NWH Medical Staff
Orientation & Annual Education
Marla Koroly, MD, FACP
Senior VP, Medical Affairs
and Chief Medical Officer
2017
1
Northern Westchester Hospital
MISSION
• To provide the highest quality diagnostic & treatment services for
our community, while assuring access to a coordinated continuum
of healthcare services. To improve and protect the health of
individuals in the community through programs that promote
healing and wellness.
VISION
• We will provide the highest quality healthcare within a supportive
community setting and state of the art facilities
2
STRUCTURE: GOVERNANCE
Three bodies have a role in governing NWH
Board of Trustees
Northwell Health - NWH
Senior Management
MEC: Medical Board
3 ELECTED Officers – President; VP; Secretary/Treasurer
3 ELECTED Members at Large
Appointed Chiefs
CEO
CMO
CFO
CNO
Administrative Supervisor
Committees:
• Performance Improvement
Coordinating Group (PICG)
• Professional Practice Evaluation (PPEC)
• Credentials
• Pharmacy & Therapeutics
• Transfusion
• Infection Prevention
• Utilization Management
• Ethics Review Committee
Governing Documents
Bylaws (Hospital & Medical Staff)
Rules & Regulations
Policies & Procedures
• On staff website
• Electronic communication
• On-Call and Coverage obligations
3
STRUCTURE: PEOPLE
Our organization includes the organized Medical Staff, employed nurses, and
other professional and support staff
Medical Staff (700+)
Hospital Based:
 Employed: Internal Medicine & Pediatric Hospitalists; Critical Care Physicians; Hospital
Neurologist; Neonatologists; Maternal-Fetal Medicine Specialist; Surgical Hospitalist &
Advance Practitioners; Surgeons (breast, plastic, vascular, thoracic); Psychiatrists;
Radiologists
 Contracted: ED, Anesthesia, Pathology, Radiation Oncology, Clinical Trials
Large Groups: (PCMH, ACO, IT); Single Specialty Groups; Solo Practitioners
Nursing Staff (400+)
Other Professional & Support Staff
•
Patient Care Team: RN, PCA, Pharmacy, Respiratory Therapy, Case Managers, Rehabilitation, Registered
Dieticians, Social Workers
•
Support: BA, Concierge, Service Associates, Transport, Facilities, Biomed, Finance
•
Clinical Informatics
4
STRUCTURE: PROGRAM
Our organization includes core services and centers of excellence, supported
by a model of wellness
Hospital-based core services
•
Advanced Imaging
•
Core Laboratory
•
Chappaqua Crossing: Rehabilitation, Balance Center, Wound Care HBOT
Centers of Excellence
•
Cancer Treatment & Wellness Center
•
Breast Institute
•
Orthopedic & Spine Institute (OSI)
•
Institute for Aesthetic Surgery & Medicine
•
Institute for Robotic & Minimally Invasive Surgery (IRMIS)
•
Surgical Weight Loss Program (Bariatric COE)
Wellness Model - Food; Physical Fitness; Mindful Wellness; Integrative Medicine
5
MANDATORY KEY TOPICS
Northwell Health provides a comprehensive Education Program on line for all
practitioners
•
•
•
•
•
•
•
•
•
Patient’s & Parent’s Bill of Rights
Abuse/Neglect/Mistreatment of patients
Advance Directives
Ethical Issues
Abuse (Child, Elder)
TJC National Patient Safety Goals
Reporting Safety/Quality Concerns
Health Literacy; Limited English Proficiency
Infection Prevention
•
•
•
•
•
•
•
•
•
Hand hygiene; Precautions; Exposures; Sharps; Waste
HIV; HBV; HCV; TB; Influenza; Pertussis; CDI
CA-UTI; CLABSI; SSI
PPE
Sepsis
Fire Safety
Disaster Preparedness & HICS (Hospital Incident Command System)
Physician Health Assessment Requirements
Compliance – Fraud & Abuse; HIPAA
6
KEY TOPICS: Advance Directives
We have a policy that governs medical decision making c/w NY State law
Family Health Care Decision Act
NY State 6/1/2010
•
Health Care Agent (HCA) – appointed in writing by the patient (Health Care Proxy)
•
Surrogate - may make healthcare decisions – including end-of-life decisions – on behalf of incapacitated
patients who do not have an HCA
-
Court appointed guardian
Spouse if not legally separated or Domestic Partner
Son or daughter 18 years of age or older
Parent
Sibling 18 years of age or older
Close friend
No surrogate (unaffiliated patient) – Attending Physician + Hospital-designated concurring Physician
•
Hospital presumes every patient has capacity, unless otherwise proven & indicated by the attending
physician, and wishes to receive appropriate medical treatment, including cardiopulmonary resuscitation
(CPR), unless otherwise indicated by an advance directive
•
Patient, HCA, or Surrogate may request to have or to not have CPR or indicate other advance directives on the
Medical Orders for Life Sustaining Treatment (MOLST) form
•
The Attending Physician must enter a DNR order c/w the patient/HCA/surrogate wishes
7
KEY TOPICS: Ethics Review Committee
Our Ethics Review Committee is available for consultation & guidance
As a profession, medicine is characterized by a specialized
body of knowledge and by a code of ethics and duty of
service that put patient care above self-interest.
