NWH Medical StaffOrientation & Annual EducationMarla Koroly, MD, FACP, MBASenior VP, Medical Affairsand Chief Medical Officer

2019

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Northern Westchester Hospital

MISSION• To provide the highest quality diagnostic & treatment services for

our community, while assuring access to a coordinated continuum of healthcare services. To improve and protect the health of individuals in the community through programs that promote healing and wellness.

VISION• We will provide the highest quality healthcare within a supportive

community setting and state of the art facilities

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Northern Westchester Hospital is part of NORTHWELL HEALTH

STRUCTURE: GOVERNANCEThree bodies have a role in governing NWH

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Board of TrusteesNorthwell Health

Senior ManagementMedical Executive Committee:

Medical BoardExecutive DirectorMedical DirectorNurse ExecutiveAdministrative Supervisor

3 ELECTED Officers – President; VP; Secretary/Treasurer3 ELECTED Members at LargeAppointed Chairs/Chiefs

Committees:• Performance Improvement

Coordinating Group (PICG)• Professional Practice Evaluation (PPEC)• Credentials• Pharmacy & Therapeutics• Transfusion• Infection Prevention• Utilization Management• Ethics Review Committee

Governing Documents• Bylaws (Hospital & Medical Staff)• Rules & Regulations• Policies & Procedures

On staff website Electronic communication On-Call and Coverage obligations

STRUCTURE: PEOPLEOur organization includes the organized Medical Staff, employed nurses, and other professional and support staff

Medical Staff (>1,000)Hospital Based: Employed:

IM Hospitalists; Critical Care Physicians; Stroke Neurologist; Palliative Care Pediatric Hospitalists; Neonatologists; Obstetricians; Maternal-Fetal Medicine Specialist Emergency Medicine Physicians; Psychiatrists; Radiologists; Pathologists Advanced Care Practitioners (NP, PA, RNFA) – OR/Surgery/ICU/ED

Contracted: Anesthesiology

Ambulatory Based:• Employed: Northwell Health Physician Partners (NHPP) - WHM; Ped Specialists; Medical

Oncologists; Radiation Oncologists; Surgeons (Breast, Plastic, Vascular, Thoracic, Bariatric)• Voluntary: Large Groups (CMM, Open Door); Single Specialty Groups (BSSNY, SO); Solo Practitioners

Nursing Staff (400+)

Other Professional & Support Staff• Patient Care Team: RN, PCA, Pharmacy, Respiratory Therapy, Case Managers, Rehabilitation, Registered

Nutritionist-Dieticians, Social Workers

• Support: BA, Concierge, Service Associates, Transport, Environmental, Facilities, Biomed, Security, Finance

• Clinical Informatics 5

STRUCTURE: PROGRAMOur organization includes core services and centers of excellence, supported by a model of wellness

Hospital-based core services• Advanced Imaging

• Core Laboratory

• Chappaqua Crossing: Rehabilitation, Balance Center, Wound Care HBOT

Centers of Excellence• Cancer Treatment & Wellness Center

• Breast Care Center

• Orthopedic & Spine Institute (OSI)

• Center for Plastic Surgery

• Institute for Robotic & Minimally Invasive Surgery (IRMIS COE)

• Surgical Weight Loss Program (Bariatric COE)

Wellness Model - Food; Physical Fitness; Mindful Wellness; Integrative Medicine

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MANDATORY KEY TOPICSNorthwell Health provides a comprehensive Education Program on line for all practitioners

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• Patient’s & Parent’s Bill of Rights• Abuse/Neglect/Mistreatment of patients• Advance Directives• Ethical Issues• Abuse (Child, Elder)• TJC National Patient Safety Goals• Reporting Safety/Quality Concerns• Health Literacy; Limited English Proficiency• Infection Prevention

• Hand hygiene; Precautions; Exposures; Sharps; Waste• HIV; HBV; HCV; TB; Influenza; Pertussis; CDI• CA-UTI; CLABSI; SSI• PPE

