.In the emergency room, all patients should have an identifying wrist or ankle tag with their full nameand medical record number. This information will be matched exactly with the information on therequisition.In the operating room and other areas where a physician draws the blood, proper patient identification,using double identifiers, neither of which is the patients room/bed number, will be the responsibility ofthe physician and the attending nursing staff.All blood bank tubes must contain the following:- Full name of patient- Hospital number/account number- Date- Time- Signature (initials) of the individual collecting the specimen.-Signature of person verifying processNote: Blood Bank tubes that are not properly labeled and signed will be discarded immediately. Theymay not be identified, labeled or signed at a later time.Specimens arriving in the Laboratory should be clocked in at the computer receiving area and handed to thecomputer clerks. Never allow specimens to remain in the patient rooms or at nursing stations. They mustbe delivered promptly to the Laboratory.Patient’s full name and medical record number must identify all specimens brought or sent to thelaboratory. Individuals delivering these specimens must remain until all requisitions and/or orderconfirmations are checked in order to determine if any additional information may be needed (i.e., timedrawn, when multiple specimens are involved, site/location on multiple test requests).Great care must be utilized in handling all infectious materials. The tube should be labeled with"CAUTION" and then placed in the plastic specimen bag labeled "Bio Hazard".2. Location of Areas for Delivery of Requisitions & SpecimensThe Computer Room and Receiving Area is located on 3 Main. The following specimens should bedelivered here and time stamped: Routine urinalysis specimens with requisitions. Routine and Stat blood specimens with requisitions. Body fluid specimens (except for culture when the Microbiology Lab is open, and forCytology). Microbiology specimens after 10:30 P.M. weekdays and after 4:00 P.M. weekends andholidays.All spinal fluids are handled as stats. They must be handed directly to a computer clerk or technologistin the computer room. The microbiology tube should be brought to Microbiology when Microbiology isopen. The same applies to stat work on other "difficult to obtain" specimens (e.g. joint fluid).Rev. 1/08

The Microbiology Lab on the second floor is open from 8 A.M. to 10:30 P.M. weekdays and 8 A.M. to4:00 P.M. on weekends. Microbiology specimens with requisitions should be brought there.Surgical Pathology and Cytopathology specimens should be placed in refrigerator outside the Urology suiteon 4 Main (see Anatomic Pathology, above).92. PHARMACYThe Pharmacy Department provides service 24 hours per day, every day. House Staff are encouraged toutilize the Pharmacy Department for drug information services, by calling ext. 2401.THE FORMULARYWinthrop-University Hospital maintains an inventory and dispenses only those drugs which have beenapproved for inclusion in the formulary. Only attending physicians and full-time faculty may request adrug for formulary consideration, by submitting a request to the Pharmacy and Therapeutics Committee.In compiling the formulary, the Pharmacy and Therapeutics Committee has been guided by the followingprinciples:1. The pharmacist, with the advice and guidance of the Pharmacy and Therapeutics Committee, shall beresponsible for specifications of all drugs, chemicals, biological and pharmaceutical preparations usedin the diagnosis and treatment of patients, and for assuring that quality is not compromised foreconomic considerations. When applicable, such products shall meet the standards of quality of theU.S. Pharmacopoeia and the National Formulary.2. The use of non-proprietary names is stressed in the formulary, and physicians are encouraged to usegeneric names in prescribing drugs.3. When a physician prescribes a drug by its proprietary name, the Medical Board of the Hospital hasauthorized the dispensation of the generic equivalent drug stocked by the Pharmacy.4. The Pharmacy and Therapeutics Committee shall report to the Medical Board of the Hospital on theworking of the formulary system and of any proposed changes in the content.5. Provision is made for the appraisal and use by members of the medical staff of drugs not included inthe Formulary and investigational drugs.6. In most instances, medication dispensed through the Hospital Pharmacy will bear the non- proprietaryname of the contents. In certain instances, the proprietary name may be used to avoid confusionarising from similar sounding names or unfamiliarity with the generic name of a drug. All personnelare urged to refer to the drug listings for guidance in this respect.CLASSIFICATION OF DRUGS STOCKED IN THE PHARMACY1. Formulary Drugs: A therapeutic agent approved by the Medical Board for inclusion in the Hospitalformulary and stocked in the Pharmacy.2. Non-Formulary Drugs: Emergency requests for FDA approved drugs not in the formulary shouldrarely be necessary since substitutes usually are available. In valid instances, the Pharmacy will makeevery effort to obtain the requested drug. Questions concerning the need for obtaining non-formularydrugs will be referred to the Chief of Service and will be contingent on his/her approval.3. Investigational Drugs: When an experimental drug or procedure involving a human subject is to beused in the Hospital, the investigator must comply with the procedures set forth by Winthrop'sInstitutional Review Board (IRB).Rev. 1/08

