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Floyd Medical Center Medical Staff Orientation Information and Resources Your orientation to Floyd Medical Center includes meetings with designated resource people, facility tours and written resource materials. The resource people and your assigned orientation facilitator are available to answer any questions you may have. You will be introduced to staff members and will become familiar with areas of the facility where you will be providing care and services. Clinical managers, clinical supervisors and staff of each area are available to assist you as you become familiar with Floyd. At the end of the online portion of your orientation, you will be asked to verify that you have reviewed the materials provided. Organizational Overview Organizational Overview Our Mission is to: > provide the communities we serve with a comprehensive and technologically advanced health care system committed to the delivery of care that is characterized by continually improving quality, accessibility, affordability and personal dignity. Our Vision is to: > be the regional health care provider of choice > deliver patient- and family-centered care that is compassionate, sensitive and respectful of each individual’s needs. Our Values Our Patients are: > our highest priority > provided high-quality, state-of-the-art health care > given respect and dignity > treated equally > provided education and information for themselves and their families Organizational Overview Our Values Our Employees are: > our most valuable asset > offered an environment that attracts and retains highly qualified personnel > encouraged and supported to reach their maximum potential through education > recognized for a job well done > provided an environment of open communication, participation in planning and respect for each employee’s contribution to our mission Our Medical Staff Members are: > our valued customers as well as partners in health care > provided an environment that attracts and maintains high caliber physicians > involved in the direction of the hospital community Organizational Overview Service Standards/Patient Satisfaction All customers, while in the care of the Floyd Medical Center health system, will be treated with dignity and respect throughout all stages of their life and death regardless of their mental status. In all our words and actions, we strive to do unto others as we would have them do unto us and our families. We use the term “customer” in the broadest sense to include patients, families, visitors, members of the community, physicians, vendors and, certainly, co-workers. Administrative Contacts Phone: 706.509.6900 Kurt Stuenkel, FACHE, President and Chief Executive Officer (CEO) Joseph Biuso, M.D., FACP, Executive Vice President and Chief Medical Officer (CMO) Sonny Rigas, Executive Vice President and Chief Operating Officer (COO) Sheila Bennett, RN, DNP, Senior Vice President and Chief of Patient Services Glenda Thomas, CPS, CPCS, Medical Staff Coordinator Organizational Overview Medical Staff Bylaws Bylaws are available by request from Administration at 706.509.6915. Medical Services A list of services provided by Floyd Medical Center is available on Floyd.org. Corporate Compliance To assist our organization and physicians with ensuring that licensing, accrediting, regulatory and legal requirements are met on an ongoing basis, we have a Corporate Compliance Plan. Physicians are encouraged to express their concerns and opinions on any issue regarding potential violations of laws, regulations, ethics, policies and/or procedures. Any questions or concerns regarding compliance at Floyd Medical Center or any of its affiliates should be reported to the Accreditation Compliance Coordinator at 706.509.5197 or any member of the Corporate Compliance Committee. The compliance Hotline number is 706.509.5120. Calls to the Hotline are not traced or taped. Persons who call the Hotline may remain anonymous, and confidentiality is maintained to the limit of the law. While practicing at Floyd Medical Center, providers will follow all HIPAA guidelines for privacy of patient information. Information on Floyd Medical Center’s Corporate Compliance Program is available by request from the Accreditation Compliance Coordinator at 706.509.5197. Corporate Compliance Our organization’s responsibilities include: • • • Documentation of care provided Charging only for necessary services provided Delivering care designed to meet the patient’s needs Any employee, physician or other individual who provides care, treatment or services and who has concerns about the safety or quality of care provided in the organization may report these concerns to The Joint Commission. Corporate Compliance Review a copy of our Standards of Business Conduct. By consistently demonstrating service standards behaviors, each employee helps fulfill the mission, vision and values of the Floyd Medical Center health system. By incorporating the service standards into performance expectations, we reinforce the importance of these behaviors and clearly communicate that they are expected to be practiced by all employees while at work. Contacts • • • Compliance Hotline, 706.509.5120 Accreditation Compliance Coordinator, 706.509.5197 Corporate Compliance Officer, 706.509.3283 Best Practices for Reducing LOS and Direct Costs of Care “These key points help provide effective patient care.” − Dr. Joseph Biuso 1. Communicate with prior-treating physicians about patients’ prior history and testing. Senior citizens only very rarely have a new chronic condition or new incidental finding. 