• Sepsis• Fire Safety• Disaster Preparedness & HICS (Hospital Incident Command System)• Physician Health Assessment Requirements• Compliance – Fraud & Abuse; HIPAA

KEY TOPICS: Advance DirectivesWe have a policy that governs medical decision making c/w NY State law

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Family Health Care Decision Act NY State 6/1/2010

• Health Care Agent (HCA) – appointed in writing by the patient (Health Care Proxy)

• Surrogate - may make healthcare decisions – including end-of-life decisions – on behalf of incapacitated patients who do not have an HCA

- Court appointed guardian- Spouse if not legally separated or Domestic Partner- Son or daughter 18 years of age or older- Parent- Sibling 18 years of age or older- Close friend- No surrogate (unaffiliated patient) – Attending Physician + Hospital-designated concurring Physician

• Hospital presumes every patient has capacity, unless otherwise proven & indicated by the attending physician, and wishes to receive appropriate medical treatment, including cardiopulmonary resuscitation (CPR), unless otherwise indicated by an advance directive

• Patient, HCA, or Surrogate may request to have or to not have CPR or indicate other advance directives on the Medical Orders for Life Sustaining Treatment (MOLST) form

• The Practitioner must enter a DNR order c/w the patient/HCA/surrogate wishes

KEY TOPICS: Ethical IssuesOur Ethics Review Committee is available for consultation & guidance

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The physician must have two special objects in view with regard to disease, namely, to do good or to do no harm. Primum non nocere

As a profession, medicine is characterized by a specialized body of knowledge and by a code of ethics and duty of service that put patient care above self-interest.

Guiding Principles• Beneficence • Non-maleficence • Respect for autonomy & self-determination• Veracity • Distributive Justice

The NWH Ethics Review Committee: Hal Federman, MD, Chair • Last Friday of every month from 12:00–1:00 PM• Open to all members of our Medical & Hospital Staff• Available ad hoc at the request of any physician, staff member, or patient or family member for

consultation & guidance on ethical issues concerning patient care and treatment• Maria Hale 914.666.1951 mhale@northwell.edu

KEY TOPICS: Infection PreventionWe adhere to standard practices to prevent transmission of infection

NWH/Northwell Infection Prevention policies & procedures• Approved by the Infection Control Committee• Available on the Staff Website• NY State Practitioners must maintain current Infection Control Training Certificate

(every 4 years)

Key Points• Vaccination – Hepatitis B, Influenza, MMR, Varicella, Tdap• Standard Precautions – assume each patient has a blood-borne disease that can

be transmitted & do not directly contact blood or body fluids of ANY patient• HAND HYGIENE – consistent use of alcohol-based hand sanitizer or soap & water• Appropriate personal protective equipment (PPE) for anticipated exposures –

gloves, gowns, safety glasses, mask• Safe use of sharp instruments• Follow post-exposure protocols• Appropriate disposal of waste & cleaning of equipment/environment• Antibiotic Stewardship – RIGHT diagnosis (indication), debridement, drug, dose,

duration, de-escalation

KEY TOPICS: Infection PreventionThere are 3 types of patient-specific transmission-based precautions in addition to standard precautions

CONTACT – C.diff, Salmonella, Shigella, MRSA, CRE, MDRO, Norovirus, Lice, Scabies• Spread by contact with skin, mucous membranes, feces, emesis, urine, wound

drainage, body fluids, environmental surfaces• Staff & visitors use gown & gloves when patient or environmental contact anticipated• Use disposable single-use or dedicated equipment

DROPLET – Influenza, N. meningiditis, Pertussis, Rhinovirus, Rubella, Mumps• Transmitted through close respiratory or mucous membrane contact• Door need not be closed – large droplets DO NOT stay airborne• Staff & visitors use surgical mask when within 6 feet of the patient