Guiding Principles
• Beneficence
• Non-maleficence
• Respect for autonomy & self-determination
• Veracity
• Distributive Justice
The physician must have two
special objects in view with
regard to disease, namely, to do
good or to do no harm.
Primum non nocere
The NWH Ethics Review Committee: Hal Federman, MD, Chair
• Last Friday of every month from 12:00–1:00 PM
• Open to all members of our Medical & Hospital Staff
• Available ad hoc at the request of any physician, staff member, or patient or family member for
consultation & guidance on ethical issues concerning patient care and treatment
• Maria Hale 914.666.1951 [email protected]
2016
8
KEY TOPICS: Infection Prevention
We adhere to standard practices to prevent transmission of infection
NWH/Northwell Infection Prevention policies & procedures
•
•
•
Approved by the Infection Control Committee
Available on the Staff Website
NY State Practitioners must maintain current Infection Control Training Certificate
(every 4 years)
Key Points
• Vaccination – Hepatitis B, Influenza, MMR, Varicella, Tdap
• Standard Precautions – assume each patient has a blood-borne disease that can
be transmitted & do not directly contact blood or body fluids of ANY patient
• HAND HYGIENE – consistent use of alcohol-based hand sanitizer or soap & water
• Appropriate personal protective equipment (PPE) for anticipated exposures –
gloves, gowns, safety glasses, mask
• Safe use of sharp instruments
• Follow post-exposure protocols
• Appropriate disposal of waste & cleaning of equipment/environment
• Antibiotic Stewardship – RIGHT diagnosis (indication), debridement, drug, dose,
duration, de-escalation
KEY TOPICS: Infection Prevention
There are 3 types of patient-specific transmission-based precautions in addition
to standard precautions
CONTACT – C.diff, Salmonella, Shigella, MRSA, CRE, MDRO, Norovirus, Lice, Scabies
• Spread by contact with skin, mucous membranes, feces, emesis, urine, wound
drainage, body fluids, environmental surfaces
• Staff & visitors use gown & gloves when patient or environmental contact
anticipated
• Use disposable single-use or dedicated equipment
DROPLET – Influenza, N. meningiditis, Pertussis, Rhinovirus, Rubella, Mumps
• Transmitted through close respiratory or mucous membrane contact
• Door need not be closed – large droplets DO NOT stay airborne
• Staff & visitors use surgical mask when within 6 feet of the patient
AIRBORNE – TB, Varicella, Measles
• Patient in negative pressure room with door closed
• Staff & visitors use N95 respirator when entering room
KEY TOPICS: Infection Prevention
NYS Law requires offering screening & immunization to specific populations
• Hepatitis C Virus (HCV) Screening - born 1945-1965
• HIV Screening - age 13-64
• Influenza Vaccine - age 6 months & older
• Pneumococcal Vaccination - age 65 & older
• Tdap – parents & anticipated caregivers of all newborns
KEY TOPICS: Sepsis
Time-sensitive interventions:
• AMI – “Door to Balloon”
• Stroke – “Door to t-PA”
• Trauma – “The Golden Hour”
• Sepsis
SIRS – 2 or more:
• Temperature > 101.0°F
• Temperature <96.8 °F
• Pulse > 90bpm
• Respiratory Rate > 20/min
• WBC count > 12,000
• WBC count < 4,000
• Band count > 5%
Pancreatitis
Infection
Sepsis
Systemic
Inflammatory
Response
Syndrome
Trauma
Burns
SIRS
2016
12
KEY TOPICS: Sepsis
The Sepsis Continuum
SIRS
Severe
Sepsis
Sepsis
Septic
Shock
RRT
Code
GREEN
•
•
•
•
•
•
•
Temperature > 101.0°F
Temperature <96.8 °F
Pulse > 90bpm
Respiratory Rate > 20/min
WBC count > 12,000
