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North Shore-Long Island Jewish Health System
HOUSE STAFF MANUAL
2009
Forest Hills Hospital
Glen Cove Hospital
Long Island Jewish Medical Center
North Shore University Hospital
Schneider Children’s Hospital
Southside Hospital
Zucker Hillside Hospital
TABLE OF CONTENTS
Mission Statement
Health System Profile
Facility Profiles
General Rules
PAGE
Absence from the Center
Assignment to Clinical Services
Conduct
Emergency Call
Evaluation Reports
Health Examinations
Group Insurance Benefits
Housing
Malpractice Insurance
Meals
Health Science Library
Control Drug (Narcotic) Registration
On-Call Rooms
Paging and Telephones
Parking
Paychecks
Sick Time
Smoking
Uniforms and Laundry
Vacations
Valuables
Resident Policies
Eligibility and Selection
Evaluations
Licensure Policy for Graduate Staff Officers
House Staff Progression Policy
House Staff Work Hours
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House Staff Moonlighting Policy
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Resident Supervision
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Remedial Action for House Staff Members 44
Counseling Services
44
Graduate Medical Education Diploma Policy 45
Closure/Reduction/Disaster Policy
46
Due Process Policy
48
House Staff Impairment Policy
52
Non-Discrimination and Non-Harassment 54
House Staff On-Call Meal Allowance
57
Leave Policy
57
Initial Appointment to the House Staff
58
Record Retention
58
Housing Policy
59
Housing Stipend
63
PGY Level Policy
64
Visa Policy
64
Basic Life Support Training Policy
69
USMLE Policy
70
Electronic Communications System Policy 70
Disability Policy
70
Office of Academic Affairs
72
Employee Health Services
72
Infectious Exposure Guidelines
73
Blood and Body Fluid Exposures
76
Emergency Department
79
Pharmacy
79
Medical Records
86
Resident Forum
92
Fire Procedures and Duties
93
Patient’s Bill of Rights
96
Telephone Directory
103
NORTH SHORE-LONG ISLAND JEWISH
HEALTH SYSTEM
Graduate Medical Education Mission Statement
The North Shore-Long Island Jewish (LIJ) Health
System is an integrated healthcare delivery system
serving the people of Long Island and the New
York metropolitan area. The health system is
organized with a serious commitment to the highest quality of patient care, medical education and
biomedical research.
The North Shore-LIJ Health System participates
actively in the training of medical students and
practicing physicians, as well as residents. The
health system is specifically committed to graduate
medical education. The health system has provided
extensive graduate medical education to residents
and fellows in the setting of extensive breadth of
clinical experience and rigorous academic training.
The health system is grounded in a philosophy
that a commitment to excellence in medical
education is closely linked to the delivery of quality
medical care. The attending and support staff
participates actively in the educational activities
of the health system and all members of the staff
are expected to embrace this philosophy.
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The health system recognizes the critical nature of
the transitional period represented by residency
training and the difficulties and pressures the
house officers face during these years. The health
system is committed to providing the resources,
including educational, financial, professional,
human, space and equipment necessary to support
and enhance the graduate medical education programs and to prepare our trainees as future healthcare professionals. The health system is organized
to conduct graduate medical education programs
in a scholarly environment with a commitment to
excellence in both patient care, as well as medical
education.
The North Shore-LIJ Health System is committed
to being in substantial compliance with the
Accreditation Council of Graduate Medical
Education (ACGME) institutional requirements
and insures that all of its training programs are
likewise in substantial compliance with their individual Resident Review Committee (RRC) program
requirements and the common requirements of the
ACGME. The North Shore-LIJ Health System is
further committed to maintaining equally high
standards for all other training programs conducted
within the health system.
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HEALTH SYSTEM PROFILE
North Shore-Long Island Jewish Health System
The nation's third largest, non-profit, secular
healthcare system, the North Shore-LIJ Health
System cares for people of all ages throughout
Long Island, Queens and Staten Island—a service
area encompassing more than five million people.
The health system includes 15 hospitals, four
long-term care facilities, a medical research institute,
four trauma centers, five home health agencies and
dozens of outpatient centers. North Shore-LIJ
facilities house more than 6,000 beds and are staffed
by over 8,000 physicians, 10,500 nurses and a total
workforce of about 37,500—the largest employer on
Long Island and the ninth largest in New York City.
The combined graduate medical education program
at the two tertiary hospitals is one of the largest in
New York State. A medical staff of more than 600
full-time physicians and dentists supervise care in
all major specialties and participate in the health
system's extensive teaching and research programs. House staff totals at the two tertiaries is
over 850 residents and fellows in more than 85
programs approved by the ACGME, Commission
on Dental Accreditation (CODA), the American
Osteopathic Association (AOA) and the Council
on Podiatric Medical Education (COPME) and
five independent fellowships.
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FACILITY PROFILES
Forest Hills Hospital (FHH) is a 222-bed (312
licensed) community hospital that provides inpatient medical and surgical care, intensive care, and
OB/GYN services. Located in an ethnically
diverse residential neighborhood in northern
Queens, our mission is to provide the highest
quality of care with sensitivity and respect for the
cultural needs of our patients and their families.
The hospital is designated as a Level II Perinatal
service. The Emergency Department is a 911
receiving site and a certified heart station, as well
as a New York State designated stroke center. We
are also an approved Community Cancer Hospital
by the American College of Surgeons.
The Department of Medicine has a full complement of medical staff specializing in internal
medicine with board certification in the following
medical subspecialties: cardiology, pulmonary,
rheumatology, infectious disease and critical care
medicine, nephrology, endocrinology, neurology
and psychiatry.
The facility serves as a teaching hospital for a fully
accredited medical residency training program in
internal medicine. There is a blend of primary care
and subspecialty experience on both inpatient and
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ambulatory services, with an extensive community based teaching network for both primary and
subspecialty education. Non-internal medicine
faculty also participates in teaching and mentoring.
Glen Cove Hospital formerly called Community
Hospital at Glen Cove began serving the residents
of Northern Nassau County in 1922. It is located
on a park-like campus interconnecting buildings,
including the main hospital pavilion, the Family
Medicine Center, the Don Monti Oncology Center
and the Pratt Auditorium
From its inception excellence in patient care and
service to the community have been the guiding
principles that allowed Glen Cove Hospital to successfully adapt to changing patient needs and the
modern medical environment. Today our hospital,
a 265-bed acute care facility, is an integral part of
the award-winning North Shore Long Island
Jewish Health System.
Glen Cove Hospital meets the comprehensive
health care needs of an ethnically and socio-economically diverse population through a combination of inpatient services, primary and preventive
services, community outreach, behavioral health,
health education and support programs.
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The centerpiece of educational activity is the
Family Medicine Residency Program that has
been enthusiastically supported by the hospital
administration, attending staff and the community
since its inception as one of the first programs in
the region in 1973. Glen Cove Hospital operates
numerous clinics and provides primary health care
for many school districts, children’s homes and
social service agencies in the community. In addition
the hospital and Family Medicine Residency
Program provide a wide range of services to nonambulatory patients in nearby nursing and extended
care facilities, as well as offering support groups
and community health education programs.
Long Island Jewish Medical Center shares the title
of clinical and academic hub of the North Shore-LIJ
Health System. It is an 829-bed voluntary, nonprofit tertiary care teaching hospital serving the
greater metropolitan New York area. It was the
first hospital in New York state to receive Magnet
designation for nursing excellence. Three
divisions comprise LIJ: Long Island Jewish
Hospital, Schneider Children’s Hospital and the
Zucker Hillside Hospital for behavioral healthcare. Long Island Jewish Hospital is a 452 bed
tertiary adult care hospital with advanced diagnostic and treatment technology and modern facilities
for medical, surgical, dental and obstetrical care.
It features the Sandra Atlas Bass Cardiology
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Center, Pain and Headache Treatment Center,
comprehensive pulmonology programs for asthma,
emphysema and sleep disorders; The Center for
New Life with private labor-delivery-recovery
suites and a high-risk pregnancy program; and the
Institute of Oncology, supported by the Joel
Finkelstein Cancer Foundation. LIJ’s graduate
medical education program is one of the largest in
New York State. A medical staff of approximately
1,400 affiliated physicians and dentists teach and
serve in the inpatient and ambulatory care units.
LIJ is an academic campus for the Albert Einstein
College of Medicine. All programs are in departments/divisions headed by full-time faculty. The
full-time staff includes more than 400 physicians
and dentists who supervise care in all major specialties and participate in the medical center’s
extensive teaching and research programs. House
staff totals over 500 residents and fellows in 45
programs accredited by the ACGME, CODA,
COPME, AOA and independent programs.
• Schneider Children's Hospital (SCH), located
on the campus of Long Island Jewish Medical
Center, is committed to comprehensive care for
children ranging from infancy to young adulthood.
The hospital has 154 beds arranged in separate
units on five floors, each with its own nursing
and social work staffs as well as playrooms. The
hospital was named one of the top 20 children’s
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hospitals in the country by Child magazine. The
hospital is a full-service, acute, medical, surgical, dental and psychiatric hospital, providing
treatment for neonates, infants, children and
adolescents in all disciplines, from common
childhood diseases to such serious illnesses as
cancer and heart disease. It is a regional center
for lung rescue, bone marrow transplantation,
cardiac surgery, neonatology and cystic fibrosis.
It has a large Outpatient Department, seeing
over 120,000 children per year as well as a pediatric
urgicenter and Pediatric Emergency Department.
The children’s hospital has tertiary satellite centers
in the communities of Commack, West Islip,
Hewlett, Flushing and Brooklyn.
• Zucker Hillside Hospital is a 223-bed psychiatric facility known for its pioneering work in
the diagnosis, treatment and research of mental
illness. The National Institute of Mental Health
has established a Clinical Research Center for
the Study of Schizophrenia at Zucker Hillside,
one of only five such facilities nationwide. A
new research study on bipolar disorders was
recently launched. The hospital’s patients live
in cottages and two-story buildings on a campus
that offers athletic facilities and a fully accredited grade school and high school. Inpatient
services include treatment for general psychiatry, schizophrenia, affective disorders, mental
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retardation and developmental disabilities for
the geriatric, child, adolescent and adult
populations. Outpatient services, including
treatment for chemical abuse, are available. The
Zucker Hillside Hospital offers a unique center
for the study of functional disabilities called the
Center for Neuropsychiatric Outcomes and
Rehabilitation Research. The hospital also uses
the latest virtual reality software to treat various
phobic disorders including the fears of flying,
heights and public speaking.
North Shore University Hospital (NSUH) is one
of the cornerstones of the health system as well as
an academic campus for the New York University
School of Medicine and the Albert Einstein
College of Medicine. The facility was named the
nation’s top metropolitan hospital in a survey
published by AARP’s Modern Maturity magazine
and a Magnet hospital for nursing excellence. The
hospital has 788 beds and a staff of 2,700 specialist and subspecialist physicians. It offers the most
advanced care in all medical specialties, including
open-heart surgery, urology, maternal-fetal
medicine and advanced neurosurgery capabilities
in the medical, surgical newborn and pediatric
patients. The Sandra Atlas Bass Cardiology
Center is a national demonstration site for the
latest equipment and procedures including one of
the New York area’s first 64-slice CT scans. The
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Don Monti Cancer Center cares for thousands of
cancer patients every year. Specialties include
bone marrow transplants, geriatric oncology,
breast cancer treatment and gynecological
surgery. The hospital is a designated Level I
Trauma Center and is recognized as a unique
provider of services for HIV/AIDS patients. The
Schwartz Ambulatory Surgery Center performs
10,000 surgical procedures annually. The hospital
continues to meet the needs of underserved
members of the community through a comprehensive
network of 65 clinics. All programs are in departments/divisions headed by full-time faculty. The
full-time staff includes more than 400 physicians
and dentists who supervise care in all major
specialties and participate in the medical center’s
extensive teaching and research programs. House
staff totals over 350 residents and fellows in
programs accredited by the ACGME, CODA and
independent programs.
culturally and socio-economically diverse population. Over 18,500 patients are admitted each year
and 2,700 babies are delivered in our maternity
unit. Community based primary care services are
provided through the hospitals management of the
Sullolk County Health Department’s Brentwood
and Central Islip Health Centers, which offer
comprehensive services to the medically underserved in our community.
