The Physicians Guide to UH Life
For more information check us out on the web:
www.universityhealth.org
TABLE OF CONTENTS
Paging Procedures
Frequently Called Numbers
Required Standard Orders
UH Senior Management
Medical Staff Services
Health Information Management
Portal System
Unapproved Abbreviations Listing for Medication Orders
Emergency Codes
Department & Committees Calendar
Composition of MEC and Committees
CME Calendar
Surgical Services/Patient Scheduling
Code of Conduct
The Practical Definition of Sexual Harassment
Physician Wellness

Health Care Professional Impairment

Practitioner Assistance Committee
COBRA / EMTALA Requirements
For Best Results…
Infection Control
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1
2
3
4–8
9
10 – 11
12
13
14 – 15
16
17
18
19
20
21
22
23 - 25
26
27
PAGING PROCEDURES
How to Page a University Health Care System Pager:
 From any hospital extension (on or off campus), dial
77.
 From any touch-tone telephone outside the hospital,
dial 722-1047.
You will be prompted to enter the page number you wish
to reach. After the four-digit pager number is entered, you
will be prompted to make a voice page or enter a phone
number to be displayed on the pager. No further action is
required. When entering a numeric page, choose a
number which will be significant to the paged party and
accessible regardless of where he or she might be. For
example, enter an extension if the paged party is in-house,
but a direct dial number if the party is outside the hospital.
Do not enter the main number of the hospital without
including an extension number.
Frequently Called Numbers
Hospital Main Number – 722-9011
Department
Access Services

Central Scheduling &
Benefits

Patient Placement
Administrator on-call
Admissions
Answering Service (UH)
Ask-A-Nurse / Physician
Referrals
Cardiopulmonary Lab
Cath Lab
Chief Medical Officer
CME Conference Line
Education Resources
Employee Health
Endoscopy Lab
ER Coordinator’s Desk
Health Information
Services
Infection Control
Laboratory / Pathology
Medical Staff Office
Nursing / house supervisor
OR Scheduling Desk
Pediatric Floor
Pharmacy

Retail Pharmacy

In-patient Pharmacy
Physician Support Services
Radiology
Surgical Services

Day Surgery Center

Endoscopy

Main Operating Room
University Physician
Associates
Vascular Lab
Well Baby Nursery
Contact Person(s)
Cyndi Copeland
Kay Buckner
William Farr, MD
Peggy Sease
Danita Ducey
Vivian Ashline
Wendy Chandler
Cecile Harwood
Christine Martin
Jo Ann Baldridge
Phone Number
774-5318, 774-5300
774-5777
774-2121
Hospital operator “0”
774-2126 / 774-5312
774-8777 / 774-2596
828-2580
774-2201
774-3186
774-8076
774-7878
774-2888
774-2238
774-2131
774-2112
774-5858
774-2543
774-5400
774-2165
Hospital operator “0”
774-5623 / 774-5619
774-2315
774-2255
774-2719
774-5211
774-2920
774-2191
774-5619
774-2086
774-5621
774-5619 / 774-5623
774-8080
774-5528
774-2331
REQUIRED STANDARD ORDERS
A listing of all standard order sets may be accessed
on University Health Care System’s Intranet. Simply
click on MD Orders.
University Health Care System
Senior Management
J. Larry Read
President/CEO
University Health Care System
Dave Belkoski
Vice President
Finance
University Health Care
System
Marilyn Bowcutt
Vice President
Patient Care Services
University Health Care
System
Pete Brodie
President/CEO
University Health Care Foundation
Ed Burr
Vice President
Legal Affairs/Compliance Officer
University Health Care System
Bill Colbert
Vice President/CIO
Information Systems
University Health Services
Dr. William Farr
Chief Medical Officer
University Health Care System
Kyle Howell
Vice President
Support and Facilities Services
University Health Services
Andrew Lasser, Dr.Ph
Executive Vice President
Business Development
University Health Care
System
Jason Moore
Executive Vice President/COO
University Health Services
and Extended Care
Rick Roche
Vice President
Human Resources
University Health
Services
Robert Taylor
Vice President
Chief Financial Officer
University Health Care
System
Doug Wilson
CEO
University Health Link
MEDICAL STAFF SERVICES / CME
Medical Staff Office
University Hospital
1350 Walton Way
Augusta, GA 30901-9884
706-774-2165 - Main
706-774-5067 - Fax
MEDICAL STAFF
OFFICE
REPRESENTATIVE
Wendy Chandler
DIRECT
PHONE
NUMBER
774-5788
wchandler@uh.org
Harriet Gulledge
774-5786
hgulledge@ uh.org
Sue Bruce
Deborah Richardson
774-5704
774-5785
Physician
Relations/CME
Julie Martinez
Departments
Coordinator
Daphne Zellars
774-7879
CME
Conference
Line:
774-7878
774-8951
sbruce@uh.org
dwrichardson@uh.or
g
jmartinez@uh.org
MEDICAL STAFF
SERVICES
Manager, Medical
Staff Office
Allied Health
Applicants
New Applicants
Reappointments
E-MAIL
ADDRESS
dzellars@uh.org
Health Information Services (Medical Records)
General Information
Health Information Services (HIS) is located on the third floor of the
Ambulatory Care Building and is open 24 hours. The Incomplete
Record Area is staffed Monday through Friday 6 a.m. – 8 p.m. For
any additional information or concerns, please contact Danita
Ducey, Director of HIS at 774-5858.