PRESCRIBING DRUGSPrescriptions may only be written by House Staff, attending physicians, dentists, podiatrists and otherauthorized practitioners licensed to practice in the State of New York. Any prescription written by amedical student must be immediately countersigned by a physician. The signature as well as the body ofthe prescription must be legible using only approved abbreviations and must have specific instructions (useof ranges is prohibited, i.e., every 2-4 hours). Physician Assistant in-patient orders need to be countersignedwithin 24 hours.1. Inpatient Prescriptions: All orders for drugs for an inpatient must be made in the patient's chart. Thefollowing information is required:-Name of drug (generic name preferred)-Strength-Directions for use-Signature of prescriber-Date and time of day2. Controlled Substances: Part 80 regulations of the New York State Department of Health regardingcontrolled substances limits the prescribing of such substances to the usual course of the physician'sprofessional practice, acting only within the scope of his or her employment in the institution.Part 80.22 of the same code requires that the institution shall operate a system to disclose to the Departmentof Health any suspicious orders, i.e., forged prescriptions, unusual frequency, unusual quantities.At Winthrop-University Hospital the prescribing of any drug by a resident shall be within the scopeof his or her duties as a member of the house staff. This does not include prescriptions for relativesor friends, or for employees of the hospital who are not seen in your supervised practice.Prescribing is thus limited to inpatients, emergency room patients, and ambulatory patients seen as part ofsupervised training. The resident’s name and degree must be stamped on the prescription pad in keepingwith New York State laws.In accordance with the laws of the United States Department of Justice, all members of the House Staffshall be assigned an identification number to be used when prescribing medications to an outpatient thatare in schedules II, III, IV, or V of the Controlled Substances Act.All members of the House Staff are assigned an identification number by the Pharmacy duringOrientation.Inpatient prescriptions for controlled substances shall be written on the patient's chart and do notrequire the assigned identification number.Outpatient prescriptions for controlled substances shall include the patient's name, address, age;the name of the drug, strength, amount, and definite dosage regime ("as directed" is not to beused); the date, prescribing doctor’s signature, and full name clearly printed, Winthrop-UniversityHospital's DEA number, and the prescribing doctor's identification number.If a House Staff member has received a DEA number privately from the government, he or she isto forego its use while employed by Winthrop-University Hospital, and use the Winthrop-University Hospital assigned identification number. Upon completion of service at WinthropUniversity Hospital the House Staff member's identification number shall become void.WUH DEA numbers and institution specific identifiers are not to be used when moonlighting.3. Total Parenteral Nutrition: To order total parenteral nutrition (TPN), the prescribing physician forcentral or peripheral venous nutrition must complete the pharmacy Parenteral Nutrition Order Form.Rev. 1/08

Intravenous fat emulsion or solutions of amino acid alone or in combination can also be ordered on thisform.The Pharmacy Parenteral Nutrition Order Form must be completed, signed and dated by the physician,and sent to the Pharmacy by 12:00 Noon on the day the solution is to be administered. Changes informulation require a new order form to be completed.4. Outpatient Prescriptions: The Pharmacy Department does not fill outpatient prescriptions fordischarged patients. All unused medication for patients going home are to be returned to thePharmacy, and new prescriptions must be written. All prescriptions for outpatients must contain thefollowing information-Full name of patient-Age of patient-Patient's address-Date prescription written-Name and strength of drug-Quantity of drug (specific as to volume, weight, or quantity of dosage units)-Directions for use-Signature and identification number. For all controlled drugs, use DEA number of institution andphysician's number assigned by institution-Signature, identification number and prescriber's name, mechanically printedTELEPHONE ORDERSTelephone orders should be used sparingly, and when used, must be done using the Read Back Policy andsigned by House Staff within 24 hours. If this is not done, the nurse will try to contact the individualresponsible for the order and if the individual cannot be contacted, the senior resident on duty for theservice will be asked to evaluate, sign, or discontinue the drug therapy. The senior resident will also beresponsible for reporting the event to the Director of Service on the next regular duty day.AUTOMATIC STOP ORDERSThe following medication stop orders are in effect:1. Controlled Drugs: Schedule II - requires renewal every 48 hours and Schedule III, IV, V - requiresrenewal every 72 hours.2. Anticoagulants: require renewal every 24 hours.3. Chemotherapeutic agents: require renewal every 24 hours.4. Antibiotics: require renewal every 5 days.5. Steroids and other hormones: require renewal every 7 days.6. Standing orders: automatically canceled when a patient undergoes surgery.BEDSIDE MEDICATIONSThe policy for the use of bedside medications at Winthrop-University Hospital is as follows:1. In general, patients should not take their own medications. If a physician requests that a specificpatient take his or her own medications, the following procedure must be carried out:The physician is to indicate on the chart the name of the medication, strength, and directions foruse along with the statement -- "Patient may take own meds at bedside."Rev. 1/08

