Orientation-Power-Point-Nov2011

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PINNACLE HEALTH
HOSPITALS
MEDICAL AND ALLIED HEALTH
STAFF
ORIENTATION
Medical And Allied Health Staff Orientation
Thank you for applying to the Medical/Allied Health Staff of Pinnacle Health System.
I hope you will find the enclosed information helpful when you begin your privileges at
Pinnacle Health. Please take the time to read through the information.
Instructions on using Pinnacle Health’s digital dictation system are enclosed. A
dictation number may be obtained from Medical Transcription at telephone number
782-4780. A Pinnacle Health Identification Badge and/or parking information may be
acquired by calling Bob Beverlin at 782-3570. Access and training for the clinical
information systems is provided during the onsite orientation.
Physician Net Access is a service offered to physicians enabling you to view patient
information from your private office. If you are interested in this service, further
information and qualifications may be obtained by contacting Information Services at
231-8840.
The Medical Staff Orientation Acknowledgement must be received in the
Credentialing Office prior to your application being presented to the
Credentials Committee. If you have any questions regarding the information,
please do not hesitate to contact the Credentials Office at 231-8582/8583/8584/8585.
WELCOME TO PINNACLE HEALTH HOSPITALS
A Tradition of Caring
PinnacleHealth System
The foundations of PinnacleHealth System dates to
1873, when Harrisburg Hospital was established. In
1909 another Harrisburg community hospital, Polyclinic
Medical Center, was established to provide healthcare
services and programs to the community.
In 1995 the two organizations merged to form
PinnacleHealth System, which included Harrisburg
Hospital, Polyclinic Hospital and Seidle Hospital (another
local hospital formed in 1936). In August 1998
Community General Osteopathic Hospital (1941), the
area’s only osteopathic hospital, merged with
PinnacleHealth System.
Our Mission . . .Our Vision . . .
Our Values . . .
Mission: PinnacleHealth System is a charitable organization dedicated to maintaining
and improving the health and quality of life for all the people of central Pennsylvania.
Vision: PinnacleHealth will be the most caring, innovative, disciplined and trusted
health system in Central Pennsylvania.
Values:
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Concern for the total well-being of people in our community and our System family
Professionalism in dealing with our customers and each other
Respect for individual dignity and for the needs, talents and differences of others
Charity towards others and from others
Collaboration with and through our employees, affiliated physicians, other health
providers and organizations
Satisfaction for those who entrust us with their care and for ourselves in fulfilling our
mission
Accountability for the quality of care and the appropriate use of community resources
Safety in each act of care for our patients, our staff and our community and the design
in the environment in which we work.
Letter from the Pinnacle Health Hospitals Medical Staff President
Dear Colleague:
On behalf of the Medical Staff of the PinnacleHealth Hospitals, it is my pleasure to welcome you. The other Medical Staff
Officers are Daniel Kambic, DO, president-elect, and, Harold Yang, MD, secretary-treasurer.
The quarterly medical staff meetings are held on the fourth Tuesday in March at 6 p.m. in Conference Rooms 1, 2, and 3,
Community General Hospital; and in June and September at 6 p.m. in the Seven Bridges Dining Room, 11th Floor,
Harrisburg Hospital and the second Tuesday in December at 6 p.m. at the Harrisburg Hilton Hotel and Towers. It is my
pleasure to introduce our new members at the September medical staff meeting. It is a good opportunity to meet your fellow
colleagues at the dinner meeting. I hope you will be able to attend.
The latest edition of our Medical Staff Bylaws, Rules and Regulations is available on the PinnacleHealth website for your
perusal and reference. We would encourage you to familiarize yourself with this document.
Our medical staff is composed of 11 departments – Anesthesiology, Cardiovascular Services, Emergency Medicine, Family
Practice, Laboratories, Medicine, Obstetrics & Gynecology, Orthopedics, Pediatrics, Radiology and Surgery. Each
department has a chairperson and most of the departments have sections and section chiefs. The medical staff organization
is included within this manual for your reference.