The Family Medicine Residency Program has
been an integral part of the hospital’s mission
since 1972. Southside has graduated over 250
family physicians who are practicing throughout
the United States. The Family Medicine
Department of more than 50 physicians has
approximately 30 of our graduates on staff.
Southside Hospital, founded in 1913, is Long
Island’s oldest and largest Community Hospital.
Since its first days, Southside’s mission has been
to provide expert, compassionate medical care to
anyone in need.
With 371 beds, Southside offers quality care in
medical, surgical, obstetric, gynecologic and pediatric specialties. The hospital serves an ethnically,
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RESPONSIBILITIES OF HOUSE STAFF
GENERAL RULES
A health system is like a small city. Its efficiency
and progress depend upon your cooperation and
adherence to the necessary rules of conduct and
code of ethics. The primary duty of all staff members and employees is the welfare of all health
system patients. As such, the health system
endorses the Patient's Bill of Rights, a copy of
which is found in the back of this book.
A. Absence. A house staff member may not leave
the assigned facility while on duty without authorization from the program director. Your program
and the Office of Academic Affairs must always
have your current home phone number.
Members of the house staff are responsible to the
medical and dental staff, department chairpersons,
chiefs and directors and ultimately to the system
president and board of trustees in all matters pertaining to the professional care of patients at the
health system.
The chief resident on each clinical service is
directly responsible to the chairman and/or program director of his service for the supervision of
the service. Other members of the house staff are
responsible to the chief resident of the service.
No member of the house staff may accept a fee for
care rendered to a patient, nor engage in the practice of medicine, surgery, dentistry or podiatry or
serve in any professional capacity in any other
institution during his term of service, except with
the express permission of his/her program director.
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B. Assignment to Clinical Services. The program
assigns all house staff members to specific duties.
If any changes are made in the on-call schedule, it
is particularly important that you notify your chief
resident and your program director.
C. Conduct. The patient's well-being lies at the
heart of all the efforts of the house staff.
Obviously, a physician's attire and grooming
should not offend patients. The house officer
should be neatly dressed. Men are expected to
wear shirts and ties and a white jacket or lab coat.
Women are expected to wear at least one white
article of clothing: jacket, shirt or lab coat. It goes
without saying that a doctor's hands must be clean
when examining patients. Conversation at the
bedside should be conducted in a fashion that
spares the patient's feelings and allays fears but
does not make the patient an "outsider" to what is
going on. Examining a patient and then withdrawing out of earshot, but within vision, to discuss the
case can only arouse needless anxieties. Judicious
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discussion at the bedside is preferred and searching analysis saved for the conference room.
Elevators, corridors, the cafeteria, etc. are public
areas used by the families of patients. HEALTH
SYSTEM STAFF MUST NOT DISCUSS CASES
OR USE PATIENT'S NAMES WHILE IN PUBLIC
AREAS. Finally, leaning on beds, seeking support
from foot rails, reading magazines on the bedside
table while the attending or other physician examines the patient, walking away from the bedside
during formal rounds and talking when another
doctor is making a point, all contribute to an
unprofessional atmosphere. Families of patients
are to be treated with respect and dignity and their
fears and anxieties are to be understood and cared
for as well.
D. Emergency Call. For an emergency such as a
cardiac arrest, immediately dial "22" at LIJ and “5555”
at NSUH. These numbers are for emergencies
only and should not be used for any other purpose.
Forest Hills Hospital
Emergency Numbers & Codes to Remember
• Code 1 – Infant Abduction – Dial 4890
• Code 22 – Internal or External Emergency –
Dial 2222
• Code 33 – Cardiac Arrest – Dial 33
• Code “Nurse Blaze” – Fire Emergency – Dial 44
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• Code BLUE – Bomb Scare – Dial 4890
• Code YELLOW – Hazardous Material Spill –
Dial 4890
Southside Hospital
Emergency Numbers & Codes to Remember
• Fire – Dial 3600
• Cardiac Arrest – Dial 13
• Security – Dial 55
E. Evaluation and Advancement Reports. The
program director of each department or program
conducts periodic performance evaluation on each
resident. In December and May of each academic
year, all program directors must complete and
return a performance evaluation and advancement
report to the Office of Academic Affairs. This document assesses the performance of each resident
in his/her program and contains the program
directors recommendations for the resident's continuation and/or promotion in the program for the
next academic year. In the event a program director
places a resident on "probation" or the resident is
not being promoted to the next level, the program
director must provide a detailed explanation for
that decision.
The performance and advancement report along
with all memos of explanation shall be reviewed
by the Office of Academic Affairs. Following
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review and approval of the performance and
advancement reports. The Office of Academic
Affairs will issue renewal contacts in January for
all house staff in good standing who shall remain
in the program. Residents not in good standing or
who will not remain in the program will be sent
letters notifying them of the basis for the action
and evaluation or why they will not be continued
in the program. Any resident who wishes to
appeal an adverse recommendation may do so
following the due process procedure as outlined in
the policy section of this manual.
F. Health Examinations. It is mandatory for house
staff members to have a physical examination by
the Employee Health Service (EHS) physician
before service begins and an annual health assessment
thereafter. The scheduling of health assessments
is the responsibility of the trainee. The phone
number for EHS is (718) 470-7563.
G. Group Insurance Benefits. The health system
has a benefit program called "FLEX" which provides
the house staff the opportunity to select health, life
and disability coverages that best suit their needs.
A number of options under these coverages are
available: medical, dental, prescription drug card
and vision, life insurance, short-term disability,
long-term disability, and healthcare and dependent
care reimbursement accounts. Dependent coverage
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for medical, dental and prescription drug/vision
coverage may be elected, for which an additional
contribution is required.
H. Housing. There are a very limited number of
housing units on the grounds of Long Island
Jewish Medical Center, North Shore University
Hospital and Glen Cove Hospital which are available to eligible members of the house staff. For
more detailed information about the availability of
these units, see the housing policy in the manual
on page 56. NSUH, LIJ and Glen Cove provides a
housing subsidy for eligible members of the house
staff. For more detailed information about the
housing subsidy, see the housing policy and/or
contact the Office of Academic Affairs at (516)
465-3192.
There are 35 apartments on the Glen Cove campus
available to the Family Medicine residents which
range from studio through 2 bedroom apartments.
For more details regarding the apartments please
call the Family Medicine Residency Department
at (516) 674-7637.
Forest Hills Hospital does not provide housing.
However, the program coordinator can assist you
in locating an apartment within the surrounding
area if necessary.
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Southside Hospital does not provide housing.
The program secretary offers assistance in locating
apartments within the surrounding area if necessary.
I. Malpractice Insurance. The health system
provides malpractice insurance protection for
house staff members while they are acting within
the scope of their duties as defined and approved
by the department chairpersons. A termination of
your employment with the health system will not
affect your coverage under this claims made policy
with regard to a medical incident occurring while
you were an employee of the health system even
if a claim arising out of that incident is made
subsequent to your termination of employment
with the health system. Any unusual occurrence
relating to the care of a patient should be reported
to your chairperson immediately and reported on
the proper form available on patient units.
When a house staff member examines and/or
treats a patient, visitor or employee who has been
involved in an unusual occurrence such as falling
out of bed, slipping on the floor, etc., the medical
information should be written in the medical
record and recorded on the appropriate hospital
form.
If notices such as summonses or subpoenas are
served to house staff members or if you are con22
tacted or approached by an attorney with regard to
a malpractice action, notify your program director
and call the Risk Management Department at
(516) 465-2655. If contacted by the Department
of Health relative to patient complaints, contact
the Office of Academic Affairs at (516) 465-3192.
J. Meals. The hospitals provide meals in the cafeteria at FHH, Glen Cove, LIJ, NSUH and
Southside at reasonable costs.
The LIJ Cafeteria operates five days a week from
7 a.m. to 2:30 p.m.
The cafeteria at North Shore University Hospital
is open daily from 6:30 a.m. to 8:30 p.m. On the
weekend, the cafeteria closes in the afternoon at
2:30 p.m. and reopens again at 5:30 p.m.
The “Deli” located in the first floor lobby is open
weekdays from 7:30 a.m. to 11 p.m. and on weekends from 11 a.m. to 11 p.m.
Kitchen Kabaret operates the food concession at
Zucker Hillside Hospital Monday to Friday from
8:30 am to 2:30 pm.
The Harvest Café at Forest Hills Hospital is conveniently located in the lobby of the hospital and
is open daily from 7:00am–7:00 pm. The New
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York City bistro-style café offers a unique and
soothing place to unwind and is available to
employees and visitors. A 20% discount is applicable to employees of the hospital. Vending
machines are also available 24 hours daily.
K. Health Sciences Library. The LIJ Health
Sciences Library is an integrated system that
includes libraries at the LIJ and Zucker Hillside
Hospital divisions. The library provides access to
over 600 electronic journals and an on-site collection
of over 20,000 books and journals. A special
collection of review books and computer programs
are available for house staff when studying for boards.
The library catalog as well as all the databases,
e-journals and e-textbooks are accessible on
EMIL, the Electronic Medial Information Library
on the health system intranet portal called HealthPort.
It is recommended that new staff register as soon as
possible in order to obtain access. Librarians are
also available for training and to conduct literature
searches for staff.
Materials not owned by LIJ or Hillside can be
ordered via interlibrary loan. Public access computers
are available at both libraries and assistance is
provided in using various computer applications.
The e-mail address for the library is [email protected].
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The LIJ library is located on the C Level of the
Schwartz Research Center. The phone number is
470-7070. The hours are Monday to Friday from
8:30 a.m. to 6:30 p.m.
The Forest Hills Hospital Health Sciences Library
is located on the ninth floor. A certified medical
librarian staffs the library and is on duty from
8:00am–4:00pm Monday-Friday. Access is available to the library 24 hours a day to the medical
residents via code.
The FHH Library has a collection of journals,
texts, audiovisual material, directories and indices.
Computers are available to residents 24 hours a
day. The Librarian will run computer searches
upon request, and place inter-library loans for
items needed. Medical books may be purchased
through the library at a discount.
North Shore University Hospital Library. The
NSUH library is open to North Shore-LIJ Health
System staff. Borrowing and interlibrary loans are
limited to North Shore, Glen Cove, CECR, and
Research Institute registered users. WebCat, the
library’s online catalog, lists all of its holdings and
provides e-links to electronic journals, books,
databases, etc. On-site, WebCat may be accessed
directly at http://medlib.nshs.edu. Remote access to
library resources is available on HealthPort through
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Electronic Medical Information Library. When
required, login information for electronic journals
is given in WebCat. The medical library will obtain
via Interlibrary Loan requested items not owned
by Interlibrary Loan.
The NSUH library is located on the first floor of
the Tower Building opposite the Rust Auditorium.
The phone number is (516) 562-4324. The hours
are from 8 a.m. to 6 p.m. Monday through Friday.
Southside Library located on main level of hospital. Residents have access 24 hrs. a day. A medical
librarian is available to assist residents.
The Zucker Hillside Library is located on the
lower level of the Littauer Building. The phone
number is (718) 470-8090. The regular hours are
Monday to Friday 9 a.m. to 5 p.m. The Zucker Hillside
Library subscribes to 175 print journals and maintains an historical collection of books and journals.
L. Controlled Drug (Narcotic) Registration.
Residents may write orders and issue prescriptions for controlled substances within the health
system or any of its affiliations or divisions. The
facility specific DEA registration number
assigned to each member of the house staff is to be
entered on the prescription, plus a suffix number,
both of which will be issued to you by the Office
of Academic Affairs. In addition, the name and
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license number of a supervising physician must
also be entered on the prescription.
Residents may not write prescriptions for controlled substances outside the health system
facilities or for employees.
M. On-Call Rooms. There are some patient units
with on-call rooms on the LIJ and NSUH campuses.
