university hospitals of cleveland - School of Medicine

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University Hospitals
Health System
of Cleveland
RESIDENTS & FELLOWS
MANUAL
Residents & Fellows Manual
RESIDENTS & FELLOWS MANUAL
TABLE OF CONTENTS
INTRODUCTORY STATEMENTS .............................................................................................. 1
INSTITUTIONAL COMMITMENT ......................................................................................... 1
WELCOME ................................................................................................................................ 2
INTRODUCTION ...................................................................................................................... 3
MISSION, VISION, VALUES................................................................................................... 4
HISTORICAL OVERVIEW ...................................................................................................... 5
PURPOSE OF THIS MANUAL ................................................................................................ 6
EDUCATION INFORMATION .................................................................................................... 6
ELIGIBILITY AND SELECTION............................................................................................. 6
EMPLOYMENT CONTRACTS ................................................................................................ 7
RENEWAL OF APPOINTMENT.............................................................................................. 7
NONRENEWAL OF APPOINTMENT ..................................................................................... 7
VISA POLICIES AND PROCEDURES .................................................................................... 7
COMPLETION OF TRAINING ................................................................................................ 8
CLOSURE REDUCTION POLICY........................................................................................... 8
RESTRICTIVE COVENANTS.................................................................................................. 8
EVALUATIONS ........................................................................................................................ 8
Evaluation of Faculty.............................................................................................................. 8
Evaluation of a Resident’s Performance................................................................................. 8
CORRECTIVE ACTION ........................................................................................................... 9
SUMMARY SUSPENSION..................................................................................................... 10
AUTOMATIC SUSPENSION ................................................................................................. 11
RESIDENT PHYSICIAN APPEALS PROCESS .................................................................... 11
GRIEVANCE PROCEDURE................................................................................................... 12
COMPENSATION ....................................................................................................................... 16
PAYROLL ................................................................................................................................ 16
DIRECT DEPOSIT................................................................................................................... 16
TAX/SOCIAL SECURITY DEDUCTIONS............................................................................ 16
AUXILIARY BENEFITS............................................................................................................. 16
PARKING................................................................................................................................. 16
VACATION.............................................................................................................................. 17
HOLIDAYS .............................................................................................................................. 17
I.D. BADGES ........................................................................................................................... 17
FLEXIBLE SPENDING ACCOUNTS .................................................................................... 17
403B MATCHED RETIREMENT SAVINGS PLAN ............................................................. 17
FITNESS CENTER .................................................................................................................. 17
DISCOUNTS ............................................................................................................................ 17
SAVINGS BONDS................................................................................................................... 17
BENEFITS
............................................................................................................................... 18
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HEALTH INSURANCE........................................................................................................... 18
CONTINUATION OF MEDICAL COVERAGE: COBRA .................................................... 18
DENTAL INSURANCE........................................................................................................... 18
PROFESSIONAL LIABILITY INSURANCE......................................................................... 18
LIFE INSURANCE .................................................................................................................. 18
SHORT-TERM DISABILITY.................................................................................................. 18
LONG-TERM DISABILITY.................................................................................................... 19
LEAVES AND OTHER ABSENCES.......................................................................................... 19
BEREAVEMENT LEAVE....................................................................................................... 19
JURY DUTY ............................................................................................................................ 19
SICK TIME............................................................................................................................... 19
FAMILY MEDICAL LEAVE.................................................................................................. 19
MATERNITY/PATERNITY LEAVE...................................................................................... 20
EXTENDED LEAVE OF ABSENCE...................................................................................... 20
PROFESSIONAL LEAVE OF ABSENCE.............................................................................. 21
ADDITIONAL BENEFIT & LEAVE CONSIDERATIONS .................................................. 21
PROGRAM POLICIES ................................................................................................................ 21
ADMISSION AND DISCHARGE OF PATIENTS................................................................. 21
Patient Access Services......................................................................................................... 21
Admitting Policy................................................................................................................... 21
ADMITTING PROCESS.......................................................................................................... 22
EMERGENCY ADMISSION .................................................................................................. 22
WHAT TO TELL YOUR PATIENT PRIOR TO ADMISSION ............................................. 22
PRE-REGISTRATION/VERIFICATION/CERTIFICATION ................................................ 22
PREADMISSION ASSESSMENT AND TEACHING ........................................................... 23
DISCHARGE OF PATIENTS.................................................................................................. 23
DEATH OF PATIENTS/AUTOPSY PERMITS...................................................................... 23
AUTOPSY OFFICE ................................................................................................................. 23
MORTICIANS.......................................................................................................................... 23
Death Certificate ................................................................................................................... 23
Autopsy Consent................................................................................................................... 24
Consent for Organ or Tissue Donation ................................................................................. 24
Determination of Next of Kin ............................................................................................... 24
DEAD ON ARRIVAL CASES ................................................................................................ 25
Notification of Clinicians of Autopsies ................................................................................ 25
Information to Clinicians Regarding Autopsies ................................................................... 25
Outside Inquiries Concerning Autopsy Findings.................................................................. 25
DUTY HOURS......................................................................................................................... 26
ON-CALL ACTIVITIES .......................................................................................................... 26
MOONLIGHTING ................................................................................................................... 27
LICENSURE............................................................................................................................. 27
Medical Licensure................................................................................................................. 27
Controlled Substance Licensure ........................................................................................... 27
Prescribing Controlled Substances over the Telephone........................................................ 28
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DISPUTES BETWEEN HOUSE STAFF AND MEDICAL SUPERVISORS........................ 28
MEDICAL RECORDS............................................................................................................. 28
Guidelines for Use of Medical Records................................................................................ 28
Guidelines for Documentation in the Medical Record ......................................................... 29
Medical Record Completion Guidelines............................................................................... 29
Protected Health Information................................................................................................ 30
MEDICAL STAFF RULES AND REGULATIONS ............................................................... 30
PHYSICIAN’S ORDERS......................................................................................................... 31
SERVICE TO INPATIENTS ................................................................................................... 31
INSTITUTIONAL POLICIES...................................................................................................... 31
ADVOCACY EFFORTS.......................................................................................................... 31
POLICY AND PROCEDURE MANUALS............................................................................. 32
CHANGE IN NAME/ADDRESS............................................................................................. 32
CRIMINAL RECORD CHECK ............................................................................................... 32
COMMUNICABLE DISEASES .............................................................................................. 33
Reporting Requirements for Communicable Diseases ......................................................... 34
Method of Reporting Communicable Diseases .................................................................... 34
DRUG SCREENING................................................................................................................ 34
INTRANET & INTERNET E-MAIL....................................................................................... 35
CONFIDENTIALITY & NON-DISCLOSURE....................................................................... 35
CORPORATE COMMUNICATIONS..................................................................................... 35
CORPORATE COMPLIANCE................................................................................................ 36
DRESS CODE .......................................................................................................................... 36
SAFETY TRAINING .............................................................................................................. 36
HOSPITAL SAFETY ............................................................................................................... 36
RADIATION SAFETY ............................................................................................................ 36
OBLIGATION TO TREAT...................................................................................................... 37
HIPAA ...................................................................................................................................... 37
NO SMOKING POLICY.......................................................................................................... 37
SEXUAL AND OTHER FORMS OF HARASSMENT .......................................................... 38
SUBPOENAS, CLAIMS, AND OTHER REQUESTS............................................................ 38
VISITORS................................................................................................................................. 38
PATIENT THERAPY LEAVE OF ABSENCE ....................................................................... 38
INSTITUTIONAL RESOURCES ................................................................................................ 39
BLOOD BANK ........................................................................................................................ 39
CHILD PROTECTION PROGRAM........................................................................................ 40
EMPLOYEE ASSISTANCE COUNSELING ......................................................................... 40
EMPLOYEE HEALTH SERVICE........................................................................................... 41
NURSING DEPARTMENT..................................................................................................... 41
NUTRITION SERVICES......................................................................................................... 42
PHARMACY............................................................................................................................ 42
PROTECTIVE SERVICES ...................................................................................................... 42
REHABILITATION SERVICES ............................................................................................. 43
SOCIAL WORK....................................................................................................................... 43
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TELECOMMUNICATIONS.................................................................................................... 44
Telephone System................................................................................................................. 44
TRANSPORT OF PATIENTS ................................................................................................. 44
RESIDENT RESOURCES ........................................................................................................... 44
CONFERENCES, ROUNDS, LECTURES, ETC.................................................................... 44
RESIDENT PARTICIPATION ON HOSPITAL COMMITTEES.......................................... 44
ASSOCIATIONS...................................................................................................................... 45
COMPUTER USE AND SUPPORT ........................................................................................ 45
FOOD SERVICE ...................................................................................................................... 47
INTERPRETER SERVICES .................................................................................................... 48
LIBRARY FACILITIES........................................................................................................... 49
MEAL TICKETS...................................................................................................................... 49
PHYSICIAN IMPAIRMENT................................................................................................... 49
ON-CALL ROOMS.................................................................................................................. 50
UNIFORMS AND LAUNDRY................................................................................................ 50
NON-APPROVED ABBREVIATIONS………………………………………………………...59
WHO'S WHO ............................................................................................................................... 62
MAP ……………………………………………………………………………………Back cover
iv
INTRODUCTORY STATEMENTS
INSTITUTIONAL COMMITMENT
As part of its mission in providing health care services, University Hospitals of Cleveland ("University Hospitals")
recognizes the need and benefits of graduate medical education. It is our firm belief that the sponsoring of graduate
medical education programs furthers our mission in the provision of quality care, responding to the community
needs and the assurance of future generations of health care professionals necessary to continue to deliver health
care to the community.
University Hospitals, its Chief Executive Officer, and the teaching staff are committed to excellence in its Graduate
Medical Education programs and care of patients. We further believe that GME programs, properly structured,
monitored and evaluated, can and do lead to improved quality care, relationships between health care providers, the
patient and patient's family and may lead to a greater awareness on the part of the consumers of health care as to
their responsibilities for their own health.
Additionally, the presence of quality educational programs has the distinct advantage of providing a mechanism for
the recruitment and retention of high quality individuals in the medical care arena interested in furthering and
improving health care delivery. Graduate medical education programs provide a firm basis and play an integral part
in the ability of University Hospitals to meet and further its purposes consistent with the philosophy, mission and
goals of the institution.
University Hospitals commits itself to the provision of organized GME programs in which Residents develop
personal, clinical and professional competence under careful guidance and supervision. These programs will assure
the safe and appropriate care of patients and the progression of Resident responsibility, consistent with each
physician's clinical experience, knowledge and skill.
University Hospitals commits itself to the provision of a scholarly environment. Faculty will engage in scholarly
activity, including research, and will make available to Residents opportunities to participate in and learn from the
scholarship of the medical community.
University Hospitals commits itself to providing committed and competent professionals to the teaching faculty of
the GME Programs. Members of the teaching faculty will be appointed by the Department Chairperson and will be
selected for their professional ability and commitment to teaching, medical education, patient care, and the scientific
and humanistic basis of medicine.
The GME programs will emphasize coordinated delivery of care with a community orientation. Special emphasis
will be placed on training primary care providers. As appropriate, University Hospitals will take advantage of
opportunities to work with other education institutions in fulfilling its educational role.
University Hospitals will also ensure that all of its graduate medical education programs meet or exceed all
Institutional and Special Requirements promulgated by the Accreditation Council of Graduate Medical Education
(ACGME) and its individual Residency Review Committees.
_____________________________________
Fred C. Rothstein, M.D.
President and Chief Executive Officer
__________________________________
Jerry M. Shuck, M.D.
Director, Graduate Medical Education and
Designated Institutional Official
1
Health System
of Cleveland
WELCOME
To The New Members of the House Staff:
Welcome to University Hospitals of Cleveland. As one of the premier teaching hospitals in the
country, we are pleased to have you as a member of our House Staff as you begin your career in
medicine.
This Manual has been prepared to provide you with general information about the Hospital. For
specific facts relating to policies and procedures, please consult the Formulary and the Hospital
and System Policy and Procedure Manuals, located on each patient division, and on the
University Hospitals Health System (UHHS) Intranet. Instructions concerning the particular
clinical services to which you are assigned will be given to you by the Director of the service.
This is an exciting time in your life, and one that offers many opportunities for continued growth.
We hope your association with University Hospitals will prove to be a rewarding and satisfying
experience.
We wish you every success.
Fred C. Rothstein, M.D.
President and CEO
Nathan Levitan, M.D.
Chief Medical Officer
Jerry M. Shuck, M.D.
Director, Graduate Medical Education
2
INTRODUCTION
Throughout this Residents & Fellows Manual (the “Manual”), the terms “Resident,” “Resident
Physician,” “House Officer” and “House Staff” refer to both residents and fellows. Resident Physicians
have an obligation to the patient care program of the institution and to the effectiveness of the educational
program to which they have been appointed. The most important criterion of the service of the Resident
Physicians is the performance of their professional duties. Professionalism includes honesty, integrity,
respect, and compassion, which includes introducing yourself to patients, explaining your role, and
treating patients as if they were members of your family.
The proper discharge of the responsibilities of Resident Physicians requires their full time effort while on
duty. All Resident Physicians shall remain within the Hospital as required by their patient care
responsibilities and shall be immediately available if on call.
The Department Chairs and Residency Program Directors have the responsibility and authority at all
times to assure the Resident Physicians’ effectiveness in the programs.
University Hospitals of Cleveland comprise a group of long established hospitals which, in partnership
with the Health Science Schools of Case Western Reserve University (Medicine, Dentistry, Nursing, and
Social Work), furnish an integrated program to provide the highest quality medical care for the sick and
injured, to advance knowledge regarding the cause, prevention and treatment of disease and disability,
and to educate men and women in the healing professions.
University Hospitals of Cleveland (UHC) and Case Western Reserve University (CWRU) are operated by
separate Boards of Directors, and have separate Administrations. Appointments to the attending staff of
UHC are made by the Board of Directors of the Hospital upon recommendation by the Clinical Council.
All members of the attending staff are on the CWRU faculty.
The medical activities are the responsibility of the Clinical Council. This group consists of the Chief
Medical Officer, the Chairs of Anesthesiology, Dermatology, Emergency Medicine, Family Medicine,
Medicine, Neurology, Neurological Surgery, Obstetrics and Gynecology, Ophthalmology, Orthopedics,
Otolaryngology-Head & Neck Surgery, Pathology, Pediatrics, Psychiatry, Radiology, Surgery, Urology,
the Director of the Ireland Cancer Center, the Director of the Genetics Center, the President, Executive
Vice President, General Managers, Director of Graduate Medical Education and the Senior Vice
Presidents of the Hospital. Two Directors and the Dean of the Medical School are ex officio members.
Standing committees of the Clinical Council study problems referred to them and make recommendations
to the Council. One of these committees is the Graduate Medical Education Committee (GMEC), chaired
by the Director of GME. This committee monitors the accreditation of each residency and Fellowship
program sponsored by University Hospitals and has responsibility for advising all aspects of residency
education. The Committee consists of Clinical Chairmen, Program Directors, senior hospital
administrators, legal counsel, and Resident representatives.
University Hospitals of Cleveland has developed the following statement of Mission, Vision and Values.
We encourage all physicians to use this as a guide to their behavior.
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MISSION, VISION, VALUES
OUR MISSION
To heal, to teach, to discover.
OUR VISION
University Hospitals of Cleveland will be the regional leader in providing high-quality,
compassionate, cost-effective health care, including the full spectrum of prevention,
diagnosis and treatment, while enhancing our status as a nationally recognized academic
health center in partnership with Case Western Reserve University.
OUR VALUES
At University Hospitals of Cleveland we value:
Patient-Centered Care
Exceptional service to each patient as our highest priority.
Caring
A consistent commitment to be caring toward our patients and each other.
Excellence
The highest caliber of health care and medical science.
Value
Wise and efficient use of resources in providing superior patient care.
Innovation
A striving for creative solutions, originality and innovation.
Scholarship
The pursuit, creation, preservation and transmission of new knowledge.
Cooperation
Cooperation, collaboration and teamwork in achieving our goals.
Integrity
Integrity and mutual respect as paramount in all activities and personal interactions.
Cultural Diversity
An appreciation for personal and cultural similarities and differences.
4
UNIVERSITY HOSPITALS HEALTH SYSTEM
University Hospitals of Cleveland
HISTORICAL OVERVIEW
The idea for University Hospitals of Cleveland can be traced back to the Civil War. The Ladies Aid Society of the
First Presbyterian Church (Old Stone Church) operated a “Home for the Friendless” to assist people displaced by the Civil War.
Seeing the need for a hospital to provide medical care for the poor of Cleveland, a group of civic leaders and parishioners of Old
Stone Church formed the Cleveland City Hospital Society, which was incorporated on May 21, l866, “to found a hospital for the
reception, care, and medical treatment of sick and disabled persons.” The first hospital opened in l866 in a small frame house on
Wilson Street; hence, the name “Wilson Street Hospital.” By l875, the hospital had outgrown the building and was relocated to
the former Marine Hospital facility (located at East 9th and Lakeside Avenue), which the trustees leased from the federal
government. When the City of Cleveland decided to build its own hospital (City Hospital) in l888, the name was changed to
Lakeside Hospital.
In l897, Lakeside Hospital signed a formal affiliation agreement with Western Reserve University School of Medicine.
About the same time construction began on a new hospital modeled after the pioneering pavilion design of Johns Hopkins
University Hospital. The new multi-pavilion Lakeside Hospital was opened in l898 and the Lakeside Training School for Nurses
was established the same year. In other parts of the city, the Babies and Children's Dispensary was established in l906 and joined
Rainbow Cottage (l887) and Lakeside Hospital in providing medical care for the children of Cleveland. The Maternity Home
(hospital) was established in l89l to provide obstetrical services and care for women; it was renamed MacDonald Hospital in
l936.
In 1925, Lakeside Hospital joined with Babies and Children's Hospital and the Maternity Hospital to form University
Hospitals of Cleveland (UHC). A year later Rainbow Hospital, located in South Euclid, affiliated with UHC. In the mid-1920’s,
construction began on new hospital facilities as well as a new School of Medicine, the Institute of Pathology and Maternity Hospital
(MacDonald Women’s Hospital) (l929) in the University Circle area. In l93l, the new Lakeside Hospital and Leonard C. Hanna House
were dedicated. Two decades later, Howard M. Hanna Pavilion (l956) for psychiatric care was opened and, in l962, the Joseph T.
Wearn Laboratory for Medical Research was dedicated. The Benjamin Rose Hospital (1953), one of the nation's first geriatric
hospitals, affiliated with UHC in 1957. In 1969, it became part of UHC and its name changed to Abington House. The Robert H.
Bishop, Jr. Building, housing operating rooms, radiology services and a new cafeteria was opened in l967. In l97l, a new children's
hospital was built, housing both Babies and Children's Hospital and Rainbow Hospital. In l974, both hospitals were combined under
one Board of Trustees as Rainbow Babies and Children’s Hospital. The 190-bed Leonard and Joan Horvitz Tower, opened on April
15, 1997, became the most technologically advanced and family oriented pediatric facility in the nation.
New additions to the medical complex in the l970s and l980s included the Mabel Andrews Wing (1972) of the Institute
of Pathology, the George M. Humphrey Building (l978), and the Harry J. Bolwell Health Center (l986). University Hospitals of
Cleveland's main campus includes: Alfred and Norma Lerner Tower (l994), Samuel Mather Pavilion (l994) and Lakeside
Pavilion for adult medical and surgical care; MacDonald Women’s Hospital (l89l); Rainbow Babies and Children’s Hospital
(l887); University Psychiatric Center at Hanna Pavilion (l956), and Bolwell Health Center (l986). University Hospitals of
Cleveland and its academic counterpart, CWRU School of Medicine, form Ohio's largest biomedical research center. In 1999,
the Research Institute of UHC was created and work will be completed on a new state of the art research facility in 2003.
UHC is part of University Hospitals Health System, a regional healthcare delivery system that includes University
Hospitals of Cleveland, UHHS Memorial Hospital of Geneva, UHHS Laurelwood Hospital & Counseling Centers, UHHS Geauga
Regional Hospital, UHHS Brown Memorial Hospital in Conneaut, UHHS Bedford Medical Center, UHHS Richmond Heights
Hospital, University Primary Physician Practices, a broad range of ambulatory centers, two skilled nursing facilities, wellness,
elderhealth and home care services, QualChoice Inc., University CompCare for the management of job related injuries, Outpatient
Surgery Center at UHC, UHHS Chagrin Highland Medical Center, and partnerships with St. Vincent Charity Hospitals, St. John
WestShore Hospital, Mercy Medical Center in Canton, Southwest General Health Center, Heather Hill Hospital and University
Suburban Health Center.
The mission of University Hospitals of Cleveland has remained constant for over 130 years
-- to heal, to teach, and to discover.
5
PURPOSE OF THIS MANUAL
The information contained in this Manual is presented for the benefit of the Residents of University Hospitals of
Cleveland (UHC). The intent of this Manual is to provide and direct the Resident Physician to necessary
information concerning the policies, procedures and practices of UHC and University Hospitals Health Systems
(UHHS), UHC and UHHS reserve the right to revise, withdraw, suspend or discontinue its policies, procedures and
practices at any time.
Except as may be set forth in the sections below, referred to as Grievance Procedures, Corrective Action/Appeal
Process, Summary Suspension, Automatic Suspension and Resident Physician Appeals Process and the contract of
employment between UHC and the Resident, this Manual is not intended to and does not enlarge or create any
additional rights of employment. It does, however, set forth and direct the Resident to many matters that the
Resident is obligated to obey or observe.
Subject to the paragraph immediately above, either the Resident or UHC may end the employment relationship for
any reason or no reason, at any time.
In no way should this Manual be considered as the only, or final, source of information on the policies, procedures
and practices of University Hospitals of Cleveland. Residents are to refer to the specific UHC Policies and
Procedures Manuals for all issues concerning employment or patient care, and are encouraged to ask their
Department Chairs for additional information or clarification on any such matters.
EDUCATION INFORMATION
ELIGIBILITY AND SELECTION
The following is the policy of University Hospitals of Cleveland regarding the recruitment, eligibility and selection
of Residents. Each applicant must file an application, provide references including a Dean's letter and, finally,
appear for a series of interviews.
A.
Eligibility. Applicants with one of the following qualifications are eligible for appointment to accredited
residency programs:
1.
2.
3.
4.
B.
Graduates of medical schools in the U.S. and Canada accredited by the Liaison Committee on Medical
Education (LCME).
Graduate of colleges of osteopathic medicine in the U.S. accredited by the American Osteopathic
Association (AOA).
Graduates of medical schools outside the U.S. and Canada who meet one of the following
qualifications:
a. Have a currently valid certificate issued by the Education Commission for Foreign Medical
Graduates (ECFMG).
b. Have a full and unrestricted license to practice medicine in a U.S. licensing jurisdiction.
Graduates of medical schools outside the U.S. who have completed a Fifth Pathway program provided
by an LCME accredited medical school.
Selection.
1. Programs at UHC select from among eligible applicants on the basis of their preparedness, ability,
aptitude, academic credentials, communication skills, and personal qualities such as motivation and
integrity. Programs shall not discriminate with regard to gender, race, age, religion, color, national
origin, disability, sexual orientation or veteran status.