The medication must be sent to the Winthrop-University Hospital Pharmacy for verification priorto the patient being able to self-administer the medication.The nurse is responsible for charting the patient’s own medications.2. The following types of medications may be left at the patient's bedside:-Ophthalmic preparations-Antacids-Nitroglycerin tablets-Birth control pills-Metered dose inhalers for asthma or COPD3. Nursing collects and stores until discharge all patient medications not used during their stay.93. PSYCHIATRIC LIAISONWinthrop’s Department of Psychiatry provides psychiatric services for inpatients and EmergencyDepartment patients. Under the direction of the Chairman of Psychiatry, the on-call psychiatrists and apsychiatric liaison provide case consultations, case management, discharge facilitation, staff education andsupport groups. Members can be contacted at ext. 2691 weekdays during daytime hours, and the on-callpsychiatrists can be reached at any time through the telephone operator.94. PHYSICIAN ASSISTANTS AND NURSE PRACTITIONERSWinthrop-University Hospital supports the utilization of Physician Assistants (PA) and Nurse Practitioners(NP) to provide medical care to patients in our institution, i.e. admitted patients, patients in the ED andoutpatient practices. PAs and NPs are licensed to practice medicine and are credentialed members of theMedical Staff who are committed to practicing as members of attending physician-directed teams. Someservices are exclusively utilize PAs and NPs, where others have PAs and NPs and residents workingtogether to provide care. The presence of PAs and NPs enables the hospital to meet its mission, maintaincompliance with ACGME standards and enhance a resident’s academic environment. They are involved atmany levels within the institution such as Administration, Medical Education, Quality Improvement andCommunity Outreach. PAs and NPs are respected members of the Medical Staff, and contribute positivelyto the medical care provided to our patients in the hospital and in the community.95. PULMONARY FUNCTION LABORATORYPulmonary Function Tests are performed between the hours of 8 A.M. to 4 P.M. Monday through Friday.Requests called in during this time will be placed in a queue and will be completed as quickly as possible.Requests may also be called in at other times at which point please leave a message on the Department'svoice mail to include the patient's name, room number, ID or MR #, diagnosis and the tests to beperformed. The Lab is located on the Lower Level - Potter Pavilion, ext. 2286. Tests include:1. Full Pulmonary Function Tests with or without Bronchodilator: Includes Flow Volume Loop, LungVolumes, Diffusion Capacity, Maximum Voluntary Ventilation. Post Bronchodilator Studies repeatFlow Volume Loop and Maximum Voluntary Ventilation.2. Bedside Flow Volume Loop: utilized for pre-operative clearance and patients unable to be brought tothe Laboratory for full testing.3. Bronchial Provocation Challenge: utilized to confirm diagnosis of hypersensitive airways.96. RADIOLOGYRADIOLOGY HOURSRev. 1/08

1. Diagnostic ProceduresEmergency Room: 24 hours a day;seven days per week, ext. 2387.Main Department: 7:30 A.M.to 4:00 P.M., Monday through Friday,ext. 2374. On Saturday and Sunday,7:00 A.M. to 3:00 P.M., ext. 2374 orext. 2387.CT Scanning: 8:00 A.M.to 11:00 P.M., Monday thruFriday, ext. 2377.Ultrasound: 8:00 A.M. to4:00 P.M., Monday throughFriday, ext. 2301.MRI: 8:00 A.M. to 8:00 P.M.,Monday through Friday,ext. 2943 or 2062.2. File Room Hours: 7:00 A.M. - 11:00 P.M. dailyRADIOLOGY REQUISITIONSThe radiology staff is here to help the Hospital's Medical Staff, including the House Staff, with theirdiagnostic work-ups. In order to facilitate this, it is the responsibility of the patient's physician to properlycomplete the radiology requisition stating the pertinent clinical information and indications for theexamination. requisitions lacking pertinent history will be sent back to the requesting physician.Such requisitions should have the physician's name printed and, unless specific orders are to the contrary,such a requisition will permit the staff to prepare the patient for the proper radiographic procedure inaccordance with the Department's recommended instructions:Requisitions must be legible and include history, reason for examination, physical and laboratoryfindings, result of any x-ray examinations, method of transportation, relevant previous surgery, andphysician's name and page number - printed. Rule out pathology (example, R/O appendicitis) isnot sufficient history.Requisitions should prominently note that precautions are needed for handling potentially ordocumented infectious patients (example: AIDS, TB, Hepatitis, etc.).Requisitions may now be submitted electronically via the computer system. It is desirable for housestaff to enter the information in the computer himself or herself rather than delegating to someone else,so correct information is provided.It is the referring physician's responsibility to order preparations on the floor. (A brief description ofthe preparations follows below.)Portable examination requests are utilized only when there is a real need for them - not forconvenience.RADIOLOGY PREPARATIONSRev. 1/08

1. Barium Enema: It is essential that patients be properly prepared for barium enemas. Failure to do soresults in costly delays. Please see the standard prep at nursing stations, or contact the Department ofRadiology.Antibiotic prophylaxis may be given to patients in the following high-risk groups:-prosthetic heart valves-conduits-cardiac patches-surgically created shuntsProphylaxis recommended is 1) Ampicillin, 2 grams I.V. 30 minutes prior, or 2) Vancomycin, 1 gramI.V. 30 minutes prior and Gentamycin, 2 mgs/kg I.V. 30 minutes prior to procedure.2. Upper GI Series: NPO (including medications) after midnight, including medications. Passage of aNG tube should be done before procedure if patient is unable to, or will not drink.3. IVP: No solids for 4 hours before the exam; fluids ad-lib; encourage PO fluids in diabetics.4. CT Scan: NPO for solids for 4 hours before exam. May have fluids.For other preparations call the Radiology Department at ext. 2374.RADIOLOGY EXAMINATIONSExaminations (especially angiograms, CT scans, sonograms, upper GI's and barium enemas) will be morepromptly scheduled and better performed if the requisition is brought to subspecialty area and discussedwith the radiologist rather than routinely sent down. Furthermore, the requesting physician will then knowwhen the exam is scheduled and may order the appropriate preparations for the examination.Please note that Special Procedure examinations require an appointment with the Radiologist. SpecialProcedures may be scheduled in the Special Procedure area.It is good patient care to make sure that the patient understands what type of exam is being performedbefore he or she is sent to the X-ray Department. Make sure an IV is started when appropriate.Please use the Radiology staff as consultants to aid you in your requests for diagnostic examinations.EMERGENCY CASESContact resident "on call" for all emergency after-hours CT scans, sonograms, radionuclide examinations,special procedures, etc.X-RAY RESULTSX-ray results are available either in the Log Book located in the GI, GU, CT, Sonography, MRI,Mammography or Nuclear Medicine areas or written on the patient's x-ray folder. Results are alsoavailable through the Radiology Department's computer system.RADIOLOGY INFORMATION SYSTEMThe Department has a computerized Radiology Information System called Maxifile that enables you toaccess your patient’s procedure record, film location and stores x-ray reports on your patients. All inquiresare made using the patient's medical record number (MRN). X-rays are filed according to this number andwhen seeking x-ray folders or reports you should know the patient's MRN. X-rays are signed out to youRev. 1/08