WBC count < 4,000
Band count > 5%
Sepsis with
Known or
organ dysfunction
suspected
• New AMS
Infection
• Lactate > 2.0
• PaO2/FiO2 > 300
+
O2 required
2 or more SIRS •• New
SBP < 90 or ↓ by 40
•
•
•
•
Cr > 2.0 mg/dl or ↑ 50%
UO < 0.5 ml/kg/h x 2h
Platelet count < 50,000
Coagulopathy
Refractory
Hypotension
SBP < 90 or
Lactate > 2.0
After fluids
KEY TOPICS: Fire Safety
All staff should be aware of fire safety measures
Two major causes of Hospital Fire
•
Smoking, Faulty Electrical Equipment
Particular risks
•
•
•
•
Patients confined to bed
Patients under sedation/anesthesia
Flammable gases such as oxygen
Large number of electrical devices & equipment
Order #1 is the Code for smoke, flames, or fire at NWH
NWH Procedure for smoke or fire
•
•
•
•
Rescue those in immediate danger
Alarm –PULL closest fire alarm box, CALL 1212 or PUSH “Fire/Code” button phone
Contain the fire/smoke spread
Extinguish or evacuate
KEY TOPICS: Compliance
Compliance simply means FOLLOWING THE RULES
Northwell has a compliance program to ensure that all business practices and delivery of care to our patients
are in compliance with applicable Hospital policies and procedures and applicable federal and state laws, rules,
and regulations. Part of this program includes avoidance of any actual, potential, or perceived conflict of
interest.
People reporting compliance issues are protected.
Key Focus Areas for Hospitals
• Submission of accurate claims and information
• Referral statutes: Physician self-referral (“Stark”) law & Federal anti-kickback statute
• Payments to reduce or limit services
• Billing Medicare or Medicaid substantially in excess of usual charge
• Emergency Medical Treatment and Labor Act (EMTALA)
• Substandard care
• Relationship with federal health care beneficiaries (Medicare patients)
• HIPAA privacy and security rules
Report Compliance Concerns & Issues:
• Division/Department chief, the Hospital Medical Director, or
the Office of Corporate Compliance at 516.465.8097
•
Anonymous reporting: Compliance HelpLine 800.894.3226
or [email protected]
2016
NWH Compliance Director:
Eric Sandhusen
516.465.3007
[email protected]
15
KEY TOPICS: HIPAA
There are specific policies to protect patient rights
HIPAA
•
•
•
Federal law to ensure the privacy & confidentiality of protected patient
information (PHI)
You may not use or disclose PHI- orally, electronically, or in writing
Hospital Privacy Officer: Debbie Pirchio – 914.666.1866
Informed Consent
•
Except in emergency situations, written informed consent must be given by each patient (or
healthcare agent or surrogate for an incapacitated patient or minor) prior to any surgical operation,
administration of anesthesia/sedation, blood transfusion, or all other MAJOR medical treatments
(medical, surgical, or diagnostic intervention or procedure which involves significant risk or
invasion of bodily integrity)
Disclosure
•
It is the practice at NWH to have honest discussions with patients about the outcomes of
treatments & procedures performed at the Hospital, including those outcomes that vary
significantly from that which was anticipated
16
KEY POLICIES & PROCEDURES
We have a code of conduct that calls for professionalism at all times
Code of Conduct – Professionalism
• High quality patient care & a culture of safety depend on teamwork,
communication, and a collaborative work environment.
• Disruptive and intimidating behavior can foster medical errors and
contribute to staff and patient dissatisfaction.