Dictation/Transcription
A pocket card of dictation instructions will be provided to you for
your reference. Please follow the format listed in the reference card.
Your dictation number is your physician identification number.
When dictating, please state the patient’s name and MR# clearly,
provide spelling, and your name.
When requesting carbon copies, please spell the physician’s name
and give an address if the physician is not local. Please remember
to identify first names for common names such as Smith and Jones.
Clearly indicate where any corrections in your dictation should be
placed.
For dictation or transcription assistance, please call 774-2841.
Documentation
Please refer to the Medical Staff Rules and Regulations regarding
documentation and completion of medical records.
Only abbreviations listed in the hospital approved abbreviation list or
on the list of abbreviations specific to University Hospital should be
used in the medical record. Medical Abbreviations, 11th Edition,
published by Neil M. Davis, is the approved listing. See attached list
of abbreviations not to use that was adopted by the Hospital.
Documentation should be legible. We maintain a file of signatures
for our reference and for use by the Pharmacy. Please sign the two
cards provided in your packet and leave them with your Orientation
Leader. Due to continued challenges with the identification of
physician signatures, the Medical Executive Committee established
that physicians use their 4-digit ID numbers along with signatures on
all patient orders. This practice can be extended when signing all
other entries.
Documentation should be complete and timely. Please document
all diagnoses, procedures, and abnormal test results. As part of our
Documentation Improvement Program and our coding process,
physicians may be queried for additional information. Your
cooperation is greatly appreciated!
Please refer all coding questions to Diane Thornton at 774-5883 or
Rita Colwell at 774-5835.
Record Completion/Delinquent Process
On August 16, 2004, an electronic medical record was
implemented. All physicians need to be trained on how to search
and navigate through the electronic record and electronically
complete their deficiencies. Call 774-5860 to schedule your training.
Records are due 14 days after dismissal. Reminder letters are
mailed 1 week prior to due date of charts. The Delinquency List is
posted every Thursday at 9:30 a.m.
The Delinquency List is updated every weekday at 2:00 p.m. for
concurrent delinquent history and physicals, operative notes,
procedure notes and cardiac cath reports.
Once placed on the Delinquent List a physician will be unable to
schedule an admission or surgery until the delinquency is
completed.
Physician Portal
HorizonWP® Physician Portal provides physicians with
anytime, anywhere access to vital patient information
from disparate sources, enhancing care delivery and
promoting rapid adoption of information technology.
With a single sign-on, physicians can access data
enabled to the portal from across the enterprise, both
inpatient and outpatient information, and personalize
views according to their workflow needs.
From within the hospital, Portal can be accessed
through our Intranet and for remote access go to
www.uhcs.org.
To schedule your Physician Portal training, please
contact the IS Helpdesk at 706-774-5050.
Unapproved Abbreviations NOT To Be Used *
Abbreviation
For
Abbreviations for
any chemotherapy
drug (e.g., VCR,
MTX, etc.)
MS or MSO4
Morphine
sulfate
Reason
Use Instead
Chemotherapy
agents are very
high risk
medications.
Write out the names
of these
medications.
Magnesium &
Morphine have
chemical names
that are very
similar.
Write out Morphine
sulfate.
No Abbreviations
for chemotherapy.
MgSO4
Magnesiu
m sulfate
QD or q.d.
Every Day
Misread as qid
(four times a
day), or OD
(right eye).
Use q-day (or Qday) or write out the
word “daily”.
QOD
Every other
day
Misread as QID,
or QD.
Write out “every
other day”.
1 mg/ml/
unit, etc.
Misread as 10
mg (etc.).