6
2.
In selecting from qualified applicants programs participate in an organized matching program, where
available, such as the National Resident Matching Program (NRMP).
EMPLOYMENT CONTRACTS
By one month prior to appointment, or reappointment, Residents will receive a letter of appointment/employment
contract from the Director of Graduate Medical Education (DIO). This contract must be signed and returned prior to
the appointment date for the contract to become valid.
All appointments are for one year or less, and may be renewed at the discretion of the institution, upon continued
evidence of satisfactory performance.
RENEWAL OF APPOINTMENT
All Residency/Fellowship reappointment contracts carry the condition that Residents must complete their present
year of training in a satisfactory manner for the reappointment to be valid at the beginning of the new academic year
beginning July 1. Advancement to the next PGY level is based upon the recommendation of the Program Director.
NONRENEWAL OF APPOINTMENT
If at any time a Program Director or Clinical Chairperson determines that a Resident is not meeting the standards of
the program he/she may recommend nonrenewal of the Resident’s appointment, or contract. Circumstances which
might result in nonrenewal of appointment are outlined in the Corrective Action section of this Manual.
The Program Director or Clinical Chairperson must submit the recommendation for nonrenewal in writing to the
Director of GME (the DIO), and will include the basis on which the action is being taken. If the Director of GME
(DIO) determines that there is sufficient reason not to renew the contract, he/she will notify the Program Director,
who will so inform the Resident in writing no later than four months prior to the end of the Resident's current
contract. In accordance with ACGME guidelines, if the primary reason(s) for non-renewal occur(s) within four
months prior to the end of the contract, UHC will make every effort to ensure that the program provides its Resident
as much written notice of the intent not to renew as circumstances will reasonably allow.
A Resident receiving notice of nonrenewal of contract may implement his/her right to due process through the
Appeals Process, as presented in this Manual.
VISA POLICIES AND PROCEDURES
FOR FOREIGN/UNITED STATES MEDICAL SCHOOL GRADUATES
It is Hospital policy to comply with the immigration laws of the United States, and all Residents must obtain and
maintain an immigration status that permits employment by the Hospital in a clinical capacity1. Although several
types of visas may qualify an International Medical Graduate (“IMG”) to practice clinically at the Hospital, it is
Hospital policy to participate only in the application for a J-l visa for an IMG Resident. This includes the
requirement that the IMG hold a valid certificate from the Educational Commission for Foreign Medical Graduates
(ECFMG). If, at any time, a Resident fails to timely obtain or retain the requisite visa status from the United States
Citizenship and Immigration Services (“USCIS”) (formerly the Immigration and Naturalization Service) the
Resident will be subject to dismissal or leave of absence, with or without pay, at the discretion of the Director of
GME (DIO), in view of all the surrounding circumstances. The Hospital does not support the pursuit of H-1B visas
for IMG Residents. Residents who are visa holders may not moonlight.
1
In accordance with regulations from the Education Commission for Foreign Medical Graduates (ECFMG)
employment outside the residency or Fellowship training program is not permitted.
7
COMPLETION OF TRAINING
Before departing University Hospitals at the conclusion of your residency/Fellowship training, you must complete
obligations to your Program Director and also to the institution. An official clearance sheet must be completed and
turned into the Office of Graduate Medical Education (Office of GME) along with your ID badge at Lakeside 3018.
This form can be obtained from your own department, or from the Office of GME. It will show evidence of your
completed medical records, and that you have returned all hospital property such as keys, equipment, parking pass,
radiation dosimeter, keys, scrubs, etc. The form also requests a forwarding address, and reminds you of your right
to continuing health insurance coverage through COBRA.
University Hospitals’ official certificates of completion are presented to departing Residents by the directors of each
program.
CLOSURE REDUCTION POLICY
If University Hospitals of Cleveland intends to reduce the size of, or close, a residency program, the institution will
inform the Residents as soon as possible. In the event of such a reduction or closure, the institution will make every
effort to allow Residents already in the program to complete their education. If any Residents are displaced by the
closure of a program or a reduction in the number of Residents, the institution will make every effort to assist the
Residents in identifying a program in which they can continue their education.
RESTRICTIVE COVENANTS
University Hospitals of Cleveland strictly prohibits the request for any Resident to sign non-competition guarantees.
EVALUATIONS
Evaluation of Faculty
All Residents are required by the ACGME (Accreditation Council for Graduate Medical Education) to complete
periodic evaluations of the faculty with whom they work. The number of faculty evaluations each Resident
completes will vary depending on service assignments and/or the size of the attending staff. Faculty evaluations,
which are retained in the individual Clinical Departments, are an important component of the professional review of
each faculty member.
Evaluation of a Resident’s Performance
Residents will be periodically evaluated by their Program Directors at the frequency mandated by the Program
Requirements for Resident Education of the specialty in which the Resident is training. Evaluations will be
communicated to the Resident in a timely manner and a record of the evaluation will be permanently maintained in
the Clinical Department. If a Resident physician requires an explanation or interpretation of his/her education
records, he/she should make such a request directly to the Residency Program Director or to the Clinical Department
Chair.
Resident evaluation will be based, in part, on at least the following:
1.
Academic Performance
a. Whether the Resident has sufficient medical knowledge;
b. Whether the Resident possesses adequate and appropriate technical skills;
c. Whether the Resident is able to use medical knowledge and/or technical skills effectively in providing
medical care; and
8
d.
2.
Whether the Resident has any deficiency that may affect his/her clinical or academic performance.
Hospital Standards
a. Whether the Resident has abided by the Residents and Fellows Manual, the Medical Staff By Laws,
and the Medical Staff Rules and Regulations;
b. Whether the Resident demonstrates ability to work cooperatively with others;
c. Whether the Resident has followed the established practices, policies and procedures of the Hospital;
and
d. Whether the Resident has abided by the Corporate Code of Conduct and applicable standards of
professional responsibility.
CORRECTIVE ACTION
At any time during the Residency Training Program, the Residency Program Director, Clinical Department Chair or
Director of GME (DIO) may determine that the Resident is not meeting the standards of the program or the
profession, for reasons that may include, but are not limited to:
1.
2.
3.
4.
Lack of professional competence, insufficient medical knowledge, or technical skills needed to carry out
their duties and responsibilities;
Any conduct that is detrimental or potentially detrimental to University Hospitals of Cleveland patients or
employees;
Demonstrated inability to work with others or behavior that is reasonably likely to be disruptive to Hospital
operations;
Activities or professional conduct that are reasonably likely to be in violation of the Medical Staff Bylaws,
Medical Staff Rules and Regulations, or any other Hospital policies and procedures; and
If the Residency Program Director, Clinical Department Chair, or Director of GME believes that corrective action is
warranted, he/she may do one or more of the following:
1. A reprimand will be mailed to the Resident, and a copy will be placed in the Resident's file.
2. If a remedial program is required, the Resident shall be so informed in a meeting with the Residency
Program Director or Clinical Department Chair. At that meeting, the Resident's deficiencies will be
identified, a remedial program will be established, and a frame for completion of the remedial program will
be discussed and documented.
A copy of this document will be given to the Resident, and a copy will be placed in the Resident's file. The
remedial plan may include limitations or restrictions on the amount and level of the Resident's patient care
activities. Such action may necessitate extension of the Resident's educational program. At the end of the
remedial period, the Resident will receive an evaluation. At that time, the Residency Program Director or
Clinical Department Chair may or may not take further corrective action.
3.
Recommend Leave of Absence, Suspension or Dismissal of the Resident. The Residency Program
Director, Clinical Department Chairman, or Director of GME (DIO) may recommend a Leave of Absence,
Suspension, or Dismissal of the Resident. The Leave of Absence may be with or without pay. Suspension
shall be without pay. Such recommendation will be made in writing, accompanied by any written
documents necessary to support the recommendation, and will be filed with the Chief Medical Officer. The
recommendation will include a time frame for a Leave of Absence or Suspension. The Chief Medical
Officer, or his designee, will convene an Initial Review Panel, which will include the Director of GME
(DIO) (who will chair the Panel); the Vice-President of the Quality Center; the Residency Program Director
(or representative); the Clinical Department Chairman (or representative); and, representatives of the Law
Department and Human Resources. Prior to the meeting, the Panel Chair will review the submitted
documents, and determine a list of individuals who the Panel may wish to interview. These individuals will
be notified to be available in the event the Panel wants to interview them. The Panel will present its
9
findings to the Chief Medical Officer, who will promptly issue a decision on the recommendation for Leave
of Absence, Suspension or Dismissal of the Resident physician.
In the event the Chief Medical Officer upholds such recommendation, the action shall become effective
immediately. During the period of Suspension without pay, or Leave of Absence without pay, the Resident
physician will not receive any cash, or other compensation. Health-related benefits will continue if the
Resident elects to pay for them directly. In all cases of Suspension or Leave of Absence, the Resident
physician will not be permitted any Hospital privileges, including computer access, nor be permitted to
attend Conferences or Rounds. The period of Leave of Absence or Suspension will result in an extension
of the Resident’s educational program. Hospital identification badge(s) and pager(s) shall be surrendered.
In the event the Chief Medical Officer rejects the recommendation, and the Chief Medical Officer imposes
no other sanction or action, the record of the event will be expunged from the Resident physician’s file.
4.
Recommend non-renewal of the Resident’s contract. If a Residency Program Director or Department
Chairman determines that a Resident is not meeting the standards of the program, he/she may make a
recommendation for non-renewal of the Resident’s contract. The recommendation must be submitted in
writing to the Director of GME (DIO), and will include the basis on which the action is being taken, along
with any written documents necessary to support the recommendation. All written information regarding
the recommendation will become part of the Resident’s file. If the Director of GME (DIO) determines that
there is sufficient reason not to renew the contract, he/she will notify the Program Director, who will so
inform the Resident in writing. Recommendations for non-renewal should be made no later than four
months prior to the end of the Resident’s current contract. If, in accordance with ACGME guidelines, the
primary reason(s) for non-renewal occur(s) within the four months prior to the end of the current contract,
every effort will be made to ensure that the program provides its Resident as much written notice of the
intent not to renew as circumstances will reasonably allow. A Resident receiving notice of non-renewal of
contract may implement his/her right to due process through the Appeals Process, as presented in this
Manual. In the event the Director of GME (DIO) rejects a recommendation for non-renewal of contract,
the Resident’s contract will be renewed for the following year.
5. No appeal is available when the action is to reprimand or institute a remedial program for the Resident. A
decision to impose a leave of absence, suspend, dismiss, or fail to renew the Resident’s contract shall
entitle the affected Resident to the Appeals Process contained in this Manual.
Where a Resident receives notice of a corrective action under the terms in this Residents & Fellows Manual,
inclusive of any amendments to this Manual that are in effect on the date of receipt of the notice, this Manual shall
govern, irrespective of any later amendments or revisions to the Manual.
SUMMARY SUSPENSION
The Residency Program Director, Clinical Department Chair or Director of GME shall have the authority, whenever
action must be taken immediately in the best interest of patient care or the Hospital, to summarily suspend all or any
portion of the privileges of a Resident physician, and such summary suspension shall become effective immediately
upon imposition.
At the discretion of the Chief Medical Officer, such suspensions may be with or without pay depending on the
allegations, facts and status on any applicable investigation.
The Chief Medical Officer will convene an Initial Review Panel within 10 calendar days of the suspension. The
Panel will include the Director of GME (who will Chair the Panel); the Vice-President of the Quality Center; the
Residency Program Director (or representative); the Clinical Department Chairman (or representative); a
representative of Human Resources and Law Department. The Panel may request an interview with the suspended
Resident. Whoever summarily suspended the Resident will provide written documents necessary to support the
recommendation. The panel will decide whether to reverse, modify, or sustain the Summary Suspension.
10
A Resident physician who has been summarily suspended shall be entitled to all of the rights provided in the
Appeals Process contained in this Manual.
AUTOMATIC SUSPENSION
A suspension of a Resident physician shall be imposed automatically if action by the Ohio State Medical Board
results in revocation or suspension of the Resident’s license or temporary certificate. Such automatic suspension
shall become effective immediately upon action by the Ohio State Medical Board. During the suspension, the
Resident will be on “unpaid leave status” and, in order to continue health benefits, will need to pay the premium
directly since, in the absence of a paycheck, deduction of that premium is not possible. If the license or temporary
certificate is reinstated, the Resident may apply for readmission into the program. If readmission into the program is
denied, the Resident physician is entitled to all the rights provided in the Appeals Process contained in this Manual.
RESIDENT PHYSICIAN APPEALS PROCESS
1.
Whenever a Corrective Action that can be appealed (Leave of Absence, Suspension, Summary Suspension,
Dismissal, Failure to Renew Contract, Failure to be Re-accepted into Program after Termination of Automatic
Suspension) is imposed on a Resident the Residency Training Director, Clinical Department Director, Director
of GME (DIO), or the Chief Medical Officer, shall provide written notification to the Resident, either in person
or by certified mail, return receipt requested, of the Corrective Action. Such notice shall contain a specific
statement of the grounds for such Corrective Action and shall refer to the resident physician’s right of appeal as
set forth below.
2.
To appeal a Corrective Action, the Resident physician must submit, within ten (10) calendar days after
receiving such notice, a written request either in person or by certified mail, return receipt requested to the Chief
Medical Officer for a hearing before an Appeals Committee. No electronic requests will be accepted.
3.
Upon receipt of a written request for a hearing the Chief Medical Officer shall appoint an Appeals Committee
consisting of seven individuals, five of whom will have a vote. The voting members will include: 1) the
Director of GME, who will Chair the Committee. If the Resident requesting the Appeal Hearing is from the
same Department as the Director of GME, the Chief Medical Officer or his/her designee will function as the
Chair; 2) two Residency Program Directors from different Departments than that of the Resident requesting the
Appeal Hearing; 3) a representative from Human Resources; and 4) a Medical Staff Member from a different
Clinical Department than that of the Resident requesting the Appeal Hearing and that of the two Program
Directors on the Committee. The non-voting members will be 1) a Resident who is a member of the Graduate
Medical Education Committee or a Chief Resident from a Clinical Department different from that of the
Resident requesting the Appeal Hearing, and 2) another Resident, from a different Department, at a similar level
of training as the Resident who filed the Appeal. The non-voting Resident members may participate in all
aspects of the deliberations prior to the vote.
The Chief Medical Officer will appoint the Manager or Coordinator of the Office of GME to serve as Secretary,
who will keep minutes of the meeting. The Chief Medical Officer, or his/her designee, will determine the date,
time, and place of the meeting.
4.
No later than ten (10) business days after receipt of the Resident's request for a hearing, the Chief Medical
Officer or his/her designee, shall notify the Resident by certified mail, return receipt requested, of the date,
time, and place of the hearing.
5.
The hearing shall be held no fewer than thirty (30) and no more than forty-five (45) business days after
receipt of the Resident's request for a hearing. A hearing for a Resident who is under Suspension, however,
shall be held as soon as the arrangements may reasonably be made, but not later than thirty (30) calendar days
from the date of receipt of the request for a hearing, unless extended by mutual consent.
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6.
From the date upon which the Chief Medical Officer receives the Resident's request for a hearing until the
date of the hearing, the Residency Program Director or Clinical Department Chair, or his/her designee, shall
permit the Resident, upon his/her request, to examine and duplicate any written materials that relate in any
way to the suspension, termination, or corrective action. No later than ten (10) business days prior to the
scheduled hearing date, the parties shall provide each other with a list of witnesses that each intends to call at
the hearing. A maximum of 3 witnesses each may be called by the resident and by the Program Director to
appear in person. An unlimited number of witnesses, however, may submit written testimonials for review by
the Appeals Committee.
7.
At the hearing, the Resident's personal presence is required. The Resident may be aided or represented by
another Resident in the Hospital's graduate medical education program or by a member of the Hospital's
Medical Staff. None of the parties to the appeal shall be aided or represented at this hearing by an attorney.
8.
At the hearing, both the Residency Program Director or Clinical Department Chair and the Resident, may
make opening statements. The Residency Program Director or Clinical Department Chair shall then present
his/her case supporting the corrective action. The Resident shall then present his/her case opposing such
suspension, termination, or corrective action. Both the Residency Program Director or Clinical Department
Chair and the Residents may make closing arguments.
9.
At the hearing, both the Residency Program Director or Clinical Department Chair and the Resident may
present written evidence, examine witnesses, and cross-examine witnesses. The Rules of Evidence that
govern proceedings in a court of law shall not apply.
10.
Within five (5) business days after the hearing, the Committee Chair (i.e., the Director of GME) shall prepare
and send to both the Residency Training Director or Clinical Department Director and the Resident, by
certified mail, return, receipt requested, a written decision which shall affirm, modify or reverse the
Resident's corrective action. This decision shall be by a majority vote of the Committee's members and shall
be based solely upon the written and oral evidence presented by the Residency Training Director or Clinical
Department Director and the Resident at the hearing. The Chief Medical Officer shall receive a copy of the
written decision.
11.
The decision of the Committee shall be final and binding upon both the Residency Program Director or
Clinical Department Chair and the Resident.
12.
A Resident who has been suspended or dismissed from the Hospital's Graduate Medical Education Program,
and who has instituted an appeal as provided herein, may resume clinical practice only if recommended in
writing by the Appeals Committee.
13.
The Resident's failure to exercise any right provided by the Appeals Process shall constitute an irrevocable
waiver of such right.
GRIEVANCE PROCEDURE
The following Grievance Procedure is available to all Residents who are members of the Resident Staff of
University Hospitals of Cleveland. It is not applicable to Residents from affiliated institutions who are on rotation at
University Hospitals.
1.
Grievances. If a Resident has reason to believe that established Hospital policies and procedures including
applicable personnel policies (with the exception of any action, policy, practice or procedure connected with the
periodic evaluation of Resident, corrective action or appeals, as set forth in this Resident Manual) have been denied
him/her or have been erroneously applied to him/her, or if a Resident has a problem (collectively, hereinafter a
“Grievance”) with any employee of the Hospital, any member of the Hospital’s Medical Staff, or any other
individual affiliated or associated with the Resident’s residency training program, the following procedure has been
established for the discussion and resolution of such a Grievance.
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2.
Meeting with Manager of Graduate Medical Education. Make an appointment to discuss the Grievance
with the Manager of Graduate Medical Education (“Manager of GME”). The Manager of GME will explain the
established policies and procedures to assist the Resident in determining whether a formal Grievance should be filed.
The Resident shall maintain authority over the final decision as to whether a Grievance exists and/or whether a
formal Grievance should be filed.
3.
Filing Grievance Notice. If, after discussing the Grievance with the Manager of GME, the Resident
believes that a Grievance exists, then the Resident must submit a written notice (the “Grievance Notice”) of the
Grievance to the Manager of GME and the Resident’s respective Program Director. All Grievance Notices must set
forth in reasonable and sufficient detail an explanation of the Resident’s Grievance. All Grievance Notices must be
properly filed by the respective Resident no later than (30) calendar days after the Resident discusses the Grievance
with the Manager of GME.
4.
Form of Filing and Disclosure of Grievance. A properly filed Grievance Notice is one that is either: (1)
personally delivered by the Resident to each of the appropriate parties and for which the Resident obtained a time
stamped copy (reflecting the date and time of delivery of the Grievance Notice) from each party to whom the
Resident personally delivered the Grievance Notice; or (2) mailed by certified mail, return receipt requested to each
appropriate party. The Manager of GME may provide copies of all Grievance Notices to the following individuals:
(1) the Resident’s Clinical Department Chair; (2) the Director of GME (DIO); and (3) the Senior Vice President and
General Counsel of the Hospital.
5.
Filing Grievance Notice with Alternate Parties and Chiefs of Staff. If due to the nature of the Grievance,
the Resident reasonably believes that it would be inappropriate to file the Grievance Notice with the Program
Director, then the Resident shall so inform the Manager of GME who shall then instruct the Resident to file the
Grievance Notice to the Director of GME (DIO). In lieu of filing the Grievance Notice with the Manager of GME
or Program Director, the Resident may, for good cause, file the Grievance Notice directly to the Director of GME
(DIO). “Good cause” shall be determined by the Director of GME (DIO) in his sole discretion and he reserves the
right to redirect the Resident to the file the Grievance with any other party deemed appropriate by the Director of
GME (DIO).
6.
Discussion with Program Director. If Resident filed the Grievance Notice with his/her respective Program
Director pursuant to Step 3, above, then the Resident and the Program Director shall meet to discuss the Grievance.
Unless the Resident otherwise agrees, such meeting shall occur no later than five (5) business days after the Program
Director’s receipt of the Grievance Notice. If the Resident chooses, the Manager of GME may accompany him/her
to this meeting to assist in the discussion of the Grievance. The Program Director shall reply in writing to the
Resident’s Grievance within five (5) business days after their meeting.
7.
Program Director Grievance Review. At any time before, during or after a Resident meets with his/her
respective Program Director, such Program Director may request the Resident to submit the names of two other
Residents from his/her service whom the Program Director may want to ask about the Grievance or specific aspects
thereof. In addition, the Program Director may ask the Resident’s respective Chief Resident to answer questions
relating to the Grievance and/or to be present at any meeting pertaining to the Resident’s Grievance. In the event the
Grievance concerns an incident that is not directly related to the Resident’s training program, the Program Director
may request the Resident to submit the names of two Hospital employees who witnessed the incident. If a person
identified as a witness leaves the employ of the Hospital prior to resolution of the Grievance, that person shall
nevertheless be recognized and accorded an opportunity to be heard during the Grievance Process set forth herein,
provided that such person left the Hospital in good standing.
8.
Follow-Up after Discussion with Program Director: Filing of Continuation Notice. If the Resident is not
satisfied with the Program Director’s resolution, and desires to follow through on the Grievance to the next step, the
Resident shall meet with the Manager of GME. The Manager of GME will help the Resident with a further review
of the Grievance to enable the Resident to make an appropriate decision whether to pursue his/her Grievance. If the
Resident desires to pursue the Grievance, then he/she shall file a written notice (the “Continuation Notice”) that he
or she wishes to continue to pursue the Grievance. This Continuation Notice may include a restatement of the
Grievance Notice, but it must also further expand or explain the Resident’s reasons for continuing to pursue the
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Grievance. This Continuation Notice must be filed with the Manager of GME within thirty (30) calendar days after
the Program Director issues his/her written resolution.
9.
Discussion with Department Chair or Division Chief. After a Resident meets with his/her respective
Program Director, if the Resident desires to pursue the Grievance, then he/she shall meet with his/her respective
Department Chair or Division Chief (depending on which is applicable). Unless the Resident otherwise agrees, such
meeting shall occur no later than five (5) business days after the Department Chair or Division Chief’s receipt of the
Grievance Notice. If the Resident chooses, the Manager of GME may accompany him/her to this meeting to assist
in the discussion of the Grievance. The Department Chair or Division Chief shall reply in writing to the Resident’s
Grievance within five (5) business days after their meeting.
10.