using a bar code format and your personal bar code which is put on the back of your ID badge atOrientation. It is your responsibility to return the films in a timely manner.97. RESPIRATORY CARERespiratory Care is a 24 hour a day/seven day a week clinical service which operates under the medicaldirection of the Pulmonary and Critical Care Medicine Division. The page operator has beeperassignments for coverage.The Respiratory Care Practitioners (RCP's) are active members of the Code team responsible forendotracheal intubation, and the initiation and ongoing monitoring of mechanical ventilation. RCP's arealso responsible for the provision of medication nebulization, oxygen therapy, continuous aerosol therapy,medication therapy, blood gas analysis, and a variety of other services, depending upon the needs of thepatient.98. SOCIAL WORK SERVICESThe Department of Social Work provides counseling to patients and families experiencing adjustmentproblems in dealing with illness and hospitalization. These problems may be emotional, social, vocationalor economic in nature. Referrals are made to appropriate community and mental health services, if a needfor continuing care is indicated.Staff provides crisis intervention in cases of suspected child abuse, domestic violence, rape, substanceabuse, trauma, terminal illness, homelessness and mental health issues.Residents may arrange for a social work consult by writing an order in the patient’s chart, at which time theRN will contact the Social Work Department personally at ext. 2341.Social workers are available after hours, on weekends and holidays on an on-call basis. Residents mustrefer the case to the nursing supervisor for emergency level screening before the on-call socialworker can be contacted.Social workers are in continuous and active collaboration with Case Management with respect to: 1)facilitating discharge plan by identifying and eliminating obstacles to timely discharge; 2) referrals to subacuteand rehabilitation facilities, skilled nursing facilities, adult homes and in-patient hospices; 3)applications for Medicaid for long term placement in Nassau County only.For additional information about social work services and procedures, please contact the Department ofSocial Work at ext. 2341.PATIENT RIGHTS99. AIDS CONFIDENTIALITY LAWArticle 27F of the NYS Public Health Law, enacted 2/89 and revised Spring 2000, describes requirementsfor medical personnel related to HIV/AIDS testing, reporting, confidentiality disclosure/consent, partnernotification and occupational exposure. Residents should be familiar with the law and its regulations,which can be found at www.health.state.ny.us. The Department of Infection Control, ext. 2724, orafter hours, through the Winthrop Operator, is available to answer specific questions.OVERVIEW OF THE LAWArticle 27-F of the New York State Public Health Law, effective February 1, 1989, was enacted:Rev. 1/08

to encourage and facilitate voluntary confidential HIV testing so that individuals can learn their HIVstatus and change behavior patterns that put them and others at risk;to limit the risk of discrimination and harm to an individual's interest and privacy; andto assure that confidential HIV related information is not improperly disclosed and to provide clearrules for the handling of such information, including permitted disclosures.DEFINITION OF CONFIDENTIAL HIV RELATED INFORMATION"Confidential HIV Related Information" is defined as any information, in the possession of a person whoprovides one or more health or social services or who obtains the information pursuant to a release ofconfidential HIV related information, concerning whether an individual has been the subject of an HIVrelated test, or has HIV infection, HIV related illness, or AIDS, or information that identifies or reasonablycould identify an individual as having one or more of such conditions, including information pertaining tosuch individual's contacts." Note: This includes cases where the only documentation may be a negativeHIV test result.CONFIDENTIALITY AND PERMITTED DISCLOSURESNo person who obtains HIV related information in the course of providing health or social services orpursuant to a special release may disclose that information except to a person or entity specificallyenumerated in the statute or unless the patient has signed a special release for the information.Included among those persons or entities to whom HIV information may be disclosed withoutproducing a special release are the following:Health care facilities and health care providers when necessary to provide appropriate care andtreatment of the individual;Agents or employees of health care providers or facilities who maintain or process medical records forbilling and reimbursement purposes;Third party payers to the extent necessary to reimburse health care providers for health care servicesdelivered; andQuality management committees or accreditation or oversight review organizations.The usual general release form used in releasing medical records information is not sufficient to permit thereleaser disclosure of HIV related information; only a special release that specifically permits the release ofHIV related information is sufficient.The Law specifically states that all HIV related information must be recorded in the patient's medicalrecord. In general, any disclosure made pursuant to the statute must be recorded in the medical record andmust be accompanied or followed by a statement prohibiting redisclosure. The statute provides fines forviolations (up to $5,000) of the Law and makes willful violations a misdemeanor.Disclosure of HIV related information without the signed consent of the patient (or authorized agent) by aWinthrop-University Hospital employee is permitted only when the release of information is necessary to:Provide appropriate care and treatment of the patient or to process medical information for billing, qualitymanagement of oversight activities.All other requests or subpoenas for patients' medical records, which contain HIV related information, are tobe directed to the Medical Records Department. This department will coordinate the release of all AIDSrelated information in accordance with the procedures set forth in the Law. Upon receipt of subpoenas andother court requests for HIV related information, Liability Control shall be contacted via the MedicalRecords Department.Rev. 1/08