DO NOT use
terminal zeros for
doses expressed in
whole numbers; DO
use a leading zero
before a decimal for
clarity, e.g. 0.5 mg.
U
Units
Misread as a
zero (0) or µ
(micro).
Write out “units”.
IU
Internation
al Units
Misread as IV or
as 10.
Write International
Units.
Zero after decimal
point (1.0, etc.)
Write out
Magnesium sulfate.
Abbreviations Strongly Discouraged
“cc”
ml; rate or
unit of
volume
Can result in
dose error by
being read as
either a zero or
a “u” (units).
Use “ml”.
SC or SQ
Subcutane
ous
Misread as SL
(sublingual).
Use sub-q, sub-Q or
write out
subcutaneous.
µ
Micro
Misread as a
zero (0) or “u”
(units).
Use Mcg or mcg.
EMERGENCY CODES
“Code Red”
An uncontrollable fire has occurred. The following steps must be followed (refer to University Hospital Policy
Handbook, G-13):
1. Remove anyone in immediate danger.
2. Close the door to the area to help contain the fire and smoke.
3. Activate the nearest fire alarm pull station. An alarm will sound throughout the entire building and send a
computerized message to Safety & Security.
4. Dial “66” and inform the operator of the “Code Red” and location of the fire.
5. Close all other doors.
6. If you are not in the immediate area of the fire, close all doors and continue with normal duties until further
instructions are given.
“Code Orange”
A hazardous spill or release has occurred in the hospital environment. All calls regarding radiation contamination
and chemical incidents should be forwarded to the Emergency Department. Notification of biological incidents
should be referred to Infection Control. Refer to University Hospital Policy Handbook, G-7.
“Code Yellow”
Assistance is needed in helping evacuate patients or move equipment. When this code is announced, each
department should send one non-managerial person to the Auditorium. Information will be given to the people sent
to the Auditorium concerning their duties and work locations. Refer to University Hospital Policy Handbook, G-13.
“Code Pink”
The Women’s Center has confirmed that an infant is missing. All employees should be on the lookout for anyone
carrying a small child, anyone with a large bag (big enough to conceal an infant), anyone in very loose-fitting clothes,
etc. If you see a suspicious person(s), contact Security immediately to give the person’s description and direction of
travel.
“Code Purple”
A unit or area needs assistance in restraining a patient. (Dial “66” and inform the operator that a “Code Purple”
exists.) When this code is announced, the Administrative Nursing Supervisor, the Resource Nurse and Security
respond to the involved area/unit.
“Code Blue”
There is a medical emergency, and a person is in dire need of medical attention. In the main hospital, employees
should dial “66”, and the in-house emergency response team will be paged to the involved area. Areas outside of
the main hospital should call “911” for an ambulance to be dispatched and then”66” to request that the
“Code Triage”
Administrative Nursing Supervisor respond. Refer to University Hospital Policy Handbook, G-117.
A disaster has occurred that is going to cause an influx of patients in the Emgerency Department. Each department
has a responsibility during a “Code Triage.” Employees should check with their supervisors for assignments. If you
are assigned to the Labor Pool, you should go to the Cardiac Cath Lab waiting room. Department Directors are
reminded to report to the Hospital Command Center (the main boardroom in Administration) to obtain information
about the disaster. Refer to University Hospital Policy Handbook, G-12.
“Shelter in Place”
When “Shelter in Place” is announced, it has been deemed that it is safer for people to stay inside the hospital than
to exit the building. This could be due to a toxic chemical release, for example. In any case, doors and windows to
the hospital will be sealed with tape, and air/heating systems will be turned off so that contaminated air will not be
circulated through the building. No one will be allowed to enter or exit the hospital until an “all clear” has been
announced. Refer to University Hospital Policy Handbook G-107.
MEDICAL STAFF OFFICE
DEPARTMENT & COMMITTEE MEETINGS
Dept/Committee
Anesthesiology
Frequency
Monthly
Cardiology
Quarterly
CardioThoracic
Credentials
Committee
Family Practice
Monthly
Quarterly
Gastroenterology
Quarterly
MEC Officer’s
Briefing
Monthly
Medical Exec.
Committee
Medical Staff
Monthly
Medicine
Monthly
Nephrology
Quarterly
Neurosurgery
Quarterly
Ob/Gyn
Monthly
Ophthalmology
Orthopaedics
Pediatrics
Quarterly
Alt months
Perinatal
Committee
Perinatal
Subcommittee
Practice
Committee
Surgery
Quarterly
Alt months
Monthly
Monthly
Monthly
Date & Time
1st Thurs. @
7:00 am
1st Tues @
5:00 pm
As Needed
2nd Monday @
5:30pm
2nd Wed @
8:00 am
3rd Thurs @
7:00 am
Weds. before
3rd Tues. @
8:00 am
3rd Tues. @
5:30 pm
Tuesday
following MEC
@ 6:30 p.m.