Department Chair or Division Chief Grievance Review. At any time before, during or after a Resident
meets with his/her respective Department Chair or Division Chief (depending on which is applicable), such
Department Chair or Division Chief shall follow the same process as in Step 7., above, offering only the same
individuals an opportunity to be heard who were heard at Step 7.
11.
Follow-Up after Discussion with Department Chair or Division Chief: Filing of Continuation Notice. If
the Resident is not satisfied with the Department Chair or Division Chief’s resolution, and desires to follow through
on the Grievance to the next step, the Resident shall meet with the Manager of GME. The Manager of GME will
help the Resident with a further review of the Grievance to enable the Resident to make an appropriate decision
whether to pursue his/her Grievance. If the Resident desires to pursue the Grievance, then he/she shall file a written
notice (the “Continuation Notice”) that he or she wishes to continue to pursue the Grievance. This Continuation
Notice may include a restatement of the Grievance Notice, but it must also further expand or explain the Resident’s
reasons for continuing to pursue the Grievance. This Continuation Notice must be filed with the Manager of GME
within thirty (30) calendar days after the Program Director issues his/her written resolution.
12.
Discussion with Director of GME (DIO). After a Resident meets with his/her respective Department
Chair or Division Chief, if the Resident desires to pursue the Grievance, then he/she shall meet with the Director of
GME (DIO). Unless the Resident otherwise agrees, such meeting shall occur no later than five (5) business days
after the Director of GME (DIO)’s receipt of the Grievance Notice. If the Resident chooses, the Manager of GME
may accompany him/her to this meeting to assist in the discussion of the Grievance. The Director of GME (DIO)
shall reply in writing to the Resident’s Grievance within five (5) business days after their meeting.
13.
Director of GME (DIO) Grievance Review. At any time before, during or after a Resident meets with the
Director of GME (DIO) such the Director of GME (DIO) shall follow the same process as in Step 7., above, offering
only the same individuals an opportunity to be heard who were heard at Step 7.
14.
Follow-Up after Discussion with Director of GME (DIO): Filing of Continuation Notice. If the Resident
is not satisfied with the Director of GME (DIO)’s resolution, and desires to follow through on the Grievance to the
next step, the Resident shall meet with the Manager of GME. The Manager of GME will help the Resident with a
further review of the Grievance to enable the Resident to make an appropriate decision whether to pursue his/her
Grievance. If the Resident desires to pursue the Grievance, then he/she shall file a written notice (the “Continuation
Notice”) that he or she wishes to continue to pursue the Grievance. This Continuation Notice may include a
restatement of the Grievance Notice, but it must also further expand or explain the Resident’s reasons for continuing
to pursue the Grievance. This Continuation Notice must be filed with the Manager of GME within thirty (30)
calendar days after the Director of GME (DIO) issues his/her written resolution.
15.
Establishment of Grievance Review Committee. The Manager of GME will inform the Hospital’s Senior
Vice President of Human Resources (or his/her designee) in writing of the Resident’s desire to proceed on the
Grievance and will provide him/her with a copy of the Continuation Notice. The Senior Vice President of Human
Resources will then: (1) select three individuals to serve as members of the Grievance Review Committee in
accordance with Step 16, below; and (2) arrange a mutually convenient meeting time to hold a hearing on the
Grievance. Subject to extenuating circumstances, the hearing shall be held within five (5) business days after the
Senior Vice President’s receipt of the Continuation Notice.
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16.
Composition and Administration of Grievance Committee. The Grievance Review Committee shall
consist of a combination of three persons: one who is a Department Chair (or Division Chief), one who is a General
Administrative Officer of the Hospital, and one who is a Residency or Fellowship Program Director. The Grievance
Review Committee will not include anyone who has been involved in the Grievance. The Senior Vice President of
Human Resources will be the chairperson of the meeting, and shall conduct the meeting pursuant to this Grievance
Procedure and all applicable policies and procedures of University Hospitals of Cleveland to ensure an orderly and
fair opportunity for all parties to present their positions.
17.
Witnesses. The Resident may, at any time prior to one (1) day before the hearing, submit to the Senior
Vice President of Human Resources the names of two Hospital employees who have information relating to the
Grievance. These employees may be asked to appear before the Grievance Committee either by the Resident, the
Senior Vice President of Human Resources or by any member of the Committee. The Department Chair (or
Division Chief) may also request not more than two people to appear before the Committee. The Resident’s
appearance before the Committee shall be limited to: (1) making a presentation not to exceed ten (10) minutes
(unless a longer period of time is permitted by unanimous approval of the Committee); and (2) responding to
questions posed by the Committee. Unless otherwise permitted by unanimous approval of the Committee, neither
the Resident nor any witness shall be permitted to sit through, attend or participate in the entire hearing. The
Committee shall have sole discretion to determine which portion(s), if any, of the hearing the Resident and/or any
witnesses shall attend.
18.
Additional Information Relating to Grievance. The Committee may, in its sole discretion, interview
additional individuals and/or seek additional information from other persons, organizations or entities if the
Committee believes that such actions would facilitate resolution of the Grievance.
19.
Providing Copies of Grievance. The Senior Vice President of Human Resources may, in his/her sole
discretion, forward copies of the Grievance Continuation Notice to all persons (including any witnesses) scheduled
to attend all or any portion of the hearing.
20.
Final Decision of Committee. The Committee must use its best efforts to give its decision in writing to the
Resident within three (3) business days after the hearing. The Committee’s decision shall be final, except in the
event such decision results in the full and final termination of the Resident’s participation in his/her residency
training program.
21.
Appeals. A Resident may appeal only a final decision hereunder. Any such appeal may be brought by the
Resident only if: (1) the Resident has complied with and exhausted all remedies pursuant to the Grievance
Procedure set forth herein; and (2) the final decision rendered hereunder expressly imposes a Leave of Absence,
Suspension, or Dismissal of the Resident or Termination of the Resident’s participation in his/her respective training
program at the Hospital. Any appeal hereunder shall follow and be in accordance with the procedures set forth in
the “Resident Physician Appeal Process” section of the Residents and Fellows Manual.
22.
Waiver of Grievance. The Resident shall waive any and all rights under this Grievance Procedure in the
event such Resident materially fails, without good cause, to comply with any of the requirements set forth herein,
including, without limitation, missing any: (1) deadline for filing a Grievance Notice or Continuation Notice; or (2)
any meeting or hearing with any party hereunder. “Good cause” shall be determined by the Director of GME (DIO)
in his sole discretion, acting reasonably.
23.
Confidentiality. All Grievances shall be kept confidential. The Resident, Manager of GME, Chief
Resident, Program Director, Department Chair, Director of GME (DIO) and any other Hospital employees, agents or
representatives that receive a Grievance Notice or otherwise receive or initiate information pertaining to a Grievance
shall keep all such information strictly confidential and shall disclose the same only to those other employees or
agents of the Hospital or other third parties or government agencies having a reasonable need to know the Grievance
and information pertaining thereto.
24.
Modification of Time Limits. All Grievance Procedure time limits may be modified by mutual agreement
of the parties based on the absence of one or more of the parties for good reason, such as scheduled vacation,
previously determined work schedule, illness or similar absence.
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COMPENSATION
PAYROLL
After registration through the Office of Graduate Medical Education (“Office of GME”), all Residents are on
University Hospitals’ payroll and commence with being paid an annual stipend. The stipend amount appropriate to
a Resident's contracted Post-Graduate Year (PGY) level will be stated in his/her contract. These established stipend
amounts are reviewed annually and amended from time to time. For information on the compensation schedule,
please consult the Office of GME.
Payrolls are prepared for a bi-weekly period ending on Saturday. Pays are dispersed through direct deposit on the
following Thursday, with the exception of a holiday week.
At the time of registration, each Resident must complete a Withholding Allowance Certificate (W-4) for the purpose
of withholding Federal Income Tax and State of Ohio Withholding Exemption Certificate (IT-4) for the purpose of
withholding State Income Tax. City income tax is also withheld. A new W-4 and IT-4 must be filed when there is a
change in family status. A Social Security number and/or immigrant visa number is required. Residents must also
complete an I-9 form, if applicable, and submit supporting documentation.
DIRECT DEPOSIT
University Hospitals of Cleveland requires direct deposit of payroll, with a bank of your choice. The necessary
enrollment forms can be obtained at the Benefits Office in Human Resources. See Policy 8, Payroll, in Volume I of
the Administrative Policy and Procedure Manual. Direct deposit is held if the Resident is on the Chronic
Suspension List for non-completion of medical records.
TAX/SOCIAL SECURITY DEDUCTIONS
University Hospitals of Cleveland is required by law to withhold federal, state, and city income taxes from your pay.
The Hospital pays its social security tax assessed by the federal government on your wages. You pay a matching
amount through payroll deduction. The amount of your contribution to social security as well as amounts withheld
for federal, state and city income taxes appear on your paycheck stub.
AUXILIARY BENEFITS
PARKING
Parking is available in a variety of structures and open lots. All are within easy walking distance to UHC. The cost
can be deducted from your paycheck on a pre-tax or post-tax basis. All parking lots and garages at University
Hospitals are operated and controlled by the Parking Office of University Circle, Inc. UCI also manages parking for
Case Western Reserve University and other University Circle institutions. If you wish to park in a lot or garage
assigned to the hospital you should apply for a permit through the office of Parking and Transportation
Management. If you are paid by the hospital, the fee may be paid by a monthly payroll deduction.
When you hold a parking permit, you assume responsibility for observing all parking regulations including the
prompt payment of any fines. Failure to do so may result in having the fine deducted from your paycheck, or having
your vehicle impounded. The parking permit and key-card must be returned to the parking office in order to cancel
your parking assignment and payroll deduction. Any questions concerning parking or appeals of parking violations
should be brought to the prompt attention of the Parking and Transportation Management Office at ext. 47255
("4PARK"). See Policy 19, Parking in Volume I of the Administrative Policy and Procedure Manual.
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VACATION
Vacations are granted and scheduled at the discretion of the department to which the Resident is assigned. Vacation
allowance is three to four weeks with departmental approval.
HOLIDAYS
Holidays are granted and scheduled at the discretion of the department to which the Resident is assigned. The
Hospital recognizes the following holidays:
New Year's Day
Memorial Day
Independence Day
Labor Day
Thanksgiving Day
Christmas Day
I.D. BADGES
Photo identification badges are issued to all UHC Residents by Programs and Services. You are expected to wear
your I.D. badge at all times while on duty. The proper way to wear your badge is above your waist with the
photo/name side showing. A $5.00 non-refundable replacement fee will be charged for stolen, lost or damaged I.D.
badges. Programs and Services is located on the first floor of Harvey House, and may be reached at extension
41737. The hours of operation are: 9:00 a.m. -12:00 p.m., Tuesday, Wednesday & Thursday
FLEXIBLE SPENDING ACCOUNTS
Flexible spending accounts are available for pre-tax payment of employee health and dental premiums, and certain
unreimbursed medical and/or dependent care expenses. Enrollment in the flexible spending benefit must be within
the first 30 days of employment or during the annual election period. You are able to designate the amount of
money that you wish to have placed in a flexible spending account. Any money that remains in an account at the
end of the year after all of your eligible expenses have been reimbursed will not be returned.
403B MATCHED RETIREMENT SAVINGS PLAN
All Residents are eligible to contribute to the 403b Matched Retirement Savings Plan. Residents who have reached
age 21, have completed one year of service and have worked at least 1,000 hours in the 12 months beginning with
the date of hire, are eligible to receive a match. UHC will match 50% ($0.50 for every $1 you contribute to the
plan) up to 4% of your salary. You are 100% vested to your matching contributions after completing three full years
(36 months) of vesting service. Refer to the Summary Plan Description for further details.
FITNESS CENTER
UHC’s on-site “ONE TO ONE Fitness Center” encompasses all aspects of health enhancement. Discounted
memberships are available to employees. Membership fees can be paid through payroll deduction.
DISCOUNTS
UHC employees receive a 10% discount on cafeteria purchases by presenting their hospital photo I.D. Discounts are
also available on selected merchandise in the Atrium Gift Shop.
SAVINGS BONDS
You may purchase United States Savings Bonds through payroll deduction. The series EE bonds offer the benefits
of tax deferral, competitive rates and complete safety with your savings. Bonds can be purchased in the following
17
denominations: $100, $200, and $500. See Policy 38, Benefit Summary, in Volume I of the Administrative Policy
and Procedure Manual.
BENEFITS
University Hospitals of Cleveland offers Residents a flexible benefits program called CHOICES. CHOICES offers
a wide selection of benefits and allows you the flexibility to select the benefits that best meet your individual needs.
From time to time, the specifics of the benefit programs change. For this reason, you should obtain copies of each
Summary Plan Description (SPD) directly from the Benefits Office in Robb House 152.
HEALTH INSURANCE
Health Insurance coverage is available through QualChoice, a health insurance company developed by University
Hospitals of Cleveland. Two medical plans are offered. The Triple Option Point of Service (POS) Plan and the
UHHS EPO Plan provide different levels of coverage. Both are designed with a managed care philosophy.
Contributions for the coverage are payroll deducted on a pre-tax basis. Coverage is effective the first day of the
month coinciding with or following your employment date.
CONTINUATION OF MEDICAL COVERAGE: COBRA
On termination of your contract with UHC, you may arrange for continued coverage under the Consolidated
Omnibus Budgeted Reconciliation Act, which guarantees an employee the right to uninterrupted coverage by his/her
employer’s medical insurance for up to 18 months after termination. Regular coverage ends on the last day of the
month in which you leave the employ of UHC. If you elect to continue coverage, you must pay the entire cost.
Information on COBRA is available through the Benefits Office.
DENTAL INSURANCE
Dental coverage is available through Delta Dental for you and your family. Covered services can be obtained in or
out of the network. The plan provides coverage for preventive, basic, and major restorative services. Your monthly
contribution is payroll deducted on a pre-tax basis. Coverage is effective the first day of the month coinciding with
or following your employment date.
PROFESSIONAL LIABILITY INSURANCE
The Hospital furnishes professional liability insurance to Residents without cost to them. This insurance covers
Residents during the time they are within and acting on behalf of University Hospitals, following schedules that
have been issued by their Program Directors. Residents are also covered for legal actions relating to their residency
training, which are initiated after they leave the program.
LIFE INSURANCE
The Hospital provides group term life insurance and accidental death and dismemberment insurance equal to one
times your annual salary. You become eligible for coverage the first of the month following 90 days of continuous
employment. Additional insurance may be purchased, up to three times your annual base salary. You can also
purchase Dependent Life Insurance, Supplemental AD&D Insurance and Long-Term Care Insurance.
SHORT-TERM DISABILITY
You are eligible for this benefit on the first of the month following 6 months of continuous active employment in the
UHC residency program. If you experience a non-occupational illness or injury that prevents you from performing
18
the material and substantial duties of your regular occupation, you may be eligible for a short-term disability benefit.
The STD plan continues payment of a portion of your salary after the satisfaction of a 14-day elimination period. If
the insurance carrier approves your claim, UNUM, you will receive 60% of your salary up to a maximum of $2,500
per week, to a maximum of 24 weeks. STD begins on the 15th calendar day of your disability and ends when you
return to work, when you are no longer disabled, or when long term disability commences.
LONG-TERM DISABILITY
The first day of the month following 90 days of continuous active employment, UHC provides you with base LTD
coverage equal to 50% of your monthly earnings to a maximum benefit of $1,500. You may purchase a higher level
of coverage equal to 60% of monthly earnings to a maximum benefit of $10,000. This benefit can be purchased
with pre-tax or after-tax dollars. Benefits are payable after you have been disabled for 180 consecutive days.
LEAVES AND OTHER ABSENCES
BEREAVEMENT LEAVE
You are eligible to receive up to three consecutive scheduled workdays off with pay in the event of the death of an
immediate family member. The three days should be scheduled between the date of the death through the day
following the funeral. You must immediately notify your Program Director of your need for bereavement/funeral
leave. Paid bereavement leave is provided for immediate family members who are defined as: spouse, children,
step-children, parents, step-parents, brothers, step-brothers, sisters, step-sisters, grandparents, grandchildren,
parents-in-law, brothers-in-law, and sisters-in-law. UHC includes same sex domestic partners as eligible family
members. You may request an unpaid leave of absence or use vacation time if more than three days of bereavement
leave are required or to attend the funeral of other family members or friends. Additional time off, whether paid or
unpaid, must be arranged through your Program Director and is based on the ability of your department to staff
adequately during your absence. See Policy 58, Bereavement, in Volume I of the Administrative Policy and
Procedure Manual.
JURY DUTY
If you receive a notice that you are to report for jury duty, notify your Program Director immediately so coverage
can be arranged for you. UHC will pay you your regular salary for the length of time connected with either the
selection process or jury duty. Upon returning to work, written proof of your jury duty must be submitted to your
Program Director in order to be reimbursed.
SICK TIME
Paid sick time, not to exceed thirty total days in any consecutive 12-month period, may be granted at the discretion
of the Program Director. However, the Program Director may not grant more than fourteen consecutive days of paid
sick time. If you are disabled beyond 14 days, you may be eligible for short-term disability benefits. If you are
eligible and the insurance carrier, UNUM, approves your claim you will be paid as indicated in the STD policy,
provided you have given appropriate notice and have submitted the required documentation.
FAMILY MEDICAL LEAVE
In accordance with the “Family and Medical Leave Act,” UHC’s unpaid leave-of-absence policy supports up to
twelve work weeks of leave during a 12-month period for the following:
•
•
•
Pregnancy/birth of a child
Placement with an employee of a child for adoption or foster care
Caring for a spouse, same-sex domestic partner, child, or parent with a “serious health condition”
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•
Your own “serious health condition”
The 12-month period is measured forward from the date your first FMLA leave begins.
To be eligible for FMLA, you must first have been employed at UHC for at least twelve months and have worked
1,250 recorded hours in the 12 months preceding the leave. You must apply for this leave and it must be approved
by the Care Advocate in Employee Health Service. The forms are available in the Office of GME.
If eligible for FMLA, FMLA must be applied for concurrently with any leave due to maternity or paternity, short or
long-term disability, and leave pursuant to “Extended Leave of Absence” in the Residents and Fellows Manual.
Leave under this provision only protects your job, i.e., job security. It does not provide any income guarantee or
entitlement. Time taken off for leave may extend the training period as necessary to comply with the appropriate
accreditation guidelines.
While on FMLA, Residents are entitled to up to twelve weeks of UHC-subsidized benefits only (see “Benefits
While on Leave”). See Policy 11, FMLA, in Volume I of the Administrative Policy and Procedure Manual.
MATERNITY/PATERNITY LEAVE
Up to six weeks of paid maternity and paternity leave is available to Residents of University Hospitals. This begins
on the date of birth or adoption of a child. It is the Resident's responsibility to notify the Program Director at least
60 days in advance of anticipated utilization of a maternity/paternity leave. Time taken off for a maternity/paternity
leave may extend the training period, as necessary, to comply with appropriate accreditation guidelines. The
department to which the Resident is assigned must approve any leave of absence. If eligible for FMLA, FMLA
must be applied for at the same time a maternity/paternity leave is requested.
EXTENDED LEAVE OF ABSENCE
(DEPENDS ON HOW MANY MONTHS COMPLETED)
1. Resident physicians with extraordinary and long-term personal or family tragedies may be granted
extended leave without pay and without loss of previously accepted residency position or status for periods of
up to one year in the following circumstances:
a.
Terminal illness.
b.
Permanent disability.
c.
Complications of pregnancy that threaten maternal or fetal life.
d.
Other “devastating conditions” or personal tragedies from which eventual recovery and/or return
to regular employment may be reasonably expected.
2. If extended leave is requested, the residency Program Director will provide the Resident written
information regarding its potential impact on:
a.
Requirements for successful program completion.
b.
Requirements for board eligibility.
3. The Program Director will also provide written information regarding availability of alternative
accommodations, such as reduced hours, night-call accommodations, modified rotation schedules and part-time
scheduling.
4. Eligibility for extended leave will be determined on a case-by-case basis by the Residency Program
Directors and/or Committee for that department. In case of a dispute, a panel consisting of three Program
Directors and two Chief Residents of other departments shall be convened by the Director of GME (DIO) to
hear arguments on both sides and make a final determination.
20
5. If extended leave or other accommodations are granted, the Residency Program Director will prepare
written documentation of the circumstances and conditions of these accommodations, as well as the necessary
requirements for the Resident to return to full active status.
PROFESSIONAL LEAVE OF ABSENCE
Unpaid professional leave of absence is granted at the discretion of the Program Director of each department. Time
taken off for leave may extend the training period as necessary to comply with appropriate accreditation guidelines.
ADDITIONAL BENEFIT & LEAVE CONSIDERATIONS
Time taken off for any leave may extend the training period, as necessary, to comply with appropriate accreditation
guidelines. Residents should check with their Program Director to make sure they are not in jeopardy of needing to
extend their training and, therefore, changing plans for a job or fellowship opportunity.
Residents are not automatically guaranteed re-entry into the training program and therefore should discuss future
arrangements with their Program Director prior to commencing a leave of absence.
An employee remains eligible for health benefits during the time he/she is on unpaid leave. During the time the
employee is not receiving pay, the usual payroll deduction obviously cannot be made. The employee, therefore, is
responsible for direct payment of benefits costs. A check for the appropriate amount must be received by the
benefits office before the 15th of each month to assure uninterrupted coverage.
An employee on FMLA is entitled to up to twelve weeks of UHC-subsidized benefits. An employee requiring
further leave after FMLA has expired, or an employee exercising any of the other forms of unpaid leave, assumes
full cost of any insurance coverage.
Any leave of any kind must be coordinated through the Care Advocate in Employee Health and the Benefits Office.
PROGRAM POLICIES
ADMISSION AND DISCHARGE OF PATIENTS
Patient Access Services
Patient Access Services (formerly known as the Admitting Department) has developed the following information to
assist the Residents’ efforts in arranging patient admission to University Hospitals of Cleveland. If you require
further information, please call x43702.
Admitting Policy
It is the policy of University Hospitals of Cleveland to:
♦
♦
♦
♦
Admit all patients without regard to gender, race, age, religion, color, national origin, sexual orientation,
disability, or veteran status.
There is no distinction with regard to race, color, creed, religion, sexual orientation or national origin in the
eligibility for, or in the manner of, assignment of patient care or provision of patient care.
All facilities are available to all patients and visitors.
Persons or organizations with occasion to refer patients for admission or care to UHC are advised to do so
without regard to the patient’s gender, race, age, religion, color, national origin, disability, or veteran status.
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ADMITTING PROCESS
All patients coming to the hospital for in-house stays, are processed at the Patient Access Services (Admitting)
Office which is located on the first floor of the Humphrey Building in Room 1626:
OB patients report directly to Labor & Delivery on MacDonald 2nd floor.
To schedule advance admission, fax a standard reservation form to 844-7355.
General Admitting Information phone numbers are 844-3929 or 844-3707
EMERGENCY ADMISSION
For adult emergency admissions call:
For pediatric emergency admissions call:
844-3701 - 844-3702
844-3705
Please have the following information available prior to calling to admit an emergency patient.