Treat all individuals with respect & dignity
No tolerance for discrimination and/or harassment
• Intimidating or threatening behavior
• Offensive jokes, slurs, negative stereotyping
• Unwanted sexual advances, innuendos, commentaries, displays
No tolerance for false accusations OR retaliatory behavior for reporting
2016
17
KEY POLICIES & PROCEDURES
We have the dueling obligations of reducing the incidence of opioid abuse, while
adequately managing pain
Assessment and Management of Pain
• All patients at NWH are entitled to a timely response to reports of pain (1996:5th vital)
• The RN caring for each patient will assess pain on initial presentation and at least every shift
thereafter
• Numerical Scale: None (0) Mild (1-3) Moderate (4-6) Severe (7-10)
• Behavioral Pain Scale: FLACC
• Neonatal Infant Pain Scale (NIPS)
I-STOP Internet System for Tracking Over-Prescribing Act – NY State
• 8/27/13 - Physicians/NPs/PAs have a DUTY TO CONSULT the Prescription Monitoring Program
(PMP) registry prior to prescribing or dispensing any controlled substance
• Practitioners may delegate consulting to office staff
• Exceptions: ED < 5 days; facility administration; hospice care; vet; technical failure
• 3/27/16 – Physicians/NPs/PAs must e-prescribe ALL prescriptions including controlled substances
(EPCS)
2016
18
QUALITY
VALUE = [Clinical Quality & Safety] [Patient Experience]
[Cost/Efficiency]
NWH Guiding Principles:
• TEAM WORK & COMMUNICATION
• PROCESS
reduce variability, increase efficiency
• ELECTRONIC MEDICAL INFORMATION SYSTEM as an enabler
•
Evidence-Based Order Sets (CPOE; ZYNX)
•
Medication Safety (CPOE, BMV, Alerts)
•
Communication & Transition (PDOC POC; DC)
2016
19
CLINICAL QUALITY
IQR: Inpatient Quality Reporting
OQR: Outpatient Quality Reporting
•
•
•
•
Evidence-based, best practice PROCESS measures
Regulatory/Accreditation Requirement
Reputational Impact www.hospitalcompare.hhs.gov
Financial Impact (P4P, VBP)
NYS Primary Stroke Center
Sepsis Protocol
20
CLINICAL QUALITY: IQR, OQR
VENOUS THROMBOEMBOLISM (VTE)
2013
2014
2015
2016
Medicine/Surgery admissions with VTE prophylaxis
or documented reason for no prophylaxis (%)
Critical Care admissions with VTE prophylaxis or
documented reason for no prophylaxis (%)
Patients with confirmed VTE discharged on warfarin
who receive discharge instructions with key
elements (%)
POTENTIALLY PREVENTABLE HA-VTE
Patients with confirmed hospital-acquired VTE who
did not have VTE prophylaxis the day before
diagnosis and no documented reason for no
prophylaxis (%)
92.6
99.1
99.6
e-CQM
87.8
100
100
e-CQM
100
100
100
100
0
0
0
0
21
CLINICAL QUALITY: IQR, OQR
Medicine Admission and Plan of Care/Progress Notes
2016
22
CLINICAL QUALITY: IQR, OQR
Surgical Specialty and Obstetrics Admission and Plan of Care/Progress Notes
2016
23
CLINICAL QUALITY: IQR, OQR
PERINATAL CARE
Of pregnant women admitted for induction or
Cesarean section from 37-39 weeks gestation,
percentage who have no documented medical
indication (percent “elective” deliveries)
(Target = 0%)
Antenatal Steroid Use in women 24-32 weeks
gestation who are at risk for preterm delivery
(Target = 100%)
C-section rate in full term, single, vertex
presentation, first time mothers (goal is to
decrease)
(Target = 23.9%)
Newborn Hospital-Acquired Blood Stream
Infections (Target = 0%)
Single term newborns fed exclusively breast milk
(Target = 70%)
2013
2014
2015
2016
4.2
1.0
0
0
66.7
83.3
100
100
31.9
41.5
43.2
42.5
0
0
0
0
N/A
66.7
62.3
61.0
24
CLINICAL QUALITY: IQR, OQR
HOSPITAL-BASED INPATIENT PSYCHIATRY (HBIPS)
2013
2014
2015
2016
Admission Screening (risk of violence, substance use,
psych trauma history, patient strengths) (%)
Multiple medications at discharge with appropriate
reason (%)
87.6
98.9
100
97.7
76.5
85.0
100
100
Alcohol Use Screening (%)
N/A
53.6
98.5
99.6
Alcohol Use Brief Intervention Offered (%)
N/A
N/A
N/A
51.1
Alcohol Use Brief Intervention Provided (%)
N/A
N/A
N/A
51.1
Tobacco Use Screening (%)
N/A
N/A
99.6
100
Tobacco Use Treatment Offered (%)
N/A
N/A
78.0
83.1
45.0
39.0
