New Physician Orientation September 2014 Welcome TO · • 3 Cardiac Cath Labs ... Provides...

NewPhysicianOrientation

September2014

Welcome TO

NewProviderOrientation

OrientationGuide

ThiscomprehensiveproviderorientationincludessomekeyinformationforyourreviewpriortopracticingatEmorySaintJoseph’sHospital.Youmightalsofindithelpfultoreferbacktothisduringyourappointmentonourstaff.

Onceyouhavereviewedallslides,pleaseprintthecertificatefoundontheorientationwebpage.ThecertificatemustbesignedandpresentedtotheMedicalStaffOfficepriortoyourappointmentdate.

EmorySaintJoseph’sHospitalHistory

!  1880:SistersofMercyopen10-bedhospital–1sthospitalinAtlanta

!  1978:MovedfromoriginallocationindowntownAtlantatonew300-bedhospitalatcurrentsite

!  1995:3rdhospitalinthenationtoachieveMagnetDesignationfornursing

!  2012:PartnershipbetweenEmoryHealthcareandCatholicHealthEastformedaJointOperatingCompany(JOC)

!  2014:Onlycommunityhospitaltoachieve5thconsecutiveMagnetDesignation

!  2016:OpenedtheOrthopeadicandSpinePavilion

•  410licensedbeds,270currentlystaffed(allprivaterooms)•  23OperatingRooms,6CVORs•  ComprehensiveCancerCenterwithWinshipCancerInstitute

andEUHMInfusioncenter•  3CardiacCathLabs,2DedicatedEPSuites,Vascular/EVT

Suiteand2SpecialsRooms•  1800Employees•  ~950MedicalStaffMembers•  ~400Volunteers

EmorySaintJoseph’sToday

Title

•  2ndinAtlanta&2ndinGAbyU.S.News&WorldReport2015–2016

•  ANCCMagnet–  5thConsecutiveDesignation–  Firstcommunityhospitalintheworld

•  CMSTop25hospital-hipandkneereplacementoutcomes

•  TJCTopPerformer2015Status– HeartAttack– HeartFailure–  Pneumonia–  SurgicalCare

MeettheSeniorLeadershipTeam!

HeatherDexterChiefExecutiveOfficer

JulieSwannChiefNursingOfficer

JeanneLandryVPHumanResources

JoAnnManningChiefFinancialOfficer

SisterRosemarySmithChiefMissionOfficer

KevinAndrewsChiefOperatingOfficer

JessicaSheridanVPOperations

FurtheringthehealingministryoftheSistersofMercy,SaintJoseph’sgivestangibleexpressiontoChrist’s

mercifullovebyprovidingcompassionate,clinicallyexcellenthealthcare

inthespiritoflovingservicetothoseinneed,withspecialattentiontothepoorandvulnerable

Ourmissionisintegraltowhoweareandinformsallaspectsofourserviceandourorganizationallife

OurMissionandCoreValues

CoreValues

Excellence

!  Weholdourselvestothehigheststandardsofqualityandprofessionalism.

Caring

!  Wedemonstratecompassion,empathyandrespectforourpatients,familiesandthosewhocareforthem.

Integrity

!  Wekeepourwordandarefaithfultowhowesayweare.

Reverenceforeachperson

!  Webelieveeachpersonissacred.

Commitmenttothoseinneed!  Wegivespecialattentiontothosewhoarepooror

underserved.

TheEthicalandReligiousDirectivesforCatholicHealthCareServices

AsaCatholichospitalweembraceTheEthicalandReligiousDirectivesforCatholicHealthCareServiceswhich

!  Affirmsthedignityofeveryperson!  Providesguidanceanddirectiononmoralissues

!  IsincorporatedintotheMedicalStaffbylaws

AllphysiciansandotherproviderswithprivilegesatESJHagreetoadheretotheEthicalandReligiousDirectivesforCatholicHealthCareServices.

PleaseclickheretoaccesstheERDs:http://http://www.usccb.org/issues-and-action/human-life-and-dignity/health-care/upload/Ethical-Religious-Directives-Catholic-Health-Care-Services-fifth-edition-2009.pdf

EthicsCommittee!  Purposes:education,policyreview,consults!  Interdisciplinaryresource!  Membershipbyappointment!  ChairedbyDr.StevenSween

EthicsConsultation!  Purposes:education,facilitation,support,counsel,providefollow-

througharoundquestionsorconcernsrelatedtoethics!  MultidisciplinarysubsetofEthicsCommittee!  Mayberequestedbyanyone(physician,staff,patient,family)!  Consultrequestline:(678)843-7527

EthicsatEmorySaintJoseph’sHospital

!  Isafullandintegratedpartnerinthecareteam

!  Providessupportandspiritualcaretopatients,families,staff

!  Servespersonsofallfaiths

!  Includesstaffchaplainsfromvariousreligioustraditions

!  Ison-site24hoursaday,7daysaweek

!  OffersthefollowingparticularCatholicMinistry-MassdailyinChapel–11:00AM-SacramentoftheEucharist-SacramentoftheSick

PastoralCareatEmorySaintJoseph’sHospital

!  CPEisanaccreditededucationalandclinicaltrainingprogramopentolaypersonsandclergyseekingtobecomechaplainsinavarietyofsettings

!  CPEstaffincludesinterns,full-timeresidentsandsupervisorsintraining

!  CPEchaplainsaugmentourPastoralCarechaplainsinservingpatientsandstaff

!  EmorySaintJoseph’shasbeenaleaderindevelopingthisimportantprogramformorethan25years

ClinicalPastoralEducationProgram(CPE)

TheOfficeofMissionServicescollaborateswiththeBoard,managementandstaffinfosteringtheintegrationofourMissionandCoreValuesthroughoutESJH.Throughreflection,ongoingeducationanddiscernmentMissionServicesassistsstaff,cliniciansandthelargercommunityofESJHtostrengthen,deepenandcelebrateourmission.