Patient Name
How Transported
Patient Hospital #
Patient DOB
Admitting Physician
Coming From
Your Beeper/Phone
Surgery Time
Referring Physician/Phone
Insurance Info
Referring Facility
Estimated Time of Arrival
Diagnosis
Covered by Attending
Covered by House Staff
On Dialysis
Emergency admissions should be scheduled according to patient needs. Special attention should be given to
providing the referring physician’s name to ensure continuity of care and follow-up. Likewise, an emphasis is
placed on identifying the facility from which the patient is being referred.
WHAT TO TELL YOUR PATIENT PRIOR TO ADMISSION
♦
♦
♦
♦
Bring insurance cards to the Admitting Office even if the information has been provided over the phone
Bring a list of medications or special dietary requirements to be given to the nurse on the floor
Please do not bring valuables. The cashier’s office will cash personal checks, and there are ATM machines
on site
Credit card payment is acceptable for payment of self-pay portion of the hospital bill
PRE-REGISTRATION/VERIFICATION/CERTIFICATION
The hospital obtains preadmission approval for all inpatient admissions when a reservation form is received at least
24 hours prior to the expected date of admission. Critical to the success of this admitting process is assuring that the
thorough and accurate representation of insurance and clinical criteria for the proposed hospital stay is on the
reservation form. The reservation form should contain current insurance information as well as clinical information
that sufficiently supports the number of inpatient days the physician is seeking to have approved for the admission in
questions. All outpatient procedures, surgeries, etc., must be pre-certified by either the department or physician
office requesting/performing the service. (See Access to Services Policy 3.9 in the Administrative Policy and
Procedure Manual.) The Patient Access Department is prepared to help your office with the insurance
verification/certification questions. Call 844-8399 for assistance.
If authorization cannot be obtained the admitting physician will be notified to postpone or cancel the procedure
pending financial clearance.
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PREADMISSION ASSESSMENT AND TEACHING
PAT is a formal program that is necessary for patients participating in the Same Day Surgery (SDS) program.
Patients will be seen and interviewed by the Admitting Department by appointment and lab work will be completed
in Preadmission Assessment and Teaching. PAT is located in Admitting proper, however, it is responsible to the
Operative Services Department. For more information on preadmission testing, call 844-1066.
DISCHARGE OF PATIENTS
Discharge time is 11:00 a.m. A patient may be discharged only on the written order of the attending physician or of
the Resident.
If a patient wishes to leave the hospital against medical advice (“AMA”), the attending physician shall be notified
for a private patient and the Resident for a staff patient.
For more complete information, refer to the Medical Staff Rules and Regulations.
DEATH OF PATIENTS/AUTOPSY PERMITS
It is the duty of the Residents concerned to be present at every death occurring on their Service, if at all possible.
Residents are responsible for making a notation of the exact time on the medical record, along with any pertinent
information, resuscitative attempts or medications administered, as well as notifying the patient's attending
physician of the death of the patient. All possible aid and comfort should be shown to the family.
AUTOPSY OFFICE
The Autopsy Office Pathology B-32, (extension 43479) facilitates and coordinates the functions of the several
components of the Service and serves as liaison between the clinicians, Residents and pathologists. It is responsible
for the transmission of all information concerning autopsies to interested clinicians. Physicians are invited to
familiarize themselves with autopsy procedure by visiting the service during normal business hours.
MORTICIANS
The Morticians are an integral and important facet of the operations of University Hospitals. They are licensed
funeral directors and embalmers with many years of experience. They act as a liaison between the funeral directors,
the hospital administrators and the clinicians. They have responsibilities to each of these groups but are under the
direct supervision of the Director of the Autopsy Service and the administrator for anatomic pathology. They are on
call 24 hours a day and can be reached at all times by calling extension 41836, pager 30209 or the telephone
operators.
Upon pronouncement of death of an inpatient, nursing staff will notify the Morticians, who will facilitate three
important events that require documentation.
Death Certificate
Proper completion of the death certificate is required for ultimate disposition of the body. In most instances the
death certificate will be signed by the attending physician or his covering physician, but may be signed by a
Resident. If the case falls under the jurisdiction of the Coroner because of violence, casualty, occupational hazard or
other cause specified by statute, the Mortician will assist in making the required report to the Coroner. If the
Coroner claims jurisdiction, the Coroner will complete the death certificate.
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The immediate cause of death, intervening causes of death and the underlying cause of death must be written in
terms of acceptable causes of death. In general, causes of death are pathologic lesions, physical traumas (including
therapeutic procedures), toxic exposures (including effects of therapeutics) or infections. Mechanisms of death,
including congestive heart failure, asphyxia, or arrhythmia, should not be used when their cause is known. Under no
circumstances should trite catch-all mechanisms such as asystole or cardiorespiratory arrest be used on a death
certificate. No abbreviations are permitted in the causes of death. Death certificates must be completed in black ink
only.
Autopsy Consent
Hospital policy mandates that every inpatient death will result in a request for autopsy. It is the responsibility of
clinicians to request autopsies, however, the Morticians, who all have extensive experience in dealing with bereaved
families, can be counted on as an important resource in obtaining autopsy consents. If no request for autopsy is
made, the reason for not requesting the autopsy must be listed on the autopsy consent form.
Consent for autopsy is obtained from the next of kin as specified by statute (see below). The next of kin may limit
the extent of the autopsy. No examination will be performed outside of the limitations specified by the next of kin,
and there should be no misrepresentation to the next of kin about the extent of the autopsy that is requested. A
complete autopsy will include examination of the thoracic, abdominal and pelvic organs, the organs of the neck, the
brain, spinal cord and vertebral column. In special circumstances, examination may be extended to other structures,
but will not include the face or hands. Care is taken during autopsy to ensure that a body may be prepared for open
casket viewing.
For some perinatal deaths, the Hospital can assume responsibility for final disposition by cremation. In such cases,
permission for disposal is not considered to be permission for autopsy, and permission for autopsy is not considered
to be permission for disposition. In cases where permission for disposition is given, the body will be held for 30
days after death before disposition.
Consent for Organ or Tissue Donation
Federal regulations require that all inpatient deaths be reported to a national office so that request for organ or tissue
donation will be made on all acceptable donors. The Morticians will make sure that the appropriate call to the organ
procurement organization “One Call for Life” is made.
Organ donation (heart, liver, kidneys, etc.) is only requested when a patient on life support nears brain death. At the
time of death, plans will have already been finalized by local organ procurement organizations and the next of kin.
All other inpatient deaths are considered as potential donors for tissue (corneas, skin, bones, heart valves). If organ
or tissue donation seems feasible, a local organ procurement organization will then gather information from hospital
staff to determine whether donation of any tissue should be requested. The local organ procurement organization
will then request specific tissues from the next of kin. Effective January 1, 2003, new statute allows organ
procurement organizations to obtain tissues without consent of next of kin from deceased patients who have
indicated organ donor status on their drivers’ licenses after July 1, 2002. It is essential that hospital staff cooperate
to assist in the tissue donation process.
Determination of Next of Kin
Permission for autopsy shall not be asked for until after death, and such permission must be signed by the legal next
of kin and witnessed by a member of the professional staff. Ohio law defines the order of precedence for next of kin
as follows:
a.
Surviving legal husband or wife.
24
b.
Legitimate children of legal age. Consent of all or as many as possible is desirable, but at least consent
of the one responsible for burial is necessary.
c.
Parents, preferably both.
d.
Brother or sister of legal age.
e.
Any other remote relative in order of their availability and apparent closeness, as evidenced by their
intention to assume responsibility for burial.
f.
Friend or common law spouse, if assuming burial responsibility.
DEAD ON ARRIVAL CASES
The following alternatives are presented as ways in which dead on arrival (D.O.A.) cases may be handled in the
Emergency Department.
•
•
•
•
Bodies brought to the Hospital D.O.A. are pronounced dead by Emergency Services. The Morticians notify
the Office of the Coroner of all D.O.A. deaths.
If the Coroner claims jurisdiction, the Morticians arrange for transportation of the body to the County
Morgue. No Death Certificate is completed by Hospital staff. A Coroner’s Report Form should be
completed by the physician pronouncing death.
If Coroner releases body and if no autopsy is granted, the body is taken to Pathology where it is called for
by a funeral director. In such cases, it is the responsibility of the patient’s physician to complete the Death
Certificate.
If Coroner releases body and autopsy is authorized by the responsible relative, the Death Certificate may be
completed by either Hospital or the Coroner as determined by the Coroner at the time of release of the
body.
Notification of Clinicians of Autopsies
The Morticians or Pathology Residents will notify the clinicians whose names are listed on the autopsy permit when
the autopsy is about begin. Chief Residents may request to be notified at the time of autopsies of patients expiring
on their respective services.
Information to Clinicians Regarding Autopsies
Immediately after typing, the Autopsy Office will send the attending physician listed in the autopsy permit a copy of
the Provisional Anatomical Diagnosis. Any inquiries by physicians in regard to past or current autopsy reports
should be directed to the Autopsy Office, extension 43479. The Morticians will give only information concerning
the time of performance and sign-out of any autopsy. For more information concerning special circumstances,
please contact the Autopsy Director at extension 43478.
Outside Inquiries Concerning Autopsy Findings
Matters relating to subpoenaed autopsy findings and reports, as well requests for copies of Provisional and/or Final
Anatomic Diagnoses by next of kin, must be referred to HIS, Release of Medical Information Section.
25
DUTY HOURS
University Hospitals strives to meet institutional and program requirements of the Accreditation Council of
Graduate Medical Education to ensure that the learning objectives of its residency programs are not compromised by
excessive reliance on Residents to fulfill service obligations. Providing Residents with a sound academic and
clinical education must be carefully planned and balanced with concerns for patient safety and Resident well-being.
Didactic and clinical education has priority in the allotment of Residents’ time and energies. Duty hour assignments
recognize that faculty and Residents collectively have responsibility for the safety and welfare of patients.
1.
2.
3.
4.
Duty hours are defined as all clinical and academic activities related to the residency program, i.e., patient
care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer
of patient care, time spent in-house during call activities, and scheduled academic activities such as
conferences. Duty hours do not include reading and preparation time spent away from the duty site.
Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all inhouse call activities.
Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged
over a four-week period, inclusive of call. One day is defined as one continuous 24-hour period free from
all clinical, educational, and administrative activities.
A 10-hour time period for rest and personal activities must be provided between all daily duty periods, and
after in-house call.
The Graduate Medical Education Committee (GMEC) is committed to assuring that residents are able to report
concerns regarding duty hours without retribution. Residents may report issues by:
1.
2.
3.
scheduling an appointment with the Manager of GME office.
scheduling an appointment with the DIO.
contacting the Association of Residents & Fellows who will supply a report to the GMEC.
ON-CALL ACTIVITIES
The objective of on-call activities is to provide residents with continuity of patient care experiences throughout a 24hour period. In-house call is defined as those duty hours beyond the normal workday when residents are required to
be immediately available in the assigned institution.
1.
2.
3.
4.
In-house call must occur no more frequently than every third night, averaged over a four-week period.
Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may
remain on duty for up to 6 additional hours to participate in didactic activities, maintain continuity of
medical and surgical care, transfer care of patients, or conduct outpatient continuity clinics.
No new patients may be accepted after 24 hours of continuous duty, except in outpatient continuity clinics.
A new patient is defined as any patient for whom the resident has not previously provided care.
At-home call (pager call) is defined as call taken from outside the assigned institution.
a. The frequency of at-home call is not subject to the every third night limitation. However, at-home
call must not be so frequent as to preclude rest and reasonable personal time for each resident.
Residents taking at-home call must be provided with 1 day in 7 completely free from all
educational and clinical responsibilities, averaged over a 4-week period.
b. When residents are called into the hospital from home, the hours residents spend in-house are
counted toward the 80-hour limit.
c. The program director and the faculty must monitor the demands of at-home call in their programs
and make scheduling adjustments as necessary to mitigate excessive service demands and/or
fatigue.
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MOONLIGHTING
Residents who engage in off-duty employment or outside professional activities not associated with their training
program at UHC are moonlighting. Moonlighting is only permitted if the following requirements are met:
1.
2.
3.
4.
You must hold a permanent DEA number as well as a permanent license to practice from the Ohio
State Medical Board;
You must obtain your own professional liability insurance since you will not be covered by the
liability insurance that is in place for Residents while in training;
You may not moonlight at any facility where you rotate for GME credit; and
You must obtain prior written approval of your Program Director.
Moonlighting that occurs within the residency program and/or the sponsoring institution or the non-hospital
sponsor’s primary clinical site(s), i.e., internal moonlighting, must be counted toward the 80-hour weekly limit on
duty hours.
Patient care activities that are external to the educational program and occur at UHC or any affiliated institution
utilized by the residency program, are considered moonlighting and must be counted toward the weekly limit on
duty hours. Ordinarily, this is not permitted, and you must have prior written approval of your Program Director.
Residents who are visa holders may receive compensation only for training activities that are part of their defined
training program. According to Educational Commission for Foreign Medical Graduates guidelines, employment
outside the residency or fellowship program is not permitted.
LICENSURE
Medical Licensure
Under Ohio law, an individual pursuing a residency or fellowship in this state must be licensed by the State Medical
Board of Ohio. The individual may either hold a Certificate (permanent license) to practice medicine and surgery in
Ohio, or apply to the Board for a Training Certificate (temporary license). The Office of GME will provide the
necessary application forms for the Training Certificate, but responsibility for timely completion and fee payment
lies with the applicant. A Training Certificate is valid only for a period of one year, but may be renewed annually
for a maximum of five years.
The Training Certificate allows Residents to follow the schedule of prescribed services, rotations, and clinical
activities that have been issued by their Program Directors. Please be advised of the following limitations regarding
temporary licensure:
1.
2.
A Resident without a permanent Ohio Medical license cannot “moonlight.”
A Resident without a permanent Ohio Medical license cannot sign any legal documents that must be filed
with the Probate Court in connection with involuntary hospitalization of patients at Hanna Pavilion.
Permanent licensure can be initiated by contacting the State Medical Board of Ohio, Columbus, Ohio, phone (614)
466-3934. The Office of GME must be kept informed of any change in licensure status.
Controlled Substance Licensure
Each Resident must have a Drug Enforcement Administration (DEA) Controlled Substance Registration Number. A
temporary DEA number, which is issued to each Resident by the Hospital and terminates at the conclusion of the
Resident’s training, is a combination of the Hospital DEA and the Resident's unique alphanumeric suffix. Federal
law mandates that use of this temporary DEA is strictly limited to the care of patients served by Residents as part of
their training program.
27
Each Resident must sign two (2) Prescription Signature Verification cards before the DEA number can be used. The
Office of GME will be responsible for submitting these cards to the Department of Pharmacy Services, where they
will be kept on file.
To obtain a permanent DEA number, contact the Drug Enforcement Administration in Washington D.C., at (202)
633-1000.
Prescribing Controlled Substances over the Telephone
Under no circumstances should Residents prescribe controlled substances over the telephone for any patient, unless
the Resident personally knows the patient as a result of providing medical treatment to him/her as part of the
Resident's training program. In addition, prior to prescribing any controlled substance over the telephone, the
Resident should first review the patient's medical record to verify any pharmacy's, patient’s, or other individual's
request for the prescription. The appropriate response to a telephone request for controlled substances from anyone
claiming to be the patient of a UHC attending physician is as follows:
1.
2.
3.
Take the patient’s name and phone number, and the name of the patient’s attending physician;
Call the attending physician with the information; and
Let the attending physician instruct you on how to respond to the request.
DISPUTES BETWEEN HOUSE STAFF AND MEDICAL SUPERVISORS
University Hospitals of Cleveland adheres to the AMA Council of Ethical and Judicial Affairs, Ethical Opinion
9.055, which states, in part, “Resident Physicians should refuse to participate in patient care ordered by their
superiors in cases in which the orders reflect serious errors in clinical or ethical judgment, or physical impairment,
that could result in a threat of imminent harm to the patient or to others.”
In such a circumstance, the Resident may refuse to provide the care ordered by the supervisor, provided the
omission will not threaten the patient’s immediate welfare. Residents should communicate their concerns,
immediately, to the physician issuing the orders, and to the Program Director or Department Chair. Residents who
raise such a complaint will not be subject to retaliatory or punitive actions, if the complaint was made in good faith,
in the interest of patient care.
The Program Director and/or the Department Chair shall immediately notify the Chief Medical Officer Office
regarding the Resident’s concerns. The Chief Medical Officer may take such action as he deems reasonable, in his
sole discretion, to investigate and resolve the situation, subject to the rights and obligations of the parties as set forth
in this Manual and the Policies and Procedures of University Hospitals of Cleveland.
MEDICAL RECORDS
The importance of complete and accurate medical records and an orderly and efficient system of charts control (to
assure accessibility) cannot be overemphasized.
At the beginning of the Resident’s service, personal instructions in the use of dictation equipment and the policies of
the Hospital will be given by Health Information Services (HIS). Should a problem arise in connection with medical
records, the staff of HIS will be glad to assist you at any time.
Guidelines for Use of Medical Records
Medical records are privileged and confidential documents and must be safeguarded according to Hospital and HIS
policies and procedures. The handling of medical records shall be governed by the following guidelines:
28
1.
Medical records must be available to HIS personnel day or night. They must:
a. Remain in specified patient care areas.
b. Be readily accessible in case of emergency.
2.
Medical records may be removed from HIS only for the following purposes:
a. For direct patient care, either for admission to the Hospital, for an appointment in the Clinics, or other
diagnostic or therapeutic services.
b. For case study or other uses by a Department or individuals authorized to requisition medical records.
Medical records for study or dictation may be requisitioned by Resident physicians for use only within
HIS.
3.
Medical records may not be removed from the Hospital except for legal purposes, and then only in the
custody of authorized HIS personnel.
4.
Medical records must be kept intact on in-patient floors and in the clinics, and must not be taken apart or
pages removed or rearranged.
Guidelines for Documentation in the Medical Record
The Hospital maintains a “unit” record (containing all inpatient, outpatient, and Emergency Department
information). Residents are reminded that medical records are legal documents, and the physicians may at some
future date be cross-examined in court under oath on the notes he/she has written. Personal opinions, or nonmedical judgments, should not be expressed in the medical record on any matters except those that pertain to the
medical care of the patient.
Rules for Entries into the Medical Record
1. ENTRIES MUST BE LEGIBLE.
2. Entries must be of a permanent nature, such as in black ink or typewritten. (Medical records written in red,
green, or other colors are not readable when photocopied.) Pencil and carbon notes are prohibited.
3. Entries must be signed, dated, and timed.
4. Entries must be complete and accurate.
5. Entries must be recorded only on officially approved UHC forms that are provided on the divisions or in
the clinics.
6. If PCOSS is unavailable, treatment or medication orders should be recorded with the dosage and interval of
all prescriptions.
7. Entries should be made chronologically with minimal blank spaces left between entries to avoid bulky
records.
8. Chemical, abrasive or other erasures or alterations, that delete the original entry, create an impression of a
falsified record and render the record valueless to the patient or to the Hospital in the event of litigation.
Corrections should be made by drawing a SINGLE LINE through the part to be corrected and the new
entry made in proper sequence, or above or below the incorrect entry. The reason for the correction, if not
obvious, should be noted in the margin. All corrections should be signed and dated by the individual
making the correction.
9. The official approved University Hospitals’ Abbreviation List may be found at the end of this Manual.
Only those abbreviations on this list may be used in a medical record.
10. Entries should not contain facetious, libelous, or otherwise inappropriate, subjective remarks.
11. Entries must be signed, not initialed. Your printed name, Department/Division, and pager number should
follow each signature.
Medical Record Completion Guidelines
1.
Incomplete medical records remain on the patient division for 24 hours following discharge to allow for
dictation of discharge summaries. Charts should be obtained from the head nurse or unit secretary (unless
29
removed for follow-up care to the patient). If the record is still incomplete when sent to HIS, it may not be
removed until completed, except when needed for direct patient care.
2.
Final diagnoses and procedures should be dictated with the discharge summary at the time of the patient's
discharge from an inpatient division. The principal diagnosis is the condition established to be chiefly
responsible for occasioning the admission of the patient to the hospital for care. Other diagnoses are all
conditions that coexist at the time of admission, or develop subsequently, which affect the treatment
received and/or length of stay. Diagnoses that relate to an earlier episode which have no bearing on this
hospitalization are to be excluded.
3.
The Hospital uses a direct-dial dictating system for Operative Reports and Discharge Summaries and can
be used on any phone. Operative reports should be dictated immediately following surgery. Clinical
resumes should be completed immediately following discharge. Directions for proper dictating procedures
will be given to Resident physicians at the time of their orientation.
4.
Incomplete medical records are considered delinquent 21 days following availability of the chart for
completion in HIS. The Delinquent Record summary by Department will be faxed or emailed to the
Residency Program Director for distribution to their resident staff. Failure to complete records in a timely
manner will result in the resident being placed in suspension status. At this time, direct deposit of
paychecks will be stopped. The checks will be sent to the Lakeside Cashier’s office, and can be claimed
only after all available charts are completed and the Resident has obtained clearance from HIS. Be advised
that during the course of a medical career, any hospital to which a former Resident may apply for privileges
will seek verification of training. Standard verification questionnaires request information on record
keeping practices. Delinquent records while a house officer may be an impediment to obtaining privileges,
as well as an embarrassment, throughout one’s professional career.
Protected Health Information
Medical records are considered Protected Health Information and are privileged and confidential documents and the
information must be safeguarded against unauthorized release according to Hospital and HIS policies and
procedures. Information regarding a patient's care and treatment shall not be divulged without the written consent of
the patient, parents or guardians of minors, or executors of estates of decreased individuals. All medical
correspondence shall be handled by HIS including:
1.
2.
3.
4.
5.
All insurance forms.
Request for various medical certificates.
Request for case summaries and other specified medical record information.
Letters to schools, unions, or places of employment.
Birth certificates/Proof of Birth letters.
No Resident shall give out any information relative to the Hospital or concerning any patient in the Hospital to a
representative of the press. Such communications are issued by Corporate Communications.
MEDICAL STAFF RULES AND REGULATIONS
In addition to being familiar with the content of the Hospital's “Administrative Policy and Procedure (AP&P)”
Manuals, and the System Manual, Resident should review the Medical Staff Rules and Regulations – 2004, all of
which are available on the Intranet. Sections of the Medical Staff Rules and Regulations, which are particularly
applicable to Residents, include the following:
Admission of Patients
General Responsibility for and Conduct of Care
Transfer of Patients
Discharge of Patients
Orders
30
Inpatient Medical Records
Consents
Special Care Units
Hospital Deaths and Autopsies
Infection Control
Obligation to Notify the Chief Medical Officer
PHYSICIAN’S ORDERS
All physician orders are entered electronically for all inpatients through PCOSS (Patient Care Operations Support
System). Orders entered directly by the physician will automatically be signed electronically. Orders taken by
nursing staff will be entered under the issuing physician's name and are to be electronically signed on-line by the
issuing physician. In the event that PCOSS is unavailable, orders must be written clearly, legibly and completely in
permanent ink and signed by the attending physician or Resident responsible for the patient's care. All orders
written must be done so on Physician's Order Sheet and must include the date and time written, the physician’s or
Resident’s signature. Supplemental verbal discussion of orders between the physician and nurse or other
professional is encouraged to provide clarity. Orders must be specific for diagnostic or treatment procedure and
include generic name of medication. The time (when appropriate), frequency, duration, and date to be carried out
should be included. For medication orders, dosage and route of administration must be noted.