Some departments maintain separate on-call quarters. There is also an on-call facility at LIJ off of
the cafeteria near the loading dock and NSUH in
the operation complex. Rooms in this LIJ facility
are available for use by residents in designated
programs. Keys for these on-call rooms can be
obtained from the House Staff Coordinator in
your department.
FHH on-call rooms are located in the south corridor on the second floor, easily accessible to the
emergency department, south elevators and stairway. The kitchenette is equipped with microwave,
refrigerator and dining table. The on-call area is
maintained by housekeeping daily. Keys are
obtained from the program coordinator at the start
of your first year of residency and must be
returned upon departure of our program.
PLEASE NOTE: THE HEALTH SYSTEM IS
NOT RESPONSIBLE FOR VALUABLES LEFT
IN ON-CALL ROOMS.
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N. Paging and Telephone System. In-house pocket
pagers (i.e., beepers) are the property of the health
system and are on loan to you. Do not, under any
circumstances, pass your beeper on to another
house staff member. Batteries for all beepers are
distributed in your immediate departments. Any
questions regarding the proper use or maintenance
of your beeper should be directed to the
Telecommunications Department at LIJ (718)
470-7750 and NSUH (516) 562-4475.
Pagers are property of Forest Hills Hospital. You
will be assigned a pager on the first day of your
training. Batteries can be obtained within the
department of medicine. If you encounter any
problems with your pager, please notify the program
coordinator as soon as possible to troubleshoot or
for replacement.
At LIJ, your beeper number is also your unique ID
which is used as part of the Medical Records
System. This is used to identify you in the patient
medical records. To page someone from outside
LIJ, dial (516/718) 470-7700 and give the name of
the person to be paged, then continue to hold until
the individual responds. To page inside LIJ, dial
25 + beeper number.
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At NSUH Dialing from the outside, dial
562-1110, enter the #3 and four-digit page number
followed by the # key and the entire call-back
number. To page inside NSUH dial extension
1110, enter #3 then the four-digit pager number
followed by the # key. Then enter the callback
number, followed by the # key.
ALL PAGES ARE TO BE RESPONDED TO
IMMEDIATELY.
House staff members may use the health system
telephones for all business calls. Personal and
long distance calls are to be made at pay stations.
In case of an emergency, calls may be billed to
your home, provided you have a private phone.
Pagers are property of Southside Hosptial. You
will be assigned a pager on the first day of your
training. Batteries can be obtained within the
depaartment of family medicine. If you encounter
any problems with your pager, please notify the
program secretary as soon as possible to troubleshoot or for replacement.
O. Parking. House staff members may park their
cars in the employee lots located at North Shore
and LIJ facilities. To obtain access to employee
lots, you must report to the Security Office to have
your employee ID card programmed and to
receive an employee parking sticker. At LIJ,
limited use garage cards are also available which
will allow free garage parking between the hours
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of 2:30 p.m. and 11 a.m. Monday to Friday and all
day on weekends and holidays. House staff will be
charged for parking at the employee rate if car remains
in the LIJ garage past 11 a.m. Monday to Friday.
FHH Parking on campus is available in the garage
adjacent to the hospital. Parking applications can
be obtained from the program coordinator along
with a $25 refundable fee. Vehicles with MD
license plates can park on the street in designated
perimeter surrounding the building.
Parking is available in Employee Parking Lots. ID
Badge is programmed for entering and leaving the lots.
P. Paychecks. Paychecks are distributed on alternate Thursdays. Paychecks are issued to the house
staff in their respective departments. You may
elect to participate in the direct deposit program at
the financial institution of your choice.
Q. Sick Time. When ill, house staff members are
required to advise the program director before
going off duty and upon returning to duty.
Depending upon the extent of the illness, house
staff members may either be sent home or admitted to the a health system facility for care.
on the grounds of the health system facilities.
S. Uniforms and Laundry. House staff members
are expected to maintain a neat, clean appearance
and to dress appropriately at all times. You will
receive the cooperation of the Linen Department
in keeping uniforms clean, pressed and mended.
House staff will be provided with a clean lab coat
on an exchange one-for-one basis. You will be
charged for uniforms that are not returned at the
end of your contract.
T. Vacations. Time off is taken at such time as
scheduling permits and are subject to approval by
the program director. House staff are entitled to 20
days off per contract year. The 20 days must be
taken within the contract year; they are not accruable.
U. Valuables. The health system cannot assume
responsibility for valuables or personal property
left in any locations around the health system
including OR lockers and on-call rooms. Any loss
or theft of property should, however, be reported
immediately to the Security Office on the campus
where the theft occurred.
R. Smoking. All health system facilities are
smoke-free. Smoking is not permitted anywhere
30
31
RESIDENT POLICIES
A. ELIGIBILITY AND SELECTION:
ELIGIBILITY
Applicants with one of the following qualifications are eligible for appointment to training
programs at the Health System:
Graduates of schools in the US-accredited by
either the Liaison Committee on Medical
Education (LCME), the Commission on Dental
Accreditation (CODA), the American Osteopathic
Association (AOA), the Council on Podiatric
Medical Education (CPME) or graduates of
Canadian medical schools approved by the
Licentiate of the Medical Council of Canada
(LMCC).
Graduates of medical schools outside the US and
Canada who have a current and valid certificate
from the Educational Commission for Foreign
Medical Graduates (ECFMG).
Graduates of medical schools outside the US who
have completed a “Fifth Pathway” program provided by an LCME-accredited medical school.
Refer to the Directory of Graduate Medical
Education: “Essentials of Accredited Residencies”.
32
Applicants who have had previous residency
training are required to submit formal written reference letter(s) from all previous program directors.
Applicants who are transferring into a health system program from another program prior to completing the training in the prior program must
obtain a written release (if under contract with
another program) from their current program
director.
SELECTION
Qualified members of the house staff are selected
through organized matching programs (e.g.,
National Residency Matching Program (NRMP)
if applicable; house staff selected outside of a
matching program are subject to the same scrutiny and must have qualifications similar to those
who are selected through a match. Members of the
house staff are selected by procedures established
by the individual training programs.
B. EVALUATIONS:
Each program must establish a system of evaluating
performance and demonstrated competency in the
areas specified in the program and institutional
requirements. Residency/fellowship program directors are responsible for implementing an effective
33
plan for assessing resident performance throughout the program and for utilizing the results to
improve resident performance.
The evaluation system must include:
• A methodology that results in an accurate
assessment of member of the house staff’s
member’s competence in patient care, medical
knowledge, practice-based learning and
improvement, interpersonal and communication
skills, professionalism and systems-based practice.
For the AOA programs, the system must also
address osteopathic principles and philosophy.
• A minimum of written semi-annual evaluations
that are communicated to each the individual
member of the house staff in a timely manner
and the maintenance of a record of evaluation
for each member of the house staff that is accessible to the house staff officer.
• A process involving use of assessment results to
achieve progressive improvements in the house
staff officers’ competence and performance.
The Program Director must also provide a final
evaluation for each member of the house staff
who completes the program. This evaluation must
include a cumulative review of the house staff
34
officer’s performance throughout his/her training.
This evaluation must also verify that the house
staff officer has demonstrated sufficient professional
ability to practice competently and independently.
The final evaluation must be part of the house
staff officer’s permanent record maintained by the
health system.
FACULTY EVALUATION
The performance of the faculty must be evaluated
by the trainee at least annually. The evaluations
should include a review of their teaching abilities,
commitment to the educational program, clinical
knowledge and scholarly activities. Members of
the house staff preparing written faculty evaluations must be provided with a process that assures
confidentially.
PROGRAM EVALUATION
The educational effectiveness of a program must
be evaluated at least annually in a systemic manner. Representative program personnel (i.e., at
least the program director, representative faculty
and at least one member of the house staff) must
be organized to review program goals and objectives and the effectiveness of the program in
achieving them. This group must have regular
documented meetings at least annually for this
purpose. In the evaluation process, the group must
take into consideration written comments from the
35
faculty, the most recent internal reviews and the
house staff officers’ confidential written evaluations.
Each program will submit to the Office of
Academic Affairs a summary report of the program evaluation exercise which should include
the results of at least the house staff officers’
assessment and the program self-assessment.
C. LICENSURE POLICY FOR GRADUATE
STAFF OFFICERS
Accredited Programs
It is the Health System’s policy that effective July
1, 2007 all residents enrolled in System Graduate
Medical Education Programs, who are eligible for
a New York State license to practice medicine,
must apply and obtain such a license upon the successful completion of their first year of training in
an accredited graduate medical education program.
Such applications for the New York State license
must be submitted to the New York State
Education department within a reasonable period
of time, but no later than 90 days, following the
successful completion of their first year of training.
Effective July 1, 2009, the trainee must present to
the program his/her New York State License within 6 months of becoming licensable.
36
Individuals entering training programs at training
level 2 or higher, who hold a New York State
license, must present a copy of the license to their
program prior to commencement of training.
Individuals, who are license eligible and are entering subspecialty training leading to second Board
certification or entering a program in the third
year of training, will not be accepted to a program
or allowed to commence training if they do not
hold a full New York State license. Individuals,
who are eligible and have completed 12 months of
training, must present a copy of the license application they submitted to New York State along
with a copy of the canceled check within 90 days
of the commencement of their second year of
training. Failure to comply with this policy will
result in the reduction of salary to the level 1 compensation status, until the required license documents are submitted to the trainees’ program.
There will be no retroactive salary adjustment.
Reimbursement
The Health System will reimburse residents in
core programs leading to first board eligibility for
application fees when they provide evidence that
they are the holder of an unrestricted New York
State license. The Health System will not reimburse for USMLE fees or for license renewals.
37
Effective July 1, 2009 - Individuals who are working
toward second Board eligibility are not eligible
for this reimbursement.
Non-Accredited Programs
Trainees in non-accredited graduate medical education programs are required by New York State
law to be holders of a current New York State
license and registration, a limited license or limited
permit to commence and continue their training.
Dentistry/Podiatry
Trainees in accredited Dental and Podiatry training
programs must have a current New York State license
and registration or limited license to continue
their training.
D. HOUSE STAFF PROGRESSION POLICY
In order for a member of the house staff to
progress from one level of training to the next and
complete a house staff sponsored training program, he/she must successfully meet the following
standards as determined by the Department’s
Education Committee in conjunction with the
program director:
• The house staff member must exhibit clinical
performance and competence consistent with
the level of training undergone as defined by the
38
individual residency/fellowship program.
• The house staff member must satisfactorily
complete all assigned courses, projects or other
standards established by the program and/or
department.
• The house staff member must demonstrate professionalism including the possession of a positive attitude and behavior, along with moral and
ethical qualities.
Upon the house staff member’s successful completion of the above criteria, the program director
will certify by inserting a formal statement into
the trainee’s training folder indicating that the
individual has successfully met the health system’s requirements for progression to the next
training level and/or graduation.
E. HOUSE STAFF WORK HOURS
In compliance with the New York State 405
Resident Work Hours, it is the policy of the health
system that the work schedule of all members of
the house staff must not exceed eighty (80) hours
per week, averaged over a four (4) week period.
Up to a three-hour transition period is allowed following a 24-hour on-call assignment. The transition period is not intended for the assignment of
39
new patient care activities but can be used to complete assignments, transition patient care and for
rounds/grand rounds, as indicated. Additionally,
members of the house staff must not be scheduled
for more than 24 consecutive hours. These time
limits include activities related to education and
training as well as assignment change up to a
three-hour transition period is allowed following a
24-hour on-call assignment. Exceptions to the
above are made based only on acute patient care
needs. In addition to these limits, scheduled rotations must be separated by not less than 10 nonworking hours and with at least one 24-hour period of non-working time provided for each week.
Non-working time is defined as time away from
training or any patient care activities.
In departments other than medicine, surgery,
obstetrics & gynecology, pediatrics and family
practice when there is a high volume of acutely ill
patients and where night calls are infrequent and
physician rest time is adequate, the department
may develop and document scheduling arrangements other than those stated above.