WearepleasedthatyouhavechosentoservewithusatESJHandwewouldliketobeapartofyourteamasyouparticipateinESJH’shealingmission.

FormoreinformationpleasecontactSisterRosemarySmithat678-843-5751.

emoryhealthcare.org

EHCPledgeAtEmorySaintJoseph’s,wehaveadoptedtheEHCPledge.

ThePledgewasdevelopedbyamultidisciplinaryteamofstaffandphysicianslookingatwaystofosteranenvironmentofteamworkandmutualrespect.Itspecifiesthesetofactionsandbehaviorsnecessarytocreatethisenvironmentandservesasatangiblemeansbywhichphysiciansandstaffcanholdeachotheraccountable.

emoryhealthcare.org

EHCPledgeAtEmorySaintJoseph’s,wehaveadoptedtheEHCPledge.

Thereisagrowingamountofresearchandevidencelinkingclinicalquality,patientandstaffsafety,andteamwork.Morethananyothertimeinourhistory,itisbecomingclearthatforustoaccomplishourgoalsandreachourvision,wemustallcommittobeingactiveparticipantsinworkingtogethertowardthatvision.Tobeeffectiveinworkingtogether,wemustallcommittorespectingandvaluingallthemembersofthevariousteamsweworkwith,aswecontinuetolearntohonorandleveragetheperspective,experienceandexpertiseeachofourteammembersbringstotheteam.ThisistheessenceofourPledge.

emoryhealthcare.org

EHCCareTransformationModel

Thecaretransformationmodelwascreatedtohelpuschangeourworkenvironment,ourprocesses,andthewayweworkwitheachother,ourpatients,andtheirfamilies.Transformingcarestartswitheachoneofusanditstartsattheheart.Transformingcareisaboutteamworkandcollaboration.

AtEmorySaintJoseph’s,wehaveadoptedtheEHCCareTransformationModel.

•  Theself-governing,organizedmedicalstaffprovidesoversightofthequalityofcare,treatment,andservicesdeliveredbypractitionerswhoarecredentialedandprivilegedthroughthemedicalstaffprocess.Theorganizedmedicalstaffisalsoresponsiblefortheongoingevaluationofthecompetencyofpractitionerswhoareprivileged,delineatingthescopeofprivilegesthatwillbegrantedtopractitioners,andprovidingleadershipinperformanceimprovementactivitieswithintheorganization.

•  Tosupportitswork,anditsrelationshipwithandaccountabilitytothegoverningbody,theorganizedmedicalstaffhaswrittendocumentsthatdescribeitsorganizationalstructureandtherulesforitsself-governance.ThesedocumentsaretheMedicalStaffBylaws,RulesandRegulationsandPolicies.Thesedocumentscreateasystemofrights,responsibilitiesandaccountabilitiesbetweentheorganizedmedicalstaffandgoverningbody,andbetweentheorganizedmedicalstaffanditsmembers.

•  AllmedicalstaffapplicantsmustagreetoabidebytheBylaws,Rulesandpolicies.Weencourageyoutoreviewthesedocumentsanddirectanyquestionstoyourdepartmentchair,sectionchiefortheMedicalStaffOffice.

TheOrganizedMedicalStaff

emoryhealthcare.org

Medical Staff Organization

Hospital Board of Directors

CEO

Organized Medical Staff

Medical Staff Officers •  Chief of Staff •  Vice-Chief of Staff

Staff Executive Committee

Anesthesiology Emergency Services

Medicine Pathology Radiology Surgery

COMMITTEES

Standing Blood Usage Review Credentials Critical Care Medical Education Peer Review Pharmacy& Therapeutics Professional Conduct

Hospital Infection Prevention Oncology Patient Safety Quality

Management Sections Cardiology Gastroenterology Hematology/Oncology Infectious Disease General Medicine - Dermatology - Endocrinology - Family Practice - Internal Medicine - Psychiatry - Physical Med & Rehab - Rheumatology Nephrology Neurology Pulmonary Disease and Critical Care

Sections Cardiothoracic General Surgery -  Colon-Rectal -  General Surgery -  Neurosurgery -  Oral & Maxillofacial

and General Dentistry -  Plastic Surgery -  Surgical Oncology Gynecology Ophthalmology Orthopaedics Otolaryngology Urology Vascular