Orders entered will be electronically received and processed by receiving departments including nursing and
ancillary departments. Orders entered directly are electronically signed and will not require physical signature by
the physician. Under circumstances when PCOSS is unavailable (downtime), physician orders must be written on
hospital approved physician order forms according to medical staff bylaws. Any order discrepancy, or clarification
that is required, will be done by clinical staff with ordering physician in accordance with medical staff bylaws and
University Hospitals Policy and Procedures for medical orders.
SERVICE TO INPATIENTS
Residents assigned to inpatients units must follow the guidelines of the UHC Medical Staff Rules and Regulations.
Specifically, Residents must evaluate admissions or transfers to critical care areas within 4 hours, and within 12
hours for patients in general care divisions. Residents must evaluate inpatients and write progress notes at least
daily. When a patient is seen with an attending, the Resident should chart that in the progress note.
Residents should answer pages as soon as possible, and respond to emergency consultations and Emergency
Department requests within 30 minutes. Residents are encouraged to consult with an attending or senior house
officer any time he/she is uncertain about a patient care issue.
INSTITUTIONAL POLICIES
ADVOCACY EFFORTS
•
•
•
Resident and Fellow physicians have a responsibility to alert their faculty and other appropriate
institutional authorities about any aspect of patient care they perceive to be substandard.
Resident and Fellow physicians must not join any organization that could consider striking or withholding
patient care services as a bargaining strategy.
Resident and Fellow physicians, acting as individuals or through their selected representatives, will be
accorded appropriate opportunities to register their concerns about the educational environment, their
working conditions, and/or the learning resources available to them. Likewise, they will be kept informed
about any planned or potential changes in the resources that may affect the quality or nature of the
institution's training programs.
31
UHC offers several mechanisms for addressing house staff concerns, whether patient care issues or about working
conditions. The Association of Residents & Fellows, the Minority Housestaff Association, the Graduate Medical
Education Subcommittee on Quality of Life and Hospital Administration are dedicated to support the concerns of all
house staff.
POLICY AND PROCEDURE MANUALS
On each Nursing Division and in the office of Department Chairs there are Administrative Policy and Procedure
Manuals (AP&P), as well as a System Manual. These manuals contain Hospital and System policies concerning
standing orders for each clinical service, medications, laboratory and X-ray routines, isolation, fluid intake,
transfusion, and infusion procedures, permits and legal forms, visiting regulations, and many other Hospital policies
and routines pertinent to your professional activities.
These manuals should be reviewed at the start of your clinical service. Residents are held responsible for the
performance of their duties in conformance with these policies and routines.
The manuals are also available online, as are Department order sets and clinical care pathways.
CHANGE IN NAME/ADDRESS
It is the responsibility of each Resident to report any changes in name, address or phone number to the Personnel
Records Department located in Robb 132A. Requests for changes must be made in writing.
Efficient distribution of W-2 forms, benefits information, and other important hospital mailings is dependent upon
the data an employee has provided.
CRIMINAL RECORD CHECK
1.
All UHC/UHHS entities conduct criminal background checks on all final candidates for employment. The
results of criminal background checks may take several weeks to be processed. Residents are permitted to
begin work before the results are received. In the event that a disqualifying conviction is returned on a
Resident, he/she will be subject to separation from the Hospital and terminated from the Residency
Program. This separation will occur even if the Resident has successfully completed some period of the
residency program before the results are received.
2.
The State of Ohio requires that all new Residents be fingerprinted on their first day of employment during
corporate orientation. A Resident may begin employment prior to the Hospital receiving the results of the
fingerprinting. If the results disclose a disqualifying criminal record, the Resident’s participation in the
Residency Program will be immediately terminated.
4.
If a candidate is not hired, or is terminated, as a direct result of the information obtained on the preliminary
State of Ohio criminal history record check, or if employment is terminated as a result of the fingerprint
criminal history check, the candidate or employee will automatically be supplied with a copy of the
background report in compliance with the Federal Fair Credit Reporting Act. See UHHS P& PM, Policy 8
for further details.
Failure to provide information necessary to complete the criminal background check, failure to provide fingerprints,
or failure to satisfactorily pass the criminal background check will cause a Resident to be released from
employment.
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COMMUNICABLE DISEASES
Communicable diseases (see accompanying list) must be reported to the Health Department of the community in
which the patient resides. The Infection Control Department nurses may identify cases through notification by the
Residents. Please leave the patient's name, hospital number and name of disease on ext. 41924. Please page the
infection control nurse with any questions. Beeper numbers are listed on the 41924 phone mail.
Know your ABCs: a quick guide to Reportable Infectious Diseases in Ohio
Based on the 2001 Revised Ohio Administrative Code §§3701-3-02, 3701-3-05,
and 3701-3-12—Diseases alphabetically, with class designation
Diseases alphabetically, with class designation
Amebiasis
A(3)
Anthrax
A(1)
Blastomycosis
C
Botulism, foodborne
A(1)
Botulism, infant
A(3)
Botulism, wound
A(3)
Brucellosis
A(3)
Campylobacteriosis
A(3)
Chancroid
A(2)
Chickenpox
B
Chlamydia infections
A(3)
(nonspecific urethritis,
cervicitis, salpingitis,
neonatal conjunctivitis,
pneumonia, and
lymphogranuloma
venereum)
Cholera
A(1)
Conjunctivitis, acute
C
Creutzfeldt-Jakob disease A(3)
Cryptosporidiosis
A(3)
Cyclosporiasis
A(2)
Cytomegalovirus
A(3)
(congenital only)
Dengue
A(2)
Diphtheria
A(1)
E. coli 0157:H7 and other A(2)
Enterohemorrhagic (shiga
toxin-producing) E. coli
Encephalitis, including
A(2)
arthropod-borne
Encephalitis, other viral A(3)
Encephalitis,post-infectionA(3)
Ehrlichiosis
A(3)
Foodborne disease
A(2)
outbreaks
Giardiasis
A(3)
Gonococcal infections
A(3)
Granuloma inguinale
A(2)
Haemophilus influenzae A(2)
(invasive disease)
Hantavirus
A(2)
Hemolytic uremic syndrome
A(2)
Hepatitis A
A(2)
Hepatitis B, including deltaA(3)
hepatitis
Hepatitis C
A(3)
Hepatitis, acute viral,
A(3)
undeterminable etiology
Herpes (congenital only A(3)
Herpes-genital
B
Histoplasmosis
C
Influenza
B
Legionnaires’ disease
A(2)
Leprosy
A(3)
Leptospirosis
A(3)
Listeriosis
A(2)
Lyme disease
A(3)
Malaria
A(2)
Measles
A(1)
Meningitis, aseptic,
A(2)
including lymphocytic
choriomeningitis
and viral meningoencephalitis
Meningitis, including
A(3)
Other bacterial
Meningococcal disease A(1)
Mucocutaneous lymph
A(3)
node syndrome
(Kawasaki disease)
Mumps
A(2)
Mycobacterial disease,
A(3)
other than tuberculosis
Nosocomial infections
C
of any type
Pediculosis
C
Pelvic inflammatory
A(3)
disease, gonococcal
33
Pertussis
A(2)
Plague
A(1)
Poliomyelitis (including A(2)
vaccine-associated cases)
Psittacosis
A(2)
Q fever
A(2)
Rabies, human
A(1)
Reye syndrome
A(3)
Rheumatic fever
A(3)
Rocky Mountain
A(3)
spotted fever
Rubella, congenital
A(2)
Rubella (not congenital) A(1)
Salmonellosis
A(2)
Scabies
C
Shigellosis
A(2)
Smallpox
A(1)
Sporotrichosis
C
Staphylococcal
C
skin infections
Staphylococcus aureus, A(2)
with resistance or intermediate
resistance to vancomycin
(VISA, VRSA)
Streptococcal disease,
A(3)
Group A, invasive
Streptococcal B in newbornA(3)
Streptococcus
A(3)
pneumoniae, invasive disease
Streptococcal toxic shock A(3)
syndrome (STSS)
Syphilis
A(2)
Tetanus
A(2)
Toxic shock syndrome
A(3)
(TSS)
Toxoplasmosis (congenital)A(3)
Toxoplasmosis
C
Trichinosis
A(3)
Tuberculosis, including A(2)
multi-drug resistant
tuberculosis (MDR-TB)
Tularemia
A(3)
Typhoid fever
A(2)
Typhus fever
A(3)
Vancomycin resistant
enterococcus (VRE)
Vibriosis
Waterborne disease
A(3)
A(3)
A(2)
outbreaks
Yellow fever
Yersiniosis
A(2)
A(3)
Reporting Requirements for Communicable Diseases
Class A
1.
Diseases of major public health concern because of the severity of disease or potential for
epidemic spread.
Report by telephone immediately upon recognition that the case, suspected case, or positive
laboratory result exists.
2.
Diseases of public health concern needing timely response because of potential for epidemic
spread. Report by the end of the next business day after the existence of a case, suspected case, or
positive laboratory result is known.
3.
Diseases of significant public health concern. Report by the close of each working week after the
existence of a case, suspected case, or positive laboratory result is known.
Class B
The number of cases is to be reported by the close of each working week.
Class C
Report an outbreak, unusual incidence, or epidemic of these diseases by the end of the next
working day.
Method of Reporting Communicable Diseases
1.
Reports of cases of notifiable diseases listed as Class A and Class B shall be made on forms
prescribed and furnished by the director; provided, however, in lieu of the written reports from
physicians required in this rule, health commissioners may accept from physicians within their
health districts verbal reports by telephone or otherwise, within the same time limitations as
required for written reports.
2.
Reports of situations when an epidemic of any disease listed as Class C is suspected shall be made
by telephone or other rapid means of communication.
3.
In reporting cases of notifiable diseases, such reports shall conform to the nomenclature of the
international statistical classification of diseases, injuries, and causes of death.
Who shall report?
Reports of notifiable diseases required by law and those listed as Class A and Class B shall be reported to the board
of health by the physician in attendance. A person in charge of a hospital, dispensary, clinic, or other institution
providing care or treatment, having knowledge of such case, shall report it unless he/she has evidence that it has
been reported by a physician. When no physician is in attendance, it shall be the duty of any individual having
knowledge of a person suffering from a disease presumably communicable or suspected of being communicable to
report forthwith to the board of health all the facts relating to the case, together with the name and address of the
person who is ill.
DRUG SCREENING
University Hospitals of Cleveland has a strong commitment to the health and safety of its employees, as well as its
patients. This commitment includes the assurance of a drug and alcohol-free work environment. The Hospital has,
34
therefore, implemented a substance abuse policy that applies to all UHC employees, making mandatory drug
screening a regular part of the pre-employment physical. Any refusal of a Resident to complete, or failure to
satisfactorily pass this screening will be turned over to the Committee of Impaired Physicians for review.
INTRANET & INTERNET E-MAIL
See Internet Use Policy 1, in the UHHS Policy and Procedure Manual.
University Hospitals of Cleveland encourages employee use of electronic mail, the University Hospitals Health
System Intranet and the Internet when it creates a more efficient work environment. However, it should be clear
that:
1.
Sending and receiving E-mail, Intranet or Internet messages regarding personal matters is not
permitted.
2.
Under no circumstances will the E-mail system, the Intranet or the Internet be used as a forum for
inappropriate, offensive or discriminatory comments.
3.
An employee should not consider the contents of his or her E-mail account (UHC, UHHS or
internet) private.
4.
The password used to restrict access to employees’ E-mail accounts is a mechanism for preventing
an unauthorized person from gaining access to University Hospitals’ information rather than
maintaining the privacy of employees’ messages.
5.
The E-mail system, including the contents of messages and accounts, will be monitored to:
a.
b.
c.
d.
e.
Evaluate the effectiveness and operation of the E-mail system
Find lost messages.
Recover after system failure.
Investigate suspected criminal acts or suspected breach of security.
Enforce other UHC policies.
6.
Employees, including Residents, who use E-mail, the Intranet or the Internet improperly will be
subject to corrective action according to Policy 36 in the Administrative Policy & Procedure
Manual, Vol. I.
7.
All UHC employees must sign a form documenting that they understand the conditions under
which an E-mail account may be used and what conduct is prohibited.
CONFIDENTIALITY & NON-DISCLOSURE
The confidential nature of medical information and the patient's right to privacy are well established. All hospital
personnel are expected to treat patient-related information in a confidential manner, sharing it only with those who
have a need to know, whether in written, oral, electronic, or any other format. Hospitals and physicians can be held
liable for the improper or unauthorized disclosure of medical information. As such, discussion of patient-related
information should be conducted only in appropriate settings, and especially not in elevators or other public areas.
At the start of your residency/fellowship at UHC, you will be asked to sign a confidentiality & non-disclosure
agreement, documenting your acceptance of this policy.
CORPORATE COMMUNICATIONS
Because of your constant relationship with patients and their visitors, your role in establishing a positive reputation
35
for the Hospital is important.
Patients are seldom qualified to judge the technical quality of medical care they receive. To patients, the most
important thing is usually the personal concern of each individual they contact in the Hospital. The patients are
extremely conscious of the many little things that add up to kindness, sympathy and understanding. University
Hospitals, through the compassion and caring of its physicians, nurses, and support staff, has consistently achieved
excellent patient satisfaction ratings.
The Hospital’s Corporate Communications (Public Relations) Department is responsible for handling inquiries and
requests from newspapers, magazines, and radio and television stations. Refer any such request to Corporate
Communications. During evening and night shifts, the Nursing Supervisor on duty may release basic condition
reports, as permitted by law, on public record cases. Other requests should be referred to the Corporate
Communications staff person on call.
CORPORATE COMPLIANCE
The compliance program at UHHS is a comprehensive strategy to ensure employees and medical staff comply with
applicable rules, regulations, and laws, as well as the Corporate Code of Conduct and Corporate Integrities
Guidelines. The UHHS Corporate Compliance Program is a comprehensive program focusing on the establishment
of standards, organizational accountability, and the self-monitoring, detection, and resolution of problems. The
ultimate goal of the Program is to create an environment and culture within UHHS where all employees and medical
staff share a commitment to carrying out our mission in an ethical, legal and professional manner.
DRESS CODE
Dress, grooming, and an overall professional appearance are important aspects of patients' expectations, and project
an image of quality healthcare. Residents, as well as all hospital employees, must abide by the “Professional
Appearance and Behavior” Policy 24, in the Administrative Policy and Procedures Manual, I. This Policy appears
in the Appendix. When scrubs are worn outside of clinical areas, a white coat or similar cover-up should be worn.
SAFETY TRAINING
Every resident is must attend an annual Safety In-Service each calendar year. As this is mandatory, failure to do so
may result in corrective action. You may obtain a schedule from the GME office.
HOSPITAL SAFETY
University Hospitals of Cleveland strives to provide its employees, patients, and visitors with a safe and healthy
environment. The Department of Employee Health and Hospital Safety (DEHHS) is on-call around-the-clock. By
calling Protective Services at ext. 44357, a safety professional will respond to emergencies. Experts in chemical,
environmental, fire and occupational safety can offer assistance with the handling of such things as hazardous
materials response, and Sick Building Syndrome investigation. Call DEHHS when you need additional safety
information at ext. 41437.
RADIATION SAFETY
The Radiation Safety Office (RSOF) is a division within the DEHHS office. Its main responsibility is to ensure that
any equipment or medical procedure that uses ionizing radiation does so safely. It is also responsible for ensuring
that the hospital complies with all federal, state and local regulations that pertain to radiation. Its staff can be
reached by calling 844-3456 or 844-1295.
36
All Residents will receive basic instruction regarding radiation safety during an orientation period. Radiation is
encountered in many areas of the hospital, but mainly in the departments of Radiology, Radiation Oncology and
Operative Services. Special instruction in radiation safety will be necessary in those areas. If Residents participate
in fluoroscopic procedures, even if only as passive observers, then they must comply with state regulations currently
in force which require that they undergo specialized training in fluoroscopy radiation safety. This can be
accomplished either by reading a book available in their department or by pursuing an on-line course available on
the RSOF website (www.uhrsof.com). An exam must be passed at the conclusion of either option.
Residents who work around radiation may also be issued small personnel dosimeters to be worn at chest or collar
level. The dosimeters measure how much radiation they have been exposed to. New dosimeters are exchanged for
old either monthly or once in three months, depending on the department. Old dosimeters must be returned in a
timely manner, usually five business days from when the new ones are provided. Failure to do so may invite a
$20.00 fine and disciplinary action. Lost and damaged dosimeters are also subject to a $20.00 replacement fee. The
money may be deducted from a paycheck. Personnel dosimeters are the subject of hospital Policy 17.21 in
Administrative Policy and Procedure Manual, Vol. II.
Pregnancy is, with some exceptions, no bar to working with radiation. Call the RSOF for more details.
OBLIGATION TO TREAT
A primary mission of the hospital is to serve and heal all persons who need its help. In addition to general legal and
ethical requirements, hospitals participating in the Medicare program are required to provide examinations and
treatment to individuals with emergency medical conditions, or women in labor, regardless of their ability to pay.
This is the Emergency Medical Treatment and Active Labor Act (EMTALA). EMTALA was passed as part of the
Consolidated Omnibus Budget Reconciliation Act of 1986, and it is sometimes referred to as “the COBRA law.”
This law requires hospitals with emergency departments to provide a medical examination “within the capabilities of
the Emergency Department” to any person requiring one without regard to the ability to pay. We must determine
whether the person has an “emergency medical condition” or is in “active labor.” If so, the law requires the hospital
to either (1) provide treatment “within the capabilities of the staff and facilities of the hospital” as may be necessary
to stabilize the emergency medical condition, or (2) arrange for a transfer of that person as set forth by the law. An
emergency patient who is not stabilized can generally only be transferred if the individual requires the transfer or if a
physician certifies that the medical benefits of transfer outweigh the risk of effecting the transfer. Substantial
penalties for violation of this law exist for both the Hospital and the physician and the statute may be enforced by
the government or an aggrieved individual.
HIPAA
The Health Insurance Portability and Accountability Act (HIPAA), passed by Congress in 1996, will affect the
healthcare industry more profoundly than any action by the federal government since Medicare. While HIPAA will
require a redesign of many of the Hospital’s formats for electronic transmission of billing information,
approximately 70% of HIPAA compliance depends upon changing our business behaviors and procedures regarding
privacy and security. As all Hospital employees will be affected by HIPAA and subject to its penalties for noncompliance, it is important that everyone keep abreast of new developments and understands the overall impact and
intent of the legislation. The HIPAA Project Team has created a website at http://intranet.uhhs.com/hipaais/ to serve
as an up-to-date resource for all employees. Residents are expected to be familiar with the UHHS policies on
Protected Health Information.
NO SMOKING POLICY
University Hospitals of Cleveland is a smoke-free environment. To provide a healthier and safer environment for
patients, visitors, staff, and employees, smoking or the possession of any lighted material is not permitted in the
buildings or on the immediate designated grounds or other facilities of UHC except in the smoking huts. These
37
structures are located on the premises, outside of MacDonald Women's Hospital, Lerner Tower, and Lot 19 behind
Lakeside Hospital.
All employees are required to adhere to this policy to ensure that UHC is a healthier and safer place in which to
work. In accordance with standard UHC practices, this policy will be enforced with all employees through the
corrective action policy.
SEXUAL AND OTHER FORMS OF HARASSMENT
It is the policy of University Hospitals of Cleveland to provide an employment environment free of sexual
harassment. (See Policy 20 in the UHHS Policy and Procedure Manual). Unwelcome sexual advances, requests for
sexual favors, and other verbal or physical conduct of a sexual nature are violations of our policy. If you believe
you have been subjected to sexual harassment, you should report it immediately in writing to your senior manager
and the director of human resources.
All complaints of sexual harassment will be promptly and confidentially investigated. Any Resident who violates
this policy will be subject to corrective action, based on the severity of the violation, up to and including
termination.
Any other form of repeated behavior, which the Resident perceives as harassment, should be reported to the Director
of GME.
SUBPOENAS, CLAIMS, AND OTHER REQUESTS
Residents may periodically receive requests for information regarding a legal claim, or potential claim, involving a
patient and the Hospital. Whenever a Resident receives such a request he/she should immediately contact his or her
residency Program Director or Clinical Department Chair and the Hospital's Law Department (Ext. 31050). The
Resident physician is not to provide any written or verbal response to such a request without authorization. This
will ensure compliance with the Hospital's procedures for release of information only to authorized persons.
Resident physicians may not witness wills or other legal documents for patients. Requests for such assistance
should be referred to the Administration Offices or the Nursing Supervisor in charge.
VISITORS
The hours and regulations for visiting are published and given to all patients. Recommendations for individual
exceptions to the regulations should be made to the Nursing Supervisor.
Residents have the obligation to discuss and answer questions about a patient’s condition with those who have a
legal right to know. Information concerning a patient is privileged and confidential and should not be divulged to
anyone except individuals specifically designated by the patient. Non-designated friends, relatives and visitors are
not entitled to such information, but their inquiries must be handled in a friendly and tactful manner. See
Uses/Disclosure of PHI to Persons Involved in Patient’s Care, UHHS Policy & Procedure Manual, Policy 8. Please
check with the nurse in charge if you are unsure what can be shared and with whom.
PATIENT THERAPY LEAVE OF ABSENCE
A patient may be granted a Therapy Leave of Absence limited to one census period only upon the order of the
patient’s physician, and provided that the patient’s physician or nurse prepares the Therapy Leave of Absence form,
explains the permit to the patient, and witnesses the patient’s signature. The physician may specify in one order the
dates and times of more than one leave of absence. A Therapy Leave of Absence extending beyond one census
period requires approval by the Finance Department.
38
INSTITUTIONAL RESOURCES
BLOOD BANK
The Blood Bank-Transfusion Medicine Service includes the transfusion service and a donor room and apheresis
facility, which serves all areas of the hospital complex. The transfusion service and reference laboratory are located
in room 2254, second floor of Mather Pavilion (adjacent to the Mather Operating Rooms). The Donor Apheresis
Center, comprising a donor room and apheresis facility is located in room B08 in the basement of Hanna House.
The Blood Bank-Transfusion Medicine Service provides a full range of blood component transfusion services
(please refer to the PCOSS Blood Bank Menu or the Blood Bank Transfusion Medicine Service Physician Order
Record Form for a listing of available services and blood components) and is staffed and open 24 hours a day, seven
days a week. It is important to emphasize the requirement that each Request for Components submitted to the Blood
Bank must be accompanied by an appropriate Indication Code (selected from the PCOSS menu or from the back of
the Order Form) and the ordering physician's signature and identification number.
Blood Bank physician coverage is provided for questions and assistance 24 hours a day, seven days a week. An oncall Transfusion Medicine Resident and an on-call attending Blood Bank physician can be reached by calling
extension 42800.