Our medical staff committee structure includes standing and special medical staff committees. Medical staff department
chairperson may also form their medical staff department committees. In addition, many of our medical staff members either
chair or serve on several PinnacleHealth Hospital committees. The medical staff committees are summarized in subsequent
pages. Please notify me if you are interested in serving on any of the medical staff committees.
Only two committees (Credentials Committee and the Medical Executive Committee) have 50 percent attendance
requirements. All active medical staff members, however, are encouraged to attend the quarterly medical staff meetings,
your department meetings, as well as any medical staff committees on which you have membership. A meeting schedule is
enclosed as a separate document.
Medical staff dues are assessed yearly with rates approved at the Annual Medical Staff Meeting. Currently the dues are
$175 for active medical staff members; no dues are assessed for affiliate and honorary medical staff members. Dues are
prorated for new members.
Again, welcome to our medical staff. We look forward to your participation.
Sincerely,
Roger Levin, MD
Medical Staff President
Letter from the President and CEO
Dear Physician:
Welcome to PinnacleHealth System. We hope this is the beginning of a long and mutually
rewarding association for you.
PinnacleHealth is the result of mergers between the area’s most respected health systems:
Capital Health System, Community General Osteopathic Hospital and Polyclinic Health System.
Together, we continue to serve the health needs of Central Pennsylvanians, as we have for over a
century. In this totality, PinnacleHealth includes PinnacleHealth Hospitals (Harrisburg, Polyclinic,
Seidle and Community General Osteopathic Hospitals); Fredricksen Outpatient Center; family
practice and urgent medical care centers; home healthcare and hospice agencies; managed care
entities and an array of healthcare services.
We pride ourselves on the high caliber of physicians who join our Medical Staff. As a member of
our Medical Staff, you should know that we’re serious about our mission in the community:
“PinnacleHealth is a charitable organization dedicated to maintaining and improving the health
and quality of life for all the people of Central Pennsylvania.”
Our success in fulfilling that mission is dependent on the personal contribution of each and every
member of our PinnacleHealth team. We look forward to working with you as we strive to
strengthen both our organization and the health and quality of life for our neighbors and ourselves.
Welcome aboard.
Sincerely,
Michael Young
President and CEO
PinnacleHealth System
Medical Staff Organization
Medical Staff Officers
July 1, 2012 through June 30, 2014
Roger Levin, MD – President
Daniel Kambic, DO – President – Elect
Harold Yang, MD – Secretary-Treasurer
Senior Vice President of Medical Affairs
Nirmal Joshi, MD
Medical Staff Organization
DEPARTMENT OF ANESTHESIOLOGY
Chairperson – Mukul Parikh, MD
Vice Chairperson – Edwin Gillman, MD
Section
Chief
Cardiovascular Anesthesiology
Zahid Khan, MD
Pain Anesthesiology
Jean Santo, MD
Neonatal Care
William Motter, MD
Obstetrics / Acute Pain Anesthesiology
Mark Dion, DO
Elected Medical Executive Committee Representative: Edwin Gillman, MD
DEPARTMENT OF CARDIOVASCULAR SERVICES
Interim Chairperson – Felix Gutierrez, MD
Vice Chairperson –
Section
Chief
Cardiac Surgery
Cardiology
Felix Gutierrez, MD
Vascular Surgery
John Calaitges, MD
Elected Medical Executive Committee Representative: Felix Gutierrez, MD
Medical Staff Organization
DEPARTMENT OF EMERGENCY MEDICINE
Chairperson – Craig Skurzinski, MD
Vice Chairperson, Jed S. Seitzinger, DO
Elected Medical Executive Committee Representative: Eleanor Dunham, MD
DEPARTMENT OF FAMILY PRACTICE
Chairperson – Larry Espenshade, DO
Vice Chairperson, Daniel Kambic, DO
Elected Medical Executive Committee Representatives: David Ferner, DO & Brian Uniacke, MD
DEPARTMENT OF LABORATORIES
Chairperson – James Piper, MD