CMO

Hospital Medicine

Officers

AnesthesiologyStevenSween,MD

EmergencyServicesKennethMiller,MD

MedicineThomasMcGahan,MD

PathologyDonaldSears,MD

RadiologyKushSingh,MD

GaryLudi,MDChiefofStaff

JamesCarlson,MDViceChiefofStaff

Department Chairs

SurgeryMarkWilkiemeyer,MD

MedicalStaffLeadership

HospitalMedicineDhavalDesai,MD

SectionLeadership

Medicine

Cardiology Byron Williams, Jr, MD

Gastroenterology Jennifer Curtis, MD

Hematology/Oncology Shannon Kahn, MD

Infectious Diseases Hugh Durham, MD

General Medicine Daniel Goodman, MD

Nephrology Shaun Conlon, MD

Neurology Matthews Gwynn, MD

Pulmonary and Critical Care Imran Iftikhar, MD

SectionLeadership

Surgery

Cardiothoracic Surgery Douglas Murphy, MD

General Surgery David Kooby, MD

Gynecology Magdi Hanafi, MD

Ophthalmology Eugene Gabianelli, MD

Orthopedic Surgery Jeffrey Peretz, MD

Otolaryngology Elizabeth Shaw, MD

Podiatry Craig Camasta, DPM

Urology John Pattaras, MD

Vascular Surgery Peter H’Doubler, MD

CommitteeChairs

BloodUsageReviewDonaldSears,MD

CredentialsJamesCarlson,MD

CriticalCareCurrentlyVacant

PharmacyandTherapeuticsIanMcMillen,MD

MedicalEducationRichardHansen,MD

PeerReviewMargaretWilliamson,MD

InfectionPreventionMitchellBlass,MD

UtilizationReviewThomasGuest,MD

InstitutionalReviewBoardAlexPark,MD

OncologyPeterRossi,MD

MedicalStaffCategories"  Active

#  Seesmorethan12patientsayear#  Hasvoteandmayholdoffice#  ERcallrequiredbymostsections

"  Courtesy #  Seeslessthan12patientsayear(includingconsults)#  MustbeactiveatanotherJCAHOaccreditedinstitution(notrequiredforoffice-based

practitioners)#  Novotingrights,maynotholdoffice#  MayhaveERcallrequirementsincertainsections(ex:otolaryngology,ophthalmology)

"  Affiliate #  Noclinicalprivileges(mayconferwithattending)#  Mayreferpatientstohospitalistservices#  MayhaveaccesstotheEMR

CategoryIAHPPractitioners(LicensedIndependentPractitioners–Licensedunderstatelawtofunctionindependently.)•  ClinicalPsychologists

CategoryIIAHPPractitioners(AdvancedDependentPractitioners-Provideamedicallevelofcareorperformsurgicaltasksconsistentwithgrantedclinicalprivileges.)•  AnesthesiaAssistants•  CertifiedRegisteredNurseAnesthetists•  NursePractitioners•  Pathologists’Assistants•  PhysicianAssistants•  SurgicalAssistants

CategoryIIIAHPPractitioners(Functionpursuanttoascopeofpractice.)•  RegisteredNurses(employedbyprivatepracticephysicians)

AlliedHealthProfessionals

DepartmentandSectionMeetings

Alldepartmentsandsectionsmeetasnecessarytoestablishstandardsofcompetencyforprivileging,toassuretheprovisionofqualitypatientcarebyitsmembersthroughreviewofpractitionerperformanceandtoprovideinputtohospitalmanagementonoperationalissuesrelatedtothatspecialty.Departmentsandsectionsmayelecttomeetindividuallyorjointlyandmayalsoelecttoestablishmeetingattendancerequirements.

GeneralMedicalStaffMeetings

Meetingsofthegeneralmedicalstaffareusuallyheld2-3timesayeartoprovideexchangewithhospitalmanagement,introductionofnewmedicalstaffmembersandreportsfromdepartments,sectionsandcommitteesasappropriate.Thesemeetingsincludereceptionsthatprovideopportunityforsocialinteractionamongmedicalstaffcolleagues.

MonthlyMeetingCalendar

TheMedicalStaffOfficegeneratesamonthlymeetingcalendarforallmeetings,includingCMEevents.Thisissenttoallmedicalstaffmembersviaemail.

MedicalStaffMeetings

PhysiciantoPhysicianCommunication

Theexpectationisthatphysicianswillcommunicatedirectlywithoneanotherwhenrequestingorrespondingtoconsultationandotherpatientcarematters.Physiciansareencouragedtoexchangecellphonenumberswithoneanother.PhysiciansmayalsoobtainalistingofphysiciancellphonenumbersfromtheMedicalStaffOffice.

Email

Thestandardcommunicationtoolisemail.Allimportantcommunicationfromhospitalmanagementanddepartments,includingtheMedicalStaffOffice,issentbyemail.ItisimportantthatyouensurethattheMedicalStaffOfficehasyourcorrectemailaddressandthatyoucheckyouremailonaregularbasistoavoidmissingimportantmessages.

Communication

Collaboration,communication,andcollegialityareessentialfortheprovisionofsafeandcompetentpatientcare.Thus,MedicalStaffmembersandAlliedHealthProfessionals(“AHPs”)practicingintheHospitalmusttreatotherswithrespect,courtesy,anddignityandconductthemselvesinaprofessionalandcooperativemanner.

TheMedicalStaffCodeofConductpolicyoutlinescollegialandeducationaleffortsthatcanbeusedbyMedicalStaffleaderstoaddressconductthatdoesnotmeetthisstandard.Thegoaloftheseeffortsistoarriveatvoluntary,responsiveactionsbytheindividualtoresolvetheconcernsthathavebeenraised,andthusavoidthenecessityofproceedingthroughthedisciplinaryprocessintheMedicalStaffCredentialsManualortheAHPManual.

AsanapplicanttotheEmorySaintJoseph’sHospitalMedicalStaff,youwillberequiredtosignanattestationthatyouagreetocomplywiththispolicy.

CodeofConduct

•  ThePeerReviewactivitiesfocusonongoingandfocusedprofessionalpracticeevaluations(OPPE&FPPE),theevaluationofthequalityofcareprovidedintheHospital,monitoringforqualityofcareissuesandtrends,andfacilitatingperformanceimprovement.