SURGERY
For the house staff in the Department of Surgery,
on-call duty in the health system during the night
shift shall not be included in the 24-hour limit, if
the Department of Surgery can assure and document
40
that the members of the house staff taking night
call are generally resting and that interruptions for
patient care are infrequent and limited to patients
for whom the house officer has continuing responsibilities. The house staff is only scheduled for
night call no more often than every third night and
a continuous assignment that includes an on-call
night shift must be followed by a non-working
period of no less than 16 hours.
EMERGENCY MEDICINE
House staff in the Emergency Medicine Program
and house staff assigned to the Emergency
Department shall be limited to no more that 12
consecutive hours per on-duty assignment.
All departments are required to develop and
implement policies and procedures to immediately relieve house staff from continuing assignments
when fatigue due to an unusually active on-call
period is observed.
F. HOUSE STAFF MOONLIGHTING POLICY
The New York State 405 Resident Work Hour
Regulations require that the health system adopt
and enforce policies that govern the moonlighting
activities of members of the house staff. As such,
it is the health system’s policy that members of the
house staff who have worked the maximum number
41
of hours permitted by law shall be prohibited from
working additional hours as physicians providing
professional patient care services.
not mean that the supervising physician must be
present in the room when the treatment/procedure
is performed.
In addition, any member of the house staff who
wishes to moonlight as a physician may do so
only within the guidelines established by their
specific program and with the written authorization of his/her chairman and program director.
“Direct visual” or “personal supervision” (the two
terms are used synonymously with each other)
means that the supervising physician must be in
attendance with the patient and the trainee while
supervising the performance of the treatment/procedure.
G. RESIDENT SUPERVISION
It is the policy of the North Shore-LIJ Health System
(“health system”) that all residents and fellows
(“trainees”) shall be supervised at all times. This
supervision may be general, direct, or direct visual
which is also referred to as personal supervision.
“General supervision” means the treatment/procedure
is furnished under the supervising physician’s
overall direction and control, but the supervising
physician’s presence is not required during the
performance of the procedure/treatment. The
attending practitioner of record, however, has the
continuing responsibility for the patient.
“Direct supervision” means that the supervising
physician must be present in the office suite or in
the unit (as applicable) and immediately available
to furnish assistance and direction throughout the
performance of the treatment/procedure. It does
42
Except in programs where the Residency Review
Committee or New York State Law require the 24hour presence of an attending physician, trainees
in their third year of graduate training may provide supervision to trainees in the same specialty.
The supervising physician must be appropriately
credentialed to perform the treatment/procedure to
be supervised and must be on duty or available in
the hospital for the duration of the assigned rotation. When the supervising physician is a trainee,
an attending physician must be available within
30 minutes travel time of the hospital.
Each department must have a detailed policy
regarding trainee supervision pertaining to their
department.
43
H. REMEDIAL ACTION FOR HOUSE STAFF
MEMBERS
J. GRADUATE MEDICAL EDUCATION
DIPLOMA POLICY
If, at the discretion of the program director or
department chair, the performance of a house staff
member is below the expected academic level, a
course of remediation should be implemented.
The time, course and content of the remedial
process must be prescribed in writing by the program director or department chair and provided to
the house staff member and the Office of
Academic Affairs at the commencement of the
process. Each house staff member subject to
remediation has the right to appeal his or her
action to the appropriate departmental committee.
A refusal by the house staff member to abide by
the remedial process prescribed by his/her department shall constitute grounds for corrective action
and possible termination from the training program.
A diploma is the document given to a member of
the house staff, at the end of his/her successful
completion of the formal period of training as
defined by the ACGME, AOA, CPME, CDM or
equivalent body. The diploma indicates the nature
of that appointment and its duration at a health
system facility.
I. COUNSELING SERVICES
It is health system policy that residents/fellows
will be offered any needed counseling services at
their own request or as identified by the program.
The Office of Academic Affairs will be available
to facilitate such referrals. Mandated referrals for
counseling or administrative evaluation will be made
in conjunction with the Office of Academic Affairs.
44
Individuals in non-accredited training programs,
which have been approved by the Graduate
Medical Education Committee will receive a
diploma upon successful completion of the formal
training period. The diploma indicates the nature
of that appointment and its duration at a health
system facility.
A diploma is an official health system document
which is signed by the program director, department
chairman, and appropriate institutional officials.
Individuals who have not completed the period of
training as defined above, will receive a document
certifying the time spent in the program.
Duplicate diplomas: It is the policy of the health
system that requests for duplicate diplomas will
not be honored.
45
K. CLOSURE/REDUCTION/DISASTER POLICY
The Health System recognizes the need for and
benefits of graduate medical education. The
Health System will provide programs in graduate
medical education, which emphasize personal,
clinical and professional development and encourage an awareness of responsiveness to ethical and
human aspects of health care among the health
professionals. The Health System will ensure that
all of its graduate medical educational programs
meet or exceed the Institutional and Special
Requirements promulgated by the Accreditation
Council for Graduate Medical Educations
(ACGME) and its individual Residency Review
Committees (RRC).
Closure/Reduction
1. The Health System agrees to notify all house
staff in the affected program of any adverse
actions cited by the ACGME for any and all
graduate medical education programs. If the
program cannot correct the citations and the
ACGME withdraws accreditation or if the
Health System decides to voluntarily withdraw
accreditation and close the residency program,
the Health System will attempt to phase out the
program over a period of time to allow the resident physicians currently in the program to finish training. If this is not possible, the Health
System and the Program Director will assist the
resident physician(s) in obtaining another
accredited residency program position. In no
46
case will a resident be terminated prior to the
end of an academic year.
2. In the event that the Health System decides to
reduce the number of residency physician positions in any graduate medical education program, the resident physicians will be notified.
If the ACGME mandates such reductions, the
Health System will reduce the numbers over a
period of time so it will not affect the resident
physicians currently in the program.
Disaster
1. In the event of a disaster or interruption of
patient care that results in a disruption of residency training, NSLIJ and its affiliated institutions will collaborate and make best efforts to
assist each other in identifying appropriate
replacements for residents whose programs
have been adversely affected.
2. The Office of Academic Affairs will provide a
central point for communications with respect
to resident placements and relocations among
the affiliated institutions.
3. To the extent feasible, given the patient volume,
the institutional and programmatic resources,
and the comparable training program(s), the
affiliated programs will make every effort to
accommodate the displaced residents.
47
L. DUE PROCESS
(Taken from Section IX of the Medical Staff Bylaws)
Section 9.3 CORRECTIVE ACTION FOR
GRADUATE STAFF MEMBERS
Subsection 9.3.1 CORRECTIVE ACTION.
Corrective action regarding a member of the
Graduate Staff may include a restriction, suspension or termination of clinical privileges, including
on a summary basis, or the involuntary nonrenewal of a contract, whenever the Graduate
Staff member’s conduct, condition, professional
or otherwise, is considered to be inconsistent with
the Hospital's standards of patient care, patient
welfare or the objectives of the Hospital; if such
conduct or condition reflects adversely on the
Hospital or the character or competence of such
Graduate Staff member; or results in disruption of
Hospital operations. A corrective action also may
be taken with regard to any Graduate Staff member
who fails to comply with any of these By-Laws,
Rules and Regulations, the Corporate By-Laws,
the provisions set forth in any Graduate Staff
Manual, the Graduate Staff member's agreement
with the Hospital, or any rules, regulations or policies
of the Board of Trustees. A corrective action may
be imposed with regard to such Graduate Staff
member by the Chair or Program Director of the
Department to which the Graduate Staff member
48
is assigned, or the Hospital’s Executive Director.
The corrective action may include, without limitation,
the restriction, suspension or termination of the
Graduate Staff member’s clinical privileges. The
corrective action shall be in writing and shall set
forth the facts upon which it is based, and shall be
forwarded to the Chair of the Graduate Medical
Education (“GME”) Committee.
Subsection 9.3.2 NOTICE. The Chair of the
GME Committee shall ensure that a copy of the
corrective action is mailed by certified mail to the
Graduate Staff member as soon as may be practicable under the circumstances. At the same time,
the affected Graduate Staff member shall be
advised of his or her right to request that a
Graduate Staff Review Committee be formed to
review the corrective action. Such request must be
made in writing to the Chairman of the Medical
Board within (10) days after the Graduate Staff
member’s receipt of the notice. Upon such
request, the Chairman of the Medical Board
Committee will appoint a Review Committee to
hear the Graduate Staff member’s request for a
review of the corrective action within a period of
not less than thirty (30) or more than sixty (60)
days of receiving the request. If the corrective
action is a summary action, the meeting may be
accelerated, upon the request of the Graduate Staff
49
member, to take place on a date that is more than
fifteen (15) days, but less than thirty (30) days
from the date of the Chairman of the Medical
Board receives the request. Absent such a request
by the Graduate Staff member, the corrective
action will be implemented. The Graduate Staff
member may submit a written statement of his or
her position to the Graduate Staff Review
Committee provided that the statement is received
by the Committee not less than five (5) days prior
to the date of the scheduled Committee meeting.
Subsection 9.3.3 GRADUATE STAFF REVIEW
COMMITTEE. If requested, a Graduate Staff
Review Committee shall be appointed by the
Chairman of the Medical Board to review a corrective action made with respect to a Graduate
Staff member. The Graduate Staff Review
Committee shall consist of (i) the Chair of the
GME Committee, or his or her designee, who
shall Chair this Committee, (ii) an Attending
physician not a member of the Department to
which the Graduate Staff member is assigned, and
(iii) a member of the Graduate Staff from another
discipline. The Graduate Staff member shall be
permitted to appear before the Committee provided that a written statement requesting such an
appearance is received by the Committee not less
than five (5) days prior to the date of the
Committee meeting. Failure of the Graduate Staff
50
member to appear shall be deemed a waiver of
any such privilege at such meeting and during any
subsequent proceedings under these By-Laws,
Rules and Regulations. No later than five (5) days
prior to the scheduled meeting, the Graduate Staff
member may request in writing to the Chair of the
Committee that he or she be represented by legal
counsel during his or her appearance before the
Committee. If the Graduate Staff member is to be
represented at the Committee meeting by legal
counsel, the Department shall be represented by
legal counsel as well. A record of the Committee
meeting shall be made by such method as shall be
determined by the Chair of the Graduate Staff
Review Committee. The meeting shall not be considered to be a formal hearing and therefore shall
not be subject to any formal rules of evidence or
procedure. The introduction of any relevant information shall be determined by the Chair. In order
to reverse the corrective action, the Graduate Staff
member shall have the obligation to persuade the
Committee that the corrective action lacks any
factual basis or that is either arbitrary, unreasonable or not in compliance with applicable law.
Subsection 9.3.4 GRADUATE STAFF REVIEW
COMMITTEE ACTION.
The action the
Graduate Staff Review Committee may take on
the request for corrective action shall be in writing.
The Committee may accept, reject or modify the
51
request for corrective action, or take any other
action that the Committee deems appropriate
under the circumstances.
Subsection 9.3.5 NOTICE OF DECISION TO
THE GRADUATE STAFF MEMBER. A copy of
all Graduate Staff Review Committee decisions
shall be given to the Graduate Staff member, the
Department Chair and the Medical Board within
fifteen (15) days after the Committee's Report is
written along with a statement of the reasons
therefor.
Subsection 9.3.6. RIGHT OF APPEAL. Should
the Graduate Staff Review Committee uphold the
corrective action, the Graduate Staff member may
request an appeal of the matter before the Dean
and Chief Academic Officer. The request must be
in writing and made within ten (10) days of the
Graduate Staff member’s receipt of the decision of
the Graduate Staff Review Committee. Upon
receipt of the request for an appeal, the Dean and
Chief Academic Officer will review the Graduate
Staff member’s record, the basis of the request for
corrective action and the Graduate Staff Review
Committee’s Report and decision. The Dean and
Chief Academic Officer may request and consider
any additional information he deems necessary.