Vice Chairperson – Frank Rudy, MD
Medical Staff Organization
DEPARTMENT OF MEDICINE
Chairperson – Richard H Jeffries, DO
Vice Chairperson – John Goldman, MD
Section
Chief
Allergy
Robert Zuckerman, MD
Dermatology
Michael Gette, MD
Endocrinology
Renu Joshi, MD
Gastroenterology
John McLaughlin, DO
General Internal Medicine
Richard H Jeffries, DO
Hematology / Oncology
Scott G Barnes, DO
Infectious Diseases
Vacant
Medical Toxicology
J Ward Donovan, MD
Nephrology
Mohamed Elnour, MD
Neurology
Nicole Purcell, DO
Physical Medicine and Rehabilitation
Steven Morganstein, DO
Psychiatry
Vacant
Pulmonary and Critical Care Medicine
Franklin Myers, III, MD
Radiation Oncology
Vacant
Rheumatology
Robert Sanford, MD
Elected Medical Executive Committee Representatives: Safa Farzin, MD, John McLaughlin, DO,
and Robert Schwartz, MD
Medical Staff Organization
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
Chairperson – Kenneth Oken, MD
Vice Chairperson, William Byrne, MD
Section
Chief
Gynecologic Oncology
Jose Misas, MD
Gynecology
Edward Woodward, MD
Obstetrics
Terry Tressler, DO
Ob/Gyn Outpatient Services
Mary Beth Hagan, MD
Elected Medical Executive Committee Representative: William Byrne, MD
DEPARTMENT OF ORTHOPEDICS
Chairperson, Ronald Lippe, MD
Co-Vice Chairperson, John Frankeny, II, MD
Co-Vice Chairperson, Walter Peppelman, DO
Section
Podiatry
Chief
Jeffrey Marks, DPM
Elected Medical Executive Committee Representative: Ernest Rubbo, MD
Medical Staff Organization
DEPARTMENT OF PEDIATRICS
Chairperson – Bhupinder Varma, MD
Section
Chief
Neonatology
Margaret Donahue, MD
Pediatric Cardiology
Vacant
Pediatric Infectious Diseases
Vacant
Pediatric Pulmonology
Vacant
Elected Medical Executive Committee Representatives: Michael Consevage, MD & Harry
Weber, MD
Medical Staff Organization
DEPARTMENT OF RADIOLOGY
Interim Chairperson – Jonathan Stephenson, MD
Section
Chief
Angiography
Vacant
Computerized Tomography
Paul Potok, MD
Diagnostic Radiology
William Miller, Jr, MD
Magnetic Resonance Imaging
Charles Austin, MD
Mammography
William Miller, Jr, MD
Nuclear Medicine
Christine Gouldy, MD
Ultrasound
Vacant
Elected Medical Executive Committee Representative: Brian Harris, PhD, MD
Medical Staff Organization
DEPARTMENT OF SURGERY
Chairperson – Raymond Kostin, MD
Vice Chairperson, R. Scott Owens, MD
Section
Chief
Otolaryngology Surgery
Roger Levin, MD
General Surgery
Raymond Kostin, MD
Neurosurgery
Barry Moore, MD
Ophthalmology
Brett Ernst, MD
Oral & Maxillofacial Surgery and Dentistry
Harry Meyers, DDS
Pediatric Surgery
Domingo Alvear, MD
Plastic Surgery
Dennis Banducci, MD
Urology
Francis Duggan, Jr, MD
Elected Medical Executive Committee Representatives: Paul Creay, MD, Luciano DiMarco, DO,
R. Scott Owens, MD
Medical Staff Committees
PinnacleHealth Hospitals Medical Staff Committees are constituted for two years. The current
appointment period is from July 1, 2012 through June 30, 2014. Some committees have threeyear appointment terms. Three voting members constitute a quorum except for the Medical
Executive Committee where a 50 percent attendance is required for a quorum. There are eleven
medical staff departments — Anesthesiology, Cardiovascular Services, Emergency Medicine,
Family Practice, Laboratories, Medicine, Obstetrics and Gynecology, Orthopedics, Pediatrics,
Radiology and Surgery.
Medical staff committees include the Medical Executive Committee described in Article VI of the
MEDICAL STAFF BYLAWS; Standing Committees of the Medical Staff described in Appendix 1,
Section 3 of the MEDICAL STAFF RULES AND REGULATIONS; and Special Committees of the
Medical Staff described in Appendix 1, Section 4 of the MEDICAL STAFF RULES AND
REGUALTIONS. Special Committees cease every two years unless reconstituted by the Medical
Executive Committee. Department chairpersons may also create department committees to
expedite their responsibilities. In addition, active medical staff members are involved in several of
the patient related hospital committees. These appointments are usually confirmed by the
Medical Staff President.