•  QualityconcernsmaybebroughttotheMedicalStaffPeerReviewCommitteebyanysourceincluding:routinemonitoring,STARSreports(incidentreports),hospitalstafforphysicians.

•  CasesreviewedbythePeerReviewCommitteeareratedusingthefollowingscale:1=routinecare,supportedintheliterature

2=notroutine,supportedintheliterature

3=questionablecare,notsupportedintheliterature

4=unacceptablecare,notsupportedintheliterature

•  TheMedicalStaffMember’sinputonthecaseissolicitedpriortofinalratingdeterminations.

PhysicianPeerReviewProcess

•  MedicalStaffappointmentcarriessomeresponsibilityinthehospital’sobligationtoprovideemergencycareforourcommunity.Inadditiontorespondingtocallsfromtheemergencyroom,oncallspecialistsmustalsorespondtocallsfromattendingphysiciansofinpatients.

•  On-callrequirementsvaryamongspecialtiesandaregenerallyprovidedtoyouduringtheapplicationprocess.Ifyouhavequestionsaboutyouron-callobligations,pleasecontacttheMedicalStaffOfficeorspeakwithyoursectionchief.

On-CallResponsibilities

•  Itisexpectedthatthepatient’smedicalrecordshouldbecompleteatthetimeofdischarge,ifnot,thephysicianhas30daystocompletetherecordincludinghistoryandphysicalexaminationreportdictatedorwrittenandsigned,operativeandinvasiveprocedurereportsdictatedandsigned,verbalorderssigned,progressnotes,principalandsecondarydiagnoses,principalprocedure(s)andcomplication(s)and(dictatedandsigned)-clinicalresume.Therecordsofdischargedpatientsmustbecompletedwithin30daysfollowingdischarge.

•  MedicalRecorddeficiencieswillmonitoredandreportedaccordingtothefollowingagingparameters: Incomplete: 0-14dayspostdischarge Warning: 15-29dayspostdischarge Suspension: 30daysandgreaterpostdischarge

•  TheHealthInformationManagementDepartmentwillcountIncomplete,WarningandSuspensionrecordsonthefirstandfifteenthcalendardayofeachmonthorthefirstworkingdaythereafter.

•  WhenaphysicianhasbeenontheSuspensionListmultipletimeswithinonecalendaryear,suspensionfineswillbeappliedaslistedbelow.ThephysicianwillremainontheSuspensionListuntilthesuspensionfineispaid.

4thsuspension-$100 7thsuspension-$1,0005thsuspension-$250 Allsubsequentsuspensions-$1,0006thsuspension-$500

•  WhenaphysicianappearsontheSuspensionListforthe7thtimewithinonecalendaryear,theStaffExecutiveCommitteewillbesonotifiedandmayrecommendfurtherdisciplinaryaction.

•  Whenaphysicianhasnosuspensionsforsix(6)consecutivesuspensioncycles,onepriorsuspensionfromthesamecalendaryearwillbeexpungedfromthephysician’ssuspensionhistory.

MedicalRecordsCompletionandSuspension

DoNotUseAbbreviationsThefollowingdangerousabbreviationsshallNOTbeused/handwrittenbymedicalandhospitalstaffinanymedicalrecorddocumentation.

DONOTUSE PleaseWrite

Levo levophed,levodopa,levothyroxine,levofloxacinorlevaquinasappropriate

MgSO4 magnesiumsulfate,magsulfateormagnesium

MSO4orMS morphineormorphinesulfate

NitroorSNP nitroprusside,niprideornitroglycerin

PIT vasopressinoroxytocinasappropriate

U units

QD,Q.D.,qd,q.d. dailyorQday

QOD,Q.O.D.,qod,q.o.d. everyotherdayor"QotherD"

X3d x3daysor3dosesasappropriate

BIWorTIW specificdaysofweek,i.e.,qMWF

IU internationalunitsorunits

Lackofleadingzerobeforedecimalpoint(.Xmg)

0.1mgiscorrectformat

Trailingzeros(X.0mg) 1mgiscorrectformat µg mcgormicrograms

Clinicaltermsdocumentedarenotalwaysthesamelanguageas“Coding”language,whichishowallprovidersareprofiled.CDIreviewclosesthislanguagegap,sothatclaimssystemsrecognizeALLfactorsthatcontributetothecomplexity/severityofagivencase.Improvingtheaccuracyofclinicaldocumentationcanreducecompliancerisks,minimizeprovidervulnerabilityduringexternalaudits,andprovideinsightintolegalqualityofcareissues.Statingthetruecomplexityofpatients’illnessreflectsallaspectsoftheencounterfromclinicalclaritytoappropriatecodingandbilling.

•  AtEmorySaintJoseph’s,CDIreviewerscoverourunitsandreviewpatientrecords.Shouldtheyhaveaclarifyingquestion,aQuerywillbeloggedandappearintheprovider’sinboxinEEMRunderthedocumentationsection.