2. Use consultations judiciously. Every consultation should contain a specific question for the consultant that justifies the need for the consultation. 3. Communicate with consultants frequently to make sure patients are moved efficiently through the continuum of care and that pre-existing issues not related to the acute admission are not unnecessarily reevaluated. 4. Do not ask consultants for permission to discharge. Notify consultants of the plan to discharge. Ask for any recommendations for post-hospital care. They will let you know if they disagree. 5. Round early in the day and attend to discharges as a priority. Best Practices for Reducing LOS and Direct Costs of Care Continued… 6. If a patient has a pending result that will likely be negative (e.g. nuclear part of a negative stress test), do the discharge instructions and dictation pending the results. When the nurse calls and it is negative, as it will be 90 percent of the time, give the final discharge order, and if necessary, dictate a two-line discharge summary addendum. 7. Revisit patients who become ready for discharge later in the day, if necessary. 8. Start discharge planning on admission. Take a careful social history on admission to identify barriers to discharge. 9. Practice evidence-based care to avoid unnecessary variation that leads to increased expense, length of stay (LOS), complications and worse clinical quality. 10. Respect pre-existing clinical relationships. A prior consultant can take care of a patient more efficiently with a more detailed knowledge of the history. 11. Checking the clinical notes area of net access on every admission will facilitate compliance with many of the listed practices. Environment of Care Emergency Codes In the event of an emergency, dial 123 within the hospital. This call will go directly to the Operator and will override all other calls being made to the switchboard. For Floyd departments and practices in outlying areas, call 911. Then notify the Safety Officer (706.509.6946; 706.509.5197) or Risk Manager (706.509.5745) regarding the incident. Fire Response: RACE Rescue − Any persons in immediate danger. If you are going to open a closed door, feel the surface first. If it is warm or hot, do not open it. Stay calm, and remember to stay low to the ground to avoid the smoke and heat. Alarm − Don’t hesitate to sound the alarm. Alert everyone via the alarm or other emergency communication. This may be pulling the fire alarm or calling 911 if you are in an office located off the main campus. Confine − The fire. Close doors and windows. Stuff towels under doors to keep smoke out. Extinguish/Evacuate − If the fire is small, you may be able to extinguish it. If the fire cannot be extinguished, be prepared to evacuate the patients. Never put yourself or others in danger by attempting to extinguish a fire you cannot control. Using a Fire Extinguisher: PASS Pull the pin. Aim the nozzle at the base of the fire. Squeeze the handles together. Sweep from side to side motions. Infection Prevention/Bloodborne Pathogens/Hand Hygiene The National Patient Safety Goals (NPSG) identifies infection prevention elements in place at Floyd Medical Center. A written plan for these elements is available from The Joint Commission. Floyd has specific guidelines regarding infection prevention and hand hygiene. The Infection Prevention department can be reached at 706.509.5740. This team is a resource for infection prevention issues and physician health requirements. Hazardous Materials Please be aware of any products you work with that may be hazardous. Emergency information is included on product labels. Hard copies of safety data sheets (SDS) are available throughout the hospital. These are also available on our intranet (GreenLink), accessible through any Floyd computer. Emergency Preparedness If called, report to the Emergency Care Center (ECC) and assist. The process for credentialing non-Floyd Medical Staff providers during a disaster is available in Policy EC-04-009. The Medical Staff participates in internal and external disasters affecting the hospital to ensure continuous and safe delivery of health care services. Review the following information and familiarize yourself with it prior to a disaster occurring. If you have any questions, contact Dr. Joseph Biuso at 706.509.6900 or Kenna Baker, Safety Officer, at 706.509.6946. Emergency Preparedness PROCEDURE 1.The Executive Vice President/CMO and/or Medical Staff President are notified by the Incident Commander or their designee to activate the call roster of the Medical Staff. 