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MOUNTAIN VISTA MEDICAL CENTER 1301 South Crismon Road Mesa, AZ 85209

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Presentation on theme: "MOUNTAIN VISTA MEDICAL CENTER 1301 South Crismon Road Mesa, AZ 85209"— Presentation transcript:

1 MOUNTAIN VISTA MEDICAL CENTER 1301 South Crismon Road Mesa, AZ 85209
New Provider Orientation Physician Allied Health

2 Thank you for choosing Mountain Vista!
Welcome to Mountain Vista Medical Center. This orientation packet will give you an overview of the hospital, leadership, services, policies and processes that are pertinent to practicing at our facility. If you have any questions about the information provided, please contact us.

3 Medical Staff Leadership 2014/2015
Chief of Staff Sudhakar Reddy MD Vice Chief of Staff Cynthia Anneski MD Secretary Hani Shennib MD Credentials Chair Richard Dinsdale MD Department of Surgery Chair Rafath Baig MD Department of Medicine Chair Monique Chang MD Department of OB/GYN Chair Manisha Purohit MD

4 Hospital Administration
Anthony Marinello, CEO Susan Dolezal, CNO Dan Houghton, CFO Joan Hoffstetter, Quality/Risk Management Sheryl Caracciolo, Compliance Officer

5 About MVMC 8 Years Old- Opened July 2007 178 beds & 20 Geropsych Unit
Level III Trauma Center daVinci SI Surgical system General Surgery Open Heart Obstetrics Urology Aggressive Codes Stemi Stroke Trauma

6 More About MVMC Teaching program Residency Programs Students
Primary affiliation with Midwestern University Affiliation with 20+ schools Residency Programs Internal Medicine Family Practice General Surgery Students Medical, PA, NP & CRNA

7 Hospital Layout Patient Rooms in Center towers 1st Floor 2nd Floor
ICU, Surgery, ER, Radiology, Cath Lab 2nd Floor Ortho/Spine & Med Surg 3rd Floor Telemetry & Geropsych Use center bank of elevators to access




11 Entrance/Parking 4 Main Entrances
Outpatient Cath Lab ER (Only entrance after 7:30pm) Main Entrance Be particularly careful not to leave valuables visible in your car

12 Physician Parking Physician covered parking is available off of Southern Avenue, east of Crismon Road. This provides easy access to the Emergency Room, ICU, and the Cath Lab. Be particularly careful not to leave valuables visible in your car


14 Medical Staff Meetings 2015
MEETING/TIME JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Credentials :00 noon 2nd Monday Monthly 12 9 13 11 8 10 14 Education Comm :30 pm 1st Monday Monthly 5 2 6 4 1 3 7 Executive :30pm 2nd Thurs after 1st Mon Monthly 22* 16 17 15 PPRC :00pm 4th Monday Monthly 23 27 25 22 24 28 26 Dept OB/GYN :00 noon 1st Tuesday Bi-Monthly Dept Medicine :30am Dept Surgery :00am 1st Thursday Monthly Cardiology Section :30am 1st Wednesday Monthly Cath Conference :00 am 2nd Wednesday Quarterly Administrative Meetings Critical Care :30 am 2nd Wednesday Bi-Monthly Pharm/Therapeutics :30 am 2nd Wednesday Bi-Monthly Infection Control :00 am Last Monday Quarterly 31 30 Quality Council :00 pm 4th Wednesday Monthly 28* 29 Service Line Meetings Ortho rd Thurs 7:00am 19 21 18 20 Stroke th Wed 12:00noon Trauma th Thurs 7:00am 29* TBD *Exception to rule

15 Electronic Medical Record
COMPUTERIZED PHYSICIAN ORDER ENTRY: Credentialed practitioners must use the computerized physician order entry (CPOE) system whenever possible, including documenting physician orders in the electronic medical record. Each credentialed practitioner will complete and sign an acknowledgement that they have completed training to use the computerized physician order entry (CPOE) system. Each credentialed practitioner will sign an acknowledgement that they understand that: they will not share their computer password with anyone else, they will not allow any other practitioner to document physician orders in CPOE while logged in under their log-in/password. if it has been identified that they have knowingly allowed another practitioner to use their log-in/password (identifier) the facility may terminate their identifier immediately. Please contact Geri Camacho at for computer training in the electronic medical record.