•  ItisimportantthatwegarnerresponsestoALLqueriesinatimelymanner.Physicians’responseratesdirectlycorrelatetodocumentationimprovement.Youcanagree,disagreeormarkthequeryundeterminableiftheanswerisunknown.Theelectronicqueryprocessisveryconvenientandstreamlined:–  OpenthequeryandClickmodify–  Placeanswertoqueryinthespaceprovidedonthequery,atthebottomonthequeryintheareamarked“ProviderResponse

Here”–  Click“sign”

•  Weappreciateyoursupportwiththisinitiative.Successwiththisprogramwillimproveaccuracyofreporting,appropriatelyrepresentingyourcasestoallagencieswhoreviewprovidersforqualityandvalueinourindustry.Moreinformationandeducationwillbeprovidedwithinyoursectionsinthecomingweeks.Ifyouneedfurtherassistancewithdocumentationoransweringqueries,pleasecontacttheClinicalDocumentationSpecialistonyourunitorcontactBonnieEppsatBonnie.Epps@emoryhealthcare.org,or404-712-4550.

ClinicalDocumentationImprovement(CDI)Program

•  Inanefforttostreamlinepatientthroughputandprovideaconsistentprocessforourcustomers,wepartnerwiththeEmoryHealthcareTransferCenterlocatedatEmorySaintJoseph’sHospitalforplacementofalldirectadmissionsandtransfers.

•  TheTransferCenterisagreatresourceforyouasaphysicianasitisone-calldoesitall.TheTransferCenterpersonnelwillcollectallpertinentinformationforpatientregistrationandworkwiththehousesupervisorforbedplacement.TheTransferCenteralsofacilitatesutilizationreviewandassistsproviderstoavoidbeingimpactedbyinappropriatetransfers.

•  Theappropriatenumbertocallfordirectadmitandtransferrequestsis404-686-8334orthefaxnumberis678-843-8348.

•  RequiredinformationifpreviousEHCadmission:

–  Patient’sName–  DOB–  Physician’sName

–  Diagnosis–  Bedtypeneeded(ICU/Med-Surg/Tele)–  Patientdemographicsheetfromoffice/transferringfacility

•  Additionalinformationrequiredifinitialencounter/admission:–  SocialSecurityNumber–  Address

–  InsuranceInformation

DirectAdmissionsandTransfersTheEmoryTransferCenter

CareCoordination

•  AtESJH,ourRNCaseManagersareunitbasedduringtheweek.TheydobothUtilizationreviewanddischargeplanningfor100%ofthepatientsonthefloor.TherearealsoSocialWorkerswhoworkalongsideoftheCareManagerswhoassistwiththecomplexdischargeplans.

•  Therearealsotwostaffmembersthatcoverthehospitalfrom3-11everydayandfrom7-7ontheweekends

•  TheCaseManagersmaytalktoyouaboutthecorrectbillingstatusforthepatientonAdmissionortocorrectthebillingstatusduringthestayasdictatedbythedifferentpayerswhenappropriate.

•  Webelievethatdischargeplanningshouldbeginonthedayofadmission.TheCMorSocialWorkerswillbediscussingtheD/Cplanwithyoutodeterminewhateachpatientneedsattimeofdischarge.

•  YoumaywriteordersforspecificDischargeplanningatanytimeintheadmission.TodothisyouwouldenteranorderintheelectronicrecordrequestingaSocialservicesconsult.

•  YouwillbeaskedtowriteordersforspecificservicesorequipmentthatwillbeneededattimeofdischargesuchasHomeHealth,walker,etc.

•  Ifatanytimeyouhavequestionsorconcernsaboututilizationordischargeplanning,pleasefeelfreetocalltheDirector,SusanFreedat37778.

•  InOctober2013,CMSputforthanewclassificationfor“inpatient”versus“observation/outpatient”services.Thepolicyisknownasthe“Two-MidnightRule.”Aspartofthisrule,CMShasinstituteda“two-midnightbenchmark”fordeterminationofadmissionstatus.Patientswhoaredeterminedtolikelyrequirehospitalizationforatleasttwomidnightsshouldbeconsideredinpatient,whereaspatientswhoarelikelytorequirehospitalizationforlessthantwomidnightsshouldbeconsideredobservation.Notethatthispolicydoesnotapplytopatientswhoareundergoinganinpatient-onlyprocedureaslistedbyCMS.

•  Howtocomply:Documentationmustsupportwhythepatientneedstobeinthehospitalforatleasttwomidnights.Tosatisfythisnewrule,twokeycomponentsmustbemet:–  Admissionorder(mustbesignedorco-signedbyanattending)priortodischarge–  Physiciancertification(statementtothenecessityofinpatientadmission)mustbesignedorco-

signedbytheattendingpriortodischarge

–  TheCaseManagerswillbereviewingtheBillingAdmissionOrderagainstpublishedMedicalNecessitycriteria(Interqual).

–  Itisveryimportanttocarefullydocumentallpertinentclinicalinformationtoassistingettingthepatientintothecorrectbillingstatus.

OverviewoftheCMS“Two-Midnight”Rule

•  TheadmissionorderinPowerChartincludescertificationlanguagestatingthatapatientisanticipatedtorequireatleasttwomidnightsinthehospitalwheninpatientstatusischosen.

•  ThiscertificationappliesONLYwhenaproviderhaschosen“inpatient.”TheorderentryfieldwillalreadyhavetheappropriateCMSlanguageattachedforpatientsin“inpatient”status.Itdoesnotapplyforpatientsinobservationstatus.

•  Anyadmitorderenteredbyanadvancedpracticeprovider,resident,nurseorERprovidermustbeco-signedbyanattendingcaringforthepatientpriortothepatientbeingdischargedfromthehospital.Todoso,rightclickontheorderandchooseco-sign.Or,youmayusetheco-signaturebuttontosigntheorder.Youcanalsoco-signtheorderfromyourEeMRinbox.

