Medical Staff Orientation and Guide 750 N. 40 th Street Phoenix, AZ

Transcription

1 Medical Staff Orientation and Guide 750 N. 40 th Street Phoenix, AZ Mission Vision Values OASIS Hospital is founded on a distinctive model that emphasizes physician participation while integrating the resources of one of the nation s largest not-for-profit healthcare systems. This relentless focus on physician participation ensures that the patient s needs are always first. MISSION Our mission statement was created with the input of our physicians. Simply put, our mission at OASIS Hospital is, Caring for Patients Like Family. VISION The vision that OASIS was founded on, and that is alive and well each day, is that we are Transforming the healthcare experience. OASIS Hospital transforms the hospital experience by incorporating a contemporary understanding of human interaction. VALUES Our core values emphasize our commitment to exceptional healthcare and embody our mission and vision. The values of Communication, Integrity, Teamwork, Excellence, and Service spell out the acronym of C.I.T.E.S as we more commonly refer to it here at OASIS. As a part of our ongoing commitment to our values, we have developed the Caught in Our C.I.T.E.S program to recognize those associates for exemplifying our core values. We invite you to share examples where you have witnessed our associates (Nurses, Housekeeping, Clinical Staff, Office Staff, etc.) upholding our core values. Look for the Caught in Our C.I.T.E.S boxes throughout the hospital to recognize an associate. HOSPITAL LEADERSHIP Governing Board Chair- Dr. David Ott President/CEO- CFO- Michael McHorney, CPA CNO Reshma Maharaj, RN Beaulieu Director of Quality Resources MEDICAL STAFF LEADERSHIP Chief of Staff- Dr. David Ott Department of Surgery Chairman- Dr. Neal Rockowitz Department of Medicine Chairman- Dr. James Stewart Department of Anesthesia Chairman- Dr. Charles Revised March 21,

2 MEDICAL STAFF SERVICES OFFICE Amanda Tichenor, Medical Staff Services Manager P (602) F (602) atichenor@oasishospital.com Katie Montoya, Medical Staff Coordinator P (602) F (602) kamontoya@oasishospital.com MEDICAL STAFF GOVERANCE 1. Knowledge of Oasis Hospital Bylaws and Rules & Regulations 2. Privileges must be requested and granted 3. Provisional period must be completed within 24 months 4. Reappointment must be completed no more than every 24 months 5. Current licensure, DEA, malpractice insurance must be current and on file 6. National Practitioner Database inquiry at the time of appointment, than at least every 2 years thereafter, when additional privileges are requested and when notified of any adverse action at any facility, healthcare organization or professional affiliation 7. Disaster privileges available for Emergency Preparedness, know your role in case of an emergency 8. Are you signed up at PECOS, it is a requirement QUALITY/PERFORMANCE IMPROVEMENT Oasis Hospital has an Organizational-wide Performance Improvement Plan and Medical Staff is critical in the success of the Program. Become a Physician Champion IOP= Improving Organizational Performance CQI= Continuous Quality Improvement (multidisciplinary approach) TQM= Total Quality Management (multidisciplinary approach) Methodology- PDCA-PLAN-DO-CHECK-ACT Priorities- Low Volume, High Risk, Problem Prone and Governing Board directed PI Projects are selected basis on services provided and rationale for the selection is recommended and approved by Performance Improvement Committee with regular communications and reports to Medical Staff Committee and Governing Board. Medical Staff are part of success of these outcomes. Are you aware of your part and participation in the selected projects? Do you know about pay for performance and accountability measures and outcomes it may affect the overall financials outcomes and are important to understand. Tools- Event Report Form for report of any unusual occurrences related incidents: Medical Staff screen form to identify unusual, quality or risk issues relating to physicians PI Teams- (Performance Improvement/Functional Teams) for addressing interdisciplinary and multidisciplinary issues Sentinel Event reviews and action plans FPPE-Focused Practitioner Performance Evaluation-cases proctored and evaluated at the at granting of new privilege, or request for additional privilege as outlined by Medical staff OPPE- Ongoing Practitioner Performance Evaluation-on going evaluation based on criteria and reviewed every 9 months Revised March 21,