AIRBORNE – TB, Varicella, Measles• Negative pressure room with door closed• Staff & visitors use N95 respirator when entering room

KEY TOPICS: Infection PreventionNYS Law requires offering screening & immunization to specific populations

• Hepatitis C Virus (HCV) Screening - born 1945-1965

• HIV Screening - age 13-64

• Influenza Vaccine - age 6 months & older

• Pneumococcal Vaccination - age 65 & older

• Tdap – parents & anticipated caregivers of all newborns

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Time-sensitive interventions:• AMI – “Door to Balloon”• Stroke – “Door to t-PA”• Trauma – “The Golden Hour”• Sepsis

Systemic Inflammatory ResponseSyndrome

SIRSInfection Sepsis

Pancreatitis

Trauma

Burns

SIRS:88.1% sensitive25.8% specific

for sepsis

KEY TOPICS: Sepsis

The Sepsis Continuum

Known/Suspected Infection

+2 or more SIRS

SepsisSIRS

Sepsis +

Signs of End OrganDamage (AMS, AKI)

and/orHypotension (<90)

and/orLactate >2

Severe Sepsis +

Refractory Hypotension(after fluids)

and/orLactate > 4

SevereSepsis

Septic Shock

• T >38oC or <36oC• HR >90 beats/min• RR >20/min• WBC >12,000/mm3 or

<4,000/mm3 or >10% bands

KEY TOPICS: Sepsis

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Three Hour Bundle• Timely lactate • Timely blood culture prior to

antibiotic• Timely administration of broad

spectrum antibiotic

Six Hour Bundle• 3 Hour Bundle +• Timely crystalloid (if

hypotensive or elevated lactate)

• Timely vasopressor administration (if hypotensive & unresponsive to fluids)

• Timely re-measurement of lactate (if initial elevated)

3 Hour Bundle

NWH New York State

2016 80.5% (107/133)Top quintile

56.9%

2017 78.5% (179/228)

63.1%

6 Hour Bundle

NWH New York State

2016 50.8% (67/132)Top quintile

36.4%

2017 55.8% (125/224)

33.7%

KEY TOPICS: Sepsis

KEY TOPICS: Sepsis

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SEPSIS EARLY MANAGEMENT BUNDLE 2015 2016 2017 2018

All recommended interventions in the appropriate time frame for severe sepsis or septic shock (%)

35.1 46.7 61.4 77.8

KEY TOPICS: Sepsis

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KEY TOPICS: Fire SafetyAll staff should be aware of fire safety measures

Two major causes of Hospital Fire• Smoking, Faulty Electrical Equipment

Particular risks• Patients confined to bed• Patients under sedation/anesthesia• Flammable gases such as oxygen• Large number of electrical devices & equipment

CODE RED is the Code for smoke, flames, or fire at NWH

NWH Procedure for smoke or fire• Rescue those in immediate danger• Alarm –PULL closest fire alarm box, CALL 1212 or PUSH “Fire/Code” button phone• Contain the fire/smoke spread• Extinguish or evacuate

KEY TOPICS: ComplianceCompliance simply means FOLLOWING THE RULES

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Northwell has a compliance program to ensure that all business practices and delivery of care to our patients are in compliance with applicable Hospital policies and procedures and applicable federal and state laws, rules, and regulations. Part of this program includes avoidance of any actual, potential, or perceived conflict of interest. People reporting compliance issues are protected.