•  CMSsaysyoucancertifyatanypointduringapatient’scare;however,fortheproviderworkflowandcompliance,itisbesttocertifyona“prediction”basis,ratherthanrightbeforedischarge.Incaseswherethepredictiondoesnotcometrue:

–  Patientexpectedtostayfortwomidnights,butdoesn’t:Mostofthetime,thepatient’sstatusandbillshouldbeobservation.Rarecircumstanceswherethepatientmaystillbebilledasinpatientincludedeath,hospitaltransfer,leavingagainstmedicaladvice(AMA)orunexpectedlyrapidrecovery.

–  Patientnotexpectedtostayfortwomidnights,butdoes:Patientswhosehospitalstaysextendbeyondtwomidnightswillgenerallybepresumedtomeetinpatientstatusifthehospitalstaywasmedicallynecessary.Patientmayalsobeinobservationstatusiftheirhospitalstaywasmedicallyunnecessary.OurUtilizationReviewstaffwillworktohelpguideandassistprovidersinthesesituations,whichiscurrentpracticenow.

ComplyingwiththeCMS“Two-Midnight”Rule

EmorySaintJoseph’snursesandtheirphysicianpartnershaveearnedtheprestigiousMagnetdesignationfiveconsecutivetimes,

beginningin1995.

PurposeofMagnet:Torecognizehospitalsthatcreateanenvironmentwherenursesandalldisciplinescaneffectivelyworktogether,flourishintheirprofessionsandprovideexcellentpatientcare

MetricsbenchmarkedandreportedtoMagnetinclude:-PatientSatisfaction -NurseSatisfaction -Patientfallswithinjury-CLABSIrate -CAUTIrate -VAErate-Restraintuse -Hospitalacquiredpressureulcers

EmorySaintJoseph’sMagnetCulture

WelcometoEmorySaintJoseph’s!OurAcuteCareNursingDepartmentslookforwardtopartneringwithyou!Togetherwecanensurethebestcareforourpatients.Hereissomeinformationaboutacutecarethatwehopeyouwillfindhelpful.

•  Allofourfloorstaffnursescarryhospitalphonesandtheirnumbersareavailableatthemaindeskoneachunit.HospitalMedicineandCaseManager’sphonenumbers/assignmentsarealsoavailableatthedesk.Pleaseasktheunitclerkforhelpidentifyingwhichstaffmemberisassignedtoyourpatientsandtheirphonenumber.

•  StaffuniformsatESJHarecolor-coded.Ineachpatientareayouwillsee:–  Nurseswithnavyblueandwhiteuniformscrubs–  Nursetechswithredandblackuniformscrubs–  Unitclerkswithatanjacket–  Housekeepingwithbrownuniformscrubs–  Respiratorytherapywitholivegreenuniformscrubs

•  EveryinpatientnursingunithasadepartmentShiftManagerorChargeNurse,whowillbehappytohelpyouasneeded.Pleaseletusknowhowwecanhelpmakeyourtransitiontoourhospitalassmoothandpleasantaspossible.Welookforwardtomeetingyou,introducingyoutoourstaffandorientingyoutoourareas.

AcuteCareNursingDepartments

EmorySaintJoseph’sHospitalDepartmentofContinuingMedicalEducation(CME)providesyouwithhighqualityactivitiesthat;enhancephysicians’abilitytoimprovetheirmedicalcompetenceandpracticeperformance,helpyouaddressidentifiedprioritiesinqualityandpatientssafety,improveyourpatientoutcomes,andguideandsupporttheprofessionalismofallparticipants.CMEeventsofferedthroughEmorySaintJoseph'sHospitalaredesignedtocapitalizeonnewdevelopmentsthatwillenhancethemedicalknowledge,skills,andclinicalperformanceofparticipantsensuringthatourpractitionersremainatthecuttingedgeofscienceandmedicineleadingininnovation.

•  RegularlyScheduledSeries(RSS)-Theseactivitieshavemultiplesessions;occuronanongoingbasis(weekly,monthly,andquarterly)andaremulti-disciplinaryinnature.ActivitiessuchasTumorBoards,QualityandM&MConferencesareplannedbyandpresentedtoEmorySaintJoseph'sHospitalstaff.ThepurposeistodiscusscomplexcasesandbestpracticeguidelinesbetweenmultipleprovidersanddisciplinestoimprovepatientcareatEmorySaintJoseph'sHospital.

•  LiveCMECourses-Theseactivitiesareindividualeventsheldlivewithlearnersparticipatinginperson.CurrentreoccurringactivitiesincludeHeart&VascularGrandRounds,MedicalGrandRounds,MedicineConference,AnesthesiaCMELecture,andTumorConference.TheDepartmentofContinuingMedicalEducationalsoprovidesannualdayconferencesheldoff-siteintheAtlantaMetroareaforourstaffandhealthcareprovidersacrosstheregionandstate.

ContinuingMedicalEducation

CMEHappenings

Anannualcalendarofon-siteactivitiesandinformationonupcomingregionalconferencescanbeviewedintheCMEEventstab(lowerleft)at-www.SAINTJOSEPHSATLANTA.ORG/CME.UpcomingCMEeventswillbehighlightedintheMedicalStaffCalendar(distributedmonthly)andontheCaptivcastTVsaroundthehospital.DetailedflyerscanbeseeninthePhysician’sLoungeandtheCMEHappeningsBoardsaroundthehospital.E-blastswillalsobesenttoannounceupcomingactivities.