The administration of blood and blood components must follow the regulations delineated in the Code of Federal
Regulations, under the Food and Drug Administration as well as guidelines outlined in the American Association of
Blood Banks STANDARDS FOR BLOOD BANKS AND TRANSFUSION SERVICES. Refer to the Nursing Policy
and Procedure Manual and the Administrative Policy and Procedure Manual for specific instructions for
transfusion of blood and blood components. Included in these Manuals are procedures to follow when an adverse
reaction to transfusion occurs. These reactions must be reported to the Blood Bank at extension 42800 for required
documentation and instructions for further action if needed.
The Circular of Information for the Use of Human Blood and Blood Components is available upon request at the
Blood Bank, room 2254, second floor of Mather Pavilion. This serves as the "package insert" for all transfusions.
Familiarity with the contents of The Circular of Information is recommended to insure appropriate transfusion
practices.
The Donor Apheresis Center (DAC), extension 41680, performs various specialized donor procedures. Patients who
wish to store autologous blood for scheduled surgery are encouraged to do so through the DAC. A physician’s
order is required.
In addition, the Donor Apheresis Center performs and encourages plateletpheresis donations for transfusion to
University Hospitals’ patients. Families and friends are encouraged to donate for these patients. Information
regarding donations can be obtained by calling extension 41680, Monday through Friday between 8 a.m. and 5 p.m.
Autologous Blood Transfusion
The Blood Bank of University Hospitals encourages patients to consider autologous blood transfusion. Those
patients who desire and are able to provide their own blood should consult with their private physician or University
Hospitals Blood Bank. Units of blood can be stored for 35 to 42 days prior to surgery. Autologous blood donors
should be under 80 years of age and donate their last unit at least one week and preferably two weeks prior to the
date of their scheduled surgery. Call 844-1680 for specific details.
BLOODLESS MEDICINE & SURGERY PROGRAM
The Center for Bloodless Medicine and Surgery at UHC’s Rainbow Babies & Children’s Hospital focuses on blood
conservation. The NICU/PICU functions as Blood Conservation Units, and the Pediatric Pre-Surgical Referral
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Service and collaborative anesthesia network within a family-centered care environment that involves the patients
and their families in the decision making process. This has lead to a multi-disciplinary approach in areas such as
cranio-facial, orthopedics, cardio-thoracic, hematology/oncology, and neonatology, the development of protocols
and procedures to prepare our children for surgery, and intra-operative cell salvage strategies to capture and reinfuse
the patient’s own blood volume. A pre-surgical evaluation service allows staff to become involved with patients
before they are even admitted. For more information, phone 844-3492.
CHILD PROTECTION PROGRAM
Child Abuse and Neglect
Ohio law requires that all health care providers, including Residents and Fellows, report suspected child abuse or
neglect. In Ohio, reports of abuse and neglect may be made to the county children's services agency (in Cuyahoga
County, the Department of Children and Family Services at 696-KIDS), and/or to the police. A Uniform Report
form must also be competed. In order to report, the physician need not be able to prove that abuse or neglect has
occurred. Mandated reporters are protected from civil and criminal liability, even if the allegation is subsequently
determined to be unfounded, provided that a report is made in good faith. Failure to report suspected abuse and/or
neglect is a fourth degree misdemeanor and may result in jail or fine. An abused child is defined in the Ohio
Revised Code as one who “exhibits evidence of any physical or mental injury or death, inflicted by other than
accidental means, or an injury or death which is at variance with the history given of it.” Neglect is the failure to
provide basic requirements for a child's development, such as food, clothing, medical attention, or supervision. This
law applies to all children up to the age of 18, or to 21 if they are developmentally disabled.
Assistance is available to Residents who believe that a child or adolescent they are treating may have been neglected
or abused. The Child Protection Service, in the Division of General Academic Pediatrics at Rainbow Babies &
Children’s Hospital provides medical consultation. Consultation includes medical evaluation of the child, advice
regarding diagnostic testing, and recommendations regarding safe disposition. Prepubertal children who are alleged
to be victims of sexual abuse may be evaluated by a member of the Child Protection Service as inpatients or, as time
and circumstances dictate, may be referred to Care Clinic for medical assessment. Social work consultation should
be obtained whenever a medical consultation for abuse or neglect is requested. (See “Social Work,” in this Manual,
for instructions regarding how to access these services). The social work staff will perform a psychosocial
assessment, gather information, assist with reporting, support the child and family, and coordinate services.
The Child Protection Team can be reached at 844-3761 for consultation and/or referrals to Care Clinic.
EMPLOYEE ASSISTANCE COUNSELING
Residents may seek consultation through the Employee Assistance (EA) Program to discuss any personal issue that
may be causing problems at work or home. These problems may include: family, marital and relationship,
emotional problems, depression, grief, eating disorders, gambling, stress (personal or work), behavioral health,
financial difficulties, legal problems, addiction (alcohol and drug).
EA is a counseling/referral service available to Residents as well as immediate family, whose personal problems are
affecting their sense of well-being and/or their job performance. EA is available to help by discussing possible
solutions and resources to address identified problems. EA services are private and confidential, in accord with
state law and institutional policies.
Although there is no cost for EA services, there may be fees associated with other services and resources to which
you may be referred. In many cases, your health insurance will defray the cost of care.
40
An EA clinician will meet with you, answer your questions, and help develop a plan to deal with issues of concern.
Call (216) 844-1982, or (216) 844-4948, to schedule an appointment. See Policy 55, Employee Assistance, in
Volume I of the Administrative Policy and Procedure Manual.
EMPLOYEE HEALTH SERVICE
The Employee Health Service provides a variety of health-related services, including post-offer pre-placement
physical examinations, evaluation and treatment of workplace injuries and illnesses, exposure surveillance and
updating immunizations.
At various times throughout your employment with University Hospitals, you will be asked to report to the
Employee Health Service for screening such as the annual PPD skin test for tuberculosis surveillance. You may
also, because of your work duties or area, be asked to have other specific screening tests and exams, many of which
are mandated by state or federal agencies.
The Employee Health Service provides medical evaluations and treatment for work-related injuries, which include
exposure to blood and/or body fluids (e.g., sharps injuries, splashes, exposures to communicable disease, falls, etc.).
It is the responsibility of Employee Health Service to determine:
•
•
•
When an employee with an injury or infection requires work restriction or work exclusion
When an employee is ready to return to work after an injury or infectious illness
Eligibility for Family and Medical Leave Act (FMLA) or other concerns related to FMLA.
Residents should report all work-related injuries or serious, unprotected exposure to communicable disease
immediately, to their Program Director before going to the Employee Health Service. If the Health Service is
closed, employees should report to the Emergency Department (ED) for appropriate initial evaluation. Residents
seen in the ED for work-related injuries or exposures must follow-up in the Employee Health Service on the next
working day. No appointment is necessary. The “Employee Incident Report” must be completed by the Resident
and Program Director, and forwarded to the office listed on the form in a timely manner.
The Employee Health Service is open Monday through Friday, except holidays, from 7:30 A.M. to 4:00 P.M. An
appointment is generally not needed unless you are having a pre-placement physical, or seeing the Medical Director.
The Employee Health Service also receives all Family and Medical Leave Act (FMLA) or UHC Medical Leave
forms. These include employees’ Certification of Physician or Practitioner providing the medical diagnosis and
need for a Leave and the Leave of Absence Request from the Program Director. The Clinical Care Advocate in the
Employee Health Service must approve FMLA/UHC Medical Leave after receiving and reviewing the submitted
forms.
NURSING DEPARTMENT
The goal of the Department of Nursing is three-fold: to give quality care to patients, to provide an exemplary
learning climate for students and staff, and to promote a spirit of inquiry in nursing. The nursing staff is committed
to the concept of collaboration in the delivery of quality patient services and welcomes opportunities to work
together with Residents to achieve this goal.
The Department of Nursing at University Hospitals is decentralized to promote clinical specialization and
accountability for nursing care as close to the point of service as possible. A vice president or director of nursing
directs nursing and patient care services in each of the clinical services: medicine, surgery, psychiatry, pediatrics and
women's health. Head nurse managers support the vice president or director of nursing in their roles. The senior
vice president for nursing is the corporate officer responsible for assuring a consistent standard of nursing care
throughout University Hospitals of Cleveland. Advanced practice nurses; clinical nurse specialists, nurse
practitioners, and nurse midwives with graduate preparation and additional certifications provide patient care,
education, and leadership in all areas to develop and maintain high standards of nursing practice. Many nurses hold
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clinical appointments in the Case Western Reserve University School of Nursing and provide learning experiences
for nursing staff and students.
NUTRITION SERVICES
The Department of Nutrition Services is responsible for the overall nutritional care of all patients. Registered,
licensed dietitians provide that nutritional care which includes screening patients to identify those at actual or
potential risk, development of care plans to address problems identified, education of patients for home management
of established dietary treatment regimes, and referral for ambulatory follow-up as necessary. The department is also
responsible for the preparation and distribution of food to all hospitalized patients. A selective menu is utilized and
every effort is made to accommodate special requirements. Commonly used normal and therapeutic diets are
described in the University Hospitals Diet Manual, available at each division nursing station.
Dietitians are available for consult about individual patient's nutritional status/therapy plan and should be consulted
whenever a patient requires dietary modification other than or in addition to those described in the Diet Manual.
Orders for home-going patient education should be written at least 36 hours in advance of anticipated discharge of
the patient to allow adequate time for full instruction. Inpatient dietitians can be contacted by calling the Nutrition
Services office located in each patient care building or by individual pager. Dietitians are available for the following
ambulatory areas: Adult, Rainbow Practice, Women's Health Center and the Ireland Cancer Center. These
dietitians provide follow-up care as well as ongoing outpatient counseling.
PHARMACY
The Department of Pharmacy Services has the responsibility for the procurement, storage, distribution and control of
all medications for patients of the University Hospitals of Cleveland. The Department provides information and
assistance on the clinical use, pharmacokinetics, administration, and adverse reactions of medications.
Policies and procedures for pharmaceutical services are developed by the Department of Pharmacy Services,
reviewed by the Pharmacy and Therapeutics Committee, approved by the Clinical Council and appear in the
Administrative Policies and Procedures Section II.
Pharmaceuticals are dispensed to hospitalized patients, patients of the Hospital’s outpatient clinics and Emergency
Departments, employees (and dependents) and medical staff (and dependents).
The Formulary of University Hospitals of Cleveland maintained, by the Department of Pharmacy Services and the
Pharmacy and Therapeutics Committee, is a continually revised list of drugs that are the most safe and effective for
use in University Hospitals. The Formulary contains a summary of policies and procedures regarding drug
distribution and control, a list of available drugs by generic name and an alphabetic cross-reference of trade names
and common synonyms.
Each Resident must complete two (2) “Prescription Signature Verification” cards. The Department of Pharmacy
Services requires an example of your signature for the purpose of authentication/verification of your prescriptions.
PROTECTIVE SERVICES
Loss of hospital, patient, or personal property under any circumstances should be reported to Protective Services.
(ext. 44357). Although the Hospital can assume no financial responsibility for personal losses, every reasonable
safeguard will be provided. Thefts or any other incidents should be reported immediately to Protective Services for
investigation. Also, suspicious persons should be reported immediately for investigation.
Residents should exert a constant interest in the personal safety of patients and in the proper protection of their
property. Please help Protective Services provide a safe and secure environment for all patients, visitors, and
employees.
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REHABILITATION SERVICES
The Department of Rehabilitation Services includes: Occupational Therapy (OT), Physical Therapy; (PT), SpeechLanguage Pathology (SLP), Audiology (Aud), Therapeutic Recreation (TR), Art Therapy (AT), the Lymphedema
Center, and the Pain Center.
The Services include comprehensive and individualized assessment and treatment of inpatients and outpatients.
Programs are designed to identify, correct and/or alleviate acute or chronic dysfunction and to promote optimal
health. Functional goals may be short-term at each rehabilitation setting to prepare the patient to move through the
continuum of rehabilitation care to another level and setting.
Referral Process
1.
2.
3.
4.
5.
Inpatient referrals for PT, OT, SP and Aud. require a physician order in the patient’s medical record.
TR and AT do not require a physician's referral.
Referral information should include:
Patient Name
Physician Name
Date of Birth
Diagnosis
UHC Number
Description of the problem to be treated/precautions
Outpatient pediatric PT, OT, & all SLP and Aud. referrals may be faxed to (216) 844-5155.
Adult outpatient PT and OT and all SLP and Aud. referrals may be faxed to (216) 844-8964.
SOCIAL WORK
Social Workers are assigned throughout the hospital to assist patients and their families with personal, emotional,
marital, family, or other problems that are often related to illness and their ability to gain maximum benefit from
health care services. In addition to counseling, social workers collaborate with physicians, nurses, and other health
care workers in medical care plans for patients. With their thorough knowledge of available health and welfare
resources in the community, they can help with arrangements for rehabilitation services, care in the home, nursing
homes, tutoring, specialized infant and children's services, or other post-hospital assistance. The social worker must
be notified in case of child abuse, or when an infant is to be discharged to a child caring agency or institution.
Business Hours:
The Social Work Department’s hours are Monday through Friday 8:30 a.m. - 4:00 p.m. (also on site Saturdays 8:30
a.m.- 5:00 p.m.). During these hours, social workers are available via individual pagers or the centralized office in
their management centers:
Med/Surg:
Pediatrics:
OB/Gyn:
(Lakeside & Hanna House Division)…………..Ext. 43869
(R.B.&C. Divisions) …………………………...Ext. 43375
(MacDonald Hospital for Women Divisions)….Ext. 43364
Emergency Department: A Social Worker covers the Emergency Department 24 hours a day, 7 days a week via
pager # 35107.
Inpatient Divisions: A standby social worker is available during non-business hours (this includes evenings,
weekends and non-business holidays) via the following pagers:
Med/Surg:
(Lakeside & Hanna House Divisions) …………Pager 35138
Pediatrics:
(R.B.&C Divisions)…………………………….Pager 35139
OB/Gyn:
(MacDonald Hospital for Women Divisions)….Pager 31802
Psychiatry:
(Hanna Pavilion Divisions)…………………….Pager 35138
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TELECOMMUNICATIONS
Telephone System
The Telecommunications Department is comprised of a complex network of processor and computer supported
telecommunications systems distributed throughout a multi-building environment. The largest of these systems
supports direct inward and direct outward dialing from most telephones, bypassing the hospital operator. Patient
telephones may be used to reach other hospital telephones or to access the digital paging system.
The Resident's quarters are equipped with telephones that Residents may use to conduct their business. General
telephone information can be found on the UHHS Intranet web site. Select “Corporate Directory” from the “On-line
Tools” drop-down menu. (See Pager instructions on the UHHS Intranet Web Page.)
The Hospital Operators make a determined effort to direct incoming calls to the correct extension. However, if you
customarily cannot be reached at a hospital extension, frequent callers can access your digital pager at any time from
their own touchtone telephone. Paging Information and Instructions are available online at UHHS connect, by
clicking on “How To” at the Corporate Directory.
The audible overhead paging system is designed for emergency business use only. Calls during the business day
will be directed to your department. The Hospital Operator will not accept messages.
Emergency Calls
Cardiac Arrest/Medical Emergency/Triple………………
Fire……………………………………………………….
Security/Protective Services……………………………..
5555
5555
(HELP) 4357
Telecommunication Numbers
Telephone Information Line…………………………….
Telephone Repair………………………………………..
Teletypewriter, (TTY)……………………………………
Hospital Operator………………………………………..
41405
41482
41544
0
TRANSPORT OF PATIENTS
University Hospitals has a highly detailed twenty-four hour tracking system for the transport of patients as well as
the movement of specimens. By dialing 7 “MOVE” (7688) and following the voice prompts, a request will be
initiated. The Manager of Graduate Medical Education will furnish information necessary to use the automated
transport system (known as “VIP”), which can be activated through the keypad of any phone. This includes codes to
designate patient, origin, destination, time and type of request. Any other questions concerning the use of the
system should be directed to the Transport Operations Office at ext. 47851.
RESIDENT RESOURCES
CONFERENCES, ROUNDS, LECTURES, ETC.
There are regularly scheduled Conferences, Seminars, Rounds, Lectures, Demonstrations, etc., presented throughout
the year under the auspices of both the Hospital and the School of Medicine. Notification of these meetings is
published in advance.
RESIDENT PARTICIPATION ON HOSPITAL COMMITTEES
Residents are encouraged to be active contributors to the Association of Residents and Fellows and the Minority
Housestaff Association. Leadership of these two associations are asked to select Resident representatives to the
44
following institutional committees: Graduate Medical Education Committee, the Institutional Review Board,
Library, and Transfusion Committees.
ASSOCIATIONS
Association of Residents & Fellows
The Association of Residents & Fellows (ARF) was formed at University Hospitals by a group of Chief Residents in
1991. Their goal was to form a democratically elected advocacy group that could present Resident concerns to the
administration in a formal fashion. A request for interested Residents is sent to all UHC house staff and
representation from every department is encouraged. The Director of GME (DIO), representing administration,
attends all regular meetings.
Since its inception, ARF has contributed to the enrichment of residency life at UHC in many ways. In addition to
maintaining a dialogue with administration, participating Residents are asked to serve on various committees at both
the hospital and the medical school. ARF sponsored seminars inform Residents on such vital issues as contract
preparation and the fundamentals of entering the managed care practice arena. Further, ARF-sponsored socials,
varying from informal pizza parties to holiday affairs, foster the interaction of Residents from every department.
With strong influence from ARF, the Academic Center for Residents and Fellows was opened on the third floor of
Lakeside in 1994. This dedicated space provides a pleasant environment away from service areas where Residents
can confer, study, and make the most of free time. The Center features a lounge, locker space, a conference room, a
study room with computers and Internet access, and kitchen facilities with chilled spring water and coffee brewing.
The Office of GME and the Minority Development Office are also located here. UHC Residents have the access to
the Center twenty-four hours a day via the coded entry door.
Membership in ARF is strictly voluntary. Funding for its activities is currently provided from three sources: Each
Resident contributes $1 per pay period, or $26 per year; hospital administration matches those contributions with an
equal amount.
House Officers Women's Association
HOWA is a group of women comprised of Residents and house officers’ wives, who offer each other welcomed
support during the hectic residency years. In addition to monthly meetings featuring speakers and serious
discussion, their other activities include a Book Club, Service Club, Gourmet Group, Girls’ Night Out, and a
children’s playgroup.
Minority Housestaff Association
This group was formed in the fall of 1996, with its members establishing the following goals:
• To participate in the active recruitment of minority housestaff at UHC.
• To provide community service to the minority population of Cleveland.
• To offer social and peer group support for UHC minority housestaff and medical students at
CWRU.
• Quarterly meetings are held in the Center for Residents & Fellows.
COMPUTER USE AND SUPPORT
1.
Introduction - Information Services Clinical Systems
University Hospitals of Cleveland (UHC) has two primary information systems utilized in the clinical arena. These
include PCOSS (Patient Care Operations Support System) and the hospital Mainframe. PCOSS is primarily a
physician order entry and results retrieval system used by all clinicians. The Mainframe offers minimal clinical data
that includes; patient visit history data, Micromedex, lab results, dictated discharge reports, radiology and OP
reports. There are many other department specific clinical systems such as PACS and IDX for Radiology and Soft
for the Lab. Additional training and instruction will be provided for clinicians required to use departmental systems.
All systems are supported 24x7. Technical assistance can be accessed by calling the Help Desk at 844-3327. You
45
may also be assigned an email account and access to the Internet. Usage of Email and the Internet are subject to
UHHS Policy & Procedure Manual, IS – 1 Internet Usage and IS – 2 Email usage policies.
The following information is presented as an overview only. Detailed information is available from Information
Services and copies of all IS policies are available on the UHHS Intranet site.
2.
Patient Confidentiality/Security
Patients have the right to absolute privacy of their clinical records. All access should be by clinical care providers
only and never by curiosity seekers or friends, neighbors, relatives or co-workers not involved in the patients clinical
care. You are privileged to access patient records with which you have legitimate clinical links. At the time sign-on
codes are assigned, you will be asked to sign a confidentiality statement. The statement verifies your understanding
of what constitutes a breach of access and the consequences of such a violation. All computer access is through to
use of an individually assigned sign-on code and unique password. For security reasons your computer sign-on code
is never to be shared or borrowed. Use of a sign-on code establishes user identity and all transactions are tracked
and logged to determine appropriateness of those transactions. PCOSS and other systems are continually running
reports to track user and their access. Audit trails are maintained to allow for periodic audits of clinician
transactions.
Confidential patient types may also be present on UHC computer systems. These VIP, employee, and psychiatric
patients will have shielded access by presenting the user with a warning screen asking them to document the reason
for access to the patient record. Both the access and the reason the record was entered will print in a report to the
Chief Medical Officer Office.
ACCESS TO ANY PATIENT DATA IS SUBJECT TO THE UHHS POLICY, COMPUTER AND
ELECTRONIC DATA SECURITY POLICY 14.3. Copies of this policy are available from Information Services
and also on the UHC Intranet site.
3.
Process for Obtaining Access
A Computer User Registration Form is the first step to acquiring a sign-on code to gain access to UHC information
systems. Forms are available in the Residency Office, on the Intranet or by calling the Help Desk at 844-3327. All
Residents and Fellows should minimally request “clinical menu” and “PCOSS” access on the form as well as email.
The Chief Resident’s department chairperson’s signature is required for “supervisor signature.”
PCOSS access requires one additional step. All users must be trained before their unique sign-on will be assigned.
The Residency Office will keep you apprised of training classes available, or contact the Help Desk at 844-3327.
Classes for Residents are 4 hours in length. At the completion of the class, Residents will be given their sign-on and
instructed as to how to enter their password. PCOSS sign-on’s are linked to the physician credentialing database. If
for some reason your privileges are suspended or revoked, your PCOSS access will be affected accordingly.
4.
Electronic Signature
To use PCOSS, a unique, randomly generated sign-on code is issued based on individual medical staff credentialing.
In addition, electronic signature identification is made which associates each user with system/patient activity.
Individual sign-on codes and passwords are to be treated as confidential and are NOT to be shared among other
individuals. Any violation or inappropriate use of personally issued sign-on codes is considered a breech of
confidentiality and is subject to disciplinary action according to UHC Security Policy. Immediate notification
should be made to the department of Information Services if you suspect that your sign-on code/password is either
lost, stolen or is being used by anyone other that it's issued user.
5.
Mainframe Clinical Menu
Access to multiple clinical menu options is available through the mainframe after completion of the designated
security forms. Menu options include retrieval of patient clinical results from radiology and laboratory departments,
designated operative reports and dictated discharge reports. Access to pharmaceutical references can also be made
through the use of Micromedex modules included in the mainframe clinical menu. Reference modules include the
Martindale guide, Poisondex and drug/drug interactions.
46
6.
PCOSS
PCOSS is the physician order entry system utilized for inpatients at UHC. After completion of scheduled system
training and medical staff credentialing verification, individual sign-on codes are issued to each physician. Patient
specific physician orders entered are electronically received and processed to all appropriate receiving departments.