Key Focus Areas for Hospitals• Submission of accurate claims and information • Referral statutes: Physician self-referral (“Stark”) law & Federal anti-kickback statute • Payments to reduce or limit services • Billing Medicare or Medicaid substantially in excess of usual charge • Emergency Medical Treatment and Labor Act (EMTALA) • Substandard care • Relationship with federal health care beneficiaries (Medicare patients) • HIPAA privacy and security rules

Report Compliance Concerns & Issues:• Division/Department chief, the Hospital Medical Director, or

the Office of Corporate Compliance at 516.465.8097

• Anonymous reporting: Compliance HelpLine 800.894.3226or CorporateCompliance@Northwell.edu

NWH Compliance Director: Eric Sandhusen516.465.3007esandhusen@northwell.edu

KEY TOPICS: Patient Rights There are specific policies to protect patient rights

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HIPAA • Federal law to ensure the privacy & confidentiality of protected patient

information (PHI)• You may not use or disclose PHI- orally, electronically, or in writing• Hospital Privacy Officer: Eric Sandhusen - 516.465.3007

Informed Consent• Except in emergency situations, written informed consent must be given by each patient (or

healthcare agent or surrogate for an incapacitated patient or minor) prior to any surgical operation, administration of anesthesia/sedation, blood transfusion, or all other MAJOR medical treatments (medical, surgical, or diagnostic intervention or procedure which involves significant risk or invasion of bodily integrity)

Disclosure• It is the practice at NWH to have honest discussions with patients about the outcomes of

treatments & procedures performed at the Hospital, including those outcomes that vary significantly from that which was anticipated

KEY POLICIES & PROCEDURESWe have a code of conduct that calls for professionalism at all times

Code of Conduct – Professionalism• High quality patient care & a culture of safety depend on teamwork,

communication, and a collaborative work environment.

• Disruptive and intimidating behavior can foster medical errors and contribute to staff and patient dissatisfaction.

Treat all individuals with respect & dignityNo tolerance for discrimination and/or harassment

• Intimidating or threatening behavior• Offensive jokes, slurs, negative stereotyping• Unwanted sexual advances, innuendos, commentaries, displays

No tolerance for false accusations OR retaliatory behavior for reporting

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KEY POLICIES & PROCEDURESWe have the dueling obligations of reducing the incidence of opioid abuse, while adequately managing pain

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Assessment and Management of Pain • All patients at NWH are entitled to a timely response to reports of pain (1996:5th vital)• The RN caring for each patient will assess pain on initial presentation and at least every shift

thereafter• Numerical Scale: None (0) Mild (1-3) Moderate (4-6) Severe (7-10)• Behavioral Pain Scale: FLACC• Neonatal Infant Pain Scale (NIPS)

I-STOP Internet System for Tracking Over-Prescribing Act – NY State • 8/2013 - Physicians/NPs/PAs have a DUTY TO CONSULT the Prescription Monitoring Program

(PMP) registry prior to prescribing or dispensing any controlled substance • Practitioners may delegate consulting to office staff• Exceptions: ED < 5 days; facility administration; hospice care; vet; technical failure• 3/2016 – Physicians/NPs/PAs must e-prescribe ALL prescriptions including controlled

substances (EPCS)• 7/2016 – Seven day supply limit for initial opioid medication for acute pain• 7/2017 – Pain Management Education Mandate Physician/NP/PA w/DEA 3hq3y

QUALITY

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VALUE = [Clinical Quality & Safety] [Patient Experience][Cost/Efficiency]

NWH Guiding Principles:

• TEAM WORK & COMMUNICATION

• PROCESSreduce variability, increase efficiency

• ELECTRONIC MEDICAL INFORMATION SYSTEM as an enabler• Evidence-Based Order Sets (CPOE)

• Medication Safety (CPOE, BMV, Alerts)

• Communication & Transition (PDOC POC; DC)Meaningful Measures• Impact to patient outcome• Impact to reputation• Financial impact• Regulatory requirement

• To summarize a wide range of measures in a single metric

• To help consumers make informed decisions

• Each hospital assigned 1 to 5 stars, based on performance on 64 selected quality metrics across 7 categories

HOSPITAL QUALITY STAR RATING

CMS released the first Hospital Quality Star Ratings publicly on July 27, 2016

QUALITY

Inpatient Quality Reporting (IQR) Outpatient Quality Reporting (OQR) Stroke Performance Measures Sepsis Performance Measures

