Presentation on theme: "MOUNTAIN VISTA MEDICAL CENTER 1301 South Crismon Road Mesa, AZ 85209 New Provider Orientation Physician Physician Allied Health Allied Health."— Presentation transcript:
MOUNTAIN VISTA MEDICAL CENTER 1301 South Crismon Road Mesa, AZ New Provider Orientation Physician Physician Allied Health Allied Health
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.
Medical Staff Leadership 2014/2015 Chief of Staff ◦ Sudhakar Reddy MD Vice Chief of Staff ◦ Cynthia Anneski MD Secretary o 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
Hospital Administration Anthony Marinello, CEO Susan Dolezal, CNO Dan Houghton, CFO Joan Hoffstetter, Quality/Risk Management Sheryl Caracciolo, Compliance Officer
About MVMC 8 Years Old- Opened July beds & 20 Geropsych Unit Level III Trauma Center daVinci SI Surgical system ◦ General Surgery ◦ Open Heart ◦ Obstetrics ◦ Urology Aggressive Codes ◦ Stemi ◦ Stroke ◦ Trauma
More About MVMC Teaching program ◦ Primary affiliation with Midwestern University ◦ Affiliation with 20+ schools Residency Programs ◦ Internal Medicine ◦ Family Practice ◦ General Surgery Students ◦ Medical, PA, NP & CRNA
Hospital Layout Patient Rooms in Center towers 1 st Floor ◦ ICU, Surgery, ER, Radiology, Cath Lab 2 nd Floor ◦ Ortho/Spine & Med Surg 3 rd Floor ◦ Telemetry & Geropsych ◦ Use center bank of elevators to access
4 Main Entrances ◦ Outpatient ◦ Cath Lab ◦ ER (Only entrance after 7:30pm) ◦ Main Entrance Be particularly careful not to leave valuables visible in your carEntrance/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 Physician Parking
Medical Staff Meetings 2015 MEETING/TIMEJANFEBMARAPRMAYJUNJULAUGSEP OCT NOV DEC Credentials 12:00 noon 2nd Monday Monthly Education Comm 4:30 pm 1 st Monday Monthly Executive 4:30pm 2nd Thurs after 1 st Mon Monthly 22* PPRC 5:00pm 4 th Monday Monthly Dept OB/GYN 12:00 noon 1 st Tuesday Bi-Monthly Dept Medicine 7:30am 1 st Tuesday Bi-Monthly Dept Surgery 7:00am 1 st Thursday Monthly Cardiology Section 7:30am 1st Wednesday Monthly Cath Conference 7:00 am 2 nd Wednesday Quarterly Administrative Meetings Critical Care 7:30 am 2 nd Wednesday Bi-Monthly Pharm/Therapeutics 7:30 am 2nd Wednesday Bi-Monthly Infection Control 9:00 am Last Monday Quarterly Quality Council 1:00 pm 4 th Wednesday Monthly 25 28* Service Line Meetings Ortho 3rd Thurs 7:00am Stroke 4 th Wed 12:00noon Trauma 4th Thurs 7:00am29* TBD *Exception to rule
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.
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.
Medical Records Dictation MVMC
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.
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: 1. Description of findings 2. Technical procedures used 3. Specimens removed 4. Postoperative diagnosis 5. Estimated blood loss 6. Name of primary surgeon and any assistants and/or anesthesiologists
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).
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.
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 Emergency Codes
Safety Information RACE ◦ Rescue ◦ Alarm ◦ Contain ◦ Extinguish/Evacuate PASS ◦ Pull ◦ Aim ◦ Squeeze ◦ Sweep MSDS ◦ Available in each unit ◦ Available online
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!
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 Non Smoking Please!
Patient Evacuation 1. Horizontal Evacuation ◦ Go through fire doors on other end of same floor 2. Vertical Evacuation ◦ Transport the patients to another floor
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
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.
Staff Isolation Precautions The patient’s door must remain closed at all times! Patient must be masked when out of room. Hand hygiene is required No flowers or plants Notify receiving area of necessary precautions if test/procedure is required Limit pt transport to essential tests/procedures A mask is required
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)
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?
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
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 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 Application Apply least restrictive restraint using appropriate technique 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 Alternative Failed? Use Alternative, DO NOT RESTRAIN Yes No
Restraints, Violent 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 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 Application & Staffing Apply least restrictive restraint using appropriate technique 1:1 staffing adjustment required Patient/family Notify Patient/family as soon as possible in the process and prove them restraint Education Material (as allowed. See G6) Monitor, Reassess & Release Reassess at least every 15 minutes using all appropriate parameters per policy Release patient if application criteria no longer exists Alternative Failed? Use Alternative, DO NOT RESTRAIN Yes No Debrief (BHU ONLY) Conduct a debriefing within 24 hours as per policy
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.
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.EMTALA
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
Star Stands for S – SERVICE T – TEAMWORK A – ATTITUDE AND ACCOUNTABILITY R - RESPONSIVENESS STAR Standards
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
Medical Staff Services Sandy Elcock, Director Tina Deddo, Medical Staff Assistant Vickie Rockwell, Credentials Coordinator
I acknowledge that I have received and reviewed the orientation packet provided to me by Mountain Vista Medical Center. Print Name SignatureDate