2011-2012 HOUSE STAFF MANUAL
Welcome to University Health System
We are so happy to have you as a part of our team! University Health System serves the people of Bexar County and beyond with superior healthcare and customer service. We are South Texas’ only Magnet healthcare organization, in the top one percent in the nation for the use of electronic health records, and our goal is to be the hospital of choice for our community, South Texas and beyond. Our expectation is that you will bring the best of yourself to our hospital and clinical locations every day, understanding that you are leaving an impression –either good or bad – on every patient and visitor you encounter.
We have 19 locations to provide the right level of level in the right location.
· University Hospital: Home to the lead Level I trauma center for all of South Texas, University Hospital cares for about 70,000 patients through our Emergency Center every year, and discharges about 22,000 patients a year. Centers of Excellence include trauma, pediatric burns, organ transplantation, neurosciences, neonatal intensive care, and heart/lung/vascular.
· University Health System – Robert B. Green Campus (University Health Center – Downtown): A one-stop-shop for ambulatory care, the Robert B. Green Campus is the site of San Antonio’s first public hospital in 1917. Now, this outpatient healthcare center is a complex is the largest and most comprehensive ambulatory care clinic in Bexar County.
· University Center for Community Health/Texas Diabetes Institute: This three-story building is dedicated to the fight against diabetes and dedicated to saving and changing lives. Comprehensive services for diabetes patients includes endocrinology, podiatry,dermatology, ophthalmology, patient education, cooking classes and a fitness center. In partnership with the UT Health Science Center, it is also home to one of the nation’s premier diabetes research programs.
· Four Family Health Centers: University Family Health Centers North, Northwest, Southwest and Southeast all provide patients with primary and specialty care. Onsite laboratory, radiology, as well as after-hours/weekend ExpressMed services are available at several locations.
· Eight Preventive Health Care Clinics: Naco Perrin, Kenwood, Westend, Old Hwy 90, Eastside, South Flores, Zarzamora, and Salinas clinics are each paired with a Family Health Center to form a Medical Home and give patients complete care close to home. These smaller clinics focus on prenatal care, family planning, children’s health and other primary/preventive care services.
· Four Dialysis Centers: Northwest, South, Southeast, West Dialysis Centers treat patients for acute and chronic kidney failure.
As a member of our house staff, you will be practicing at some of these facilities and playing a vital role in the mission of our Health System. We are counting on you to help us provide every patient with high quality, patient-centered care.
We welcome you and hope that this manual will help give you a basic understanding of University Health System procedures and routines. If you have specific questions about something, we ask that you talk to the chief resident of your service, your service chief and the administrative staff.
The Physicians Oath of Hippocrates
I do solemnly swear, by whatever I hold most sacred:
That I will be loyal to the profession of medicine and just and generous to its members;
That I will lead my life and practice my profession in uprightness and honor;
That into whatsoever house I shall enter, it shall be for the good of the sick to the utmost of my power, holding myself far aloof from wrong, from corruption, from the tempting of others to vice;
That I will exercise my profession solely for the cure of my patients, and will give no drug, perform no operation, for a criminal purpose, even if solicited; far less suggest it;
That whatsoever I shall see or hear of the lives of men which is not fitting to be spoken, I will keep inviolably secret. These things I do swear.
And now, should I be true to this, my oath, may prosperity and good repute be ever mine; the opposite, should I prove myself forsworn.
Mission, Vision and Values for the University Health System
Mission
The mission of the University Health System is to promote the good health of the community by providing the highest quality of care to both inpatients and outpatients, by teaching the next generation of health professionals and by supporting research thereby advancing medical knowledge and improving the delivery of patient care.
Vision
We will continuously improve the health and well-being of the people of Bexar County, South Texas and beyond.
Values
· Our patients come first
· We work as a team
· We work for the community
· We have the highest regard with respect, dignity, sensitivity and trust when it comes to treatment
· We will be experts at our jobs
· Education and research are important to excellent patient care
George B. Hernández. Jr.