16 Incomplete Medical Records
DEFINITION A patient’s medical record is considered incomplete/delinquent if deficiencies have not been completed within thirty (30) consecutive days after the patient’s discharge. NOTIFICATION Practitioners will be notified, by mail, of incomplete and delinquent medical records on a biweekly basis by the Health Information Management Services Department. A certified notice, return receipt requested, will be mailed to the practitioner on the last Wednesday of the month on suspension for delinquent medical records. SUSPENSION Suspension will be as outlined in the Bylaws for Automatic Suspension. The practitioner’s privileges will be suspended as follows: Admitting privileges Scheduling of elective surgical cases (already scheduled cases may proceed) The practitioner may not serve on the Emergency No-doc call schedule. Except OB practitioners whose patients present to the Hospital in labor Upon completion of delinquent medical records, the suspension will be removed.

17 Medical Records Dictation MVMC

18 Medical Records Dictation MVMC

19 Medical Records Dictation MVMC

20 Authentication & Abbreviations
AUTHENTICATION: All clinical entries in the patient’s medical record shall be legible, accurately dated, timed and authenticated by written or electronic signature. The practitioner whose signature the electronic signature represents is the only one who possesses the password and he alone uses it. A signed confidential statement must be on file for each physician. Practitioners granted group signature rights may use electronic signature utilizing their own passwords only. ABBREVIATIONS: The Medical Executive Committee approved the Hospital list of “Do Not Use” abbreviations. An official record of the sanctioned unapproved abbreviations is kept on file in the Health Information Management Services Department and is available at all nursing stations. Orders with unapproved abbreviations must be clarified and rewritten; failure to use proper abbreviations and use of prohibited abbreviations may result in medical staff action.

21 Operative Reports A comprehensive operative progress note must be entered in the medical record immediately after a surgery or procedure to provide pertinent information for use by any individual who is required to attend to the patient.  Operative Reports may be dictated or written in the medical record immediately following surgery. The Operative Progress Note Form may be used. In addition to the immediate written post-procedure note, all operative or procedure reports must be dictated within 24 hours of the procedure. All dictated or written Operative Reports shall include: Description of findings Technical procedures used Specimens removed Postoperative diagnosis Estimated blood loss Name of primary surgeon and any assistants and/or anesthesiologists

22 Progress Notes Progress notes shall be written at least daily on all patients. Dated progress notes shall be recorded at the time of observation, sufficient to permit continuity of care and transferability. Patient’s clinical problems should be clearly identified in the progress notes and correlated with specific orders and test and treatment results as appropriate. Progress notes will not be required on the day of a patient’s discharge as long as the patient meets the pre-established discharge criteria set by that department. Physicians will be notified if their patients fail to meet criteria on discharge day and will then be responsible for progress note(s).

23 Consultation Reports Consultation reports shall contain:
evidence of a review of the patient’s record by the consultant pertinent findings on examination of the patient the consultants opinion, and recommendation The attending practitioner shall be responsible for reviewing consultant’s opinions prior to surgery or invasive procedures, as appropriate.

24 Emergency Codes Have been standardized and are the same through out the valley. The codes are listed on the back of your badge. Code Red: Fire Code Blue: Adult Cardiac Arrest Code Blue Pediatric: Pediatric Cardiac Arrest Code STEMI: Active Heart Attack Code Gray: Combative Person Code Silver: Combative Person with Weapon Code Pink – Infant/Child Abduction Code Brown: Evacuation Code Green: Wandering Patient Code Orange: Hazardous Spill Code Yellow: Bomb Threat Code Triage: Disaster Code 2000: Fire Alarm System Down

25 Safety Information MSDS RACE PASS Available in each unit
Rescue Alarm Contain Extinguish/Evacuate PASS Pull Aim Squeeze Sweep MSDS Available in each unit Available online

26 Safety Tips Do not leave valuables in nurse’s stations
Do not leave anything visible in your vehicle Report all suspicious behavior (Ext 44) Look for badges!

27 Non Smoking Please! Mountain Vista is a Tobacco Free Facility
No Smoking in the Break Rooms No Smoking in the Parking Lots Smoking allowed on public sidewalks off MVMC property

28 Patient Evacuation Horizontal Evacuation
Go through fire doors on other end of same floor Vertical Evacuation Transport the patients to another floor

29 Electrical Safety Always use three prong power plug
To remove, pull from plug, not from cord Red plugs are for Emergency Power Equipment Failure/Damaged Contact Nursing Dept for that floor

30 Infection Control Infection Prevention: Wash Hands
Before seeing patients After seeing patients (even if wearing gloves) The best way to protect your patients and yourself is to wash your hands frequently. Hands must be washed after removing gloves. Hands can be washed with soap and water but if not contaminated you may use the instant hand sanitizer which must remain wet for 20 seconds to be effective.

31 Staff Isolation Precautions
A mask is required Hand hygiene is required Limit pt transport to essential tests/procedures Notify receiving area of necessary precautions if test/procedure is required Patient must be masked when out of room. No flowers or plants The patient’s door must remain closed at all times!