100. PATIENT RELATIONSStaff in the Patient Relations Department are available to answer questions about the Patient's Bill ofRights, Patient's Responsibilities and Advance Directives; and to interpret the Hospital's policies,procedures and services to the patient and family. This department provides a channel through whichpatients can seek solutions to problems, concerns and unmet needs.All patient complaints are investigated, responded to, and included as part of the hospital-wide QualityManagement Program.Referrals are welcome from all sources, including medical staff, nursing, allied health professionals,family, and patient. It is recommended that a referral to the Patient Relations Department (ext. 2058) bemade as soon as a potential problem is detected so that a prompt resolution may be achieved.101. PATIENTS’ BILL OF RIGHTSWinthrop-University Hospital subscribes to the Patients’ Bill of Rights as the cornerstone for delineatingthe rights and responsibilities of patients. Every patient, upon admission, receives written notice of theserights in the admission package. Printed material is available to patients in several different languages. Allconcerns regarding care provided should be directed to Patient Relations (see above) A patient's rightsinclude but are not limited to:Access to Care: Individuals shall be accorded impartial access to treatment or accommodations that areavailable or medically indicated, regardless of race, creed, sex, national origin, or sources of payment forcare.Respect and Dignity: The patient has the right to considerate, respectful care at all times and under allcircumstances, with recognition of personal dignity.Privacy and Confidentiality: The patient has the right, within the law, to personal and informational privacyas manifested by the following rights:1. To refuse to talk with or see anyone not officially connected with the Hospital, including visitors, orpersons officially connected with the Hospital but not directly involved in the patient's care.2. To wear appropriate personal clothing and religious or other symbolic items, as long as they do notinterfere with diagnostic procedures or treatment.3. To be interviewed and examined in surroundings designed to assure reasonable visual and auditoryprivacy. This includes the right to have a person of one's own sex present during certain parts of aphysical examination, treatment, or procedure performed by a health professional of the opposite sex,and the right not to remain disrobed any longer than is required for accomplishing the medical purposefor which the patient was asked to disrobe.4. To expect that any discussion or consultation involving the patient's case will be conducted discreetly,and that individuals not directly involved with the patient's care will not be present without thepatient's permission.5. To have the patient's medical record read only by individuals directly involved in the patient'streatment or in the monitoring of its quality. Other individuals can only read the patient's medicalrecord with written authorization or that of the patient's legally authorized representative.6. To expect all communications and other records pertaining the patient's care, including the source ofpayment for treatment, be treated as confidential.Rev. 1/08

7. To request a transfer to another room if another patient or a visitor in the room is unreasonablydisturbing.8. To be placed in protective privacy when considered necessary for personal safety.Personal Safety: The patient has the right to expect reasonable safety insofar as the hospital practices andenvironment are concerned.Identity: The patient has the right to know the identity and professional status of individuals providingservice and to know which physician or other practitioner is primarily responsible for the patient's care.This includes the patient's right to know of the existence of any professional relationship among individualswho are treating the patient as well as the relationship to any other health care or educational institutioninvolved in the patient's care. Participation by patients in clinical training programs or in the gathering ofdata for research purposes would be voluntary.Information: The patient has the right to obtain, from the practitioner responsible for coordinating thepatient's care, complete and current information concerning the patient's diagnosis (to the degree known),treatment, and any known prognosis. This information should be communicated in terms the patient canreasonably be expected to understand.When it is to medically inadvisable to give such information to the patient, the information should be madeavailable to a legally authorized individual.Communication: The patient has the right of access to people outside the hospital by means of visitors andby verbal and written communication. When the patient does not speak or understand the predominantlanguage of the community, access to an interpreter should be provided.Consent: The patient has the right to reasonable informed participation in decisions involving health care.This should be based on a clear, concise explanation of the patient's condition and of all proposed technicalprocedures, including the possibilities of any risk of mortality or serious side effects, problems related torecuperation and probability of success. The patient should not be subjected to any procedure without thepatient's voluntary, competent and understanding consent or consent of a legally authorized representative.Where medically significant alternatives for care or treatment exist, the patient shall be so informed.The patient also has the right to know who is responsible for authorizing and performing the procedure ortreatment. The patient shall be informed if the hospital proposes to engage in or perform humanexperimentation or other research/educational projects affecting the patient's care or treatment. The patienthas the right to refuse to participate in any such activity.The patient has the right to make known his or her wishes regarding anatomical gifts. Health care proxyforms or donor cards are available for this purpose.Consultation: On request and at the patient's expense, the patient has the right to consult with a specialist.Refusal of Treatment: The patient may refuse treatment to the extent permitted by law. When refusal oftreatment by the patient or a legally authorized representative prevents the provision of appropriate care inaccordance with professional standards, the relationship with the patient may be terminated uponreasonable notice.Transfer and Continuity of Care: A patient may not be transferred to another facility or organization unlessthe patient has received a complete explanation of the need for the transfer and of the alternatives to such atransfer, and unless the transfer is acceptable to the other facility or organization. The patient has the rightto be informed of any continuing health care requirements following discharge from the Hospital. It is theresponsibility of the patient's physician and/or practitioner to do so.Hospital Charges: Regardless of the source of payment for care, the patient has the right to request andreceive an itemized and detailed explanation of the total bill for services rendered in the Hospital. TheRev. 1/08