President/Chief Executive Officer
TABLE OF CONTENTS
Patient Bill of Rights …………………………………………………………………. 8
Hallway Prescribing …………………………………………………………………. 9
Standards of Conduct/Service Excellence ….…………………………………………. 9
Confidentiality..………………………………………………………………………... 10
HIPAA Violation Disciplinary Guidelines for Residents…...…………………………. 10
Protected Health Information (PHI) …………………………………………………. 10
Information Assets …………………………………………………………………. 12
Age of Majority ...…..…………………………………………………………………. 13
Ordering and Transcribing …………………………………………………………. 13
Selected Procedures
Prohibited Abbreviations …………………………………………………………. 14
Admitting Procedures …………………………………………………………………. 14
Responsibility for Care …………………………………………………………. 14
Authorization for Admissions …………………………………………………. 14
Observation …………………………………………………………………………. 16
Urgent/Emergent Inpatient Admission Requests …………………………………. 16
Transfer Center……...…………………………………………………………………. 16
Dismissal………………………………………………………………………………. 18
Outpatient Surgery Physician Guidelines …………………………………………. 18
Preoperative Testing Requirements …………………………………………………. 20
General Procedure When a Patient Dies …………………………………………. 20
Code of Criminal Procedures-Medical Examiner’s Cases …………………………. 21
Completion of Death Certificates …………………………………………………. 22
Reporting to Medical Examiners on EC Deaths and DOAs…...……………………. 25
Autopsies …………………………………………………………………………. 25
Release of Body …………………………………………………………………. 26
Anatomical Law Related to Cadavers……..………………………………………… 26
Public Information Regarding Patients………………………………………………… 26
Safety Procedures …………………………………………………………………. 28
Quality Improvement and Patient Safety …………………………………………. 30
National Patient Safety Goals Established by The Joint Commission………………. 30
Frequently Asked Question …………………………………………………………. 32
Risk Management...……………………………………………………………………. 33
Infection Control……………………………………………………………………….. 34
Bundle of Care of Evidence-Based Best Practices…………………………………… 35
Hand Hygiene………………………………………………………………………… 36
Transmission Based Isolation Precautions…………………………………………… 39
Antibiotic Resistant Bacteria-Strategies for Prevention …….……………………….. 40
Case Management………...…………………………………………………………….. 42
Pitfalls to Avoid………………………………………………………………………. 43
Selected Policies
Patient’s Right to Consent………………………………………….…………………… 43
Drug Sample Policy……………………………………………………………………….. 43
Advance Directives …………………………………..………………………………… 44
Determination of Death …………………..…………………………………………….. 44
Restraints and Seclusion Policy……………………………………………………….. 44
Consultative Policy……………………………………………………………………. 45
Specific Policies
Reporting Communicable Diseases and Conditions…………………………………. 45
Standard Transmission-Based Precautions…….……………………………………… 48
Isolation Precautions for Common Infectious Conditions……..……………………… 49
Tuberculosis Policy……………………………………………………………………. 58
Bloodborne Pathogens Exposure Control Plan Policy………………………………… 63
Requests for Information about Current or Former House Staff Members……… 75
Personnel Policies and Benefits
Due Process Procedures………………………………………………………………... 76
House Staff Recognition Program……………………………………………………… 76
Substance and Chemical Abuse Counseling…………..……………………………….. 76
Sexual Harassment and Exploitation Counseling……………………………………… 76
Graduate Medical Education Agreements……………………………………………… 77
Military and Elective Rotators ………….……………………………………………… 77
Pay Policy……………………………….……………………………………………… 77
Gym Memberships…………………………………………………………………..…. 78
Meal Cards………………………………………………………………..……………. 78
After Hour Meal Program...…………………………………………………….………. 78
Lab Coats………………………………………………………………………………. 78
Scrub Station System…………………………………………………………………... 79
Vacation/Sick Leave…………………………………………………………………… 80
Leave of Absence...... 80
Worker’s Compensation...... 81
Open Enrollment and Qualifying Events……………………………………………… 82
Medical/Dental Plans….………………………………………………………………. 82
Life Insurance……………….………………………………………………………… 83
Deferred Compensation Plan………………………………………….……………….. 83
Choice CARE Employee Assistance Program………………………………………… 83
Professional Liability Coverage ...…………………………………………………….. 83
Blood Program…………………………………….…………………………………… 83
Clearance Procedures…………………………….……….……………………………. 83
University Health System Facilities...... 84
Patient Services & Programs
ChildSafe……………………………………….……………………………………… 85
Bexar County Family Justice Center…………….…………………………………….. 86
The Center for Health Care Services Crisis Care Center….…………………………… 86
Child Abuse and Child Neglect………………….…………………………………….. 86
Premiere Program………………………………………………………………………. 87
Cardiology Services:
Cardiac Catheterization Laboratory…………………………….……………………. 87
Non-Invasive Cardiology/ECG Lab...... 87
Medical Specialty Services………….…………………………………………………. 88
Endoscopy Center……………………………………………………………………. 88
Neurodiagnostic Center………………………………….…………………………… 88
Sleep Disorder Center…………………….………………………………………….. 89
Pulmonary Function Laboratory………………….………………………………….. 89
Vascular Laboratory……………………….…………………………………………. 89
NurseLink…………..………………………………………………………………….. 90
Food Service……………………………………………………………..…………….. 90
Nutrition Clinic……………………………………………………..………………….. 90
Pathology Services……………………………………………..……………………… 91
Patient Care Services (Nursing)………………………………………………………… 91
Patient Satisfaction……………………………………………………………………… 92
Interpreter Services……………………………………………………………………... 93
Pharmacy Services ………..……………………………………………………………. 93
Radiology……………………………………………………………………………….. 96
Rehabilitation Medicine………………………………………………………………… 99
Renal Dialysis ………………..………………………………………………………… 104
Respiratory Care Services ……………………………………………………………… 102
Social Work……………………………………………………………………………... 105
Spiritual Care…………………………………………………………………………… 108
Volunteer Advocate Program for Rape Victims ………..……………………………… 108
House Staff Support Services
Clinical Information Services…………………………………………………………… 108
Food Service/Cafeterias ………………………………………………………………… 109
Learning Resources……………………………………………………………………… 110
Library Services…………………………………………………………………………. 111
Research Department……………………………………………………………………. 113
Medical Records………………………………………………………………………… 114
Protective Services……………………………………………………………………… 119
Communications
General Information…………………………………………………………………….. 121
University Hospital Directory…………………………………………………………… 122
University Hospital Nursing Directory………………………………………………….. 124
University Health Center-Downtown Directory………………………………………… 125
University Family Health Centers………………………………………………………. 126
Digital Pager System ...... ……………………………………………………………….. 129
The Patient Bill of Rights
The following “Patient Bill of Rights” is made available to the patients of the University Health System according to the recommendation of the America Hospital Association (AHA). House staff need to be aware of the contents of the document. This statement is an adaptation from that issued by AHA.