3 MEDICAL RECORDS 1. Complete your medical records. All records must be completed within 30 days of discharge 2. Complete H&P s can be used if it was completed within 30 days of admission, but must update any changes regarding patient condition within 24 hours of admission or prior to surgery 3. Informed consent must contain risks, benefits and alternatives 4. Complete operative and procedure reports must be completed immediately after the procedure 5. Discharge summaries must be completed on all patients. If the stay is less than 48 hours, the last progress note may be used as the discharge note if it contains the outcome of hospitalization, the case disposition, and any provisions for follow up care. All records must contain a diagnosis 6. Verbal and telephone orders are to be timed, dated and signed by the author within 48 hours DICTATION INSTRUCTIONS: MEDTECK: (866) Enter 4 digit ID 2. Enter 1 digit work type 3. Dictate after the tone. Please use the following format: a. Your Name b. Patient Name c. Medical Record Number PLEASE DICTATE CLEARLY 4. Work Types 1. History and Physical Report 2. Operative Report 3. Other 5. Key Pad Commands 1. Playback 2. Record 3. Review 4. Pause 5. Start new 6. Go To End 7. Fast Forward 8. Re-Record 9. Disconnect 0. Overwrite *1. Confirmation Number # Help Menu Please write down job number for tracking purposes Dictate in a quiet place Speak slowly and clearly Spell names and dictate date of service Spell sound alike medications If you need assistance, please contact: Sonda Morales HIMS Lead (602) Revised March 21,

4 RESTRAINTS 1. Restraints must be ordered, PRN orders are not allowed 2. Order must specify how long restraints should be applied (time limit cannot be longer than 24 hours) 3. Order must specify reason, size and type 4. Progress notes must be written in regards to progress and reason at least every 24 hours 5. Orders written for aggressive and destructive behaviors must have a face to face evaluation buy a licensed independent practitioner at least every 24 hours MODERATE SEDATION/ANALGESIA (CONSCIOUS SEDATION) 1. All patients are to be treated the same/one level of care hospital wide 2. Approved privileges for are required 3. A drug induced depression ADVANCE DIRECTIVES 1. Patients are asked at the time of admission 2. Located in the patient chart 3. Label on the front of the chart BIOETHICS 1. Medical Staff Committee (MEC) 2. Convened at the request of patients, families, physicians and/or team members or as scheduled by the medical staff office SMOKING 1. No smoking allowed in the hospital or on the campus in accordance with Oasis policy. CONFIDENTIALITY 1. Remote access login is to be kept confidential at all times and used at minimum as necessary 2. Disclosure and misuse of login and password is prohibited RULES/CODE OF CONDUCT Oasis Hospital will not permit unprofessional behavior and the Rules of Conduct are outlined in the hospital s policy. Members of the Professional Medical Staff are expected to fulfill their Professional Medical Staff obligations in a manner that is within generally accepted bounds of professional interaction and behavior, including but not limited to the following: (a) (b) (c) (d) The Professional Medical Staff promotes a culture and an environment that values integrity, honesty and fair dealing with each other, and a caring environment for patients, Practitioners, employees and visitors. Interactions with all persons shall be conducted with courtesy, respect, civility and dignity. Members of the Professional Medical Staff shall be cooperative and respectful in their dealings with other persons in and affiliated with the Hospital. Rude and offensive behavior, as well as refusal to communicate or comply with the rules of the Professional Medical Staff and the Hospital may constitute disruptive behavior. Patient care and Hospital operations can be adversely affected whenever such behavior occurs. All Hospital personnel play an important part in the ultimate mission of delivering quality patient care. Quality patient care embraces, in addition to care of specific patients and medical outcomes, matters such as timeliness of services, appropriateness of services, timely and thorough communications with patients, their families, and general patient satisfaction with the services rendered and the individuals involved in rendering those services. Revised March 21,

5 (e) (f) (g) Discrimination, harassment or intimidation by a member of the Professional Medical Staff against any individual on the basis of race, religion, color, national origin, ancestry, physical disability, mental disability, marital status, sex, gender or sexual orientation shall not be tolerated, and shall be an actionable offense under these Bylaws. Sexual harassment, one type of prohibited harassment, is unwelcome verbal or physical conduct of a sexual nature which may include verbal harassment (such as epithets, derogatory comments or slurs), physical harassment (such as unwelcome touching, assault, or interference with movement of work), and visual harassment (such as the display of derogatory cartoons, drawings, or posters). Sexual harassment includes unwelcome advances, requests for sexual favors, and any other verbal, visual, or physical conduct of a sexual nature when (1) submission to or rejection of this conduct by an individual is used as a factor in decisions affecting hiring, evaluation, retention, promotion, or other aspects of employment; or (2) this conduct substantially interferes with the individual s employment or creates an intimidating, hostile, or offensive work environment. Sexual harassment also includes conduct which indicates that employment and/or employment benefits are conditioned upon acquiescence in sexual activities. All allegations of sexual harassment shall be immediately investigated by the Medical Executive Committee and, if confirmed, will result in appropriate corrective action, from reprimands up to and including termination of Professional Medical Staff membership or Clinical Privileges, if warranted by the facts. Complaints and disagreements shall be aired constructively, in a non-demeaning manner, and through official channels. Professional Medical Staff members shall cooperate with the Medical Executive Committee s procedures for investigating and addressing incidents of perceived misconduct. IMPAIRED PRACTITIONER RECOGNITION AND REPORTING 1. Reporting of suspected impairment may be made by any of the following mechanisms and is to be kept strictly confidential: a. Any individual at Oasis Hospital who has reason to believe the practitioner may be impaired b. Self-Referral c. Referral by a family member 2. Reports are to be made to the CEO, Chief of Staff, and/or Risk Manager. The report must include the specific date, time and actions leading to the suspicion of impairment. 3. The CEO in conjunction with the Chief of Staff determines whether the facts presented warrant implementation of an investigation. This process is to include the evaluation of the credibility of the complaint, allegation and concern. INFECTION CONTROL 1. Wash your hands 2. Practice Universal Precautions 3. Surveillance is targeted based on our Infection Control Plan and Risk Assessment 4. Isolation system- Body Substance Precautions and 3 categories of isolation (Contact, Airborne, Droplet) 5. Preventing central line infections and associated blood infections is a patient safety goal and priority measure 6. Preventing multi-drug resistance and MRSA is a patient safety goal and priority 7. TB is required for Medical Staff membership Revised March 21,