Measure Group(Domain)

Weight Measures

Mortality 22%30 Day Mortality: AMI Heart Failure

COPD PneumoniaStroke

Safety 22% Hospital Acquired InfectionsSurgical Complications (hip/knee)

Readmission 22%30 Day Readmission Rate: AMI Heart Failure

COPD PneumoniaStroke THA/TKAAll

Patient Experience 22% Patient Experience Survey Scores

Imaging Efficiency 4%Simultaneous Brain & Sinus CTCardiac Imaging preoperatively for low risk surgerySpine MRI for LBPThoracic & Abdominal CT with contrast

Timeliness of Care 4% Emergency Department decision to admit to departureEmergency Department time to ECG for Chest Pain

Effectiveness of Care 4%Colonoscopy screening & surveillancePerinatal CareExternal Beam Radiotherapy for Bone MetastasesCT/MRI w/in 45 minutes for stroke

CLINICAL QUALITY: IQR

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PERINATAL CARE 2014 2015 2016 2017 2018

Of pregnant women admitted for induction or Cesarean section from 37-39 weeks gestation, percentage who have no documented medical indication (percent “elective” deliveries) (Target = 0%)

1.0 0 0 0 3.6 (1/28)

Antenatal Steroid Use in women 24-32 weeks gestation who are at risk for preterm delivery (Target = 100%)

83.3 100 100 100 100

C-section rate in full term, single, vertex presentation, first time mothers (goal is to decrease) (Target = 23.9%)

41.5 43.2 42.5 34.2 34.5

Newborn Hospital-Acquired Blood Stream Infections (Target = 0%) 0 0 0 0 0Single term newborns fed exclusively breast milk (Target = 70%)

66.7 62.3 61.0 60.6 56.6

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HOSPITAL-BASED INPATIENT PSYCHIATRY (HBIPS) 2014 2015 2016 2017 2018

Screening for Metabolic Disorders (%) N/A N/A N/A 93.5 90.8Multiple medications at discharge with appropriate reason (%) 85.0 100 100 93.3 83.3Alcohol Use Brief Intervention Offered (%) N/A N/A 51.1 68.7 48.6

Tobacco Use Treatment Offered (%) N/A 78.0 84.1 93.3 93.2Specified Elements in Care Transition (%) N/A N/A N/A 86.5 94.0Timely Transmission of Transition Record (%) N/A N/A N/A 84.2 93.0

CLINICAL QUALITY: IQR

TIMELINESS OF CARE: IQR, OQR

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EMERGENCY DEPARTMENT FLOW MEASURES 2014 2015 2016 2017 2018 ED Admitted Patients – Median Decision to Admit to Departure (minutes) – TARGET = 43 68 52 49 74 66ED All Patients – Median Arrival to Practitioner (minutes) – TARGET = 13 14 16 13 13 15ED Treated & Released Patients – Median Arrival to Departure (minutes) – TARGET = 145 160 150 158 151 163ED CT Result for Acute Stroke within 45 minutes (%) – TARGET = 100% 88.9 71.4 81.8 84.6 71.4ED Chest Pain – Median Time to ECG (minutes) – TARGET = 5 3.0 3.0 3.5 5.0 4.0ED Chest Pain – Median Time to Transfer (minutes) – TARGET = 30 42.5 54.0 53.0 47.5 37.5

SAFETYWe support a culture of safety in which we openly discuss events as an opportunity for improvement and monitor several hospital-acquired conditions

• Culture of Safety

• Safety Event Reporting System

• Hospital Acquired Infections• Catheter associated urinary tract infection (CA-UTI)

• Central Line Associated Blood Stream Infection (CLABSI)

• Multidrug Resistant Organisms (MRSA/CRE)

• Clostridium difficile Intestinal Infection (CDI)

• Surgical Site Infections (Colon, Hip, Hysterectomy)