3rd Tues @
8:00 am
4th Tues @
8:00 am
Meet same
Group meets
1st Thursday @
7:00am
As Needed
As Needed
1st Tues @
7:30 am
3rd Wed @ 7:00
am
2nd Tues @
7:30 am
1st Fri @ 7:00
am
1st Thurs @
7:00 am
Location
DR 5
DR1
MSO CR
DR 5
DR4
MSO Conf. Rm.
DR 1
*
Employee Main Dining
DR 1
DR 3
Dr. Oetting’s Office
DR 1
Ortho. Office
DR 2/3
DR 3
CR #10
DR #4 &5
DR #2 &3
UNIVERSITY HOSPITAL
MEDICAL STAFF EXECUTIVE COMMITTEE
INFORMATION SHEET
2007
President
President-Elect
Past President
Secretary/Treasurer
Vice-President
Vice-President
Vice-President
Member-at-Large
Member-at-Large
Anesthesiology
William Callaghan, MD
Gregory Oetting, MD
Mark Smith, MD
Charles Spurr, MD
Mark Keaton, MD
Kenneth Smith, MD
Scott Burns, MD
Gregory Cook, M.D.
Cissy Mullinax, M.D.
C. F. Johnson, MD
John Hennecken, MD
Cardiology
Family Practice
Medicine
Neurosurgery
OB/GYN
Orthopaedic Surgery
Pathology
Pediatrics
Radiology
Surgery
James Harrover, III, MD
James Cato, MD
Gregory Oetting, MD
W. G. Watson, MD
Thomas Parfenchuck, MD
Kailash Sharma, MD
Alan Getts, MD
Kent Johnson, MD
Randy Cooper, MD
1348 Walton Way, Suite 5100, Augusta, GA
30901
820 St. Sebastian Way, Suite 8A, Augusta,
GA 30901
1303 D’Antignac St., Suite 2500, Augusta,
GA 30901
820 St, Sebastian Way, Suite 5B, Augusta,
GA 30901
(706) 724-8611
1348 Walton Way, Suite 4300, Augusta, GA
30901
1824 Walton Way, Augusta, GA 30901
(706) 821-2944
1348 Walton Way, Suite 4100, Augusta, GA
30901
1348 Walton Way, Suite 4100, Augusta, GA
30901
1350 Walton Way, Emergency Room,
Augusta, GA 30901
1350 Walton Way, Operating Room,
Augusta, GA 30901
818 St. Sebastian Way, Suite 404, Augusta,
GA 30901
(706) 722-1381
465 N. Belair Rd, Suite 1C, Evans, GA
30809
2123 Wrightsboro Rd., Augusta, GA 30904
(706) 854-2160
820 St. Sebastian Way, Suite 8A, Augusta,
GA 30901
1430 Harper Street, Suite A, Augusta,
GA30901
820 St. Sebastian Way, Suite 8A, Augusta,
GA 30901
1350 Walton Way, Pathology, Augusta, GA
30901
3121 Peach Orchard Road, Ste. 102,
Augusta, GA 30906
2727 Walton Way, Augusta, GA 30909
(706) 724-9607, ext. 2458
818 St. Sebastian Way, Suite 408, Augusta,
GA 30901
(706) 722-2334, ext. 2560
(706) 724-9607, ext. 2458
(706) 722-6900
(706) 722-2400
(706) 737-9250
(706) 722-1381
(706) 774-2176
(706) 774-2245
(706) 774-9000
(706) 736-5244
(706) 724-2261, ext. 2467
(706) 722-3401, ext. 2441
(706) 774-5400, ext. 5411
(706) 792-5040
(706) 737-4275, ext. 2478
Emergency Department Representative:
Richard Eckert, MD
Administrative Representatives:
William L. Farr, Jr., MD
Chief Medical Officer
Kerry Diver, MD
Associate Medical Director
Jason Moore
COO/President University Health Services and Extended
Care
J. Larry Read
CEO/President University Health Care System
University Hospital, 1350 Walton Way,
ER Services, 30901
774-2176, ext. 2176
University Hospital, 1350 Walton Way,
Augusta, GA 30901
University Hospital, 1350 Walton Way,
Augusta, GA 30901
University Hospital, 1350 Walton Way,
Augusta, GA 30901
(706) 774-8076, ext. 8076
University Hospital, 1350 Walton Way,
Augusta, GA 30901
(706) 774-8045, ext. 8045
(706) 774-8085, ext. 8085
(706) 774-8061, ext. 8061
Marilyn Bowcutt
Vice-President, Patient Care Services
University Hospital, 1350 Walton Way,
Augusta, GA 30901
(706) 774-5746, ext. 5746
Ex Officio Members:
Charles McClure, MD
1303 D’Antignac Street, Suite 2800, 30901
722-8817, ext. 2736
University Hospital
Continuing Medical Education
CONTINUING CONFERENCE LIST – 2007
CME
Credit
TIME
LOCATION
Orthopaedic Combined
Case Conference
Breast Health
Case Conference
Lunch & Learn for
Dentists
1.00
7:30 – 8:30 am
Classroom 4
1.00