patient has the right to timely notice prior to termination of eligibility for reimbursement by a third-partypayer for the cost of care. The patient has the right to obtain a copy of the medical record, for a reasonablecharge. Copies cannot be denied because of inability to pay.Hospital Rules and Regulations: The patient should be informed of the hospital rules and regulationsapplicable to conduct as a patient. Patients are entitled to information about the Hospital's mechanism forthe initiation, review, and resolution of patient complaints.102. PATIENT RESPONSIBILITIESPatient responsibilities and the responsibilities of children’s parents and/or guardians include but are not belimited to:Provision of Information: A patient has the responsibility to provide, to the best of the patient's knowledge,accurate and complete information about present complaints, past illnesses, hospitalizations, medicationsand other health matters. Unexpected changes in the patient’s condition should be reported to thepractitioner by the patient. The patient is responsible for reporting whether the patient clearly comprehendsa contemplated course of action and what is expected of the patient.Compliance with Instructions: A patient is responsible for following the treatment plan recommended bythe practitioner primarily responsible for the patient's care. This may include following the instructions ofnurses and allied health personnel as they carry out the coordinated plan of care, implement the responsiblepractitioner's orders, and enforce the applicable Hospital rules and regulations. The patient is responsiblefor keeping appointments and, when unable to do so, for notifying the responsible practitioner or thehospital.Refusal of Treatment: If the patient refuses treatment or does not follow the practitioner's instructions, thepatient is responsible for these actions.Hospital Charges: The patient is responsible for assuring that financial health care obligations are fulfilledas promptly as possible.Hospital Rules and Regulations: The patient is responsible for following Hospital rules and regulationsaffecting patient care and conduct.Respect and Consideration: The patient is responsible for being considerate of the rights of other patientsand Hospital personnel and for assisting in the control of noise, and the number of visitors. The patient isresponsible for being respectful of the property of other persons and of the Hospital.Safekeeping Personal Articles: The patient is responsible for the safekeeping of personal articles, whichshe/he chooses not to send home. The Hospital is not responsible for the loss of personal articles.SAFETY PROCEDURES103. ACCIDENT/INCIDENT REPORTINGInformation concerning any accident, incident or unusual occurrence involving a patient or visitor shouldbe reported on Winthrop-University Hospital's Quality Management "Incident Report Form" (#0172742)available at all nursing stations. The form is sent to Risk Management and Insurance Services (ext. 2206).A similar form is to be filled out for employees involved in an accident or incident. The "EmployeeAccident, Incident - Security Report" is available in the Human Resources Office and should be forwardedto the Security Department upon completion.104. ACCIDENT PREVENTIONRev. 1/08

Patient falls are the most common cause of injury to patients while in the hospital. While some falls aremore serious than others, all falls can lead to serious injury or death and may prolong the hospital stay.Every patient fall that results in an injury to a patient is reportable to the Department of Health with 24hours of occurrence, and must be reported to Risk Management and Insurance Services immediately.The best means of preventing patient falls is to be aware of who is at high risk and to follow reasonablesafety precautions. Risk factors for patient falls include:Over age 65History of previous fallsPhysical instability or disability, such as dizziness, balances problems, unsteady gait with joint difficulties.Neurological deficitsSensory impairmentImpaired mental status, such as confusion, disorientation, impaired memory, impaired judgment24 to 48 hours post-operativeMedications with side effects that may impair mental statusUse of ambulatory devices, such as walkers, crutches, canes or wheel chairsSAFETY PROCEDURES FOR PATIENTS AT HIGH RISKA safe environment can minimize the risk of patient falls. The bed should be in the lowest possibleposition. Bedside equipment and supplies such as call lights and bedpans should be within the patient'seasy reach. Encourage the use of side rails when appropriate and at bedtime. Adequate lighting in theroom, bathroom and hallway, especially at night, is important. Floors should be clear of cords, tubing orequipment that might contribute to a fall.Both the patient and the patient's family should be familiar with the physical setting and facilities. Patientsshould be familiar with the use of bed controls, use of side rails and use of the call systems.A further preventive measure in terms of falls is to order the lowest, effective dose of sedatives, analgesicand amnesiac drugs. Check with the Pharmacy Department for dosage.105. EMERGENCY PREPAREDNESSFIRE AND SAFETY REGULATIONSFire and Safety Training and Emergency Management are included in the Orientation program for allWinthrop house staff. Annual updating is done by the individual departments.106. INFECTION CONTROLInfection Control policies and procedures, as well as the Exposure Control Plan for Bloodborne andRespiratory Pathogens, are described in the Infection Control Manual, a copy of which is kept at everynursing station and in every department.To protect yourself, your co-workers, and your patients from airborne and bloodborne infections, follow theHospital Exposure Control Plan. This includes, but is not limited to, the Standard Precautions listed below.These are applicable to all House Staff. For additional procedures specific to Pediatrics, Neonatology,Obstetrics and Surgery, please see the respective department's House Staff procedures.STANDARD PRECAUTIONSStandard Precautions are in place for the care of all patients regardless of their diagnosis or presumedinfectious status. Standard precautions are intended to protect an individual for exposure to blood borneRev. 1/08