32 Isolation Precautions
There are three types of isolation precautions Contact – Identified by an orange sign you must wear gloves upon entering the patient room. You must wear a gown if you anticipate direct contact with the patient or their environment. Droplet – Identified by a pink sign. You must wear a surgical mask with face shield upon entering the patient’s room Airborne – Identified by a green sign. You must a N-95 respirator mask, the door to the patient’s room must remain closed at all times and the patient’s visitors should wear a N-95 respirator mask while in the patient’s room. Follow all posted precautions Use appropriate Personal Protective Equipment (PPE)

33 National Pt Safety Goals
Identify Patients Correctly Use at least 2 ways to identify patients Staff Communication Report information correctly & efficiently Prevent Infection Follow hand cleaning guidelines Follow proven guidelines Time Out Is this the correct patient? Procedure? Location?

34 Patient Fall Prevention
Patient fall risk assessment is done on: Admission When there is a change in status or condition On transfer to another unit

35 Restraints, Non-Violent
Assessment Patient exhibits clinical justified application criteria Non-Violent/Non-Self Destructive Pulling at or interfering with Invasive tubes/lines Patient Safety- Attempting to crawl our of bed and/or exhibiting disorientated/confused behavior resulting in potential injury to self Surgical/Wound Maintenance (picking at site, in manner that hinders healing process) Try Alternate Interventions, per policy Use Alternative, DO NOT RESTRAIN No Alternative Failed? Yes Obtain Order & initiate Obtain orders from LIP or authorized designee (NP, PA, Resident) Initial order must not exceed 24 hours, renewed orders must not exceed one calendar day RN may initiate restraint if LIP not available and the patient is at immediate risk, but must obtain an order within 12 hours Notify the treating physician ASAP if the treating physician did not provide the order Patient/family Notify Patient/family as soon as possible in the process and prove them restraint Education Material Monitor, Reassess & Release Reassess at least every 2 hours if greater than 18 years of age & every 1 hour if less than 18 years of age using all appropriate parameters per policy Release patient if application criteria no longer exists Application Apply least restrictive restraint using appropriate technique

36 Restraints, Violent No Yes Assessment
Patient exhibits clinical justified application criteria Violent/Self Destructive A situation in which there is an imminent risk of the patient physically harming himself or herself, staff, or others and non-physical intervention would not be effective Try Alternate Interventions, per policy Use Alternative, DO NOT RESTRAIN Alternative Failed? No Yes Patient/family Notify Patient/family as soon as possible in the process and prove them restraint Education Material (as allowed. See G6) Obtain Order & initiate Competent RN may initiate use based on assessment Obtain order from LIP or authorized designee. A FACE-TO-FACE ASSESSMENT MUST BE COMPLETED BY THE LIP OR AUTHORIZED DESIGNEE WITHIN 1 HOUR OF APPLICATION. Timeframes that the order cannot exceed are age specific: > 18 years = 4 hours; 9-17 yr = 2 hours; <9yrs = 1 hour Notify the treating physician ASAP if the treating physician did not provide the order Monitor, Reassess & Release Reassess at least every 15 minutes using all appropriate parameters per policy Release patient if application criteria no longer exists Debrief (BHU ONLY) Conduct a debriefing within 24 hours as per policy Application & Staffing Apply least restrictive restraint using appropriate technique 1:1 staffing adjustment required

37 Personal Electronic Equipment
CELL PHONE USE – TEXTING & PHOTOGRAPHING PATIENTS - The sending of text messages that contain hospital or patient- related health information is strictly prohibited. It is prohibited to use a cell phone camera to photograph patients.

38 EMTALA EMTALA – Emergency Medical Treatment and Active Labor Act
EMTALA – Requires a hospital with a dedicated Emergency Department to provide a medical screening and determine whether or not the individual has an emergency medical condition which if present must be treated or stabilized.

39 HIPAA HIPAA – Health Insurance Portability and Accountability Act was passed by congress in The purpose of HIPAA was to create national standards to protect a person’s health information

40 STAR Standards Star Stands for S – SERVICE T – TEAMWORK

41 ALERT LINE The Alert Line is a “totally confidential 24/7 line to report violations of IASIS Code of Conduct”. If you witness anything unethical or illegal please Sheryl Caracciolo at You may also call

42 Medical Staff Services Sandy Elcock, Director Tina Deddo, Medical Staff Assistant Vickie Rockwell, Credentials Coordinator

43 I acknowledge that I have received and reviewed the orientation packet provided to me by Mountain Vista Medical Center. Print Name Signature Date

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