7:00 – 8:00 am
Classroom 3
1.00
12:30-1:30 pm
Wednesday
Each
Wednesday
1st & 3rd
Wednesday
3rd
Thursday
Each
Thursday
1st
Thursday
3rd or 4th
CardioVascular
Conference
Lung Cancer
Conference
G U Pyelogram Case
Conference
The Thursday Noon
Conference
Non-Invasive
Cardiology Conference
Rheumatology Journal
Club
1.00
8:00 – 9:00 am
1.00
7:00 – 8:00 am
Center For Oral &
Maxillofacial Surgery
671 N. Belair Road
Evans, GA 30809
Cafeteria Dining Room
1
Classroom 3
1.00
6:30 – 7:30 am
Classroom 4
1.00
12:00-1:00 pm
1.00
12:00-1:00 pm
Cafeteria Dining
Rooms 1 – 3
Cafeteria Dining Room
6
1.50
7:30 – 9:00 pm
Augusta Arthritis Center
811 13th St., Suite 14
Augusta, GA 30901
Friday
1st
Infectious Diseases
Conference
1.00
10:00-11:00am
Classroom 3
DAY
CONFERENCE
Monday
Each
Tuesday
Each
Tuesday
3rd
All classrooms are located in the University Hospital Educational Center, 3rd floor of the Ambulatory Care
Wing.
University Hospital is accredited by the Medical Association of Georgia to sponsor continuing medical
education for physicians.
The CME Office is located within Medical Staff Office on the 3rd Floor. Listed below is contact information
for University Hospital’s CME Coordinator:
Name:
Julie Martinez
Office #:
(706) 774-7879
Fax #:
(706) 774-5213
To obtain information regarding CME activities you may dial our CME Conference Recording Line at (706)
774-7878. This recording is updated daily to notify callers if a Conference has been cancelled. To obtain
a complete listing of events you may also visit our website at www.universityhealth.org simply click on
Education & Events, and then select Physician CME.
SURGICAL SERVICES
Surgical Services is comprised of the following areas: AM Admit, Direct Admit, Preadmission Testing,
Anesthesia Evaluation and OP Infusion Services, Endoscopy, Day Surgery Center and Day Surgery Evans,
Central Sterile Processing, Holding Room, Operating Room and Post Anesthesia Care Unit.
Computerized patient scheduling can be accomplished by dialing the following phone numbers for the
respective areas:
Day Surgery Center and Day Surgery Evans: 774 -2086
Endoscopy: 774-5621
Main Operating Room: 774-5619 or 774-5623
Block scheduling for busy surgeons can be approved by the Chair, Surgical Services and the Director,
Surgical Services.
Surgeons are encouraged to send their patients to the Preadmission Testing/Anesthesia Evaluation
Center located on the first floor. A well prepared surgical patient can prevent case delays and assure the
surgical team has the necessary equipment and instrumentation in place for a smooth patient transition to the
operating room suite. History, physical and informed consents are the accountability of the operating surgeon
and must be completed prior to the patient leaving for the operating suite. Case delays are documented and
reported to the Chair of Surgical Services.
Computerized procedure/preference cards are used to detail the needs of a surgeon to provide patient
specific care. It is important that you work with the Surgical Services Team to ascertain appropriate detailing
of your preferences. University uses specific vendors to ascertain supplies, instrumentation and equipment.
All special requests are handled through a product evaluation team that looks at cost effectiveness and quality
for patient care. If you are electing to do a new procedure, the OR teams need at least a week’s notice, after
appropriate credentialing is completed, to assure reimbursement and supplies/equipment. Each surgical
services is asked to provide input into the capital and operating budgets annually.