• Medication Errors

• Nursing (Falls, Pressure Ulcers)

SAFETYOur hospital-wide alert codes help create a safe environment for patients, staff, and visitorsSummary of NWH Codes:Code Blue – Adult Cardiac/Respiratory arrest age 18 and olderCode W – Pediatric Cardiac/Respiratory arrestCode 100 – Neonate Cardiac/Respiratory arrest

Code Fusion – Acute Hemorrhage

Rapid Response Adult – Rapid response team (RRT) – serious change in conditionRapid Response Junior – Pediatric rapid response team (RRT) – serious change in conditionCode Stroke – Activate rapid response team (RRT)Code Sepsis – Activate rapid response team (RRT)

Code RED – Fire or smoke alertCode Amber – Pediatric or Infant abducted/missingCode Flight – Adult patient has eloped or is missingCode DECON – Decontamination response team for external event

• Code Grey – Agitated person/Disruptive Behavior• Code Green Active – Security Stat; active shooter in building• Code HICS – Hospital Incident Command System – event disrupting normal operations• “All Clear” – announced 2x following resolution

SAFETY: Restraint & SeclusionRestraint or seclusion may only be used when absolutely necessary to ensure the safety of a patient, staff member, or other individual

Mechanical Restraint (non-violent: two point) – restraint to both wrists to prevent a patient from interfering with life sustaining equipment

Mechanical Restraint (violent: four point) – restraint to both wrists AND ankles to protect the patient from injuring him/herself or others

Medication Restraint – any medication used for the purpose of restricting or managing behavior or freedom of movement that is NOT a standard treatment or dosage for a patient’s condition

Seclusion – involuntary confinement alone in a room from which a patient is physically prevented from leaving (only on our behavioral health unit)

Key Points• Must be ordered by attending or covering physician or ACP ONLY after face to face physician evaluation

• May NOT be ordered PRN and should be discontinued at the EARLIEST possible time

• Must be renewed at specific time intervals (daily for 2 point, every 4 hours for 4 point)

• Physician must do a daily evaluation of the patient

SAFETY: Venous Thromboembolism (VTE)Medicine/Critical Care Admission and Plan of Care/Progress Notes provide guidance for assessment of VTE risk for admitted patients

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SAFETY: MRI SafetyMandatory questions when ordering an MRI help ensure MRI Safety

• The Magnet is ALWAYS on and is 40,000 x stronger than gravity• All equipment brought into room must be non-ferrous• Patients who can NEVER have an MRI:

• Other implanted devices must have proper documentation and verification of safetyo stents, valves, IUD, wire mesh, shunts, ports, orbital or penile prostheses, cochlear

implants

PATIENT EXPERIENCENWH is a designated Planetree Hospital with distinction

IOM: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions

Planetree (1970s) - a framework for patient-centered care

• Caring interactions with providers• Access to meaningful information• Involvement of family• Healing physical environment• Role of spirituality• Arts in healing• Food in healing

PATIENT EXPERIENCEHCAHPS – Hospital Consumer Assessment of Healthcare Providers & Systems is how we measure patient experience

PATIENT EXPERIENCENWH exceeds national & state performance in patient experience survey scores

EFFICIENCYTo achieve HIGH VALUE CARE, in addition to focusing on quality, safety, and patient experience, we need to optimize resource utilization & efficiency

• Cost of Care: Utilization Management• Appropriate Level of Care – Observation/Admission

“2 midnight rule”

• Optimum utilization of resources

• Time Efficiency/Discharge Planning: Length of Stay

• Clinical Documentation Excellence

PROFESSIONAL PRACTICE EVALUATION - PPEThe organized Medical Staff must continuously monitor the competency & performance of ALL practitioners granted privileges