Tobacco Use Treatment Provided (%)
25
CLINICAL QUALITY: IQR, OQR
EMERGENCY DEPARTMENT FLOW MEASURES
2013
2014
2015
2016
ED Admitted Patients – Median Arrival to Departure
(minutes) – TARGET = 240
ED Admitted Patients – Median Decision to Admit
to Departure (minutes) – TARGET = 43
ED All Patients – Median Arrival to Practitioner
(minutes) –
TARGET = 13
ED Treated & Released Patients – Median Arrival to
Departure (minutes) – TARGET = 120
ED Median Time to Pain Management for long bone
fracture (minutes) – TARGET = 38
ED CT Result for Acute Stroke within 45 minutes (%)
– TARGET = 100%
ED Chest Pain – Median Time to ECG (minutes) –
TARGET = 10
ED Chest Pain – Aspirin at Arrival (%) – TARGET =
100%
ED Chest Pain – Median Time to Transfer (minutes)
– TARGET = 30
272
309
278
275
39
68
52
49
15
14
16
13.0
141
160
150
158
37
36
45
43
53%
88.9%
71.4%
81.8%
3.5
3.0
3.0
3.5
100%
100%
100%
100%
85.0
42.5
54.0
53.0
26
SAFETY
We support a culture of safety in which we openly discuss events as an
opportunity for improvement and monitor several hospital-acquired conditions
• Culture of Safety
• Safety Event Reporting System
• Hospital Acquired Infections
•
Catheter associated urinary tract infection (CA-UTI)
•
Central Line Associated Blood Stream Infection
•
Ventilator Associated Pneumonia
•
MRSA/CRE
•
Clostridia difficile Intestinal Infection
•
Surgical Site Infections (Colon, Hip, Hysterectomy)
• Medication Errors
• Nursing (Falls, Pressure Ulcers)
SAFETY
Our hospital-wide alert codes help create a safe environment for patients, staff,
and visitors
Summary of NWH Codes:
 Code 444 – cardiopulmonary arrest age 18 and older
 Code 444 Junior – cardiopulmonary arrest age < 18 years
 Code Pink – possible infant/child abduction
 Code H – maternal hemorrhage
 Code Purple – behavioral emergency/risk
 RRT – Rapid Response Team - serious change in patient’s medical condition
 RRT/Code Grey – possible stroke in hospital/ED
 RRT/Code Green – possible severe sepsis or septic shock in hospital/ED
 Code HICS – Hospital Incident Command System – an event possibly disruptive to normal
hospital operations (emergency hotline ext 7911)
•
•
•
•
Active Shooter – active shooter in building
Order #1 – fire or smoke alert
Watch Plan – fire system disruption
Plan Water Crisis - loss of water pressure
•
•
•
Plan 02 – emergency oxygen shut down
Plan Generator – loss of Con-Ed electrical
power
Plan PBX – phone system failure
SAFETY: Restraint & Seclusion
Restraint or seclusion may only be used when absolutely necessary to ensure the
safety of a patient, staff member, or other individual
Mechanical Restraint (non-violent: two point) – restraint to both wrists to prevent a patient from
interfering with life sustaining equipment
Mechanical Restraint (violent: four point) – restraint to both wrists AND ankles to protect the patient
from injuring him/herself or others
Medication Restraint – any medication used for the purpose of restricting or managing behavior or
freedom of movement that is NOT a standard treatment or dosage for a patient’s condition
Seclusion – involuntary confinement alone in a room from which a patient is physically prevented
from leaving (only on our behavioral health unit)
Key Points
•
Must be ordered by attending or covering physician or NP/PA ONLY after face to face physician evaluation
•
May NOT be ordered PRN and should be discontinued at the EARLIEST possible time
•
Must be renewed at specific time intervals (daily for 2 point, every 4 hours for 4 point)
•
Physician must do a daily evaluation of the patient
SAFETY: MRI Safety
Mandatory questions when ordering an MRI help ensure MRI Safety
• The Magnet is ALWAYS on and is 40,000 x stronger than gravity
• All equipment brought into room must be non-ferrous
• Patients who can NEVER have an MRI:
• Other implanted devices must have proper documentation and verification of
safety
o stents, valves, IUD, wire mesh, shunts, ports, orbital or penile prostheses, cochlear implants
PATIENT EXPERIENCE
NWH is a designated Planetree Hospital with distinction