2.The CMO in conjunction with the Medical Staff Officer, notifies the Medical Staff as follows: • • • • Medical Staff President/Medical Staff President Elect Department Chairs Medical Directors Alphabetically calls the Medical Staff 3.The CMO, Medical Staff President or designee will assume the responsibilities of Medical Staff Director for the Emergency Operations Center upon notification from the Incident Commander. Emergency Preparedness 4. The Chief Medical Officer, Medical Staff President or designee reports directly to Labor Pool Area/Doctor’s Lounge. 5. The CMO, Chief of Staff or designee works in conjunction with the Incident Commander, Operations Chief and the Medical Staff President to assign Medical Staff members to areas of need. 6. The Medical Staff leadership/members are oriented to the Disaster Plans, and any changes to these plans via new member/new chair orientation and the Medical Executive Committee. In addition, Medical Staff leadership members are encouraged to participate in the Homeland Security Presidential Directive 5 requirement by taking the National Incident Management System (NIMS) online courses IS-100.HCb, IS200.HCa, IS-700.a, and IC-800.b available from FEMA Emergency Management Institute. Emergency Preparedness The goal of this communication is to determine what each medical specialty has to bring to the table in the event that a disaster occurs in the City of Rome/Floyd County or outlying areas to allow the best possible utilization of our physicians. This will allow the Incident Commander and/or his/her agents to decide where physicians should report when they first arrive based on where needs exist. Disaster Management Physician Responsibilities Department of Surgery Disaster Management Physician Responsibilities Department of Anesthesia Should be assigned to the ECC or Surgery for airway management, analgesia (nerve block), surgical anesthesia Behavioral Health Should be assigned to ECC or Inpatient Unit to assist with pre-existing and acute psychiatric issues Department of Emergency Medicine Triage patients (use tag system). Acute resuscitation (ABCs). Stabilize patients for admission, discharge or Surgery. Sign out patients to admitting/treating physician. Incident command will receive frequent reports from ECC to allow timely assignment and dispatch of necessary specialists and expeditious transfer to Surgery, ICU or floor with necessary information. Disaster Management Physician Responsibilities Department of Laboratory Medicine Stand by for deluge of blood work and blood bank specimens, tissue samples (especially if plague/epidemic). If necessary, request assistance of outside labs, from other hospitals and facilities. Department of Family Practice Assist with disposition of walking wounded and admission to floor for support. Request help from outside facilities for transfer of stable, pre-existing patients out from our floors if we need space, offer to accept patients from other pre-existing inpatients from other facilities if they are in need. Department of Pediatrics Assist with resuscitation and stabilization of pediatric patients and transfer to inpatient unit or more appropriate facility, when stable. Department of Radiology Read films stat. If requested, track down treating physician with report. Disaster Management Physician Responsibilities Department of Medicine Cardiology Assist Internal Medicine. Be available in ECC/ICU/Telemedicine for management of cardiac problems, echos, etc. Gastroenterology Assist Internal Medicine. Evaluate and treat GI bleeders (scopes). Oncology Assist Internal Medicine. If plague, assist with lab medicine workup. Be prepared for immediate plasmaphoresis in toxic exposure cases. Disaster Management Physician Responsibilities Hospitalists Assist with disposition of walking wounded and admission to floor for support. Request help from outside facilities for transfer of stable, pre-existing patients out from our floors if we need space. Offer to accept pre-existing inpatients from other facilities if they are in need. Infectious Disease If plague/bioterrorism, work with lab medicine to find causative agent. If not, assist Internal Medicine. Internal Medicine Assist with disposition of walking wounded and admission to floor for support. Request help from outside facilities for transfer of stable, pre-existing patients out from our floors if we need space. Offer to accept pre-existing inpatients from other facilities if they are in need. Disaster Management Physician Responsibilities Nephrology Assist Internal Medicine with acute/chronic renal patients; be available for acute dialysis in toxic exposure. Neurology Diagnose/treat