Authentication is automatically complete for all orders entered directly through UHC electronic signature policy.
7.
Training
Training for PCOSS is required prior to the release of individual security sign-on codes. Training will include great
detail on electronic signature, clinical menus, orders, etc. Training may be scheduled by the Residency Office, your
clinical department coordinator or by scheduling an appointment via the Help Desk at 844-3327.
8.
Intranet and Internet E-Mail Policy
Email is available for use throughout the hospital complex. A number of administrative reports are on-line through
this function as well as hospital news. Users registering for email functionality should receive a manual explaining
the use of email.
UHC encourages employee use of electronic mail, the University Hospitals Health System (UHHS) Intranet and the
Internet when it creates a more efficient work environment.
Sending and receiving email, Intranet or Internet messages regarding personal matters is not permitted.
Under no circumstances will the email system, the Intranet or the Internet be used as a forum for inappropriate,
offensive or discriminatory usage.
An employee should not consider the contents of his or her email account (UHC, UHHS or Internet) private.
The password used to restrict access to all employees’ email account is a mechanism for preventing an unauthorized
person from gaining access to University Hospitals information rather than maintaining privacy of employee
messages.
The email system, including the contents of messages and accounts, will be monitored to:
Evaluate the effectiveness and operation of the email system
Find lost messages
Identify inappropriate usage
Recover after system failure
Investigate suspected criminal acts or suspected breach of security
Enforce other UHC and UHHS policies
Employees, including Residents, who use email, the Intranet or the Internet improperly will be subject to
disciplinary action according to policy 36 in the Administrative Policy & Procedure Manual, Vol. I.
All UHC employees must sign a form documenting that they understand the conditions under which an email
account may be used and what conduct is permitted.
FOOD SERVICE
Bishop Cafeteria
Monday through Friday
Breakfast
Lunch
Dinner
Saturday, Sunday, Holiday
6:30 a.m. to 2:00 a.m.
6:30 a.m. to 10:00 a.m.
10:00 a.m. to 4:00 p.m.
4:00 p.m. to 7:00 p.m.
6:30 a.m. to 7:00 p.m.
A selective menu that includes sandwiches, snacks, salads, and beverages are available during all open hours. A
selection of hot entrees are available during normal meal times.
47
Vending Machines
Vending machines are available and open 24 hours per day in the cafeteria and other satellite locations. A bill
changer is available for your convenience in the main cafeteria. Items available for purchases are snacks, beverages,
ice cream, and full meals.
Einstein Bagel Co.
Saturday, Sunday and Holidays
6:30 a.m. to 2:00 p.m.
CLOSED
Einstein Bagel Co. is located in the Atrium opposite Bishop Cafeteria and offers specialty coffees made from “the
finest beans the world has to offer.” Baked fresh daily, muffins, scones, bagels, soups, salads and special recipe
cookies.
JAVA JiVE Espresso Bar
Saturday, Sunday and Holidays
6:30 a.m. to 5:00 p.m.
CLOSED
JAVA JiVE is sponsored by the Auxiliary of University Hospitals and a portion of the proceeds is returned to the
Hospital for special projects. JAVA JiVE is located in the Bolwell Health Center Lobby and offers a variety of
coffees, including iced, frozen, brewed, and flavored, as well as fresh baked yummies. They also offer grind-toorder beans, which are roasted fresh every week.
INTERPRETER SERVICES
Family members and friends may not translate for a patient when medical information is being discussed. Federal
law requires all language interpreters used by hospitals to be proficient in their field and competency-tested, so that
they can ensure that the medical information being shared with the patient has been translated accurately. In
addition, offering a third party interpreter to patients allows the patient to keep personal medical information
confidential.
Language Line is a language translation service available to all UHC departments 24 hours a day, seven days a
week. Language Line may be used anytime a non-English speaking patient wishes to communicate with healthcare
providers (or vice versa) for a brief or unscheduled discussion, or during urgent care situations. This service is
especially useful when obtaining informed consent for surgery or medical procedures, initiating new treatments or
medications, or explaining a diagnosis or prognosis. To call the Language Line, use a UHC hospital telephone and
dial x4INTE (44683). Please see the unit manager or call the hospital operator for the required information and
specific instructions for using the service. You will be asked to provide an organization name, hospital ID number
and personal code to process the call. To hear a recorded demonstration of a typical call scenario at no charge, call
1-800-821-0301.
If a discussion with a non-English speaking patient is being scheduled in advance and may be lengthy, schedule a
translator from the International Service Center. In-person translator services work well for scheduled doctor
appointments, family meetings, patient education and training sessions. To schedule a translator from the
International Service Center, call 216-781-4560. (Please note: UHC’s International Relations department provides
translation services to all patients enrolled in their program. To schedule translation services for International
Relations patients, call x45677.) Hospitals are required to offer third party interpreter services to hearing impaired
individuals as well, to ensure the information is accurately translated and a patient’s confidentiality is protected.
Sign language services may be arranged for hearing impaired patients by calling the Cleveland Hearing and Speech
Center at 216-231-8787, or Deaf Services of Cleveland at 216-382-9828.
48
LIBRARY FACILITIES
The Core Library, located at Lakeside 3119, is the central library facility of UHHS. It includes a print reference
journal/book collection and access to numerous satellite libraries throughout UHHS. The Core Library home page
on the UHHS Intranet is found at: http://intranet.uhhs.com/corelibrary. This website includes links to MD Consult,
OVID Online, PubMed and 250 full text online journals. Instruction in using online resources is available to groups
and individuals. Request forms for interlibrary loans are available on the webpage as well as other links. Core
Library staff also provide database searches, interlibrary loans and help in accessing information resources from
home or office. The library is open to Residents at all times, and is staffed from 8:30 am to 5:50 pm, MondayFriday. For help or information, call 844-1208.
MEAL TICKETS
Meal tickets are issued through the department in which the Resident is serving to cover partial cost of meals for
Residents on-call. During a 24-hour in- house call period 3 tickets are issued for meals. Residents on a float system
working in excess of 14 hrs will receive 2 tickets for meals. Residents taking call from home receive no tickets.
PHYSICIAN IMPAIRMENT
To provide a safe environment, UHC Residents have a responsibility to report to work in a fit condition. The care of
our patients requires excellent performance by all staff at all times. Residents are required to meet the Hospital’s
requirements for Fitness for Duty as defined in Policy 17, Volume I, of the Administrative Policy and Procedure
Manual.
The determination that a Resident may need a Fitness for Duty evaluation will be based upon his/her work
performance, and any other indicators observed by supervisory or non-supervisory personnel. Program Directors
shall consult with the EA Coordinator for information about requesting a Fitness for Duty evaluation.
Fitness for Duty – A confidential and mandatory referral process, which evaluates an employee’s ability to
perform his/her job functions when pronounced changes, which negatively impact his/her work
performance, are demonstrated. Fit employees are those physically and mentally able to perform the
standards required of his/her position. Types of impairment covered by Fitness for Duty include:
1.
Psychological Impairment. Significant changes in behaviors and/or psychological state. This may
include but not be limited to: threats of harm against self or others, destruction of property or
threats of destruction, dramatic mood swings, explosive anger or acting-out behaviors, extreme
disclosure of personal information, and disorganized thoughts. When related to suspected
substance abuse, including alcohol, refer to Policy 43, “Substance Abuse Policy” and Policy 43B,
“Substance Abuse Screening Policy”, both in Volume I of the UHC Administrative Policy and
Procedure Manual.
2.
Physical Impairment. Significant changes in physical ability to perform job duties and meet the
physical standards that impact current job responsibilities. They may include, but are not limited
to, diminished ability to walk, lift, climb, operate equipment, see, hear, or any physical
deterioration that compromises a Resident’s ability to perform his/her job.
Call (216) 844-1982, or (216) 844-4948, for consultation or to schedule an appointment with an EA coordinator.
See Policy 17, Fitness for Duty in Volume I of the Administrative Policy and Procedure Manual.
49
ON-CALL ROOMS
Every effort is made to ensure acceptable accommodations in a pleasant and restful environment to Residents while
on call. Comfort, safety, and convenience to service areas have been considered by a committee consisting of
representatives of the Surgical, Medicine, and Pediatric Housestaff, and select faculty. After investigating all
available space, then considering needs, the committee finally allocated each room to a department. Every room is
marked with a standardized sign noting its department. It is the responsibility of that department to assign its rooms
to interns, Residents or students. Security measures other than those already in place are also the responsibility of
the individual departments. Requests for additional call rooms are made in writing, following the instructions on the
UHC SPACE REQUEST FORM, and given to the Manager of Graduate Medical Education who will forward them
to the appropriate individual. Additional on call room space will then be considered and approved only if space
becomes available.
UNIFORMS AND LAUNDRY
The official uniform for Residents is a white lab coat worn over appropriate attire. The Hospital will furnish each
Resident with three lab coats on the day of orientation and two coats every year thereafter. Residents requiring
scrubs must consult their individual training departments for instructions on obtaining them.
For initial laundry service, a laundry form should be filled out at the Uniform Room in the sub-basement of Lakeside. Coats
will be permanently marked with the Resident's laundry number. Laundry service is available once a week.
OFFICIAL APPROVED ABBREVIATIONS LIST
Also see Non-Approved Abbreviations following this section.
AICA………. anterior inferior cerebellar
artery
AIDS………. acquired immune
deficiency syndrome
AK…………. above the knee
AKA……….. also known as
ALL………… acute lymphphocytic
leukemia
ALS………… amyotrophic lateral sclerosis
AM………… morning
AMA……….. against medical advice
ambul……… ambulatory
amt…………. amount
anes………… anesthesia
ant…………. anterior
AODM…….. adult onset diabetes mellitus
AP………….. anterior-posterior projection
A&P repair… anterior & posterior repair
APTT……… activated partial
thromboplastin time
aq………..….. water
A
ā………….. before
A2………… aortic second sound
aa…………… of each
AAxL……….. anterior axillary line
As & Bs……. apneas & bradycardias
abd………… abdomen
ABG…………arterial blood gas
AC…………...before meals
accom………. accommodation
ACTH………. adrenocorticotrophic
hormone
ad…………… right ear
ad lib…………as desired
ADHD………Attention Deficit Hyperactive
Disorder
AE………….. above elbow
Af ………….. atrial fibrillation
AFB…………acid fast bacilli
AG…………..abdominal girth
A/G Ratio…...albumin/globulin ratio
50
CABG……… coronary artery bypass graft
CAD………... coronary artery disease
cal……….….. calories
CAPD…….… continuous ambulatory
peritoneal dialysis
CAT………... computerized axial tomogram
cath………..... catheterize
CBC………... complete blood count
CBF…….…... cerebral blood flow
CBG…………capillary blood gas
aq dist……….distilled water
ARC……..…. acquired immune deficiency
syndrome (ADS) related
complex
ARD(S)…….. adult respiratory distress
(syndrome)
AROM………artificial rupture of
membranes
A/R………… apical/radial pulse
as…………… left ear
ASA…………acetylsalicylic acid (aspirin)
ASAP………. as soon as possible
ASCVD…….. arteriosclerotic
cardiovascular disease
ASD…………atrial septal defect
ASU…………Ambulatory Surgery Unit
ATN…………acute tubular necrosis
AV………… arteriovenous
AVD……… atrioventricular defect
AWOL………absent without leave
Ax………… axis (in cylindrical lenses)
axillary
D
DB…………..direct bilirubin
D&C…………dilatation and curettage
D&E ………dilatation & evacuation
Dept…………department
DHEAS…….. dehydroisoandrosterone
sulfate
DIC………….disseminated intravascular
coagulation
diff ………….differential white blood cell
count
DIL…………. dilatation
dil……………dilute
DIP…………..distal interphalangeal joint
div………….. division
DJD………… degenerative joint disease
DKA……….. diabetic ketoacidosis
DL………….. danger list
dl…………… deciliter
DNR…………do not resuscitate
DOA…………dead on arrival
DOB…………date of birth
DOE…………dyspnea on exertion
DOL…………day of life
Dr……………doctor
drng………… drainage
DTR…………deep tendon reflexes
DVT…………deep vein thrombosis
Dx or dx……..diagnosis
B
BAER……… brainstem auditory evoked
response
Ba………….. barium
BCP………… birth control pill
bid………….. twice daily
bIH……….. bilateral inguinal hernia
BOW……….. bag of waters
BP………….. blood pressure
BPD………… bronchopulmonary dysplasia
BPH………… benign prostatic hypertrophy
BR………….. bathroom
BRP………… bathroom privileges
BRBPR…..… bright red blood per rectum
BS………..… blood sugar
BTL………… bilateral tubal ligation
BUN…………blood urea nitrogen
Bx……………biopsy
E
ea…………….each
EBL………….estimated blood loss
EBM…………expressed breast milk
EBV………….Epstein-Barr virus
C
c…………..… with
CA………….. carcinoma
Ca…………... calcium
51
F/U…………..follow-up
FUO…………fever of undetermined or
unknown origin
FWB……….. full weight bearing
Fx……………fracture
ECG………….electrocardiogram
ECHO………..echocardiogram
ECMO……….extracorporeal membrane
oxygenation
ECT …………electroconvulsive treatment
EDC…………estimated date of
confinement
EEG………… electroencephalogram
EENT………. eye, ear, nose, throat
EFM…………electronic fetal monitors
EGA…………estimated gestational age
EKG…………electrocardiogram
EMG…………electromyography
ENG…………electronystagmography
ENT………… ear, nose and throat
EOG…………electro-oculography
EOM…………extra-ocular muscles
epis…………..episiotomy
E/S…………..essentially the same
ESR………….erythrocyte sedimentation
rate
ESRF………. end-stage renal failure
ESRD……… end-stage renal disease
ETOH……… ethanol (alcohol)
ETT………… endotrachial tube
EUA…………examination under anesthesia
exam……….. examination
ext………….. external
G
G…………… grunting
GFR………… grunting, flaring & retracting
GGT……….. gamma-glutamyl
transpeptidase
GH…………. growth hormone
GI……………gastrointestinal (system)
GM or gm….. gram
G/P…………. gravida/para
G6PD………. glucose 6 phosphate
dehydrogenase
GSW ………. gunshot wound
GT………….. gastrointestinal tube
GTT………… glucose tolerance test
gtt……………drops
GU…………. genitourinary (system)
GVH……… graft versus host
Gyn………….gynecology
H
(H) or (h)……hypodermic
h……………. hour
HA…………. headache
HAL……….. hyperalimentation
HBP……….. high blood pressure
HBsAB…….. hepatitis B surface antibody
HBsAG……. hepatitis B surface antigen
HC…………. head circumference
HCG……….. human chorionic
gonadotropin
Hct…………. hematocrit
HCVT……… hypertensive cardiovascular
disease
HDL……….. high density lipoprotein
H&E……….. hematoxylin & eosin stain
He…………. helium
HEENT……. head, eyes, ears, nose, &
throat
Hg…………. mercury
Hgb………… hemoglobin
F
FB…………...foreign body
FBS………… fasting blood
Fe……………iron
FeSO4……………ferrous sulfate (iron)
FEV1……………..forced expiratory volume on
first sound
FFN………….fetal fibrinectin
FH……………family history
FHR………… fetal heart rate
fl……………. fluid
FSE………….fetal scalp electrode
FSH………….follicle stimulating hormone
FTA………… fuorescent treponemal/titer
antibody
FT 3I…………free triiodothyronine index
FT4I………… free thyroxine index
52
IV……………intravenous
IVC………….intravenous cholangiogram
IVF…………. in vitro fertilization
IVH………… intraventricular hemorrhage
IVP…………. intravenous pyelogram
IVPB……….. IV piggyback
HGH……….. human growth hormone
HIAA………..hydroxyindoleacetic acid
HIV………….human immunodeficiency
virus
H/O………… history of
H20………… water
HOPI……….. history of present illness
H&P………. history and physical
HPF………… high power field
HPV……….. human papilloma virus
HR………… heart rate
HSV……….. herpes simplex virus
HT………….. height
HTLV………. human T-cell lymphotrophic
virus
HTN……… hypertension
HVA……… homovanillac acid
hwb………… hot water bottle
Hx………… history
J
JT……………jejunal tube
K
K…………… potassium
Kcal………… kilocalorie
kg……………kilogram
KUB…………kidney, ureter, bladder
KVO……… keep vein open
L
L……………. length
l…………….. liter
(L)………….. left
LA………….. left arm (subcutaneous)
lab………….. laboratory
LAD……….. left anterior descending
(artery)
lat……………lateral
LBCD………. left border of cardiac dullness
LBP………… lower back pain
LD………… left deltoid
LDH……… lactic dehydrogenase
L&D……… labor and delivery
LDL………… low density lipoprotein
LE…………...lower extremity
LED…………lupus erythematosus
disseminata
LE prep……...lupus erythematosus prep
LF…………... low forceps
LFT………… liver function test
lg…………… large
LGM……….. left gluteus maximus
LH………….. luteinizing hormone
LHRH……….luteinizing hormone releasing
hormone
Li…………… lithium
L12CO3……… lithium carbonate
liq………….. liquid
I
ICA………….internal carotid artery
ICP…………..intracranial pressure
IDDM……… insulin dependent diabetes
mellitus
IDM………… infant of diabetic mother
IM………….. intramuscular
inf……………inferior
inj……………injection
INO………….internuclear ophthalmoplegia
int……………internal
I&O………….intake and output
IPPA…………inspection, palpation,
percussion & auscultation
IPPB…………intermittent positive pressure
breathing
IR……………infrared
Irrig………….irrigate
ITP…………..idiopathic thrombocytopenia
purpura
ITT…………..insulin tolerance test
IUD………….intrauterine device
IUGR………..Intrauterine growth
retardation
IUP…………. intrauterine pregnancy
IUPC………...intrauterine pressure catheter
53
MTP………… metatarsophalangeal joint
MTR………... medication treatment record
monitor
MVA………. motor vehicle accident
MWB………. minimal weight bearing
LL………….. left leg (subcutaneous)
LLL………… left lower lobe
LLQ…………left lower quadrant
LMP…………last menstrual period
LOA…………leave of absence
LP……………lumber puncture
lph……………lower power field
LS……………Labstix
LUL………….left upper lobe
LUQ…………left upper quadrant
LVG…………left ventrogluteal
LVH…………left ventricular hypertrophy
LVL…………Left vastus lateralis
N
N…………… nitrogen
Na…………. sodium
N/A………… not applicable
NAD……….. no apparent distress
NC………….. nasal cannula
NCV……….. nerve conduction velocity
NEC…………necrotizing enterocolitis
neg…………. negative
ng……………nanogram
NG………….. nasogastric (tube)
NH3……………… ammonia
NICU……….. Neonatal Intensive Care Unit
NIDDM…….. non-insulin dependent
diabetes mellitus
NKA………... no known allergies
NKDA……… no known drug allergies
nM…………. nanomole
NO…
nitrous oxide
no………….. number
non rep………do not repeat
NPD…………no pathologic diagnosis
NPH…………neutral protamine Hagedorn
(insulin)
NPN…………neonatal parental nutrition
NPO…………nothing by mouth
NS…………...normal saline
NSR………… normal sinus rhythm
NSU…………Neuroscience Intensive Care
Unit
NTE………… neutral thermal environment
NTG…………nitroglycerin
N/V/D……… nausea, vomiting, diarrhea
NWB………..non-weight bearing
M
MAP……….. mean arterial pressure
MAS……….. meconium aspiration
syndrome
MAxL……….midaxillary line
MCA………...middle cerebral artery
mcg………….microgram
MCL……….. midclavicular line
MCP………. metacarpophalangeal joint
mEq …………milliequivalent
MER……….. milk ejection reflex
mg………….. myasthenia gravis
MG……….. milligram
MgH……….. magnesium
MGW……….magnesium sulfate, glycerin
and water enema
MHB………..maximum hospital benefit
MI………….. myocardial infarction
MICU………. Medical Intensive Care Unit
min…………. minute
ml……………milliliter
mm ………… millimeter
mmHg……… millimeter of Mercury (for
tonometry)
Mn…………. manganese
Mo…………. molybdenum
mod………… moderate
MOM……….milk of magnesia
mOsm………. milliosmol
MRI…………magnetic resonance imaging
MRSA ………methycillin-resistant
staphylococcus aureous
O
O…………… objective
O2………….. oxygen
OA………….. occiput anterior (ROP &
LOA = right or left OA)
54
PERRLA…… pupils equal, round, reactive
to light and accommodation
PFT………….pulmonary function test
Pg……………picogram
PH………….. past history
pH………… hydrogen ion concentration
PI…………… present illness
PIC…………. percutaneous intravenous
catheter
PICA……….. posterior inferior cerebellar
artery
PICU……….. Pediatric Intensive Care Unit
PID…………. pelvic inflammatory disease
PIP………….. peak inspirator pressure
PKU…………Phenylketonuria
plt……………platelet
PM…………..afternoon/evening
PMHx…………… past medical history
PMI………… point of maximal impulse
PMP…………previous menstrual period
PMS…………premenstrual syndrome
po……………by mouth
PO4……….. phosphate
POC………… products of conception
POD…………postoperative day
Pos………….. positive
Post………….posterior
post-op………postoperative
PP……………postpartum
PPD………… purified protein derivative
PPN………… peripheral parenteral nutrition
PR………… per rectum
pre-op………. prior to operation
prep………… surgical preparation
Pres………….presentation
prn…………. whenever necessary
PROM……… premature rupture of
membranes
pro time….…. prothombin time
PS………….. pressure support
PSP…………. phenolsulfonphthalein
PSU………… Pediatric Sedation Unit
PT………….. physical therapy
Pt…………… patient
PTCA………. percutaneous transluminal
coronary angioplasty
OB…………. obstetrics
Obl…………. oblique (muscle)
OD…………. overdose
OG………….. oral gastric
OI……………oxygen index
Oint………… ointment
OOB……….. out of bed
OOT…………oral gastric tube
OP………….. occiput posterior (ROP &
LOP = right or left OP)
OPD…………outpatient department
OR………….. operating room
ORIF……….. open reduction internal
fixation
ortho………...orthopedic
OS………….. left eye
OT………….. occupational therapy
OU…………. each eye, both eyes
P
P……………. plan
p……………. after (or)
P2……………pulmonic second sound
PA………….. posterior-anterior
PACU………. Post Anesthesia Care Unit
Pap…………. Papanicolaou (smear)
PAT………… paroxysmal atrial tachycardia
PaxL…………posterior axillary line
Pb………….. lead
pc…………… after meals
pc-2 hr PC…. blood specimen drawn two
hours after a meal
PCA………… patient-controlled analgesia
PCVC………. percutaneous central venous
catheter
PD………….. peritoneal dialysis
PDA…………patent ductus arteriosus
PD&C……….postural drainage and
clapping
PE…………... pulmonary embolism
ped………….. pediatrics
PEEP……….. positive end expiratory
pressure
PERLA……... pupils equal & reactive to
light and accommodation
55
ROS………… review of systems
RPR………… rapid plasma reagin
RR………….. respiration rate
RRm……….. Recovery Room
RSV…………respiratory syncytial virus
RT………….. respiratory therapy
R/T…………. related to
RTC………… return to clinic
RT3U………. resin triiodothyronine uptake
RUL……….. right upper lobe
RUQ……….. right upper quadrant
RVG……….. right ventrogluteal
RVH……….. right ventricular hypertrophy
RVL……….. right vastus lateralis
Rx…………. prescription
PTH………… parathyroid hormone
PTL………… preterm labor
PTT………… partial thromboplastin time
PVC………… premature ventricular
contraction
PVL………… periventricular leukomalasia
PVR………… pulmonary vascular
resistance
PWB……….. partial weight bearing
PZI…………..protamine zinc insulin
Q
q……………. every
q1(2,3)h…….. every 1 (2,3) hours
q 15 m……… every 15 minutes
qHS or qhs… every night
qid …………. four times a day
QNS……….. quantity not sufficient
QOH or qoh…every other hour
qpr…………. at earliest convenience
qs…………… every shift
qwk………….once a week
S
s…………….. without (or)
SAH…………subarachnoid hemorrhage
SCU………… Special Care Unit
SDH ……….. subdural hematoma
Sec………….. second
sed rate………sedimentation rate
SG………….. specific gravity
SGA…………small for gestational age
SGOT………. serum glutamic oxalacetic
transaminase (also AST)
SGPT……….. serum glutamic pyruvic
transaminase (also ALT)
SICU……….. Surgical Intensive Care Unit
SIDS……….. sudden infant death
syndrome (crib death)
SIMR………. synchronous intermittent
mandatory ventilation
SL………….. sublingual
SLR………… straight leg raising
sm………….. small
SOB………… shortness of breath
Sol………….. solution
sos………….. administer once if necessary
S/P…………. status post
SP Gr………. specific gravity
SR ………… systems review
SROM……… spontaneous rupture of
membranes
S/S…………. signs and symptoms
R
(R)…………. right
R…………… respirations
RA…………. right arm (subcutaneous)
RAP ……….. right atrial pressure
RAST……… radioallergosorbent test
RBC……….. red blood cell
RCA…………right coronary artery
RCM……….. right costal margin
RD………….. right deltoid
RDS………… respiratory distress syndrome
rec'd……….. received
Reg………… regular insulin
retic count….. reticulocyte count
RGM………. right gluteus maximus
RHD………. rheumatic heart disease
RL…………. Right leg (subcutaneous)
RLL………… right lower lobe
RLQ…………right lower quadrant
RML……….. right middle lobe
RML Epis….. right mediolateral episiotomy
R/O………… rule out
ROM……….. range of motion
56
T&X……….. type and crossmatch
Tx……………treatment
TxS…………. type and screen
ss…………… (and) one half
SSE………… soapsuds enema (also SS
enema)
stat…………. immediately
STD…………sexually transmitted disease
STS………… serological test for syphilis
sup…………. superior
surg………… surgery or surgical
SVD………… spontaneous vaginal delivery
SVR………… systemic vascular resistance
SVT………… supraventricular tachycardia
sx…………… symptoms
syr………….. syrup
Sz…………… seizures
U
UA…………. urinalysis
UAC ………. umbilical artery catheter
UCG……….. Urinary chorionic
gonadotropins
UE………….. upper extremity
UGI………… upper gastrointestinal tract
UL…………. upper lobe
ul………….. microliter
uM…………. micromole
ung………… ointment
URI………… upper respiratory infection
US …………. ultrasound
UT………….. uterus
UTI…………. urinary tract infection
Utox…………urine toxicology
UUN………... urine, urea, nitrogen
UV…………. ultraviolet
UVC……….. umbilical vein catheter
T
T……………. temperature
T3…………………. triiodothyronine
T4…………………. thyroxine
T&A……….. tonsils and adenoids
TAB…………therapeutic abortion
tab………….. tablet
TAH………… total abdominal hysterectomy
TB…………. tuberculosis
TCM……….. transcutaneous monitor
TD………….. tardive dyskinesia
TdT…………. terminal deoxynucleotidyl
transferase
TEDS……….. anti-embolism stockings
temp………… temperature
TENS……….. transcutaneous electrical
nerve stimulation
TGV………… transposition of great vessels
TIA…………. transient ischemic attack
TIBC……… total iron-binding capacity
tid……………three times a day
TP………… total protein
TPN…………total parenteral nutrition
TPR………… temperature, pulse and
respirations
TSH………… thyroid stimulating hormone
TSP………… total serum protein
TUG…………total urinary gonadotropins
TUR…………transurethral resection
TURP………. transurethral resection of
prostate
V
Vag
vaginal
Vag Hyst…… vaginal hysterectomy
VBAC……… vaginal birth after cesarean
VBG……….. venous blood gas
VC………….. vital capacity
VCU……….. voiding cystourethrogram
VDRL……… Venereal Disease Research
Laboratory
VER……….. visual evoked response
vert………… vertical
VF…………. visual fields
VLDL……… very low density lipoprotein
VM………… ventimask
VMA………. vanillylmandelic acid
VNA……….. Visiting Nurse Association
VRE……….. vancomycin-resistant enterococcus
VRSA……… vancomycin-resistant
staphylococcus aureous
VS…………. vital signs
VSD……….. ventricular septal defect
57
+…….…..positive
1º…..……primary
Ψ………..psych
?………...questionable
2º………..secondary
3º………..tertiary
VT………… ventricular tachycardia
W
WA…………. while awake
WBC……….. white blood cell or count
wgt…………. weight equals
wh………….. white
wk…………. week
WNL……….. within normal limits
wt……………weight
ALSO SEE LIST NEXT PAGE OF
ABBREVIATIONS NOT TO BE USED.