Upon completion of his review, the Dean and
Chief Academic Officer will notify the Graduate
52
Staff member, the Department Chair and the
Medical Board of his decision in writing within
ten (10) days of the issuance of his decision. The
decision of the Dean and Chief Academic Officer
will be final and binding upon all parties. Failure
by the Graduate Staff member to make a request
for an appeal within the time frame set forth in
this Paragraph will be deemed to be a waiver by
the Graduate Staff member of any further appeal
of this matter, and the decision of the Graduate
Staff Review Committee shall be deemed conclusive and final.
Subsection 9.3.7 FINALITY OF ACTION.
Decisions of the Dean and Chief Academic
Officer shall be conclusive and final. There shall
be no further Hospital proceedings.
Subsection 9.3.8 THE HOSPITAL’S BY-LAWS.
Nothing contained herein shall be deemed to be to
the exclusion of any further or different remedies
or proceedings contained in the By-Laws of the
Hospital or elsewhere in these By-Laws, Rules
and Regulations.
Section 9.4 WITHDRAWAL OF SUSPENSION.
A summary suspension may be withdrawn by the
committee or person imposing the same at any
time prior to a meeting of the Graduate Staff
Review Committee.
53
M. HOUSE STAFF IMPAIRMENT POLICY
If a resident/fellow is practicing the profession
while the ability to practice is impaired by alcohol,
drugs, physical disability or mental disability,
he/she must be referred to the health system
Impaired Physician Committee to undergo evaluation
and/or drug screening. During the period of evaluation, the resident/fellow will be relieved of all
responsibilities for patient care. Participation in
non-clinical activities during the evaluation period
is at the discretion of the program director and
department chair. When such action is taken, the Office
of Academic Affairs must be notified immediately.
N. NON-DISCRIMINATION AND
NON-HARASSMENT
The health system is committed to maintaining a
work environment that is free from discrimination
and harassment. In keeping with this commitment,
the health system does not tolerate discrimination
against its employees by anyone, including any
supervisor, co-worker, vendor or client.
54
Harassment consists of unwelcome conduct,
whether verbal, physical or visual, that is based
upon a person’s protected status, such as sex, gender,
color, race ancestry, religion, national origin, age,
physical handicap, medical condition, disability,
marital status, sexual orientation, veteran status,
citizenship status or other protected group status.
The health system does not tolerate harassing conduct that affects job benefits that interferes with an
individual’s work performance, or that creates an
intimidating, hostile or offensive work environment.
Unwelcome sexual advances, requests for sexual
favors, and physical, verbal or other conduct
based on sex constitute sexual harassment when:
• Submission to the conduct is an explicit or
implicit term or condition of employment.
• Submission to or rejection of the conduct is
used as the basis for an employment decision, or
• The conduct has the purpose or effect of unreasonably interfering with an individual’s work
performance or creating an intimidating, hostile
or offensive work environment.
Sexual harassment may include persisting in (after
the person has protested) explicit sexual propositions, sexual innuendo, suggestive comments,
sexually-oriented “kidding” or “teasing,” “practical jokes,” jokes about gender-specific traits, foul
or obscene language or gestures, display of foul or
obscene printed or visual material, and physical
contact such as patting, pinching or brushing
against another’s body.
55
All employees are responsible for ensuring that
harassment is avoided. If you feel that you have
experienced or witnessed harassment of any kind,
you are strongly urged to immediately notify the
Human Resources Department at your facility. If
you are uncomfortable in relating such a complaint to that person or if you are not satisfied with
the response, you may report the harassment to
Corporate Human Resources.
O. HOUSE STAFF ON-CALL MEAL
ALLOWANCE
The health system forbids retaliation against anyone
for reporting harassment, assisting in making a
harassment complaint, or cooperating in a harassment investigation.
All members of the house staff seeking a leave of
absence (LOA) for medical reasons must follow
the procedures outlined in the Health System
Employee Handbook. In short, members of the
house staff seeking a medical LOA should contact
the Corporate Benefits Office and submit all
required documentation to that office. Members
of the house staff should give as much advance
notice of the need for medical LOA (but not the
reason) and the expected duration of the LOA to
his/ her program director. All requests for nonmedical LOA’s must be reviewed and approved by
the house staff member’s program director and/or
department chair.
The health system’s policy is to take all complaints seriously and if properly reported, to
investigate all such complaints thoroughly and
promptly. Except as may be necessary to adequately investigate such complaints, the health
system will keep the complaints and the terms of
their resolution confidential. If an investigation
confirms that harassment has occurred, the health
system will take corrective action including such
appropriate discipline, up to and including immediate termination of employment.
56
It is the policy of the North Shore-LIJ Health
System that house staff members whose programs
require in house call are provided with a meal
allowance.
P. LEAVE POLICY
Members of the house staff on approved LOA’s
must arrange with their program director, if
required, to make up for training time lost by
extending the duration of their training including
depending on the duration of the LOA, repeating
57
the training level year at issue. Such arrangements
must comply with the requirements of all accreditation and certifying agencies. Programs directors
should coordinate with the Human Resources
Department and the Office of Academic Affairs on
all matters relating to LOAs.
Q. INITIAL APPOINTMENT TO THE
HOUSE STAFF
It is the policy of the North Shore-LIJ Health
System) that all individuals entering a graduate
medical education training program must meet the
criteria for entering a residency training program
established by the department, the health system
and its facilities, governmental agencies and
accrediting bodies. Contracts for appointment to
the house staff will not be issued if the abovereferred criteria are not met.
R. RECORD RETENTION
Application material from all applicants who have
applied to a training program, must be retained for
three years.
Demographic and summary data regarding individuals who have been appointed to the graduate
staff must be retained permanently.
58
S. RESIDENT HOUSING POLICY
Eligibility Criteria
There are currently 245 on-campus apartments
that are assigned to resident physicians training in
programs that will make them eligible to sit for
their first boards. These residents have been prequalified to reside in campus housing by their
department chairpersons or their designee and are
usually assigned housing units locations adjacent
to the hospital to which they have their primary
assignment. The duration to the apartment rental will
run concurrently with the length of the resident’s
training program which will make them eligible to
sit for their first boards. Real Estate Services will
coordinate all arrangements to rents these apartments
to the pre-qualified residents.
The inventory and location of the apartments is:
173 apartments at North Shore University
Hospital (NSUH) in Manhasset
72 apartments at the Long Island Jewish Medical
Center (LIJ) in Glen Oaks
31 apartments at Glen Cove Hospital, in Glen Cove
The Office of Academic Affairs will determine the
total number of apartments allotted to each Clinical
Department for the LIJ and NSUH campuses.
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Process and Eligibility for Housing
• By March 15th of each year, the Department
Chairperson or his designee at LIJ and NSUH
will provide Real Estate Services with a list of
residents that will be vacating their on-campus
housing at the end of the academic year which
is generally June 30th.
• The department will compile and submit a list
of residents who are eligible and wish to reside
in on campus housing at LIJ or NSUH to Real
Estate Services by March 30 of each academic
year. The departments may use the following
priority criteria to select eligible residents they
wish to be assigned to live in on campus housing:
i. Residents coming from outside of the metropolitan area
ii. Residents with families
iii. Residents residing in the metropolitan area
iv. Current residents in need of a different apartment
size due to a change in family composition.
v. After all entering residents have been
assigned campus apartments and there are
still apartments available, residents that do
not currently reside on campus, but are in
advanced years of training leading to their
first board eligibility, may be considered for
on-campus housing at the discretion of their
Department Chairperson as a last priority.
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• Real Estate Services will provide each resident
on the list with a housing application beginning
April 7th of each academic year.
• All resident housing applications must be
returned to Real Estate Services within 15 days
of receipt of the application. All resident applications must be filled out completely, including
social security number and family size.
Incomplete applications will be returned to the
applicant causing processing delays which
could delay or jeopardize the eligible residents
ability to secure campus housing.
Apartment Assignment
On or about May 10th of each year, Real Estate
Services will assign available apartments to residents
who were identified by the department and have
submitted a completed application for housing.
Note: Fellows are not eligible to apply for or to
reside in on-campus housing. Effective with the
July 1, 2007 academic yearthere will be no exceptions
to this rule. Residents including chief residents
going onto fellowship programs who resided in
housing will no longer be eligible for housing and
must move out of the unit when they have completed
their training leading to first board eligibility.
Requests for apartments or to remain in an apartment from trainees in programs in child psychiatry
61
and child neurology will be reviewed on a case by
case basis.
On or about May 15th, Real Estate Services will
formally, in writing, notify all residents that they
have been accepted to reside in on campus housing.
The residents must reply to the offer of campus
housing within 7 days of the offer. Failure to do so
will result in forfeiture of the offer of campus housing.
If a resident is offered campus housing and rejects
it for any reason, he/she will be removed from the
list and will not be eligible to apply for campus
housing until the next academic year.
Individuals living in the on campus housing will not
be eligible to receive the monthly housing stipend.
Residents who move out of the on campus housing
unit in the middle of the academic year and before
June 30th remain responsible for the rent until
Real Estate Services is able to re rent the unit. The
resident will not be eligible to receive the monthly
housing stipend until the beginning of the next
academic year. There are no exceptions to this rule.
Residents living in on campus housing are required
to vacate the unit upon the expiration of their lease or
by no later than June 30th of the year they complete
training leading to their first board eligibility.
Individuals, who fail to vacate the unit by June
62
30th will forfeit all claim to their security deposit
and will be charged a penalty fee of $100.00 per
day for failure to vacate. Such action will be considered unprofessional behavior, which will be
noted in your permanent residency file.
Housing Stipend
All residents working toward their first board
eligibility that are not offered and assigned a unit
in housing will be eligible for a housing stipend to
help defer the cost of off campus housing.
Fellows are not eligible for a housing stipend.
Requests for stipends from trainees in programs in
child psychiatry and child neurology will be
reviewed on a case by case basis.
The amount of the housing stipend is determined
by the GMEC annually. Information about the
specific amount of the stipend can be obtained
from the Office of Academic Affairs.
The housing stipend will be included in the resident’s salary and will continue for the duration of
the individual’s residency, consistent with the
individual’s appointment and qualification for
housing as a graduate medical education trainee,
unless the individual takes possession of an oncampus apartment.
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T. PGY LEVEL POLICY
Effective July 1, 2006, all trainees will be paid at
the PGY level that is commensurate with their
training level in their program. Trainees should
not get credit for accumulation of previous training
in random programs. Trainees already in programs
will be grandfathered. When Chief Residents in
Medicine and Pediatrics in the Health System
complete a non-accredited Chief Resident year
(PGY 4), they will be given credit for that year when
entering a fellowship program. Chief Residents
from other institutions, who enter a fellowship
program in the Health System, will also receive
credit. Trainees, who leave a program to do a year
of research and return to the program, will not be
given credit for time spent doing research.
U. VISA POLICY
PURPOSE: It is the policy of the Health System
that the Office of Academic Affairs must review
and approve all visa applications for individuals
enrolling in Health System sponsored graduate
medical educations programs.
The Health System sponsors the following visas
for trainees:
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H1B VISA
The Office of Academic Affairs (OAA) completes
and files with the United States Citizenship and
Immigration Services (USCIS) the applications
and required documents for the H1B visa.
REQUIREMENTS: The program must notify the
OAA that they have an applicant entering their
program, who is seeking the H1B visa, as soon as
the formal offer is made. The program must also
inform applicants seeking an H1B visa that they
must contact the OAA immediately after being
accepted to a training program and supply the
OAA with copies of the following documentation:
• Valid passport (all pages including current I-94)
• Current visa, if applicable
• Applicants must have passed Parts 1, 2 and 3 of
USMLE. Failure to have passed Part III of the
USMLE examination will preclude individuals
from obtaining a H1B visa. All individuals
wishing to obtain an H1B visa should have
taken and passed Step III of the USMLE and
submitted the Step III results to the OAA by no
later than May 1st , prior to the commencement
of their training, so that the H1B visa application can be prepared and submitted to the
USCIS in time for the individual to obtain the
visa and start the program by July 1.