IOM: Providing care that is respectful of and responsive to individual patient
preferences, needs, and values and ensuring that patient values guide all
clinical decisions
Planetree (1970s) - a framework for patient-centered care
•
•
•
•
•
•
•
Caring interactions with providers
Access to meaningful information
Involvement of family
Healing physical environment
Role of spirituality
Arts in healing
Food in healing
PATIENT EXPERIENCE
NWH exceeds national & state performance in patient experience survey scores
PATIENT EXPERIENCE
NWH Emergency Department patient experience scores reached the top 5%
95th
EFFICIENCY
To achieve HIGH VALUE CARE, we need to optimize resource utilization &
efficiency, in addition to focusing on quality, safety, & patient experience
• Cost of Care: Utilization Management
• Appropriate Level of Care – Observation/Admission
“2 midnight rule”
• Optimum utilization of resources
• Time Efficiency/Discharge Planning: Length of Stay
• Clinical Documentation Excellence
PROFESSIONAL PRACTICE EVALUATION - OPPE
The organized Medical Staff must continuously monitor the competency &
performance of ALL practitioners granted privileges
Profile for JOHN BONE, MD
Goal: an unbiased, reliable, and efficient
structure and process for the Medical Staff to
measure their own performance with a goal
of continuous improvement in patient care
SERVICE: ORTHOPEDIC SURGERY AND SPORTS MEDICINE
SPECIALTY: ORTHOPEDIC SURGERY
Profile last viewed by Provider: 01/18/2016
24 Month Values
Status
Indicator
My
Score
Peers
Score
Target
SPC Current
Alert Period
My
Score
Start
Month
A - Volume and Acuity
86
670
N/A
Jul-Dec
15
410
Jan
2014
Volume Admissions Inpatient PPE
29
330
N/A
Jul-Dec
15
120
Jan
2014
Volume Procedures Inpatient NW PPE
32
359
N/A
Jul-Dec
15
119
Jan
2014
0
3
N/A
Jul-Dec
15
0
Jan
2014
1
5
N/A
Jul-Dec
15
2
Aug
2014
Volume OSI Orthopedics Surgical
TOTAL PPE
86
663
N/A
Jul-Dec
15
407
Jan
2014
Volume OSI Joint Replacement PPE
32
304
N/A
Jul-Dec
15
114
Jan
2014
Volume OSI Knee Uni-Compartment
Navio PPE
0
13
N/A
Jul-Dec
15
0
Jan
2014
38
272
N/A
Jul-Dec
15
233
Jan
2014
100.0% 100.0% 100.0%
Jul-Dec
15
100.0%
Feb
2015
Volume Procedures Total NW PPE
A1 - Inpatient
A2 - Observation
Volume Consultations Observation
PPE Reports
A3 - Emergency Department
Volume Consultations ED PPE
Reports
Patient safety & quality
Fairness & collegiality
• Focused Professional Practice Evaluation
• Ongoing Professional Practice Evaluation
• PPEC
• Case Review – rated 1-3
• Aggregated data review every 6 months
A6 - OSI
Volume OSI Sports Medicine Surgery
PPE
B - Medical Knowledge Skill Judgment
Core VTE1 - VTE Prophylaxis Med
Surg NW PPE
Core VTE6 - Preventable HA-VTE NW
PPE
No
Data
0.0%
0.0%
Jul-Dec
14
No Data
No
Data
PSI-15 Accidental Puncture or
Laceration PPE
0
0
0
Jul-Dec
15
0
Jan
2014
PSI-12 Postoperative Pulmonary
Embolism PPE
0
0
0
Jul-Dec
15
0
Jan
2014
PSI-12 Postoperative Deep Vein
Thrombosis PPE
0
0
0
Jul-Dec
15
0
Jan
2014
PSI-13 Postoperative Sepsis PPE
0
2
0
Jul-Dec
15
0
Jan
2014
PSI-14 Postoperative Wound
Dehiscence PPE
0
0
0
Jul-Dec
15
0
Jan
2014
B3 - Patient Safety Indicators - PSI 90
Other Documents for Review
(in orientation packet and on Northwell site)
Policies
•
•
•
•
•
Disruptive, Intimidating, and Inappropriate Behavior
Impaired Physicians
Perioperative Evaluation of Adults
Sepsis Protocol
Assessment and Management of the Patient with Pain
General Information
•
•
•
•
•
•
•
•
•
•
•
•
Committee for Physician Health
Dictation Procedures (for medical record documentation)
Hospital Department Contact Sheet
The Hal Federman, MD Health Sciences Library
Welcome Letter from the Medical Staff Liaison
Welcome Letter from Officers of the Medical Staff
Meditech Training & Parking Key ID Badge Information
Meditech Remote Access Instructions
Northern Westchester Hospital 24/7 Language Interpretation Services
American Sign Language Interpretation Services
Policy Tech Policies & Procedures Overview
Quick Guide to the NWH Physician Section of the NWH Staff Web Site
YOUR THOUGHTS
Marla Koroly, MD, FACP
[email protected]
914.666.1950