6 NATIONAL PATIENT SAFETY GOALS The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them. Identify patients correctly NPSG Use at least two ways to identify patients. For example, use the patient s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment. NPSG Make sure that the correct patient gets the correct blood when they get a blood transfusion. Improve staff communication NPSG Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up. Use medicines safely NPSG Take extra care with patients who take medicines to thin their blood. NPSG Record and pass along correct information about a patient s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor. Use alarms safely NPSG Make improvements to ensure that alarms on medical equipment are heard and responded to on time. Prevent infection NPSG Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning. NPSG Use proven guidelines to prevent infections that are difficult to treat. NPSG Use proven guidelines to prevent infection of the blood from central lines. NPSG Use proven guidelines to prevent infection after surgery. NPSG Use proven guidelines to prevent infections of the urinary tract that are caused by catheters. Identify patient safety risks NPSG Find out which patients are most likely to try to commit suicide. Prevent mistakes in surgery UP Make sure that the correct surgery is done on the correct patient and at the correct place on the patient s body. UP Mark the correct place on the patient s body where the surgery is to be done. UP Pause before the surgery to make sure that a mistake is not being made. EMERGENCY MANAGEMENT 1. The hospital will maintain a physician in the facility at all times for treatment of inpatients, and in the event of someone presenting to the facility seeking emergent/urgent services. 2. The facility is staffed 24 hours per day, seven days per week, with the services of a physician Hospitalist or Intensivist. 3. The Hospitalist/Intensivist will be the person responsible for the Medical Screening Exam (MSE) of any person who presents to the facility for emergent or urgent services. 4. The specialty of orthopedics is represented in the facility in the event of the presentation of a patient with an orthopedic injury. Other medical specialties are beyond the scope of services within the facility. 5. If a specialty is not represented by the physicians on staff in the facility or a specialty is required outside of the hospitals scope of services, transfer of the patient after stabilization is appropriate. Revised March 21,

7 SAFETY/SECURITY AND LIFE SAFETY Oasis Hospital prohibits firearms in accordance to Arizona Health and Safety Code. To report an emergency in the hospital dial 3911 Emergency codes are: CODE RED-Fire CODE BLUE-Cardiac/Respiratory Arrest CODE YELLOW- Bomb Threat CODE GREEN- Combative Person CODE TRIAGE- Disaster/Mass Casualty Incident CODE ORANGE- Hazardous Spill/Release (Decon) CODE SILVER- Combative Person with a weapon CODE PINK- Infant/Pediatric Abduction Remove- Patients & Others Alarm- Pull station & call Contain- Close all doors Extinguish- Fire if possible Pull pin Aim at the base of the fire Squeeze the handle Sweep side to side DISASTER & EMERGENCY PRIVILEGES AND ROLES 1. Disaster privileges may be granted to volunteer licensed independent practitioners who are not members of the Medical Staff when the Emergency Plan has been activated. 2. The decision to grant disaster privileges will be made on a case by case basis after receipt of Key Identification Documents as outlined in the policy. Once given disaster privileges, either an identification badge, wristband, or vest will be assigned for you to wear. 3. Medical Staff Members are expected to actively participate in the organization s Emergency Operation Plan. 4. In case of any code all Medical staff will report to the charge nurse for further instructions. MEDICATION USAGE: Oasis Hospital has an approved Medication formulary which is located for your use on each patient care area. Medications not currently on the formulary medications must be requested utilizing the non-formulary request form. Pre-printed orders may be developed but must be approved prior to use by the MEC and Governing Board and reviewed at least annually. Revised March 21,