infections in body and other body fluids. This means treating all blood and/or body fluids as potentiallyinfectious.1. Wear gloves when contact with blood or body fluids can be reasonably anticipated, such as forinvasive procedures, examining of or contact with a patient's mucous membrane or non-intact skin, etc.Gloves must be discarded before leaving the patient's room, and then hands are washed for at least 15seconds or sanitized with the alcohol based hand sanitizer.2. Wear a gown if your clothes may be splashed with blood or body fluids.3. Wear protective gear such as masks or eye protection or face shields when aerosolization or splatteringof blood and body fluids is possible.NEEDLESTICK/OTHER BLOOD OR BODY FLUID EXPOSUREFor exposures to blood or body fluids, either through needle sticks or ocular, mucosal or gross cutaneousexposures:STOP-WASH-REPORT-GO1. administer first aid to self. If needlestick, wash with soap and water. If splatter, irrigate area withwater.2. report incident to supervisor/manager3. complete paperwork (Blood and Body Fluid Exposure Report)4. Report to the Employee Health Department within 1 hour of the exposure to be evaluated. IfEmployee Health is closed, go to the Emergency Department.TRANSMISSIONS-BASED PRECAUTIONSIn addition to the Standard Precautions, there are Transmission Based Precautions designed for the care ofspecific patients known or suspected to be colonized or infected with epidemiologically significantpathogens that can be transmitted by the airborne, droplet or contact means from skin or surfaces. Theseinclude:-Airborne precautions-Droplet precautions-AFB isolation-Contact precautions-Contact isolationFor the patient admitted with or developing transmissible infections, follow exactly what theIsolation/Precautions card tells you to do. These cards will be posted outside the patient's room and/or overthe patient's bed. Do not take anything into these patients' rooms, such as your stethoscope or chart. Anyarticles removed from the patient's room must be wiped down with sani-cloth or with hospital approveddisinfection spray.Report any exposure to childhood exanthems to Infection Control, (ext. 2724) or Employee Health Service(ext. 2534) even if you are immune to the diseaseTB RESPIRATORS (“N-95” RESPIRATORS)OSHA standards require that health care workers be fitted annually with an N95 Respirator mask. Thiswill be the responsibility of each department. These masks must be worn during contact with patientsRev. 1/08

diagnosed as having tuberculosis or being ruled out for tuberculosis. Such patients are in rooms designatedas “negative air pressure rooms”.107. MEDICAL WASTE DISPOSALInfectious waste “Regulated Medical Waste” includes pathological, biological, laboratory, human bloodand blood products, all materials saturated with blood, animal carcasses and other articles that might causepunctures or cuts (i.e. needles, syringes and scalpels). Waste disposal policy requires that all itemssaturated and/or dripping with blood or body fluids be placed in a red plastic trash bag. These bags are inutility rooms and in other designated patient areas.Used needles and syringes or sharps are to be placed in rigid sharp containers located in all patient roomsand patient care areas throughout the hospital. Please do not leave used sharps lying around for someoneelse to dispose of. You are responsible for discarding any sharps you use.108. NO SMOKING POLICYDemonstrating its commitment to disease prevention and health promotion, Winthrop-University Hospitalis a smoke-free environment. Smoking is prohibited for patients, staff and visitors in all Hospital facilities.Rev. 1/08

Winthrop-University HospitalFrequently Called NumbersMEDICAL SERVICE NUMBERSAnesthesiology.................................... 2215Cardiac Catheterization ...................... 2590EEG..................................................... 2369EKG..................................................... 2420Endoscopy (GI).................................... 2767Hemodialysis ...................................... 9480O.R. Office ......................................... 2694O.R. Booking ...................................... 2424Pathology (Anatomic)Administrative Director....................... 2468Cytology.............................................. 4561Histology............................................. 4562Morgue ............................................... 2491Pathology Residents............................ 4560Surg. Path Office ................................ 2475Pathology (Clinical)Administrative Director....................... 2468All Calls After 4 PM ............................ 2379Blood Bank ........................................ 2469Chemistry, Routine ............................. 2801Chemistry, Special ............................. 2449Computer Room (Results).................... 2379Hematology ......................................... 2790Immunology ........................................ 4575Microbiology ....................................... 2471Physical Therapy................................. 2278Pre-Admission Testing ........................ 2756Pulmonary Function Lab ................... 2286RadiologyCAT Scan............................................ 2377Emergency ......................................... 2387Main Department ................................ 2374MRI..................................................... 2062Nuclear Medicine ............................... 2778Radiation Therapy ..................................... 2501Ultrasound................................................ 2301Respiratory Care.................................. 2251MICU Blood Gas Lab........................... 2480SICU................................................... 2703ADMINISTRATIVE NUMBERSAcademic Affairs ....................................... 2521Administration ........................................ 2200Admitting .................................................. 2525Alcohol Services ....................................... 2796Benefits .................................................... 2912Biostatistician........................................... 3887Conference RoomsConference Center.............................. 2455Hoag-1 Conference Room.................... 2027House Staff Lounge ............................. 2461Discharge Planning .................................. 2075Rev. 1/08