Marking the surgical site is required for procedures involving right/left distinction, multiple structures (such
as fingers and toes), or levels (as in spinal procedures). The Licensed Independent Practitioner will verify
procedure/site by placing an indelibly mark 'O' prior to the preparation of the surgery or procedure with a
nurse observing that the site marking will be visible once the patient is positioned, prepped and
draped.
Imaging studies will be made available for the procedure and the nursing staff is accountable for completing
an OR/Procedure checklist. In the OR suite, the licensed independent practitioner will lead the "time-out"
with the surgical team (scrub, circulator, surgeon and anesthesiologist) immediately prior to incision
and after the patient is positioned, prepped and draped to confirm the following:
1. Correct patient identity.
2. Correct procedure comparing the consent and schedule.
3. Correct site or side when laterality, multiple structures, or multiple levels are involved
including imaging and site marking as applicable.
4. Correct position.
5. Availability of correct implants and any special equipment or special requirements
6. When the surgeon/procedurist needs images to verify the site, the images are available
and displayed according to the requested orientation.
7. All of the above MUST be CORRECT to proceed with the surgery.
8. If more than one procedure is to be performed by differing surgeons/procedurists, a
second time out is to be completed when the second surgeon/procedurist arrives,
immediately prior to the beginning the second procedure.
We realize the operating environment can be a stressful situation but we in Surgical Services believe working
as a team of professionals demonstrating respect and dignity for each other promotes a collaborative and
cohesive team.
We welcome you to University and please let us know how we can assist in your successful transition.
Code of Conduct:
All University Hospital Medical Staff members are expected to conform to the behaviors
specified in the code of conduct as listed below:
1. Behavior reflects that the patient always comes first.
2. Treats patients and coworkers with dignity and respect and holds team members
accountable to do the same.
3. Sets a positive example with quality of work.
4. Helps other team members to grasp and understand issues. Communicates information
clearly and professionally.
5. Ensures that patient’s privacy and confidentiality are maintained.
6. Respects different points of view and shares positive ideas and thoughts about work. Avoids
gossip and other negative styles of communication.
7. Accepts constructive criticism and suggestions about job performance and behavior in a
positive manner. Is receptive to change.
8. Addresses concerns and conflicts in a constructive manner. Focuses on issues and not
personalities.
9. Recognizes the value of each employee and treats each individual with dignity and respect
at all times.
10. Interacts positively with employees by informing them of expectations, providing feedback
and paying compliments as appropriate.
11. Projects a positive, professional image.
12. Uses resources and materials efficiently and effectively.
13. Is committed to continuously improving. Stays current with profession as well as hospital
and regulatory policies.
14. Complies with hospital policies and regulatory standards (JCAHO, OSHA, Medicare,
Medicaid, etc.) in delivering the best possible care, maintaining a safe work environment,
and documenting the delivery of service.
15. Respects the rights of patients by identifying themselves upon entering a patient’s room.
Contacts the Speech and Hearing Department or Administrative Nurse Supervisor if they are
having difficulty communicating with a sensorially deprived or low English proficiency patient.
THE PRACTICAL DEFINITION OF SEXUAL HARASSMENT
In practical terms, there are two kinds of sexual harassment:
Quid Pro Quo: Where employment decisions or expectations (e.g., hiring decisions,
promotions, salary increases, shift or work assignments, performance expectations) are based
on an employee’s willingness to grant or deny sexual favors. Examples of quid pro quo
harassment:



Demanding sexual favors in exchange for a promotion or a raise.
Disciplining or firing a subordinate who ends a romantic relationship inappropriately.
Changing performance expectations after a subordinate refuses repeated requests for a
date.
Hostile environment: Where verbal or non-verbal behavior in the workplace: (1) focuses on
the sexuality of another person or occurs because of the person’s gender, (2) is unwanted or
unwelcome and (3) is severe or pervasive enough to affect the person’s work environment.
The following are examples of behaviors that can create a hostile environment if they are
unwanted and uninvited:








Off-color jokes or teasing
Comments about body parts or sex life
Suggestive pictures, posters, calendars or cartoons
Leering, stares or gestures
Repeated requests for dates
Excessive attention in the form of love letters, telephone calls or gifts
Touching – brushes, pats, hugs, shoulder rubs or pinches
Assault/rape
For Code of Conduct and Sexual Harassment Concerns please contact:
William Farr, M.D. – Chief Medical Officer at 706-774-8076
Wellness:
Health Care Professional Impairment
This information on Health Care Professional Impairment is devoted to helping the medical
staff and allied health professionals become more knowledgeable about impairment. Patient
safety is our overriding principle. For health care professionals to provide safe care, they must
be able to think clearly, assess clinical situations accurately, and act in the best interest of the
patient. Impairment, no matter what the cause, leads to unsafe decisions and therefore,
jeopardizes patient care.