TrackingCMEAttendanceInordertologyourattendanceatCMEactivitiesmakesuretosign-inontheCMEAttendanceRecord.Thisshouldbeavailableoutsidethemeetingspaceorinsidetheclassroom.Pleasemakesuretoprintfirstandlastnameandlistthelast4digitsofyourSS#.Thisinformationcreatesauniqueidentifierthatwilltrackyourpersonalattendanceinformation.EvaluationFormsareavailableateachactivityforyoutogivevaluablefeedbacktopresentersandtheCMEOffice.

ShareyourExpertiseand/orIdentifyEducationalNeedsWeencourageallourmedicalstafftoconsidersharingtheirknowledgeandexpertisebypresentingduringoneofourregularlyscheduledactivities.TovolunteertopresentortorequestweaddressspecifictopicscalltheCMEOfficeat678-843-5105oremailSharon.Baldwin@emoryhealthcare.org.


MedicalEducationVideoLibrary

Weunderstandthatitisoftenveryhardtogetawayfromclinicalresponsibilitiestoattendprograms.Whileweallknowthatnothingreplacesliveinteractivelearning,circumstancesarisethatresultintheneedtoparticipateinanactivityatatimethatismoreconvenient.TheMedicalEducationVideoLibrarywascreatedtoaddressthisneed.PleasenotethatCMEcreditisNOTavailableforon-demandviewing.

Thecurrentcatalogincludeslecturesbyourownmedicalstaff,local,nationalandinternationalexperts.VideosincludelecturesfromHeart&VascularGrandRounds,MedicalGrandRounds,MedicineConferences,AnesthesiaCMELecturesandlocalandnationalconferences.Newlecturesareaddedmonthlyandarearchivedfortwoyears.

Foroff-siteviewingoftheMedicalEducationVideoLibraryvisitwww.SAINTJOSEPHSATLANTA.ORG/CME.ClicktheLearningtab(lowerleft),thenclicktheMedicalEducationVideoLibraryIconandselecttheactivityheaderthatrelatestoyourdesiredlecturetopic.Pleasenote,videoswillnotstreamwhileaccessingthewebsitethroughtheVDT—UsetheCME-OnDemandIcononyourVDTApplicationspage.

CatchingthemostrecentCMElectureisnowaseasyasaclickonyourEmoryVDTApplicationspage.LocatetheCMEOn-DemandIconinyourVDTApplicationsmenuandsaveittoyourFavoritesforquickaccess.SelecttheCMEtabandchoosefromthefollowingoptions:Heart&VascularGrandRounds,MedicalGrandRounds,MedicineConference,AnesthesiaCMELectureandlocalandnationalconferences.


RequestingyourESJHCMETranscript•  Individualcertificatesarenotissuedforparticipationinon-siteprograms.Tosimplifytrackingattendance

theCMEOfficemaintainsaphysiciandatabaseofallESJHCMEactivities.TorequestacopyofyourpersonalCMETranscriptcontacttheCMEOfficeat678-843-5105oremailSharon.Baldwin@emoryhealthcare.org.Pleasenote,transcriptsforattendanceatCMEactivitiesheldatotherEmorylocationsmustbeobtainedfromtheEUSOMCMEOffice.

ContactInformation&OfficeLocation:

•  TheCMEOfficeislocatedontheGroundFloorofthehospital(acrossfromthecafeteria).(phone)678-843-5105


•  24/7Campuscoverage–  Panicdevicesinparkingdecks–  Camerathroughoutinteriorandexterior

•  ReportSecurityandSafetyEmergenciesx35555(678-843-5555)

•  SafetyManual–  EHCIntranetandRedBinder

•  IDBadges

UnifiedEmergencyCodesLookforthelime-greenUnifiedEmergencyCodeCardsinthePhysicianLoungeorobtainonefromsecurity.ThesearedesignedtobefoldedandkeptinyourIDbadgeholder.

Security/Safety

CodeRed–IndicatesFireorSmokeConditions

ResponsetoCodeRed–R.A.C.E.R-Rescue-anyoneinimmediatedanger.A–Alarm-activatefirepullstation,dial5555tonotifytheoperatortopage“CodeRed”andlocation.C-Contain-closingalldoorsandwindows,ensure02zonevalvethatservesthefireareashut-off.E–Extinguish-usingafireextinguisherandfollowingacronym“PASS”Pull,Aim,Squeeze,Sweep.•  Testing/Training

–  Drillsconductedoncepershiftperquarter•  KnowLocation

–  NearestFireAlarmPullStationandFireExtinguishers

–  MedicalGasShut-OffValve–  Outsidemeetinglocationintheunlikelyeventofevacuation

•  EmergencyNumberx35555(678-843-5555)•  Evacuationwillonlyoccurwhenannouncedoverhead.

FireSafety-ResponsetoCodeRed

Whatdoyoudoifyouthinkthere’sanerror?–  Reportittothedepartment’smanagerordirector,ifnotaddressedproceedto

yoursectionchief,departmentchair,chiefofstafforchiefmedicalofficer–  Documenttheerrorappropriately–  Youwillneedtonotifythepatient/family

Whatifitseemsthatnoonelistens?–  Alwaysgivethehospitalanopportunitytoaddressconcernsthroughescalation–  Ifyoufeelyourconcernshavenotbeenaddressed,youmaycontactJointCommission

onAccreditationofHealthcareOrganization(JCAHO)–  Email:[email protected]–  Phone:800-994-6610–  Nodisciplinaryactionwillbetakenbecauseanemployeereportssafetyorqualityof

careconcernstoJointCommission

ErrorReportingintheHospital

PhysicianLoungeThePhysicianLounge,locatedonthe1stfloor,isintendedtoprovidephysicianswithacollegialenvironmentwheretheycaninteractwithoneanother.