• Medical School diploma and final transcript
65
•
•
•
•
(Documents in languages other than English
must be accompanied by an English translation)
Current and valid ECFMG certificate
Copy of the license from their home country
pertaining to the practice of medicine, if applicable.
Current Curriculum Vitae – detailing the applicant’s education and professional history to
date.
Pay stubs for the last 30 days worked, if individual worked in the United States.
The above material must be sent with the application fee in the form of a check drawn on a United
States Bank or an international money order
payable to the United States Citizenship and
Immigration Services (USCIS). This amount will
be reimbursed to the applicant by the program
once training has commenced. Applicants seeking
Premium Processing of their H1B application
must also include the additional Premium
Processing Fee.
H1B Visa Extension Applications
Applicants, who currently hold the H1B visa and
require an extension, must submit copies of the
same documents listed above at least 6 months
prior to the expiration of their current H1B visa.
The application materials must also include a
check drawn on a United States Bank or an inter66
national money order payable to the United States
Citizenship and Immigration Services (USCIS)
for the application fee. Applications for extensions do not require Premium Processing.
Duration of H1B Visa
The total duration of the H1B visa is 6 years.
However, applications can only request a maximum
duration of 3 years. The duration of an application
will be determined by the length of the applicant’s
training program. Applications for individuals
entering preliminary programs will be for 1 year
and the individual will need to apply for an extension
if they are accepted into a categorical position at
the end of the preliminary program training.
Consulate Interview
Individuals, who are outside of the United States,
must identify the consulate where they will apply
for their visa. After receiving the original
Approval Notice from the OAA, applicants will
make an appointment at the consulate to apply for
and pick up the H1B visa. The appointment to
pick up the visa should be made well in advance
of the date they are due to start training.
Obtaining an appointment for an interview can
take as long as 30 days. Programs may hold a
position for up to 60 days (after July 1st) for individuals encountering difficulty securing the visa
from the consulate. At the end of the 60 days, the
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program may withdraw the offer of the position.
The OAA will work with the program to notify all
appropriate parties of the offer withdrawal, including
the NRMP, Human Resources and USCIS.
offer of the position. The OAA will work with the
program to notify all appropriate parties of the
offer withdrawal, including the NRMP, Human
Resources and ECFMG.
J-1 VISA
Trainees applying for the J-1 visa must supply the
OAA with the documents listed on either the
ECFMG Checklist for Continuation of J-1 Visa
Sponsorship in ACGME Accredited Clinical
Training Programs or the ECFMG Checklist for
Initial J-1 Visa Sponsorship in ACGME
Accredited Clinical Training Programs. (See
attached documents)
FI VISA
Applicants, who are foreign nationals, who are
graduating from a United States Medical School,
are allowed to extend their F1 visa for an additional year to begin their clinical training as a resident.
The necessary documents for the extension are
prepared and filed by the applicant’s medical
school. The applicant will need to apply for the
H1B or J1 visa for subsequent years of training.
Duration of J-1 Visa
The duration of the J-1 visa is 7 years; however,
documents must be submitted annually to extend
the visa.
V. BASIC LIFE SUPPORT TRAINING
Consulate
Individuals, who are outside of the United States,
must pick up their visa at a United States consulate and apply for the J-1 visa well in advance of
the date they are due to start training. Obtaining
an appointment for an interview can take as long
as 30 days. Programs may hold a position for up
to 60 days for individuals encountering difficulty
securing the visa from the consulate. At the end
of the 60 days, the program may withdraw the
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It is the Health System policy that effective July 1, 2009,
all residents/fellows enrolled in a Health System
Graduate Medical Education Program must at a
minimum be currently certified in Basic Life
Support prior to commencing training and must
maintain certification throughout the entire period
of their graduate medical education training.
Training programs in which the care of critically
ill patients is likely, should consider requiring their
trainees to be continually certified in advanced
cardiac life support throughout the duration of
their training.
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W. USMLE POLICY
Y. COMPLIANCE WITH DISABILITY LAWS
Effective July 1, 2010, the North Shore-LIJ
Health System will require that all trainees take
and pass Step 2 of the USMLE by December 31st
of his/her internship year (PGY 1 year). For
trainees entering a residency program during the
second year of training (PGY 2 year), the trainee
must have taken and passed Step 2 of the USMLE
prior to the start of his/her training. All trainees
must take and pass Step 3 of the USMLE by
December 31st of their PGY2 year. Trainees, who
do not pass Step 3 by December 31st of their PGY
2 year, may face termination from his/her training
program effective at the end of their PGY 2 year.
It is the Health System’s policy to ensure that
qualified individuals with a disability are not discriminated against on the basis of their disability
with respect to job application, hiring, advancement, compensation, job training and other terms,
conditions and privileges of employment.
X. ELECTRONIC COMMUNICATION
SYSTEMS
A qualified individual with a disability may
request a reasonable accommodation to help
him/her perform the essential functions of his/her
position. The Health System will accommodate a
request for a reasonable accommodation unless
the proposed accommodation would impose an
undue hardship.
It is the policy of the Health System to provide its
employees with electronic communication systems, which may include, but are not limited to,
computers, email and Internet access for work
related activities. Employees are responsible for
protecting their passwords. They must not share
their user ID or password with any unauthorized
persons.
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71
OFFICE OF ACADEMIC AFFAIRS
ber unless otherwise permitted by the law.
The Office of Academic Affairs is located on the
first floor of the Waldbaum Dialysis Center at 125
Community Drive. OAA personnel will assist you
with any questions you may have including, but
not limited to, housing, immigration, licensure,
meal allowance, employment verification, loan
deferments, etc. You are encouraged to contact
them at (516) 465-3192 for any assistance you
may need.
1. Infectious Exposures Guidelines
(a) If a member of the house staff has been
exposed to a contagious infectious disease that
has the potential to impact patient care and/or
the a member of the house staff’s co-workers,
the house staff member’s program director
must be notified. The member of the house
staff may be referred to EHS for evaluation
and/or the Infection Control Nurse notified.
EMPLOYEE HEALTH SERVICES
(b) Employees Health Services will then contact
the member of the house staff’s program
director to notify him/her of the a member of
the house staffs working status. If the a member
of the house staff is to be sent off duty the
program director will be notified of absenteeism in accordance with Infectious Disease’s
recommendations.
House staff who sustain a work related illness or
injury while on duty or who are suspected of having an infectious disease will be referred by their
program director to the Employee Health Service
(EHS) for evaluation and treatment. If at the time
of the referral EHS is closed or the house staff
member requires emergent services, (i.e. radiology,
suturing, stat medications) the house staff member
will be evaluated in the Emergency Department (ED).
House staff medical information obtained by
EHS/ED may be released to authorized representatives of the Health System on a need to know
basis with the exception of AIDS related information. All AIDS related information may only be
released with the consent of the house staff mem72
(c) Exposure to Meningococcal Disease
Any individual felt to have intimate respiratory
contact with a patient with meningococcal
disease is a candidate for chemoprophylaxis.
Cipro 500 mg x 1 po or Rifampin 600 mg
twice a day x 2 days PO has been shown
effective for this purpose. Ceftriaxone 250 mg
IM x 1 is given to exposed pregnant a member
of the house staffs.
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(d) Exposure to Varicella
Staff members who have a susceptible
Varicella-Zoster immune status, who have
been exposed will be evaluated and tested.
EHS will make the determination for removal
of duty of those individuals who have negative
immune status during the time they would be
expected to be infectious. (i.e. 9-21 days).
Varicella Immunization (Varivax) is offered to
all a member of the house staffs free of charge
at EHS.
(e) Exposure to Measles
Individuals with susceptible measles immune
status who have been exposed will be evaluated. Those with negative immune status will be
evaluated to determine the need to remain out
of work during the time they would be expected to come down with the disease (5-21 days).
Individuals who develop the disease will
remain out of work for at least 5 days after the
appearance of the rash.(or) Individuals
exposed who do not have adequate evidence of
immunity to Measles will be excluded from
work beginning 5 days post exposure to either
21 days from exposure date or 5 days after the
appearance of the rash.
(f) Exposure to Pertussis
A member of the house staffs with definitive
74
exposure to pertussis will be offered antimicrobial prophylaxis. A member of the house
staffs who develops symptoms (unexplained
rhinitis or acute cough) after exposure will be
excluded from patient care until 5 days after
the start of appropriate therapy.
(g) Exposure to Rubella
Those exposed who do not have adequate
evidence of immunity will be excluded from
work beginning 7 days post exposure to either
23 days after last exposure or 5-7 days after
rash appears.
(h) Exposure to Scabies
Employee Health Service will evaluate exposed
personnel for signs and symptoms of mite
infestation and provide appropriate therapy for
confirmed or suspected scabies. Symptomatic a
member of the house staffs will be treated with
Kwell (Lindane 1%) or Elimite. Women who
are or think they may be pregnant will be
assessed for treatment.
(i) Exposure to Tuberculosis
i. Testing will be conducted for a member of
the house staffs who are exposed to infectious TB patients where adequate infection
control procedures have not been taken.
ii. Unless a negative skin test has been docu75
mented within the preceding 3 months each
exposed a member of the house staff
(except those who are already known to
have positive reactions) should receive a
PPD (Mantoux) skin test as soon as possible.
iii. If the skin test is negative, the test should
be repeated 12 weeks after the exposure
ended.
iv. Persons with previously known positive
skin test reactions who have been exposed
to an infectious patient should be evaluated
for active TB, but do not require a repeat
skin test or a chest x-ray examination,
unless they have symptoms suggestive of
active TB.
v. A reaction of 5mm or more is considered
positive in persons with recent exposure to
active TB and they must be referred to
Infectious Disease or Pulmonary medicine
2. Blood And Body Fluid Exposures
(a) All personnel exposed to blood or body fluids*
percutaneously (puncture, laceration or bite),
permucousally (splash to eye, nose or mouth)
or through non-intact skin, should immediately
decontaminate the wound with soap and water.
Mucous membranes should be irrigated with
tap water or normal saline.
76
(b) Body fluids include blood, and other fluids
containing visible blood and other potentially
infectious fluid: semen, vaginal secretions,
cerebrospinal, synovial, pleural, peritoneal,
pericardial and amniotic fluids.
(c) Immediately after decontamination, personnel
should notify his/her supervisor and then
report to the ED without delay. Bring the
Name and Medical Record number of the
source patient with you to the ER.
(d) The ED practitioner will attain lab specimens
as indicated to test for the following; Hepatitis
BsAg, Hepatitis BsAb, Hepatitis C Ab, CBC,
LFTs, UCG, UA (as needed)
(e) Employees HIV testing and counseling will be
performed in EHS only.
3. Hepatitis B prophylaxis
Hepatitis B Immunoglobulin will be offered when
indicated and /or Hepatitis B Vaccine and would
be given if the employee hasn’t already completed
their vaccination series or does not have positive
titers.
4. Hepatitis C prophylaxis
No prophylactic treatment currently available,
liver function and HCVAb labwork to be repeated
77
3 and, 6, and 9 months post exposure and/or
whenever indicated.
5. HIV prophylaxis
Post Exposure Prophylaxis is initiated immediately
in the ER (Combivir & Viread ) when indicated.
Testing of the source patient, should be arranged
by the patient’s Charge Nurse. Laboratory tests to
be ordered: HIV testing with consent, Hepatitis
BsAg, Hepatitis CAb,
It is recommended that individuals follow up in
EHS within 3 days of the exposure for HIV testing
as well as review of their lab results. Source
patient lab results will be reviewed at this time
as well.
EMERGENCY DEPARTMENT
This is a most important service to the community.
You have a major role in providing patient care
and good public relations. The Emergency
Department Guide for house staff describes its
policies and procedures and is available in the
Emergency Department. You must be thoroughly
acquainted with this guide. House staff assigned
to the Emergency Department are under the
administrative and medical supervision of the
Chairman of Emergency Services or his/her
designee. At the beginning of your assignment to
the Emergency Department, you will be expected
to attend an orientation program.
