2021-2022 House Staff Manual Revised March 25, 2021
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2021-2022 HOUSE STAFF MANUAL REVISED MARCH 25, 2021 WELCOME TO UNIVERSITY HEALTH We are so happy to have you as part of our team! University Health is a nationally recognized teaching hospital and network of outpatient healthcare centers, serving the people of Bexar County and beyond with the highest level of care and customer service. We are South Texas’ first Magnet healthcare organization having earned this prestigious accreditation since 2010. Our goal is to be the hospital of choice in our community and throughout South Texas. Our expectation is that you will bring the best of yourself to our hospital and all clinical locations every day, and understand that you are leaving a lasting impression—either good or bad—on every patient and visitor you encounter. We have locations across the community to provide the right level of care in facilities that are warm, welcoming and convenient for our patients. These include: University Hospital (Level I trauma center) More than 25 outpatient care centers Four school-based health centers Three dialysis centers Two ExpressMed urgent care centers Two ambulatory surgery centers Two healthyUexpress mobile units The new Women’s and Children’s Hospital is currently under construction and expected to open in 2023. Please visit UniversityHealthSystem.com to learn more about our services and locations. As a member of our House Staff, you will be practicing at some of these facilities and playing a vital role in the mission of our Health System. You will find additional information about these facilities in the section titled University Health Facilities and Services. We are counting on you to help us provide every patient with high-quality, patient-centered care. We welcome you and hope that this manual will help give you a basic understanding of University Health policies and procedures. If you have specific questions about something, we ask that you talk to the chief resident of your service, your service chief, administrative personnel, or Professional Staff Services. University Health 2021-2022 House Staff Manual Revised March 25, 2021 1 STANDARDS OF CONDUCT/SERVICE EXCELLENCE University Health must create a caring environment to fulfill its basic mission of providing quality healthcare. The House Staff establish a caring environment through teamwork and by giving complete and efficient care, while respecting the dignity and worth of all individuals. It is expected that everyone shall express a sincere interest in helping others by exercising patience, understanding and courtesy at all times. The absence of noise in a hospital creates an atmosphere of restfulness and dignity, which is favorable to the recovery of patients and to the satisfactory performance of all the hospital’s work. The relationships in any health care facility are strictly confidential. House Staff members are required to exercise the utmost discretion in the conversations and communications regarding patients, co-workers, and University Health business. University Health 2021-2022 House Staff Manual Revised March 25, 2021 2 MISSION, VISION, VALUES OF UNIVERSITY HEALTH Mission The mission of University Health is to improve the good health of the community through high quality, compassionate patient care, innovation, education and discovery. Vision We are leading the way to be one of the nation’s most trusted health institution. Values Our patient care will be: High quality and compassionate above all Attentive, kind and helpful without exception, and Wise in the use of resources George B. Hernández, Jr. President/Chief Executive Officer University Health 2021-2022 House Staff Manual Revised March 25, 2021 3 TABLE OF CONTENTS Welcome To University Health 1 Standards of Conduct/Service Excellence 2 University Health Mission, Vision, Values 3 SECTION I: University Health Facilities and Services 8 SECTION II: Communications 9 SECTION III: House Staff Personnel Policies and Procedures 11 Professional Staff Services 11 Dress Code 11 Employment Eligibility Requirements 12 Employee Health Services 13 Graduate Medical Education Agreement 13 Pay Policy 14 Accessing Your Payroll Information 14 Licensure/Training Permits 14 Controlled Substance Certificates 15 Basic/Advance Life Support Certification 15 Military and Elective Rotators 15 Due Process Procedure 16 Counseling Services 16 House Staff Recognition Program 17 Gym Memberships 18 Resident Meal Credits 18 Lab Coats 19 Scrub Station Access 19 Safe Ride Home 20 Employment Verification 21 Clearance Procedures 21 SECTION IV: House Staff Benefits 22 Open Enrollment and Qualifying Events 22 Medical, Dental and Vision Plans 23 Disability Plans 23 Deferred Compensation Plans 24 Employee Assistance Program 24 