MOUNTAIN VISTA MEDICAL CENTER
1301 South Crismon Road
Mesa, AZ 85209
New Provider Orientation
Physician
•Allied Health
•
Thank you for choosing Mountain 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 2014/2015
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Chief of Staff
◦ Sudhakar Reddy MD
Vice Chief of Staff
◦ Cynthia Anneski MD
Secretary
o Hani 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 Administration
Anthony Marinello, CEO
 Susan Dolezal, CNO
 Dan Houghton, CFO
 Joan Hoffstetter, Quality/Risk Management
 Sheryl Caracciolo, Compliance Officer
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About MVMC
8 Years Old- Opened July 2007
 178 beds & 20 Geropsych Unit
 Level III Trauma Center
 daVinci SI Surgical system
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General Surgery
Open Heart
Obstetrics
Urology
Aggressive Codes
◦ Stemi
◦ Stroke
◦ Trauma
More About MVMC
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Teaching program
◦ Primary affiliation with Midwestern University
◦ Affiliation with 20+ schools
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Residency Programs
◦ Internal Medicine
◦ Family Practice
◦ General Surgery
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Students
◦ Medical, PA, NP & CRNA
Hospital Layout
Patient Rooms in Center towers
 1st Floor
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◦ ICU, Surgery, ER, Radiology, Cath Lab
 2nd
Floor
◦ Ortho/Spine & Med Surg
 3rd
Floor
◦ Telemetry & Geropsych
◦ Use center bank of elevators to access
Entrance/Parking
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4 Main Entrances
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Outpatient
Cath Lab
ER (Only entrance after 7:30pm)
Main Entrance
Be particularly careful not to leave valuables
visible in your car
Physician Parking
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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.
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Be particularly careful not to leave valuables
visible in your car
Medical Staff Meetings 2015
MEETING/TIME
Credentials
2nd Monday
Education Comm
1st Monday
JAN
FEB
MAR
APR
MAY
JUL
AUG
SEP
12:00 noon
Monthly
12
9
9
13
11
8
13
10
14
12
9
14
4:30 pm
Monthly
5
2
2
6
4
1
6
3
7
5
2
7
22*
12
12
16
14
11
16
13
17
15
12
17
23
23
27
25
22
27
24
28
26
23
28
Executive
4:30pm
2nd Thurs after 1st Mon Monthly
PPRC
4th Monday
5:00pm
Monthly
3
Dept Medicine
1st Tuesday
7:30am
Bi-Monthly
Dept Surgery
1st Thursday
7:00am
Monthly
8
5
5
2
7
4
2
6
3
1
5
3
Cardiology Section
1st Wednesday
7:30am
Monthly
7
4
4
1
6
3
1
5
2
7
4
2
Cath Conference
2nd Wednesday
7:00 am
Quarterly
7
11
7
2
1
DEC
12:00 noon
Bi-Monthly
3
5
NOV
OCT
Dept OB/GYN
1st Tuesday
Administrative Meetings
Critical Care
7:30 am
2nd Wednesday
Bi-Monthly
6
JUN
4
13
3
6
12
1
11
14
11
13
8
9
11
14
11
13
8
9
11
Pharm/Therapeutics
2nd Wednesday
7:30 am
Bi-Monthly
Infection Control
Last Monday
9:00 am
Quarterly
23
Quality Council
4th Wednesday
1:00 pm
Monthly
25
25
28*
27
24
29
26
23
28
25
23
19
19
16
21
18
16
20
17
15
19
17
Service Line Meetings
Ortho
3rd Thurs 7:00am
25
31
30
Stroke
4th Wed 12:00noon
28
25
25
22
27
24
22
26
23
28
25
23
Trauma
4th Thurs 7:00am
29*
26
26
23
28
25
23
27
24
22
TBD
TBD
*Exception to rule
Electronic Medical Record
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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.
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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.
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Please contact Geri Camacho at 480-710-6210 for computer training in the
electronic medical record.