All medical staff committees submit written reports of their activities (via their meeting minutes)
and any recommendations to the Medical Executive Committee. Relevant recommendations are
then submitted by the Medical Executive Committee to the Board of Directors for action. Activities
of the Medical Executive Committee are reported to the medical staff at every quarterly meeting
by its chairperson (Medical Staff President).
A 50 percent attendance requirement is required for members of the Medical Executive
Committee and the Credentials Committee. Other members are encouraged to support the
Medical Staff Committees to which they accept appointment. The Medical Staff Rules and
Regulations identify the Medical Staff Committees, the chairpersons, main purposes and general
constituencies. Please read the relevant section in the Medical Staff Bylaws and related
documents for more information.
Forbidden and Approved Abbreviations
FORBIDDEN abbreviations or Dose Designations
PinnacleHealth System
Approved Abbreviations/Symbols
Medical Staff Bylaws, Rules and Regulations
The latest edition of our Medical Staff Bylaws, Rules and
Regulations is available on the PinnacleHealth website for your
perusal and reference. We would encourage you to familiarize
yourself with this document.
We also have a document, Medical Staff Bylaws for Dummies and
very busy physicians, which is a condensed version of the
Bylaws.
Credentialing Policies and Procedures
The latest edition of our Medical Staff Policies and Procedures is
available on the PinnacleHealth website for your perusal and
reference. We would encourage you to familiarize yourself with
these documents.
For information regarding the processing of your application, please
refer to Policy # 3, Initial Appointment Policy or Policy # 21, Allied
Health Staff Initial Appointment Policy.
Also, please review Policy # 17, Emergency Medical Staff
Privileges.
Compliance
Mission: The Compliance Department is responsible to plan, design,
organize, implement and maintain system-wide compliance programs
to comply with all laws, regulations and internal policies.
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Our Services
Monitor compliance policies and procedures
Provide a resource for compliance related questions
Conduct compliance audits and monitoring services
Administer the Compliance Hotline
Conduct compliance education and training
Respond to detected compliance deficiencies and establish
action plans
Perform voluntary disclosures (self reporting) to Office of
Inspector General (OIG) for material compliance violations
Infection Control
Mission: The PinnacleHealth Infection Control Department is
committed to providing high quality patient care in a safe
environment by reducing the risk of infection. Please review the
Infection Control web page.
Continuing Medical Education
The CME mission of Pinnacle Health System is to provide diverse
educational programs that improve the knowledge, skills and attitudes of the
physicians and other clinical staff of the institution. Such programs should
enhance practice performance and ultimately improve overall health care
delivered by the clinical providers. These goals are integral to Pinnacle
Health’s overall mission of improving health and quality of life for all people
in the region.
Purpose:
The purpose of our CME programs is to provide diverse educational
opportunities to improve the knowledge, skills and attitudes of the
physicians and other clinical staff of the institution. We will address core
competencies such as patient care, communication skills, medical
knowledge, practice-based learning and improvement, system-based
learning and professionalism. The Continuing Medical Education
Committee, with the assistance of the Performance Improvement
department, will work to ensure that the education it provides meets the
specific patient care needs of the institution. We will achieve this mission by
the continued development, assessment, conduct and evaluation of our
CME offerings.
Performance Improvement
The Performance Improvement Department's mission is
to improve performance in six key elements of quality
care:
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Safety - preventing harm
Effectiveness - evidence-based care that results in
maximum benefit
Patient Centeredness - respectful and responsive to
patient needs
Timeliness - reduce waits and delays
Efficiency - achieve best outcomes with least
resources, avoid waste and overuse
Equity - quality care does not depend on gender,
ethnicity, socioeconomic status, or location
Security
The Department of Security Services has an
office located at each hospital campus. Staff
includes security supervisors and both full and
part time Security Agents. Each hospital facility
is staffed 24 hours daily, seven days a week.