Profile for JOHN BONE, MD SERVICE: ORTHOPEDIC SURGERY AND SPORTS MEDICINE

SPECIALTY: ORTHOPEDIC SURGERY Profile last viewed by Provider: 01/18/2016

Status Indicator My Score

Peers Score Target SPC

Alert Current Period

24 Month Values

My Score

Start Month

A - Volume and Acuity

Volume Procedures Total NW PPE 86 670 N/A Jul-Dec 15 410 Jan

2014

A1 - Inpatient

Volume Admissions Inpatient PPE 29 330 N/A Jul-Dec 15 120 Jan

2014

Volume Procedures Inpatient NW PPE 32 359 N/A Jul-Dec 15 119 Jan

2014

A2 - Observation

Volume Consultations Observation PPE Reports 0 3 N/A Jul-Dec

15 0 Jan 2014

A3 - Emergency Department

Volume Consultations ED PPE Reports 1 5 N/A Jul-Dec

15 2 Aug 2014

A6 - OSI

Volume OSI Orthopedics Surgical TOTAL PPE 86 663 N/A Jul-Dec

15 407 Jan 2014

Volume OSI Joint Replacement PPE 32 304 N/A Jul-Dec 15 114 Jan

2014

Volume OSI Knee Uni-Compartment Navio PPE 0 13 N/A Jul-Dec

15 0 Jan 2014

Volume OSI Sports Medicine Surgery PPE 38 272 N/A

Jul-Dec 15 233 Jan

2014

B - Medical Knowledge Skill Judgment

Core VTE1 - VTE Prophylaxis Med Surg NW PPE 100.0% 100.0% 100.0% Jul-Dec

15 100.0% Feb 2015

Core VTE6 - Preventable HA-VTE NW PPE

No Data 0.0% 0.0% Jul-Dec

14 No Data No Data

B3 - Patient Safety Indicators - PSI 90

PSI-15 Accidental Puncture or Laceration PPE 0 0 0 Jul-Dec

15 0 Jan 2014

PSI-12 Postoperative Pulmonary Embolism PPE 0 0 0 Jul-Dec

15 0 Jan 2014

PSI-12 Postoperative Deep Vein Thrombosis PPE 0 0 0 Jul-Dec

15 0 Jan 2014

PSI-13 Postoperative Sepsis PPE 0 2 0 Jul-Dec 15 0 Jan

2014

PSI-14 Postoperative Wound Dehiscence PPE 0 0 0 Jul-Dec

15 0 Jan 2014

Goal: an unbiased, reliable, and efficient structure and process for the Medical Staff to measure their own performance with a goal of continuous improvement in patient care

Patient safety & quality Fairness & collegiality

• Focused Professional Practice Evaluation FPPE• Ongoing Professional Practice Evaluation OPPE• Professional Practice Evaluation Committee PPEC

Case Review – rated 1-3 Aggregated data review every 6 months

Other Documents for Review(in orientation packet and on Northwell site)

Policies• Professional Behavior• Impaired Physicians• Perioperative Evaluation of Adults• Sepsis Protocol• Assessment and Management of the Patient with Pain• Acceptable Computer Use Behavior• Zero Tolerance Work Place Violence

General Information• Committee for Physician Health• Dictation Procedures (for medical record documentation)• Hospital Department Contact Sheet• The Hal Federman, MD Health Sciences Library• Welcome Letter from VP Medical Staff Services Central Office• Welcome Letter from Officers of the Medical Staff• Welcome Letter from the Medical Staff Liaison• Meditech Training & Parking Key ID Badge Information• Meditech Remote Access Instructions• Northern Westchester Hospital 24/7 Language Interpretation Services• American Sign Language Interpretation Services• Policy Tech Policies & Procedures Overview• Quick Guide to the NWH Physician Section of the NWH Staff Web Site• NWH Medical Staff Bylaws• NWH Medical Staff Rules and Regulations

YOUR THOUGHTS

Marla Koroly, MD, FACP, MBA mkoroly@northwell.edu914.666.1950