Incomplete Medical Records
DEFINITION
 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.
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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.
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Medical Records Dictation MVMC
Medical Records Dictation MVMC
Medical Records Dictation MVMC
Authentication & Abbreviations
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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.
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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 Reports
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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 findings
2. Technical procedures used
3. Specimens removed
4. Postoperative diagnosis
5. Estimated blood loss
6. Name of primary surgeon and any assistants and/or anesthesiologists
Progress Notes
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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 Reports
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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
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The attending practitioner shall be responsible for reviewing
consultant’s opinions prior to surgery or invasive procedures,
as appropriate.
Emergency Codes
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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
Safety Information
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RACE
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Rescue
Alarm
Contain
Extinguish/Evacuate
PASS
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Pull
Aim
Squeeze
Sweep
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MSDS
◦ Available in each unit
◦ Available online
Safety 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!
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Non Smoking Please!
Mountain Vista is a Tobacco Free Facility
 No Smoking in the Break Rooms
 No Smoking in the Parking Lots
 Smoking allowed on public sidewalks off
MVMC property
Patient Evacuation
Horizontal Evacuation
◦ Go through fire doors on other end of
same floor
2. Vertical Evacuation
◦ Transport the patients to another floor
1.
Electrical Safety
Always use three prong power plug
 To remove, pull from plug, not from cord
 Red plugs are for Emergency Power
 Equipment Failure/Damaged
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◦ Contact Nursing Dept for that floor
Infection Control
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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 Precautions
A mask is required
Hand hygiene is required
Limit pt transport to essential tests/procedures
Notify receiving area of necessary precautions if
test/procedure is required
Patient must be masked when out of room.
No flowers or plants
The patient’s door must remain closed at all times!
Isolation Precautions
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There 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 precautions
 Use appropriate Personal Protective Equipment (PPE)
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National Pt Safety Goals
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Identify Patients Correctly
◦ Use at least 2 ways to identify patients
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Staff Communication
◦ Report information correctly & efficiently
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Prevent Infection
◦ Follow hand cleaning guidelines
◦ Follow proven guidelines
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Time Out
◦ Is this the correct patient? Procedure? Location?
Patient Fall Prevention
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Patient fall risk assessment is done on:
◦ Admission
◦ When there is a change in status or condition
◦ On transfer to another unit
Restraints, Non-Violent
Assessment
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
No
Alternative
Failed?
Use
Alternative,
DO NOT
RESTRAIN
Yes
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
Application
Apply least restrictive restraint using appropriate technique
Patient/family
Notify 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
Restraints, Violent
Assessment
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
Use
Alternative,
DO NOT
RESTRAIN
No
Alternative
Failed?
Yes
Patient/family
Notify 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
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
Debrief (BHU ONLY)
Conduct a debriefing within 24 hours as per policy
Application & Staffing
•Apply least restrictive restraint using appropriate technique
•1:1 staffing adjustment required
Personal Electronic Equipment

CELL PHONE USE – TEXTING &
PHOTOGRAPHING PATIENTS - The sending
of text messages that contain hospital or patientrelated health information is strictly prohibited. It is
prohibited to use a cell phone camera to photograph
patients.
EMTALA
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EMTALA – Emergency Medical Treatment
and Active Labor Act
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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.
HIPAA
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HIPAA – Health Insurance Portability and
Accountability Act was passed by congress in
1996.
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The purpose of HIPAA was to create national
standards to protect a person’s health
information
STAR Standards
Star Stands for
S – SERVICE
T – TEAMWORK
A – ATTITUDE AND ACCOUNTABILITY
R - RESPONSIVENESS
ALERT 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 Services
Sandy Elcock, Director
480-358-6158
Tina Deddo, Medical Staff Assistant
480-358-6164
Vickie Rockwell, Credentials Coordinator
480-358-6163
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I acknowledge that I have received and reviewed the orientation packet provided to me by
Mountain Vista Medical Center.
Print Name
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Signature
Date