Your Rights as a Patient at the University Health System
The University Health System, its doctors, nurses and entire staff are committed to assure you excellent care. It has always been our policy to respect your individuality and dignity. This listing is published to be certain you know the long-standing rights that are yours as a University Health System patient.
1. You have the right to considerate and respectful care.
2. You have the right to obtain from your physician complete and current information concerning your diagnosis, treatment, and prognosis in terms you can understand. When it is not medically advisable to give such information to you, the information should be made available to an appropriate person. You have the right to know the name of the physician responsible for coordinating your care.
3. You have the right to receive from your physician information necessary to give an informed consent prior to the start of any procedure and/or treatment. Except in emergencies, information for informed consent should include the specific procedure and/or treatment, the medical risk involved and the expected length of time for your recovery. Where medically significant alternatives for care or treatment exist, or when you request information concerning medical alternatives, you have the right to such information. You also have the right to know the name of the person responsible for performing procedures and treatments.
4. You have the right to refuse treatment to the extent permitted by law, and to be informed of the medical consequences of your action.
5. You have the right to every consideration of personal privacy concerning your medical care program. Case discussion, consultation, physical examination, and treatment are confidential and should be conducted discreetly.
6. You have the right to expect that all communication and records pertaining to your care will be treated as confidential.
7. You have the right to expect that within its capacity, the hospital must make reasonable response to your request for services. The hospital must provide evaluation, service and/or referral as indicated by the urgency of your case. When medically permissible, you may be transferred to another facility only after you have received complete information and explanation concerning the needs for and alternatives to such a transfer. The institution to which you are to be transferred must first accept you for transfer and care.
8. You have the right to obtain information as to any relationship of your hospital in other health care and educational institutions insofar as your care is concerned. You have the right to obtain information as to the existence of any professional relationships among individuals, by name, who is treating you.
9. Since this hospital is affiliated with a university engaged in medical, dental and nursing education, you may be involved in educational studies. We believe the presence of these students and their faculty supervisors adds to the quality of care given in this hospital.
10. Depending upon the nature of your illness, you may be asked to participate in research projects which can offer you the latest advances in the field of medicine; however, before you participate in any research project, you have the right to refuse to be part of such a study. If you refuse to participate in a research study, you have the right to receive the best care the hospital can offer under the circumstances.
11. You have the right to expect reasonable continuity of care. You have the right to know in advance what appointment times and physicians are available for your care. You have the right to expect the hospital will provide a mechanism whereby you are informed by your physician or his delegate of your continuing health care requirements following discharge.
12. You have the right to examine and receive an explanation of your bill, regardless of source of payment.
13. You have the right to know hospital rules and regulations apply to your conduct as a patient.
As a patient, you also have certain responsibilities which should be carried out in your own best interest:
· Appear for your appointments on time.
· Telephone the hospital if it is impossible for you to report at the scheduled time.
· Bring to your appointment information about past illnesses, hospitalization, medications and other matters relating to your health.
· Be open and honest with us about instructions you receive concerning your health; that is, let us know immediately if you do not understand them or if you feel the instructions are such that you cannot follow them.
· Be considerate of other patients, and see that your visitors are considerate as well-particularly with reference to noise, which can be disruptive to other patients.
· Be prompt about payment of hospital bills, providing us the information necessary for insurance processing and clearing up any questions you may have concerning your bills.
Hallway Prescribing
Employees are prohibited from stopping doctors in the hallways and asking for medical advice and/or prescriptions. House staff should therefore refuse to diagnose or prescribe under these circumstances.
Standards of Conduct/Service Excellence
The University Health System must create a caring environment to fulfill its basic mission of providing quality health care. House staff establishes a caring environment through teamwork and by giving complete and efficient care, while respecting the dignity and worth of all individuals.