PHARMACY
The Pharmacy Department operates under a strict
formulary system. Only those drugs approved by
the Pharmacy and Therapeutics Committee, a
committee of the medical board, are stocked in the
pharmacy. Therefore, it is required that medication
orders be restricted to items listed in the institution’s hospital formulary. The on-line formulary is
available by accessing the health system icon at
any terminal throughout LIJ or throughout the
health system on HealthPort.
78
79
The Pharmacy Department has authorization to
interchange medications generically. The
Infectious Disease Service or the Pharmacy
Department must approve restricted antibiotics.
The use of any investigational drugs or an FDA
approved drug used in a non-FDA approved manner
must be approved by the chairman of the department and by the Institution Review Board (IRB).
The following guidelines for ordering medication
must be followed:
• The name, strength, dosage schedule and route
of administration of each drug should be clearly
indicated on each medication order. Orders for
"1 vial" or "1 ampule" are unacceptable.
• Medication orders must be legible and complete.
Orders with illegible and/or incomplete information require either a phone call or the return of
the prescription to the prescriber. This is time
consuming and bothersome to all involved.
• All orders must be signed. Signature must be legible.
• The generic name of the medication should be used.
• The metric system of weights and measures
should be used.
• Clearly indicate the position of the decimal
point. A misread or misplaced decimal point can
result in the administration of massive doses of
medication, sometimes 10, 100 or even 1000 times
the amount normally prescribed. Writing a zero
80
before the decimal point aids in avoiding errors.
• The use of potentially confusing Latin abbreviations is discouraged. To avoid confusion, write
out the directions: every day, every other day,
four times a day, etc.
• To improve patient compliance, avoid vague and
confusing instructions on outpatient prescriptions such as "take as necessary" or "take as
directed." If possible, the symptom indication, or
the intended effect for which the drug is being
used should be included in the instructions. (For
example, Take... for cough.) Whenever possible,
specific times of the day for drug administration
should be indicated. This should be specifically
stated on the prescription by indicating appropriate times for drug administration
• When institutional prescription blanks are used,
a separate prescription blank should be used for
each drug prescribed. In addition to his/her legible
signature, the prescriber should print his/her
DEA registration number, NYS license number
and beeper or telephone number on each prescription blank. The presence of this information
will expedite communication when the pharmacist is required to contact the prescriber prior to
the filling of a medication order.
• All inpatient medication orders are written on
the doctor's order form. Whenever possible,
medication orders should be written for the exact
number of doses or the exact period of time the
81
drug is to be administered. Orders must be written
in compliance with the Automatic Stop Order
Policy.
difficult to ascertain, the covering prescriber
(house staff/PA/attending) will be contacted for
order clarification.
UNAPPROVED ABBREVIATIONS – GENERAL
STATEMENT OF PURPOSE:
To decrease the potential for medication errors
associated with the use of abbreviations and dose
expressions.
• Prescribers will be educated on the importance
of avoiding the use of these abbreviations/
dosage expressions and the potential for error
which exists with its use.
POLICY:
On a daily basis, the Pharmacy Department will
be responsible for evaluating all medication
orders to ensure that unapproved abbreviations are
not utilized.
Please refer to each site-specific list of unapproved abbreviations. Orders that contain these
dangerous abbreviations or dose expressions will
not be accepted, the prescriber will be contacted
and the order must be rewritten.
• All prescribers contacted for orders which may
contain these abbreviations/dosage expressions
will be recorded in the patient's profile as a clinical intervention. This will allow the Pharmacy
Department to access monthly reports that can
help to identify any patterns or trends, which
may require more intense education or monitoring. In the event that the prescriber’s identity is
82
• The Pharmacy Department will monitor this
quality indicator, reports will be presented to the
PICC on a regular basis and appropriate action
will be taken as necessary.
AUTOMATIC STOP ORDER POLICY
The Joint Commission on Accreditation of
Healthcare Organizations and Section 405.1027 (e)
of the NY State Health Code require the medical
staff to establish a stop order policy for medications. The purpose of this policy/procedure is to
insure that the duration that medications ordered
and administered are periodically reviewed.
Medication orders are automatically cancelled and
must be reordered whenever a patient undergoes
surgery, is transferred from a critical care unit or is
transferred from one service to another service within
the institution. Please refer to the automatic stop
order policies as they may differ at each institution.
83
DISCHARGES AND AMBULATORY
PRESCRIPTIONS
The New York State Serialized prescriptions
should be used for all prescriptions written. New
York State has mandated as of April 1,2007, no
prescription will be accepted unless written on the
official serialized prescription blank. Pharmacy
will be responsible to supply these prescription to
the nursing units and clinical department for use
by practitioners.
The following procedure is to be followed when
completing any prescription form:
• All prescriptions must be written in ink, indelible pencil, or, apart from the practitioner's signature, a typewriter.
• Only one medication is to be entered on a prescription form. Enter the date and the patient's
name, address and age in the appropriate areas.
• If the medication is a controlled substance, enter
the prescriber’s DEA (Drug Enforcement
Administration) number. Interns/residents will
use the institution-specific division DEA number followed by his/her suffix as assigned by the
Office of Academic Affairs.
• If the medication is for a Medicaid or HIP
patient, a new prescribing requirements went
into effect on or about June 1, 2000.
Prescriptions for these patients must have the
doctor’s state license number and the institu84
tion’s specific Department of Health Medicaid
Management Information System (MMIS) ID
(this number is preprinted on the blank as of 401-06) indicated on the prescription blank.
Residents who do not have a valid New York
State License must have the prescription countersigned by a fellow, chief resident or attending
physician with the valid license number noted.
Retail pharmacies will not fill this population of
prescriptions without the correct information.
• The name, strength in the metric system, dosage
schedule and route of administration must be
clearly indicated on each prescription. Include
the quantity to be dispensed. Generic nomenclature is encouraged.
• Indicate refill instructions, if any.
• Legibly sign the prescription at the bottom. If a
trade name medication is required, write “DAW"
in the box below the signature.
• The prescriber’s name is to be printed (or
stamped) in the area provided.
• Enter assigned pager (beeper) or telephone number.
The presence of this information will expedite
communication when the pharmacist is required
to contact the prescriber prior to the filling of a
medication order.
The Pharmacy Department does not fill discharge
prescriptions. They must be given to the patient
for filling at his/her community pharmacy.
85
MEDICAL RECORDS
The health system has a modified source-oriented
medical record system which varies according to
the clinical department. The arrangement of the
medical record is sectionalized for easier access to
such items as X-ray reports, laboratory reports,
progress notes, and the like. This is the format you
will be expected to keep your records. The health
system prides itself on the character of its records
and each member of the house staff must make
every effort to maintain this standard. House staff
members are required to complete certain parts of
the medical record on all service cases, medical
cases, neonatology cases and others as assigned.
Delineation of intern and resident responsibilities
can be verified in the office of the chairperson of
the department.
Documentation includes:
1. A comprehensive discharge summary for any
case except normal newborns with uncomplicated deliveries. The exception to this at NSUH
is interventional cardiology cases and adult and
pediatric surgeries less than 48 hours.
2. You must document a final diagnosis using no
abbreviations.
3. A comprehensive history and physical exami86
nation signed and dated within 24 hours of
admission.
4. A dictated operative report immediately following surgery. This standard is required by the
Joint Commission on Accreditation of Hospital
Organizations (JCAHO) and the hospital's rules
and regulations.
At LIJ, you may dictate from any touch-tone telephone within the facility by dialing extension
4444. At NSUH, you may dictate from inside the
hospital by dialing extension 2990 or from the
outside by dialing 516-562-2990. At both sites
you will be given voice prompts that will guide
you through the dictation process. For more
detailed information about the medical record dictation process at either site, call the site specific
medical records department.
The information included in the dictated operative
report is as follows:
a) Surgeon's full name, as well as assistant's name.
b) Patient's full name spelled out.
c) Patient's medical record number.
d) Date of procedure.
e) Anesthetic agent.
f) Pre-operative diagnosis.
g) Description of operation.
h) Post-operative diagnosis.
87
i) Findings.
j) Technical procedures used.
k) Complications.
1) Specimens removed.
m) Estimated blood loss.
n) General condition of patient.
5. A progress note must be entered into the medical record immediately following surgery. The
note must include:
a) Indication for Procedure
b) Pre-op diagnosis
c) Post-op diagnosis
d) Procedure
e) Findings
f) Surgeon
g) Assistants
h) Anesthetic agent
i) Anesthesiologist
j) Estimated Blood Loss
k) Blood replaced
l) Complications
m) Specimen's removed
6. Discharge note and discharge orders.
7. Diagnosis and procedure record before patient's
discharge.
8. When writing in the medical record at LIJ SCH
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or Zucker your signature must be accompanied
by your beeper number. Include your printed
name if your signature is illegible.
9. When it is discovered that a patient’s medical
record contains minor errors in transcription,
spelling, etc., the corrections shall be effected
by putting one line through the incorrect information, it should be noted as an “error,” initialed and the date the change is actually made
is the date that should be documented and
inserting the correct information directly above.
The original information should not be deleted
or obliterated.
a. if the correction involves a name change, an
alphabetical cross reference should be maintained in addition to the unit number system.
b. if it is discovered that a wrong entry was made
in the record regarding writing in wrong
patient’s record, then the wrong entry should
have a line drawn through it and should be
noted as an “error,” initialed and the date the
change is actually made is the date that should
be documented.
c. if the physician wants to add additional information to the record after the patient is discharged, an addendum may be written, dated
and signed with the current date of the entry.
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When it is discovered that a patient’s medical
record contains more significant errors involving
test results, physician orders, inadvertently omitted information and similar substantive entries,
this information will be reported at the next regularly scheduled meeting of the Medical Records
Committee.
10. Medical records must be completed within 30
days after discharge of patient as stated in the
health system bylaws.
11. You will be notified of incomplete medical
records by notices sent out from the Medical
Records Department on a weekly basis. A
medical record becomes delinquent when it
has not been completed within 30 days following the patient's discharge. The names of
delinquent house staff members are automatically forwarded to administration and department chairpersons for disciplinary action.
Such disciplinary action means that noncompliance with medical record requirements will
be a factor used in consideration for future
appointments and letters of recommendation.
All available medical records must be completed in order for a house staff member to
receive his diploma at the end of the year.
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12. MEDICAL RECORDS MAY NOT BE
REMOVED FROM THE FACILITY.
13. Medical records may be requested for studies,
research, conferences, etc., for a period not to
exceed seven calendar days.
14. Requests for release of medical record information must be referred to the Medical
Records Department. Call the LIJ correspondence unit at extension 7440 and at NSUH at
extension 4260 if you have any questions.
15. Requests for reports used for studies can be
obtained by contacting the Quality Management
Coordinator at LIJ at extension 7457/7485 and
at NSUH at extension 4039.
16. The Termination Clearance Form must be
completed by the Medical Records Department
to ensure that all medical records assigned to
you are completed.
Hours of Operation LIJ:
Monday to Friday 8 a.m. – 7 p.m.
Weekends and holidays –by appointment only
Hours of Operation NSUH:
Monday to Friday 8 a.m. – 4 p.m.
Weekends and holidays 8 a.m. – 4 p.m.
Hours of Operation FHH:
Monday to Friday 7:00am–12 Midnight
Weekends and holidays 9am–5pm
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Records can be requested at extension 4190.
Records of patients discharged within 6 months
are immediately available. Records of patients
discharged prior to 6 months are stored off-site
and can be delivered within 24hours from request.
Residents are required to report to medical records
a minimum of once a week to closeout any incomplete records. A medical record review schedule
with weekly assigned day is given to the residents
at the beginning of the academic year. Charts will
be pulled and ready for residents on their assigned
day. Please call in advance to have your incomplete
records pulled if going to the medical records
department on a day that is not assigned to you.
RESIDENT FORUM
The Resident Forum provides house staff a forum
to air and discuss issues important to them and
their training experience. The forum is resident/
fellow organized and led. All training programs
are expected to have a representative present at
the monthly meetings.