What is impairment?
Health care professional impairment exists when the health care professional cannot effectively
perform the duties of the job. Most often impairment is due to drug or alcohol use or abuse, but
it can also be caused by emotional, mental or even physical illnesses. The prevalence of
impairment among health care professionals is slightly lower than among other professionals
and is about the same as in the general population.
Chronic impairment due to drug and alcohol abuse can be successfully treated if recognized and
treated early. Even though some chronic and degenerative diseases such as Alzheimer’ worsen
over time, their progression might be slowed with treatment.
Practitioner Assistance Committee (PAC)
University Hospital’s Medical Staff has established a PAC to provide education and support to a
practitioner affected by any physical, emotional, psychiatric impairment, or potential impairment,
involving, among other conditions, alcohol and drug abuse, psychiatric disability, physical
impairment, problems of aging, sexual misconduct, and the distress of everyday medical
practice. The PAC will provide assistance and monitoring to enable a practitioner to gain
restoration of optimal functioning rather than initiating disciplinary action.
What should I do if impairment is suspected?
Any hospital personnel, allied health professional or physician concerned about a practitioner’s
condition and ability to function professionally may contact either the department chairman
of the appropriate department or the President of the medical staff At this time, the practitioner
may be referred to the PAC. A practitioner may also refer himself/herself to the committee.
COBRA / EMTALA Requirements
All Medicare participating hospitals (such as University Hospital) must provide
a medical screening exam (that involves, as necessary, use of ED resources,
including specialized tests and consultations routinely available to the ED) to
any individual who comes to the emergency department and requests
examination or treatment for a medical condition. The federal government
contends that EMTALA also applies whenever a patient presents to L&D triage
and requests examination. The medical screening examination requirement is
limited to determining whether or not the patient has an emergency medical
condition. While the statute refers to presenting to the emergency department,
the implementing regulations expand the examination requirement to any other
location in the hospital at which the patient initially presents and requests
examination and treatment for what the patient perceives may be an
emergency medical condition. For example, if a patient walks in the main
hospital lobby and asks to be examined for crushing chest pain, the patient
must be taken to the ED and offered a medical screening examination. If the
individual is determined to have an emergency medical condition, the
requirement becomes making efforts to stabilize the condition or provide for an
appropriate transfer. These services must be provided regardless of the
individual’s ability to pay and without delay to inquire about the individual’s
method of payment or insurance status.
Applicable federal law definitions are as follows:
The term “emergency medical condition” means-(A)
a medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) such that the
absence of immediate medical attention could reasonably
be expected to result in -(i)
placing the health of the individual (or, with
respect to a pregnant woman, the health of the
woman or her unborn child) in serious jeopardy,
(ii)
serious impairment to bodily functions, or
(iii)
serious dysfunction of any bodily organ or part; or
(B)
with respect to a pregnant woman who is having
contractions-(i) that there is inadequate time to effect a
safe transfer
to another hospital before delivery, or
(ii)
that transfer may pose a threat to the health or
safety of the woman or the unborn child.
The term “to stabilize” means, with respect to an emergency medical
condition, to provide such medical treatment of the condition as may be
necessary to assure, within reasonable medical probability, that no material
deterioration of the condition is likely to result from or occur during the
transfer of the individual from a facility (including during the time from
discharge until the patient could reasonably be expected to achieve followup on an outpatient basis), or, with respect to a pregnant woman having
contractions, to deliver (including the placenta).
An unstabilized patient may be transferred only if a physician determines that
the benefits of the transfer outweigh the risks or if the transfer is requested by
the patient who has been informed of both the hospital’s EMTALA obligations
and the risks of transfer. Patient Care Practice Standard No. 6010-062
contains forms to be used when transferring any patient to another treatment
facility.
A hospital with specialized care facilities must, within its capacity, accept a
request from another hospital for an appropriate transfer of a patient who
requires such specialized care. Failure to adhere to this requirement is one of
the major sources of government imposed sanctions. Medical staff policies
address when and how a physician may decline a request to accept a transfer
from another hospital.
Below are relevant excerpts from the Medical Staff Rules and Regulations.