idiopathic illnesses. Assist Internal Medicine. Pulmonary Should be assigned to the ECC or Critical Care area for critical care management, vent management, bronchoscopy. The Disaster/Mass Casualty Response Plan is available in Policy EC-04-003. Risk Management Unusual Occurrences Floyd has an automated system for reporting and follow-up of unusual occurrences. Alert unit nursing staff of any occurrence, and they will initiate the required incident reporting. If you have questions about incidents, reporting or follow up, please contact the Risk Manager at 706.509.5745. Our Employee, Patient, Visitor Incident Reporting Using Online rL Solutions Policy is Policy AD-03-005. Risk Management Floyd’s Risk Manager is available to assist physicians with legal questions, identifying individuals able to give consents, end-of-life issues, potential suit situations or events that legal counsel may need to be made aware of. Contact the Risk Manager at 706.509.5745 (office). Risk Management Sentinel Events A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, occurring at or associated with services provided by Floyd. Floyd is committed to improving the quality of patient care. The occurrence of a sentinel event (as defined herein) or "near miss" may identify an opportunity for improvement. Floyd will, thus, seek to identify and respond appropriately to all sentinel events/near misses occurring at or associated with services provided by Floyd. In response to an identified sentinel event or near miss, Floyd will conduct a timely, thorough and credible root cause analysis and will develop, implement and monitor the effectiveness of an appropriate plan of action, which is designed to reduce the risk of the occurrence of similar events in the future. Our Sentinel Events Guidelines are available in Policy AD-01-060. Secure Access Areas Access to some areas of the facility is restricted to authorized badge holders. For occasional access, use the intercoms adjacent to the locked doors. If you will be seeing patients in these areas regularly, the clinical manager for the area will request ID badge access for you. Once activated, swipe your Floyd-issued ID through the scanner adjacent to the locked doors. Secure Areas: • Inpatient Surgery • Emergency Care Center (ECC) • Labor and Delivery/Postpartum/Nurseries • Pediatrics • ICU • Doctors Dining Room • Doctors Lounge (keypad access) • Medical Records (keypad access) You will be given a numeric code during orientation for areas with keypad access. Customer-Focused Patient Care Customer-Focused Patient Care Quality Floyd is committed to providing care that follows evidenced based standards. The following are major inpatient populations that we are currently monitoring: • • • • • • • • • • • • Stroke (AHA/ASA Get with the Guidelines) Venous Thromboembolism (CMS) Total Hip and Knee Replacement (Marshall Steele) Hip Fracture (Marshall Steele) General and Vascular Surgery (NSQIP) Spine Surgery (TJC) Perinatal Care (CMS) Neonatal Intensive Care (VON) Blood Utilization (Blood Assurance) Type 2 Diabetes (TJC/ADA) Inpatient Psychiatric Patients at Floyd Behavioral Health (CMS) Palliative Care (TJC) (Sponsoring organizations are listed in parentheses.) For more information, contact the Director of Quality Management at 706.509.5196. Customer-Focused Patient Care Pain Management Pain is population specific, varying with factors such as age, cultural diversity and cognitive impairments. All providers should be knowledgeable about how to assess and manage pain in their patients. Clinical staff can provide details on the pain management scales used at Floyd. The Pain Assessment/Management Policy is PCS-01-005. Customer-Focused Patient Care Restraints Physicians who solely order restraints must be aware of and have read the appropriate policy (PCS-03-006). Physicians who apply restraints must show competency in the application of the restraint. Abuse and Neglect Floyd’s abused and neglected victim assessment and reporting policy (PCS-01-006) was developed to assist with identifying those patient characteristics that are indicative of having been abused or neglected. The policy provides a protocol for patient identification and assessment, describes characteristic findings and signs of high-risk situations. It also defines the procedures for reporting abuse and neglect. Customer-Focused Patient Care Cultural Sensitivity and Diversity Floyd’s patient population reflects diversity in race, ethnic origin, religion and age. Providers should treat each patient as an individual, identifying any special needs related to culture, and meeting those needs in a sensitive manner. Floyd staff members are trained not to treat the patient as they, the staff, would want to be treated but instead to use communication skills to find out how the patient prefers to be treated. We recommend: when in doubt, ask. Language services and support are available for patient care. Interpreters are