Educational Media Services ...................... 2665Emergency Department ............................. 2211Employee Health ....................................... 2534External Affairs ......................................... 2706Health Information Services ...................... 2512Health Sciences Library ............................ 2802Home Care ................................................ 8000Housing - House Staff ............................... 2036Human Resources ..................................... 2351Infection Control ....................................... 2724Information Desk ...................................... 2244Medical Staff Office .................................. 2205Nursing Administration............................. 2361Patient Relations ....................................... 2058Pharmacy (Drug Information) .................... 2401Quality Management ................................. 2510Risk Management& Insurance Services ........................ 2206Social Work .............................................. 2341Sponsored Programs................................. 2552Utilization Management............................. 2075Women’s ContemporaryCare Associates ............................... 3010DEPARTMENT CHAIRS/DIVISIONCHIEFSInternal Medicine, Chair........................... 2381Cardiology .......................................... 6951Endocrinology ..................................... 2540Gastroenterology................................. 2527Geriatrics............................................ 2588Infectious Disease .............................. 2505Nephrology ......................................... 2169Neurology ........................................... 4525Oncology/Hematology......................... 9500Pulmonary Medicine ........................... 2004Rheumatology ..................................... 2097Ambulatory Care, Chair ............................ 2727Anesthesiology, Chair ............................... 2215Obstetrics/Gynecology, Chair................... 2264Gynecology (Director) ......................... 2655Obstetrics (Director) ........................... 2264General Surgery, Chair ............................. 8700Thoracic Cardiovascular Surgery .............. 2384Pathology, Chair ....................................... 2450Anatomic............................................. 2475Clinical............................................... 2450Psychiatry, Chair ...................................... 2691Pediatrics, Chair....................................... 2288Ambulatory Pediatrics (Dir.) ............... 4423Neonatology (Dir.) ............................... 3853Ped Endocrinology (Dir.) ..................... 3090Rev. 1/08

Pulmonary (Dir.) ................................. 4937Urology, Chair .......................................... 2305Orthopedics, Chair................................... 2263NURSING STATIONS ANDPATIENT ROOM NUMBERSDelivery Room........................................... 2271GP 2 (220-228) ........................................ 2321GP 3 (320-329 ......................................... 2388GP 4 (400 - 433) ...................................... 2324Hoag 1 (107-118) ..................................... 2190Hoag 2 (200 - 218) ................................... 2675Hoag 3 I.C.U.'sCCU - Rooms 300 - 306 ..................... 2685MICU - Rooms 307-313...................... 2687RICU - Rooms 314-319 ...................... 2686Hoag 5 ..................................................... 2681Hoag 6 (600 - 618) ................................... 2671ICU Nursery.............................................. 2406Main 3 (330-348) ..................................... 2281Nursery..................................................... 2806Pediatrics (345-359) ................................ 2226Potter 2 (260-276).................................... 2334Potter 3 (360 -376) ................................... 2337Potter 4 (460 -477) ................................... 2237Recovery Room.......................................... 2430Surgical ICU (Main 400's) ......................... 2701W-2 (280-295 .......................................... 2241W-3 (380-395) ......................................... 22911 North (Delivery Room)............................ 22712 North (239-259) .................................... 23453 North (335-348 ..................................... 2265CULTURAL/RECREATIONAL NUMBERSNew York CityAmerican Museum ofNatural History ............ (212) 769-5100Brooklyn Academyof Music....................... (718) 636-4100Brooklyn BotanicGardens...................... (718) 623-7200Carnegie Hall .................. (212) 903-9600Empire State Building ..... (212) 947-1360Guggenheim Museum ..... (212) 423-3500Lincoln Center for the ...............................Performing Arts............ (212) 721-6500Metropolitan Opera......... (212) 362-6000New York State Theatre ... (212) 870-5570Metropolitan Museumof Art............................ (212) 535-7710Museum of Modern Art.... (212) 307-6420New York BotanicalGardens, Bronx .......... (718) 817-8705N.Y. Aquarium, Brooklyn (718) 265-3400N.Y. Zoological Society(Bronx Zoo) .................. (718) 220-5100Radio City Music Hall ..... (212) 307-7171Rev. 1/08

Rockefeller Center .......... (212) 332-3400Shea Stadium - NY MetsTickets Office .............. (718) 507-8499South Street SeaportMuseum....................... (212) 748-8600Statue of Liberty Ferry .... (212) 269-5755United Nations................ (212) 759-5950Whitney Museumof American Art.......... (212) 570-3676Nassau/SuffolkBrookhaven National Laboratory -Exhibit Center.............. (631) 282-2345Garvies PointMuseum....................... (516) 571-8010Jones Beach MarineTheatre ........................ (516) 221-1000Nassau County Museumof Art............................ (516) 484-9337Nassau VeteransMemorial Coliseum ...... (516) 794-9300Old Bethpage VillageRestoration................... (516) 572-8408Old Westbury Gardens ... (516) 333-0048Planting Fields Aboretum (516) 922-9200Sagamore Hill.................. (516) 922-4447Sands Point Preserve...... (516) 883-1612Theodore RooseveltSanctuary .................... (516) 922-3200Tillis Center for thePerforming Arts............ (516) 626-3100Vanderbilt Planetarium... (631) 854-5544Westbury Music Fair ...... (516) 334-0800Rev. 1/08