Medical Staff Rules and Regulations
Article II Section 3. Care of Unassigned Patients:
Any patient who presents at the hospital who has not been referred by or
is not the patient of a specific Medical Staff member, and who does not
express a desire for the medical services of a particular staff member,
shall be assigned to the chief of an appropriate department, who shall
assign the patient to a specific staff member in the department only after
due consultation with that staff member. Nothing in this provision shall
interfere with the patient’s right to request his or her own physician if such
a choice is expressed. Any patient who requests examination or
treatment shall receive an appropriate medical screening examination
within the capacity of the emergency department to determine whether an
emergency exists. A medical staff member scheduled under the Hospital
on-call list is obligated to respond to a request to provide treatment
necessary to stabilize a patient in this hospital, whether an inpatient or an
outpatient.
Article II Section 7. Transfer of Patients:
a) A patient may be admitted for the treatment of any and all conditions and
diseases for which the hospital has facilities and personnel. When the
hospital does not provide the services required by a patient or for any
reason the hospital cannot admit a particular patient who requires
inpatient care, the hospital or the attending staff member, or both, shall
assist the patient in making arrangements for care in an alternate facility
so as not to jeopardize the health and safety of the patient. No request
or arrangement to accept transfer into a critical care unit may be
finalized without coordination with the administrative nursing
supervisor. In the event a hospital seeking transfer of an unstable
patient asserts that University Hospital has specialized capabilities or
facilities necessary for stabilizing the patient that are not available at the
requesting hospital, the transfer request may not be refused without
coordination with the administrative nursing supervisor to ensure
compliance with federal law Emergency Medical Treatment and
Labor Act (EMTALA).
b)
If the patient is to be transferred to another health care facility, the
responsible staff member shall enter all the appropriate information on
the patient’s medical record prior to the transfer. Any transfer to
another acute care hospital shall be coordinated with the administrative
nursing supervisor to ensure compliance with EMTALA’s duty to
stabilize and only “appropriately” transfer any patient. A patient shall
not be transferred to another medical care facility until the receiving
facility has consented to accept the patient and the patient is
considered sufficiently stabilized to transport. Copies of the clinical
records of sufficient content to ensure continuity of care shall
accompany the patient.
Treating hospitals and/or physicians who fail to meet these requirements risk
significant fines and penalties, including a personal fine for treating physicians.
Civil monetary fines of up to $50,000 per violation may be imposed. The
standard for imposing civil monetary fines has been changed from knowingly
to negligently violating the standard. Additionally, CMS may terminate the
Medicare provider status of hospitals and/or physicians violating the EMTALA
statute.
The above information is a very brief overview of both physician and hospital
requirements under EMTALA. Please also note that at this time we are
awaiting some finalized changes to these EMTALA regulations. The proposed
changes were published in the May 9, 2002 Federal Register. The EMTALA
regulations can be found in the Federal Register 42 C.F.R. 489.24. If you
have any further questions, you may contact the University Health Care
System Compliance Department at 774-8044.
Physician to Physician
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Personally call consultants
Provide and insist on good handoffs at coverage changes –
weekends, nights, time off
Take ownership of patients when covering. Address treatment
and disposition decisions
Patient Flow & Case Management
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Work closely with case managers on the units
Set goals for the stay and for the day – communicate with the
team to effect your intent
Pre-plan discharges and communicate with patient & family
High Reliability Care Delivery
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Use Standard orders and protocols whenever feasible
Respond promptly to calls from floors and ED
Act decisively when Rapid Response Team (MET: Medical
Emergency Team) calls and asks for help
Heed advice of nursing supervisors, ED nurses and case
managers regarding proper level of care, nursing capabilities to
care for your patient
INFECTION PREVENTION
PROGRAM
STANDARD BARRIERS
STANDARD
PRECAUTIONS
STANDARD
ENVIRONMENTAL
PRECAUTIONS
EXPANDED
PRECAUTIONS
EXPANDED
PRECAUTIONS
 Standard Precautions include hand hygiene and must be used in the care of every patient.
 The same holds true for Standard Environmental Precautions.
 These important basic Precautions are essential to the safety of patients, visitors and
healthcare workers. They are the means by which University Hospital prevents transmission
(spread) of microorganisms (germs) from one person to another.
 When increased infection risk requires, the Infection Control Committee expands on
Standard Precautions and posts mandatory requirements.
Sanitize Before...
 Patient contact
 Putting on gloves to insert a CVAD
 Inserting Foleys, peripheral IV or arterial lines, or other invasive procedures that don’t
involve surgery
Sanitize After...
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Contact with a patient’s intact skin
Contact with body fluids, secretions, excretions, non-intact skin or wound dressings
Contact with the patient’s bed, furniture, BP cuff and other in-room supplies or equipment
Glove removal
For more information, please contact the Infection Control Office at 706-774-2536.