MOUNTAIN VISTA MEDICAL CENTERMOUNTAIN VISTA MEDICAL CENTER1301 South Crismon Road1301 South Crismon Road

Mesa, AZ 85209Mesa, AZ 85209

New Provider New Provider OrientationOrientation

• PhysicianPhysician•Allied HealthAllied Health

Thank you for choosing Mountain Thank you for choosing Mountain Vista!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 Medical Staff Leadership 2014/20152014/2015Chief of Staff

◦ Sudhakar Reddy MDVice Chief of Staff

◦ Cynthia Anneski MDSecretaryoHani 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 AdministrationHospital Administration

Anthony Marinello, CEOSusan Dolezal, CNODan Houghton, CFOJoan Hoffstetter, Quality/Risk

ManagementSheryl Caracciolo, Compliance

Officer

About MVMCAbout MVMC8 Years Old- Opened July 2007178 beds & 20 Geropsych UnitLevel III Trauma CenterdaVinci SI Surgical system

◦ General Surgery ◦ Open Heart◦ Obstetrics◦ Urology

Aggressive Codes◦ Stemi◦ Stroke◦ Trauma

More About MVMCMore About MVMCTeaching program

◦Primary affiliation with Midwestern University

◦Affiliation with 20+ schoolsResidency Programs

◦Internal Medicine◦Family Practice◦General Surgery

Students◦Medical, PA, NP & CRNA

Hospital LayoutHospital Layout

Patient Rooms in Center towers1st Floor

◦ICU, Surgery, ER, Radiology, Cath Lab2nd Floor

◦Ortho/Spine & Med Surg3rd 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 car

Entrance/ParkingEntrance/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 ParkingPhysician Parking

Medical Staff Meetings 2015Medical Staff Meetings 2015

Electronic Medical RecordElectronic 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 480-710-6210 for computer training in the electronic medical record.

Incomplete Medical RecordsIncomplete Medical RecordsDEFINITION 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 Medical Records Dictation MVMCMVMC

Medical Records Dictation Medical Records Dictation MVMCMVMC

Medical Records Dictation Medical Records Dictation MVMCMVMC

Authentication & Authentication & AbbreviationsAbbreviations 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 ReportsOperative 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 findings2. Technical procedures used3. Specimens removed4. Postoperative diagnosis5. Estimated blood loss6. Name of primary surgeon and any assistants and/or

anesthesiologists

Progress NotesProgress 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 ReportsConsultation 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 CodesEmergency Codes

Safety InformationSafety Information

RACE◦Rescue◦Alarm◦Contain◦Extinguish/

Evacuate

PASS◦Pull◦Aim◦Squeeze◦Sweep

MSDS◦Available in each

unit◦Available online

Safety TipsSafety 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 RoomsNo Smoking in the Parking LotsSmoking allowed on public

sidewalks off MVMC property

Non Smoking Please!Non Smoking Please!

Patient EvacuationPatient Evacuation

1. Horizontal Evacuation◦ Go through fire doors on other

end of same floor2. Vertical Evacuation

◦ Transport the patients to another floor

Electrical SafetyElectrical Safety

Always use three prong power plugTo remove, pull from plug, not

from cordRed plugs are for Emergency

PowerEquipment Failure/Damaged

◦Contact Nursing Dept for that floor

Infection ControlInfection 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 PrecautionsStaff 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 PrecautionsIsolation PrecautionsThere 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 precautionsUse appropriate Personal Protective

Equipment (PPE)

National Pt Safety GoalsNational Pt Safety Goals

Identify Patients Correctly◦Use at least 2 ways to identify patients

Staff Communication◦Report information correctly &

efficientlyPrevent Infection

◦Follow hand cleaning guidelines◦Follow proven guidelines

Time Out◦Is this the correct patient? Procedure?

Location?

Patient Fall PreventionPatient 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-ViolentRestraints, Non-ViolentAssessment

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

ApplicationApply least restrictive restraint using appropriate technique

Patient/familyNotify 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, ViolentRestraints, ViolentAssessment

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/familyNotify 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

PersonalPersonal Electronic Electronic EquipmentEquipmentCELL 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.

EMTALAEMTALA

HIPAAHIPAA

HIPAA – Health Insurance Portability and Accountability Act was passed by congress in 1996.

The purpose of HIPAA was to create national standards to protect a person’s health information

Star Stands forS – SERVICET – TEAMWORKA – ATTITUDE AND ACCOUNTABILITYR - RESPONSIVENESS

STAR StandardsSTAR Standards

ALERT LINEALERT 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 602-251-8596. You may also call 1-877-898-6080

Medical Staff ServicesMedical Staff ServicesSandy Elcock, DirectorSandy Elcock, Director

480-358-6158480-358-6158

Tina Deddo, Medical Staff AssistantTina Deddo, Medical Staff Assistant480-358-6164480-358-6164

Vickie Rockwell, Credentials CoordinatorVickie Rockwell, Credentials Coordinator480-358-6163480-358-6163

 

I acknowledge that I have received and reviewed the orientation packet provided to me by Mountain Vista Medical Center.

 

 

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