X
x……………. times (e.g., prn x 6 or q 15 m
x 8)
XR…………. x-ray
XRT……….. radiation therapy
Z
Zn………….. Zinc
SYMBOL ABBREVIATIONS
≅…….…approximately
@…….…at
∆………change
√…….…check
↓……….decreased
º………...degree
=………..equals
♀…….…female
↑………..increased
♂……..…male
–……..….negative
#…….…...number
Ø….…..…none
58
NON-APPROVED ABBREVIATIONS
SPECIAL ISSUE - do not use these dangerous abbreviations or dose designations
Abbreviation/Dose
Intended Meaning
Expression
Misinterpretation
Correction
Apothecary symbols dram
minim
Misunderstood or misread
(symbol for dram misread for
“3” and minim misread as
“mL”).
Use the metric
system.
AU
aurio uterque (each
ear)
Mistaken for OU (oculo
uterque—each eye).
Don’t use this
abbreviation.
discharge
discontinue
Premature discontinuation of
medications when D/C
(intended to mean “discharge”) Use “discharge”
and “discontinue.”
has been misinterpreted as
“discontinued” when followed
by a list of drugs.
D/C
Drug names
Use the complete
spelling for drug
names.
ARAºA
Vidarabine
cytarabineARAºC
AZT
Zidovudine
(RETROVIR)
azathioprine
c.c.
Cubic centimeter
Mistaken for U (units) when
poorly written
CPZ
COMPAZINE
(prochlorperazine)
chlorpromazine
DPT
DEMEROLPHENERGANTHORAZINE
diphtheria-pertussis-tetanus
(vaccine)
HCl
hydrochloric acid
potassium chloride (The “H” is
misinterpreted as “K.”)
HCT
Hydrocortisone
hydrochlorothiazide
HCTZ
Hydrochlorothiazide hydrocortisone (seen as
HCT250 mg)
IU
International Unit
Maisread as IV (intrevenous)
or 10 (ten)
MgSO4
magnesium sulfate
morphine sulfate
MSO4
morphine sulfate
magnesium sulfate
59
Write ml for
milliliters
Write
International Unit
Abbreviation/Dose
Intended Meaning
Expression
Misinterpretation
MTX
Methotrexate
mitroxantrone
TAC
Triamcinolone
tetracaine,
ADRENALIN,cocaine
ZnSO4
zinc sulfate
morphine sulfate
Correction
Stemmed names
“Nitro” drip
nitroglycerin infusion sodium nitroprusside infusion
“Norflox”
norfloxacin
NORFLEX
µg
microgram
Mistaken for “mg” when
handwritten.
Write microgram
o.d. or OD
once daily
Misinterpreted as “right eye”
(OD—oculus dexter) and
administration of oral
medications in the eye.
Use “daily.”
TIW or tiw
three times a week.
Mistaken as “three times a
day.”
Don’t use this
abbreviation.
per os
orally
The “os” can be mistaken for
“left eye.”
Use “PO,” “by
mouth,” or
“orally.”
q.d. or QD
every day
Mistaken as q.i.d., especially if Use “daily” or
the period after the “q” or the “every day.”
tail of the “q” is misunderstood
as an “i.”
Qn
nightly or at bedtime Misinterpreted as “qh” (every
hour).
Use “nightly.”
Qhs
nightly at bedtime
Misread as every hour.
Use “nightly.”
q6PM, etc.
every evening at 6
PM
Misread as every six hours.
Use 6 PM
“nightly.”
q.o.d. or QOD
every other day
Misinterpreted as “q.d.” (daily) Use “every other
or “q.i.d. (four times daily) if day.”
the “o” is poorly written.
sub q
subcutaneous
The “q” has been mistaken for Use “subcut.” or
“every” (e.g., one heparin dose write
ordered “sub q 2 hours before “subcutaneous.”
surgery” misunderstood as
every 2 hours before surgery).
60
Abbreviation/Dose
Intended Meaning
Expression
Misinterpretation
Correction
U or u
unit
Read as a zero (0) or a four (4),
causing a 10-fold overdose or
greater (4U seen as “40” or 4u
seen as 44”).
“Unit” has no
acceptable
abbreviation. Use
“unit.”
IU
international unit
Misread as IV (intravenous).
Use “units.”
Cc
cubic centimeters
Misread as “U” (units).
Use “mL.”
x3d
for three days
Mistaken for “three doses.”
Use “for three
days.”
BT
bedtime
Mistaken as “BID” (twice
daily).
Use “hs.”
Ss
sliding scale (insulin) Mistaken for “55.”
or ½ (apothecary)
Spell out “sliding
scale.” Use “onehalf” or use “½.”
> and <
greater than and less
than
Mistakenly used opposite of
intended.
Use “greater than”
or “less than.”
/ (slash mark)
separates two doses
or indicates “per”
Misunderstood as the number 1 Do not use a slash
mark to separate
(“25 unit/10 units” read as
doses.
“110” units.
Use “per.”
Name letters and
dose numbers run
together
(e.g., Inderal40 mg)
Inderal 40 mg
Misread as Inderal 140 mg.
Always use space
between drug
name, dose and
unit of measure.
Zero after decimal
point (1.0)
1 mg
Misread as 10 mg if the
decimal point is not seen.
Do not use
terminal zeros for
doses expressed in
whole numbers.
No zero before
decimal dose
(.5 mg)
0.5 mg
Misread as 5 mg.
Always use zero
before a decimal
when the dose is
less than a
whole unit.
61
WHO’s WHO
Residency & Fellowship Programs
DEPARTMENT
TRAINING DIRECTOR
COORDINATOR PHONE
MAIL STOP
********************************************************************************************************
Anesthesiology
Matthew Norcia, MD
Chris Adamovich 47335
BHS 5077
Anesthesia - Pain
Mark Boswell, MD
Anesthesia - Critical Care
Joel Zivot, MD
Penny Melkerson 48077
LKS 5007
Pediatric Anesthesiology
Mark Goldfinger, MD
------------------------------------------------------------------------------------------------------------------------------------------------Cardiology
Frank D. Brozovich, MD
Pat Brenner
47603
LKS 5038
Clinical Cardiac E.P.
Bruce Stambler, MD
------------------------------------------------------------------------------------------------------------------------------------------------Cardiothoracic Surgery
Robert Stewart, MD
Kim Johnson
44815
LKS 5011
------------------------------------------------------------------------------------------------------------------------------------------------Dermatology
Bryan Davis, MD
Kris Myers
45794
LKS 5028
Dermatopathology
Anita Gilliam, MD
------------------------------------------------------------------------------------------------------------------------------------------------Endocrinology
Baha Arafah, MD
Tammy Walker
202-0764
LKS 5030
------------------------------------------------------------------------------------------------------------------------------------------------Family Medicine
Michael Rowane, DO
Jackie Demico
45483
BHC5036
------------------------------------------------------------------------------------------------------------------------------------------------Gastroenterology
Gregory Cooper, MD
Avery Gottfried
26714
WRN 5066
Linda Shenk
45386
------------------------------------------------------------------------------------------------------------------------------------------------Geriatrics
Teresa Dolinar, MD
Barb Goulden
46321
FRH 7018
------------------------------------------------------------------------------------------------------------------------------------------------Genetics
Georgia Weisner, MD
Delores Dargon
41612
LKS 6055
------------------------------------------------------------------------------------------------------------------------------------------------Hematology/Oncology
Omar Koc, MD
Dawn Stull
202-1167
BRB 4937
-------------------------------------------------------------------------------------------------------------------------------------------------Infectious Disease
Robert Salata, MD
Nancy Hagen
41761
FOL 5083
------------------------------------------------------------------------------------------------------------------------------------------------Medicine
Keith B. Armitage, MD
Deena Segal
42562
LKS 5029
-------------------------------------------------------------------------------------------------------------------------------------------------Nephrology
Donald Hricik, MD
Carol Bennett
45525
LKS 5048
-------------------------------------------------------------------------------------------------------------------------------------------------Neurology
Stephen Sagar, MD
Kris Stacy
45550
HAN 5040
Child Neurology
Nancy Bass, MD
Clinical Neurophysiology
Bashar Kitirji, MD
-------------------------------------------------------------------------------------------------------------------------------------------------Neurosurgery
Robert Ratcheson, MD
Lois Hengenius
45747
HAN 5042
-------------------------------------------------------------------------------------------------------------------------------------------------Obstetrics/Gynecology
Nancy Cossler, MD
Marcia Rothstein 48551
MAC 5034
-------------------------------------------------------------------------------------------------------------------------------------------------Ophthalmology
Michael S. Lee, MD
Pat Mulhall
48577
WRN 5068
-------------------------------------------------------------------------------------------------------------------------------------------------Oral Surgery
Michael Powers, DDS
Loretta Dahlstrom 202-6731
Dental School
------------------------------------------------------------------------------------------------------------------------------------------------Orthopedics
Randall Marcus, MD
Ellen Greenberger 43233
HH 5043
Orthopedic –Spine
Henry Bohlman, MD
Julie Bunkelman 41050
-------------------------------------------------------------------------------------------------------------------------------------------------Otolaryngology
James Arnold, MD
Natalie Wheeler 48433
LKS 5045
-------------------------------------------------------------------------------------------------------------------------------------------------Pathology
Robert Hoffman, MD
43478
Kathy Griswold
44896
PATH 5077
Cytopathology
Fadi Abdul-Karim, MD
Mattie Slater
41807
Hematopathology
Howard Meyerson, MD
------------------------------------------------------------------------------------------------------------------------------------------------Pediatrics
Martha Wright, MD
Vicki Erhardt
43641
RBC 6002
--------------------------------------------------------------------------------------------------------------------------------------------------
62
WHO's WHO
Residency & Fellowship Programs
DEPARTMENT
TRAINING DIRECTOR
COORDINATOR PHONE
MAIL STOP
********************************************************************************************************
Pediatric Fellowships
Christine Johnson 45528
RBC 6003
Steven Nipple
43230
Peds Behavioral
Laura Sices
Jeanette Rhyner
41607
Peds/Cardiology
Ernest Siwik, MD
Dayenette Ellington43528
Peds/Critical Care
Michael Anderson, MD
Virginia Salerno 43310
Peds/Emergency Medicine
Martha Wright
48716
Peds/Endocrinology
Mark Palmert, MD
Paula Nieckarz
43661
Peds/Gastroenterology
Gisela Chelimsky, MD
Sherrie Irwin
41833
Peds/Hema/Oncology
Sarah Alexander, MD
43345
Peds/Infectious Disease
Grace McComsey, MD
Hedy Katz
45111
Peds/Neonatology
Cynthia Bearer, MD
Cecily Lewis
43387
Peds/Nephrology
Ira Davis, MD
41389
Peds/Pulmonary
James Chmiel, MD
Samella Crump
202-4917
--------------------------------------------------------------------------------------------------------------------------------------------------Pediatric Dentistry
Seth Canion, DDS
Amy Hull
202-3290
Dental School
--------------------------------------------------------------------------------------------------------------------------------------------------Plastic Surgery
Edward A. Luce, MD
Valerie Rowan
41236
LKS 5044
--------------------------------------------------------------------------------------------------------------------------------------------------Psychiatry
Adult
William Campbell, MD
Tamika Williams 43450
HPV 5080
Addiction
Christina Delos Reyes, MD Kelly Kelley
45987
Child & Adolescent
Mary Ellen Davis, MD
Rhea Fortune
43658
HPV 5040
Forensic
Philip Resnick, MD
Joyce Parker
43415
HPV 5040
Geriatric
John Sanitato, MD
Rhea Fortune
43414
---------------------------------------------------------------------------------------------------------------------------------------------------Pulmonary/Critical Care
Rana Hejal, MD
Regina Steffen
30871
LKS 5067
---------------------------------------------------------------------------------------------------------------------------------------------------Diagnostic Radiology
Vikram Dogra, MD
Joanne DeCaprio 43113
BSH 5056
---------------------------------------------------------------------------------------------------------------------------------------------------Radiation Oncology
Janice Lyons, MD
Laura Sender
42536
LTR 6068
---------------------------------------------------------------------------------------------------------------------------------------------------Radiology – Neuroradiology
Robert Tarr, MD
Joanne DeCaprio 43113
BSH 5056
---------------------------------------------------------------------------------------------------------------------------------------------------Radiology-Vascular Interventional
Joseph LiPuma, MD
43108
---------------------------------------------------------------------------------------------------------------------------------------------------Rheumatology
Ali Askari, MD
Carmie Jefferson 42289
FOL 5076
---------------------------------------------------------------------------------------------------------------------------------------------------Surgery
Debra Graham, MD
Elaine Higgins
43027
LKS 5047
---------------------------------------------------------------------------------------------------------------------------------------------------Urology
Martin I. Resnick, MD
Karen Flanagan
43011
LKS 5046
--------------------------------------------------------------------------------------------------------------------------------------------------Vascular Surgery
Jerry Goldstone, MD
Jasmine Pardo
41313
LKS 7060
---------------------------------------------------------------------------------------------------------------------------------------------------Graduate Medical Education
Office
Jerry M. Shuck, MD
Director
43872
LKS 5049
Will Rebello
Manager
43887
Mary Bican
Specialist
75184
Barbara Zuik
Coordinator
75183
----------------------------------------------------------------------------------------------------------------------------------------------------
63
Abbreviation List (Approved)
Abbreviation List (Non-Approved)
Admission and Discharge of Patients
Advocacy Efforts
Appeals Process
Association of Residents & Fellows
Associations
Automatic Suspension
Auxiliary Benefits
Benefits
Bereavement Leave
Blood Bank
Bloodless Medicine
Change in Name/Address
Child Abuse and Neglect
Child Protection Program
Closure Reduction Policy
COBRA Medical Coverage
Communicable Diseases
Compensation
Completion of Training
Computer Use and Support
Conferences, Rounds, Lectures, Etc.
Confidentiality & Non-Disclosure
Controlled Substance Licensure
Corporate Communications
Corporate Compliance
Corrective Action
Criminal Record Check
DEA Number
Dead on Arrival Cases
Deaf Services
Death of Patients/Autopsy Permits
Dental Insurance
Direct Deposit
Disease Reporting Requirements
Disputes - House Staff and Supervisors
Dress Code
Drug Screening
Duty Hours
Eligibility
E-Mail Policy
Employee Assistance Counseling
Employee Health Service
Employment Contracts
EMTALA
Evaluation of Faculty
Evaluation of Resident
Extended Leave of Absence
Family Medical Leave Act
Fitness Center
Fitness for Duty
Flexible Spending Accounts
Food Service
Grievance Procedure
Health Insurance
HIPAA
Historical Overview
Holidays
Hospital Committee Participation
Hospital Safety
House Officers Women's Association
I.D. Badges
Institutional Commitment
Institutional Policies
Institutional Resources
Interpreter Services
Intranet & Internet E-Mail
Introduction
Jury Duty
Leaves and Other Absences
Library Facilities
Licensure
Life Insurance
Long-Term Disability
Map
Maternity/Paternity Leave
Meal Tickets
Medical Licensure
Medical Record Completion Guidelines
Medical Records
Medical Staff Rules and Regulations
Minority Housestaff Association
Mission, Vision, Values
Moonlighting
No Smoking Policy
Nonrenewal of Appointment
Nursing Department
Nutrition Services
Obligation to Treat
50
59
21
31
11
45
45
11
16
18
19
38
39
32
39
40
8
18
32
16
8
45
44
35
27
35
36
9
32
27
25
48
23
18
16
34
28
36
34
26
6
46
40
41
7
64
37
8
8
20
19
17
49
17
47
12
18
37
5
17
44
36
45
17
1
31
38
48
35
3
19
19
49
27
18
19
66
20
49
27
29
28
30
45
4
27
37
7
41
42
37
On-Call Activities
On-Call Rooms
Parking
Patient Access Services
Patient Therapy Leave of Absence
Payroll
PCOSS - Introduction
PCOSS -Physician's Orders
Pharmacy
Physician Impairment
Physician's Orders
Policy & Procedure Manuals
Prescribing over the Telephone
Professional Leave of Absence
Professional Liability Insurance
Protective Services
Purpose of this Manual
Radiation Safety
Rehabilitation Services
Renewal of Appointment
Resident Resources
Restrictive Covenants
Retirement Plan - 403b
Safety Training
Savings Bonds
Selection
Service to Inpatients
Sexual and Other Harassment
Short-Term Disability
Sick Time
Sign Language Services
Social Work
Subpoenas, Claims, and Other Requests
Summary Suspension
Tax/Social Security Deductions
Telecommunications
Transport of Patients
Uniforms and Laundry
Vacation
Visa Policies & Procedures
Visitors
Welcome
Who's Who
26
50
16
21
38
16
45
30
42
49
31
32
28
21
18
42
6
36
43
7
44
8
Manual Revisions:
Complete 020604
Pages 9-13 030804
Page 36
032304
Page 62-63 090904
65
17
36
17
6
31
37
18
19
48
43
38
10
16
44
44
50
17
7
38
2
62
66
RECEIPT
I HEREBY ACKNOWLEDGE RECEIPT OF THE UNIVERSITY
HOSPITALS OF CLEVELAND RESIDENTS & FELLOWS MANUAL (THE
“MANUAL”).
BY SIGNING BELOW, I FURTHER ACKNOWLEDGE
AND AGREE THAT I READ AND UNDERSTAND THE MANUAL AND
AGREE, AS A CONDITION OF MY RESIDENCY, TO BE BOUND BY
AND COMPLY WITH THE MANUAL.
___________________________________________
Name of Resident
___________________________________________
Signature of Resident
___________________________________________
Date
___________________________________________
Department
67

university hospitals of cleveland - School of Medicine

Transcription

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