Professional Liability Coverage 25 SECTION V: House Staff Leave Policies 25 Vacation/Sick Leave 25 Leave of Absence 26 Maternity/Paternity Leave 26 FMLA 26 University Health 2021-2022 House Staff Manual Revised March 25, 2021 4 House Staff Time Donation Program 29 SECTION VI: Medical Records 29 Medical Record Content Timelines 29 Inpatient and Outpatient Records 29 Medical History and physical examination 29 Informed Consent Timeline 29 Operative Report or other high risk procedure 29 Verbal and Telephone Orders 29 Non-Violent and Violent Restraint Orders 30 Discharge Summary 30 Autopsy 30 Electronic Medical Record Access 30 Record Content Requirements 30 Diagnostic and Therapeutic Orders 31 Evidence of Informed Consents 31 Transfer From One Medical Service to Another 31 Documentation Requirements of Attending Physicians 32 Retiring of Medical Records 32 Downtime Procedures 32 SECTION VII: House Staff Support Services 33 Clinical Information Services 33 Cafeteria Food Service 34 Center for Learning Excellence 35 Basic and Advanced Life Support 36 Library Services 36 Police and Protective Services 38 Facility Access 39 Registration and Identification 39 SECTION VIII: Confidentiality 40 Release of Information 40 Health Insurance Portability and Accountability Act (HIPAA) 41 Information Assets 45 SECTION IX: Environment of Care and Occupational Safety 45 Safety Procedures 45 House Staff Safety Responsibility 46 On-The-Job Incident Reporting 47 Emergency Management 48 SECTION X: Infection Control and Prevention 49 COVID-19 49 Bundle of Care of Evidence-Based Best Practices 51 Hand Hygiene 54 University Health 2021-2022 House Staff Manual Revised March 25, 2021 5 Standard Precautions 56 Transmission-Based Isolation Precautions 59 Antimicrobial Resistance and Stewardship 61 SECTION XI: Quality Improvement and Patient Safety 63 SECTION XII: Risk Management 65 SECTION XIII: Departmental Information 67 Rehabilitation Medicine 67 Research Department 69 Pharmacotherapy and Pharmacy Services 70 Prohibited Abbreviations 74 Outpatient Prescriptions 74 Controlled Substance Prescriptions 74 Texas Prescription Monitoring Program 75 Meds-To-Bed Program 76 Controlled Substances Diversion Prevention Program 76 SECTION XIV: Selected Policies 77 Patient’s Right to Consent 77 Consultative Services 77 Drug Sample Policy 77 Hallway Prescribing 78 Advance Directives 78 Determination of Death 78 Restraint and Seclusion Policy 79 SECTION XV: Patient Care/Clinical 82 Patient Bill of Rights 82 Patient Procedures 84 Case Management 84 Utilization Review 84 Admissions Procedures 86 Patient Placement Center 88 PREOP/Holding/Phase II Surgery Physician Guidelines 88 SAFE Anesthesiology Clinic 91 Patient Deaths 91 Autopsies 93 Anatomical Law Related to Cadavers 99 SECTION XVI: Patient Services and Programs 100 Bexar County Family Justice Center 100 The Center for Health Care Services Crisis Care Center 100 Child Abuse and Child Neglect 100 PREMIEre Program 101 University Health 2021-2022 House Staff Manual Revised March 25, 2021 6 Cardiology Services 102 Medical Specialties Services 103 Nurselink 105 Nutrition Services 105 Nutrition Clinic 106 Pathology Services 106 Patient Care Services 107 Patient Relations 108 Interpreter Services 109 Radiology Services 110 Renal Dialysis 113 Respiratory Care Services 114 Spiritual Care 116 University Health 2021-2022 House Staff Manual Revised March 25, 2021 7 SECTION I UNIVERSITY HEALTH FACILITIES AND SERVICES University Health is a nationally recognized academic medical center and network of outpatient health centers. University Health is committed to delivering patient-centered, compassionate, culturally competent and high-quality healthcare based on a strong foundation of outcomes-based research and innovative teaching. It is the first public health system in Texas to earn Magnet designation by the American Nurses Credentialing Center. Over the past two decades, University Health has expanded access to primary, specialty and preventive healthcare services, and currently operates more than 25 health centers and clinics throughout Bexar County. University Health recently converted to the Epic Electronic Health Records system across all locations, and is in the top one percent in the nation for its use of information technology. Community First Health Plans, owned by University Health, is the region’s only nonprofit HMO and insurance provider. University Medicine Associates is University Health’s nonprofit provider group practice. University Hospital (4502 Medical Drive) is the 716-bed acute care hospital of University Health. It serves as the primary teaching hospital for UT Health San Antonio, and is the premier Level I Trauma Center for the estimated 2 million residents of Bexar County and South Texas. In October 2016, the American College of Surgeons (ACS)