•  Duetolimitedspace,APPsdonothaveaccesstotheloungebutarewelcomewhenaccompaniedbyaMedicalStaffmember.•  Whileresidentsandfellowsdohaveaccess,itispreferredthattheyalsobeaccompaniedbyaMedicalStaffmember.

•  Inconsiderationofothers,weaskthatphysicianslimitthenumberofguests(APPs,housestaffandothers),especiallyduringpeaktimes.•  Breakfastservice:6:00am–9:45amLunchservice:11:00am–2:00pm

CafeteriaChargesbyMedicalStaffMembersIthasbeenalongstandingcustomatESJHtoallowMedicalStaffmembers(physiciansonly)tochargemealsinthecafeteriaafterhoursandonweekends.Guidelinesforthiscourtesyareasfollows:

•  Monday-Friday:onlyafter5pm(Nobreakfastorlunchcharges.)

•  Weekends•  $10limit•  Cashierwillprovideaformtobecompletedandsigned

FitnessCenter•  Doctor’sOfficeBuilding5667;GroundFloor–Suite180

•  FitnesscenterandclassesareopentoallphysiciansontheESJHMedicalStaffandtoAPPsofcontractedservicesoncampus-Emergency,AnesthesiaandPathology.(Privatepractice/communityAPPsdonothaveaccess.)

•  Stopbytoregister.HospitalIDrequired.

ParkingWhenyouvisitthehospitalsecurityofficetoobtainyourHospitalIDbadge,yourcampusparkingwillbeaddedtothatbadgeinaccordancewiththefollowingguidelines:

•  ForproviderswithofficesonESJHcampus,daytimeparkingmustbearrangedwithyourbuildingmanagement.YourIDbadgeaccesswillonlyallowyoutoenterthePhysicianParkinglot(adjacenttotheED)betweenthehoursof5pmand6am.

•  MedicalStaffmembers(physicians)whodonothaveanESJHcampusofficemayparkinthePhysicianParkinglot(adjacenttotheED)24/7.

•  AHPsandhousestaffwhodonothaveanESJHcampusofficemayparkintheEmployeeParkingdecks.

MedicalStaffAmenities

TheMedicalStaffOfficefunctionsastheadministrativecenterfortheorganizedmedicalstaffandisthe“homeoffice”fortheChiefofStaffandotherelectedofficersofthemedicalstaff.,aswellastheChiefMedicalOfficer.Wearelocatedincloseproximitytothephysicianloungetoprovideeasyopportunityforinteractionbetweenourdepartmentstaffandmedicalstaffmembers.

TheMedicalStaffOfficecanassistwith:

–  Credentialing:initialandreappointmentapplicationsformedicalstaffmembersandcredentialingforyourextenders(RN,NP,PAorsurgicaltech)whoassistyouinthehospital

–  ERon-callschedulesandmeetingcalendars–  Committeemembership–  Requestsforadditionalclinicalprivilegesandeligibilitycriteriafornon-coreprivileges–  Proctoring–  Physicianqualityreports–  Interpretationofbylaws,rules&regulations,andpoliciesofmedicalstaff,hospitalandhealthsystem–  Departmentandsectionmeetings–  Addresschangenotifications–  Verificationlettersforotherinstitutions

DonnaColella,CPMSM,MedicalStaffOfficeManager678-843-7310,[email protected],MedicalStaffLiaison,678-843-5127,[email protected],MedicalStaffLiaison,678-843-7318,[email protected],CredentialsVerificationSpecialist,678-843-7997,[email protected]

TheMedicalStaffOffice

ID/BadgeOnceyoureceiveconfirmationfromtheMedicalStaffOfficethatyourapplicationandclinicalprivilegeshavebeenapproved,youwillbeabletoobtainyourhospitalIDbadgefromtheSecuritydepartment,locatedonthegroundfloorofthehospital.YourIDbadgeshouldbewornoncampusforsecurityandsafetypurposes.Thisbadgewillgiveyouaccessto:

•  Parkinglots•  PhysiciansLounge-locatedonthefirstflooracrossfromHospitalAdministration•  SurgeonsLounge–LocatedonthefirstflooracrossfromthemainentrancetotheSurgery

department.•  Clinicalareassuchasthesurgerydepartment,Cath/EPLab,Emergencydepartment•  HealthInformationManagementdepartment(MedicalRecords)

HospitalTourTheMedicalStaffOffice,678-843-7998,canassistyouinarrangingahospitaltour.

GettingStarted

Thankyouforviewingthenewproviderorientationslides.

Welookforwardtocollaboratingwithyoutoshareourmissionandvaluesofmakingapositivedifferenceinthehealthofour

communities.

WelcometoEmorySaintJoseph’sHospital!

Thankyou!

IherebyattestthatIhavereviewedtheNewProviderOrientationslides.

ProviderName(print):___________________________________

ProviderSignature:______________________________________

Date:__________________________________________________

Please print, complete and submit this certificate to the Medical Staff Office. Fax: 678-843-5308

CertificateofCompletion

New Physician Orientation September 2014 Welcome TO · • 3 Cardiac Cath Labs ... Provides...

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