available onsite and on call for Spanish speaking patients. Telephone interpretation is available for multiple languages and/or when interpreters are not available. NexTalk telecommunication equipment is available for communication with hearing impaired patients. The Floyd Chaplain is available as a resource for managing religious and spiritual concerns with patients. The Chaplain can be reached at 706.509.5199. Customer-Focused Patient Care Patient Rights/Ethical Issues Floyd has an Ethics Committee available for consultations. Consultations may be requested by physicians, staff, patients or their families. The Ethics Committee reviews pertinent information and may make recommendations to providers. The ethics consult process (PCS-04-008) can be activated by contacting the Chaplain at 706.509.5199. Patient Satisfaction Floyd’s goal is to be the health care provider of choice for our region. To help achieve that, we continually seek feedback from patients and use their experiences to improve service where needed and to recognize those cited when service is exemplary. Patients may respond to questions about the care received from their physician. You can receive details about your satisfaction ratings by contacting the Service Excellence Coordinator at 706.509.5195. Customer-Focused Patient Care Pharmacy Services Details about Floyd’s formulary and policies and procedures related to medications are available on GreenLink, Floyd’s intranet, which is accessible only through a Floyd computer. The Pharmacy is open for inpatient orders 24/7. Clinical pharmacists are available to serve as a resource to providers and to provide Total Parenteral Nutrition (TPN) services, aminoglycoside and vancomycin dosing, renal dosage adjustments, and anticoagulation dosing and monitoring. Call 706.509.5910 for assistance with pharmacy-related services. Confidentiality/HIPAA Review Floyd's Notice of HIPAA Privacy Practices. Customer-Focused Patient Care Health Information Medical Records will provide a personal dictation number and instructions for dictating. Floyd complies with the Repeat/verify verbal order requirement, GA Rules/Regs for Hospitals 111-8-40-18 (Policy PCS-06-007). Floyd’s electronic medical record (EMR) software, Cerner, is used to provide you with access to patient information, reports and results. You will be trained in the use of portal and related secured access requirements by a member of the Clinical Informatics staff. Anticoagulation Education for Providers The National Patient Safety Goals require that we provide education regarding anticoagulant therapy to prescribers, staff, residents and families (Policy PCS-06-051). The education should include the following elements: • • • • Importance of follow-up monitoring Compliance Drug-food interactions Potential for adverse drug reactions and interactions Floyd meets this requirement by providing excerpts from the ACCP Guidelines. Special Services Special Services Parking The main Doctors Parking Lot is located on Turner McCall Blvd. in front of the 330 Physicians Center. Use your Floyd ID badge at the gate for access. Limited and restricted physician parking is also available at the main entrance to the Emergency Care Center (ECC) for physicians coming in on call. Dining A private Doctors Dining Room is located adjacent to the cafeteria. Access is by Floyd ID badge. A complimentary buffet lunch is provided Monday – Friday from 11:15 a.m. – 1:30 p.m. You may get additional items from the cafeteria serving line or stations. Please let the cashier know that you are a member of the Medical Staff. Special Services Courtesy Discount Policy Floyd Medical Center offers a courtesy discount for health care in accordance with specific terms, conditions and exceptions as outlined in our Professional Courtesy Discount policy. A copy of this policy can be requested from Administration. Policies and Summaries Policies Patient Safety Rapid Response Team – Policy PCS-14-001 Universal Protocol for Prevention of Wrong Site Surgery – Policy PCS-03-003 Standard and Transmission Based Precautions – Policy EC-06-001 Pharmacy Dosage Adjustment for Renal Insufficiency – Policy PCS-06-030 IV to PO Interchange by a Pharmacist – Policy PCS-06-032 IV Potassium Guidelines – PCS-07-002 Range of Orders for Medications – PCS-06-008 Therapeutic Interchange – PCS-06-027 Resources Resources Floyd Telephone Directory This is a list of phone numbers to clinical and non-clinical departments. Annual Report Annual reports for the Floyd health care system are available on FloydStraightforward.org. Verification Verification To verify your review of the Medical Staff Orientation for Floyd Medical Center, complete this short form. Once you complete the verification form, a member of our Medical Staff Credentialing Team will be in touch within one to two business days. If you have questions, contact our Medical Staff Credentialing Team at 706.509.6915 or email us at [email protected].