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FIRE PROCEDURES AND DUTIES
Every possible precaution has been taken to prevent the outbreak of fire in the health system. In
the event of fire, the safety of everyone depends
on the ability of all staff to take necessary measures to ensure that all patients, staff and visitors are
protected. All staff members are responsible for
reporting any condition which could possibly
develop into a fire.
Fire Drills. Fire Drills are conducted to practice
and review the methods and procedures used to
extinguish a fire and for a safe and orderly evacuation of the building if necessary.
Every house staff member must know:
1. Location of fire alarm boxes, fire exits, and fire
extinguishers.
2. How to operate fire alarms boxes.
3. How to operate fire extinguishers.
When discovering a fire remember code word
“RACE”
Rescue – Remove to safe area
Alarm – Pull alarm box and dial the hospital
emergency number
Confine – Prevent spread of fire by closing the
door to the effected area.
Extinguish – Prevent extension of fire
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When the fire alarm bells sound, house staff members shall ascertain the location of the alarm from
alarm charts posted at every alarm box. You
should then proceed to the location and take
charge of patient care as soon as possible.
report to the scene of the fire and take whatever
steps are necessary to safeguard patients and combat the fire under the direction of the fire response
team until the arrival of the Fire Department.
Code word for fire at Forest Hills Hospital is
“Nurse Blaze”. Location of fire can be identified
according to the alarm charts posted at every
alarm box. Once fire bells sound, report to designated station and await further instructions from
the operator. You may return to your duties once
the all clear has been given.
Report Alarms. Code word for fire at NSUH and
LIJ is “Dr Red.”
There are two ways to report a fire in a health system facility:
1. Pull alarm box
2. Dial emergency number
Procedures to be followed in the event of a fire—
Between the hours of 9 a.m. and 4 p.m., Monday
through Friday, all house staff members on duty
should report to the patient units where they will
assist in closing doors and windows to prevent
spread of smoke and fire and prepare for the
removal of patients. On evening and night shifts
and on weekends, all house staff on duty shall
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95
PATIENT'S BILL OF RIGHTS AND
RESPONSIBILITIES
Those of us who are concerned with patient
care—the patient, the physician, and the hospital
staff—are partners in the healthcare process, and
each of us must recognize and respect the rights
and dignity of others and uphold our own responsibilities.
PATIENT'S RIGHTS
The Patient's Bill of Rights was established by the
New York State Department of Health as a vehicle
for better communication between the patient and
the hospital staff. The health system staff is
trained and committed to carry out these principles. We know that their effective applications
will lead to improved care and greater patient satisfaction. As a patient in a hospital in New York
State, a patient has the right, consistent with law, to:
1. understand and use these rights. If for any
reason the patient does not understand or you
need help, the hospital must provide assistance, including an interpreter.
2. receive treatment without discrimination as to
race, color, religion, sex, national origin, disability, sexual orientation or source of payment.
3. receive considerate and respectful care in a
clean and safe environment free of unnecessary restraints.
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4. receive emergency care if needed.
5. be informed of the name and position of the
doctor who will be in charge of their care in the
hospital.
6. know the names, positions and functions of
any hospital staff involved in their care and
refuse their treatment, examination or observation.
7. a no smoking room.
8. receive complete information about their diagnosis, treatment and prognosis.
9. receive all the information that you need to
give informed consent for any proposed procedure or treatment. This information shall
include the possible risks and benefits of the
procedure or treatment.
10. receive all the information you need to give
informed consent for an order not to resuscitate. You also have the right to designate an
individual to give this consent for you if you
are too ill to do so. If you would like additional information, please ask for a copy of the
pamphlet "Do Not Resuscitate Orders — A
Guide for Patients and Families."
11. refuse treatment and be told what effects this
may have on your health.
12. refuse to take part in research. In deciding
whether or not to participate, you have the
right to a full explanation.
13. privacy while in the hospital and confidentiality of all information and records regard97
ing your care.
14. participate in all decisions about your treatment and discharge from the hospital. The
hospital must provide you with a written discharge plan and written description of how
you can appeal your discharge.
15. review your medical record without charge
and obtain a copy of your medical record for
which the hospital can charge a reasonable
fee. You cannot be denied a copy solely
because you cannot afford to pay.
16. receive an itemized bill and explanation of all
charges.
17. complain without fear of reprisals about the
care and services you are receiving and to
have the hospital respond to you and if you
request it, a written response. If you are not
satisfied with the hospital's response, you can
complain to the New York State Department
of Health. The hospital must provide you
with the Department of Health’s telephone
number.
18. authorize those family members and other
adults who will be given priority to visit consistent with your ability to receive visitors.
19. Make known your wishes in regard to an
anatomical gifts. You may document your
wishes in your healthcare proxy or on a donor
card available from the hospital.
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PATIENT'S RESPONSIBILITIES
The Statement of Patient's Responsibilities was
designed as a companion to the Bill of Rights in
an effort to encourage patients to participate in
their own healthcare and treatment. The health
system believes that a mutual understanding of the
Patient's Bill of Rights and Responsibilities will
result in more effective delivery of healthcare
services.
To the extent possible, the health system requests
patients to:
1. understand that it may become necessary during your hospital stay to relocate you to another bed on the nursing floor or to another medical service within the hospital. These decisions are based on medical needs. We are sorry
for any inconveniences that relocating you
may cause.
2. provide information relating to insurance and
other sources of payment. Please make
arrangements to meet your financial obligations or seek help, if necessary, by calling the
Medicaid Eligibility Program at (718) 470-7544.
3. provide accurate and complete information
about your past illnesses, hospitalizations,
medications and other matters relating to your
health and to answer any questions concerning
these matters.
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4. understand your health problems and treatment
to your own satisfaction and to ask questions if
you do not understand.
5. provide information to your physician or other
healthcare professionals about unexpected
results of treatment or changes in an expected
course of treatment.
6. participate in your healthcare planning by talking openly and honestly about your concerns
with your physician and other healthcare professionals.
7. cooperate with your physician and other health
professionals in carrying out your healthcare
plan both as an inpatient and after discharge.
8. understand that the patient or family member
accepts the consequences and outcomes of
refusing recommended treatment and/or failure
to follow the practitioner's instruction.
9. understand the importance of following hospital rules and regulations concerning patient
care and conduct.
10. to be considerate of others by reducing the
amount of unnecessary noise, by not smoking
or causing distractions. We also ask that
patients and families respect the property of
other persons and that of the hospital.
11. be responsible for safekeeping of all your personal articles. We urge you to send home all
valuables and clothing you will not need as a
patient. Articles such as dentures, hearing
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aids, contact lenses, etc., should also be sent
home if you do not need them while in the
hospital. If you do need these articles, you are
personally responsible for their safekeeping.
Please ask for a denture cup in which to keep
your dentures when not in use. Do not place
them on your food tray or underneath your
pillow. The hospital is not responsible for the
loss of personal articles that are not absolutely
necessary for patient health.
We ask that you be considerate of your fellow
patients, respecting their need for privacy and a
quiet environment.
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TELEPHONE DIRECTORY
Forest Hills Hospital
Robert T. Hettenbach
Executive Director
(718) 830-4001
Geraldine Randazzo, RN,
MS, CNAA
Deputy Executive Director
(718) 830-4002
Mary Heffernan, RN, MS
Nurse Executive
(718) 830-4040
Miriam Smith, MD
Chairman, Internal Medicine
(718) 830-4359
Mark Goldberg, MD
Residency Program Director
(718) 830-4359
Adrien Lawrence
(718) 830-4352
Residency Program Coordinator
Glen Cove Hospital
Dennis Connors
Executive Director
(516) 674-7580
Dr. George F. Dunn
(516) 674-7580
Senior Vice President for Medical A ffairs
Chairman Family Medicine
102
103
Jon Sendach
(516) 674-7580
A ssociate Executive Director for Finance
Carolyn Mueller, RN
(516) 674-7580
A ssociate Executive Director for
Quality Management
Susan Kwiatek, RN
(516) 674-7580
A ssociate Executive Director for
Patient Care Services
Gloria Cohen, RN
(516) 674-7667
A ssociate Executive Director for
Human Resources
William J. Bennett, MD
(516) 674-7637
Program Director, Family Medicine
Julie Gomez
(516) 674-7637
Residency Program Coordinator,
Family Medicine
North Shore-Long Island Jewish Health System
Lawrence Smith, MD
(516) 465-3194
Chief Medical Officer
David Battinelli, MD
Chief A cademic Officer
104
(516) 465-3192
Carolyn C. Snipe
Director of Graduate
Medical Education
(516) 465-3178
Marie Toto
(516) 465-3173
Coordinator, House Staff System
Long Island Jewish Medical CenterAdministration
Dennis Dowling
(718) 470-7764
Regional Director
John Steele
Deputy Executive Director,
Chief Operating Officer
(718) 470-4885
Jeremy Boal, MD
Medical Director
(718) 470-7606
Kerri Scanlon, RN
Nursing Director
(718) 470-7825
North Shore University Hospital Administration
Dennis Dowling
(516) 562-4050
Regional Director
Susan Sommerville
Executive Director
(516) 562-4050
Kathleen Capitulo, RN
Chief Nurse Executive
(516) 562-4050
105
Peter Walker, MD
Medical Director
(516) 562-4887
Schneider Children’s Hospital
Arthur Klein, MD
(718) 470-3201
Sr. Vice President of Children’s Services,
Chief of Staff, Schneider Children’s Hospital
Jay Enden, MD
Medical Director
Catherine Hottendorf, RN
(631) 968-3800
A ssociate Executive Director, Nursing
Richard J. Bonanno, MD
Residency Director
(631) 968-3295
Tochi Iroku-Malize, MD,
MPH, FHM
A ssociate Residency Director,
Director of Hospitalist Program
(631) 968-3295
(631) 968-3295
Chantal Weinhold
Executive Director
(718) 470-3201
Eric Chaiken
A ssociate Executive Director,
Operations
(718) 470-8874
Cari Quinn, RN
A ssociate Executive Director,
Patient Care Services
(718) 470-3171
Margaret Manzari
Residency Secretary
Andrew Steele, MD
Medical Director
(718) 470-3440
Zucker Hillside Hospital
Joseph Schulman
Executive Director
Southside
Winifred Mack, RN, BSN, MPA (631) 968-3001
Executive Director
Michael Delman, MD
Sr. V.P. A cademic A ffairs
(631) 968-3700
106
Robert Power
(631) 968-3001
A ssociate Executive Director, Finance
(631) 968-3001
(718) 470-8001
William Jacobowitz, RN
A ssociate Executive Director,
Operations
(718) 470-8466
Peter Manu, MD
Medical Director
(718) 470-8291
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NS-LIJ DEPARTMENT CHAIRPERSONS
ANESTHESIOLOGY
John Di Caupa, MD
CARDIOTHORACIC SURGERY
Alan Hartman, MD
DENTISTRY
Ronald J. Burakoff, DMD
EMERGENCY MEDICINE
Andrew Sama, MD
MEDICINE
Stephen Kamholz, MD
NEUROLOGY
Ronald Kanner, MD
OB/GYN
Adiel Fleischer, MD
OPHTHALMOLOGY
Ira Udell, MD
ORTHOPEDIC SURGERY
Stanley Asnis, MD
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OTOLARYNGOLOGY & COMMUNICATIVE DISORDERS
Allan Abramson, MD
(516) 562-4887
PATHOLOGY
(516) 562-4970
PEDIATRICS
(718) 470-7111
PSYCHIATRY
(516) 562-3090
RADIATION ONCOLOGY
(718) 470-7270
RADIOLOGY
(718) 470-7311
SURGERY
(718) 470-4570
UROLOGY
James M. Crawford, MD, PhD
Fred Bierman, MD
John Kane, MD
Louis Potters, MD
Mitchell Goldman, MD
Gene Coppa, MD
Louis Kavoussi, MD
(718) 470-7555
(718) 470-7491
(718) 470-3201
(718) 470-8141
(718) 470-7196
(516) 562-4800
(718) 470-7210
(718) 470-7221
(516) 470-2020
(516) 627-8717
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