Please review the many services offered by
security on their web page.
A Pinnacle Health Identification Badge and/or
parking information may be acquired by calling
Bob Beverlin at 782-3570.
Level of Intensity
The Pinnacle Health Hospitals has established
procedures by which the attending physician,
the patient, and the patient's family or legal
representative may decide appropriate levels of
medical care reflecting the patients wishes.
Each patient upon admission to the Pinnacle
Health Hospitals shall have a Level of Intensity
(LOI) assigned.
Please review Administrative Policy # 113, Level
of Intensity of Care Assignment.
Infant Deliveries by Gestational Carrier
PinnacleHealth Hospitals shall provide an appropriate
environment for infant deliveries by gestational carries
which responds to the medical needs of the patients and
which acknowledges judicially recognized rights
regarding deliveries by gestational carries.
Please review Administrative Policy # 161, Infant
Deliveries by Gestational Carriers.
Laboratory
The PinnacleHealth System maintains a full
service clinical laboratory. The clinical
laboratory is comprised of the following
departments: blood bank, routine clinical lab
(chemistry, coagulation, hematology,
toxicology, urinalysis), and microbiology.
Additionally, comprehensive cytological and
tissue pathology services are offered by the
department of laboratory medicine.
The Commonwealth of Pennsylvania
licenses this clinical facility and it is fully
accredited by CLIA (Clinical Laboratory
Improvement Amendments). The laboratory
also maintains current accreditation from the
following agencies: The College of American
Pathologists (CAP) and the Joint
Commission. The Blood Bank also
maintains current accreditation status from
the American Association of Blood Banks
(AABB) as well as following Food and Drug
Administration (FDA) regulations. The
laboratory is staffed by highly trained
professionals and adheres to a strict quality
control program.
Frequency and cost are the main factors
that determine whether tests are
performed on site. For limited volume or
technically demanding tests, PinnacleHealth
uses appropriate reference laboratories.
The laboratory strives to provide its patients
with the best type of care and services
available. Specimens are processed upon
receipt, and test results are reported within
the shortest possible period of time as
dictated by the limits of the method used for
the specific test that was requested. The
laboratory information system consists of the
Sunquest Flexilab and WindoPath software
systems. The laboratory’s systems are
interfaced with the hospital information
system; Siemens Soarian. This allows the
laboratory to receive orders for laboratory
tests, as well as admission, discharge and
patient transfer information. A results
interface is responsible for the transmission
of laboratory results back into Soarian, so
that results are available through a result
inquiry function from any hospital terminal.
Laboratory results are also available on the
intranet via Physician Net Access.
A regularly scheduled courier service is
available to pick up specimens and deliver
reports directly to your office for your
convenience. This service enables us to
provide the fastest possible turnaround time
for your test results. Couriers are also
available on an as-needed basis.
Many tests are available on a STAT basis.
Results will be available within one hour
after the specimen is received in the
laboratory.
Library Services
The staff of PinnacleHealth Libraries provides professional Library
services to meet the information, education, and research-related
needs of PinnacleHealth medical staff, employees, and patients, and
offers access and assistance to community members with health
information needs.
Pinnacle Health Auxiliary
The Auxiliary is an organization of men and women
dedicated to volunteerism within Pinnacle Health
Hospitals. They conduct many fundraising projects each
year that benefit a wide variety of patient care programs
and promote community awareness.
Our Auxiliary membership is open to all those interested
in giving of their time for these important services. For
further information please visit Auxiliary web page.
Pain Management
Pinnacle Health believes pain relief is an integral
part of comprehensive care. Pain relief requires
individualized treatment to total pain: physical,
psychological, social and spiritual pain. Pain
management involves collaboration among
patients, families, and the health care team to
facilitate healing and comfort, and improve the
quality of life. A patient has the right to pain
management through assessment, interventions
and reassessment. Optimal pain relief facilitates
the patient’s ability to cope and heal, thereby
enhancing quality of life.
Please review Administrative Policy # 327, Pain
Management.
Thank you for completing the Medical and
Allied Health Staff Orientation program.
You are required to complete an orientation
attestation found by clicking on the highlighted
link.
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