mssmem.com

I forget…what did that email say? oh yeah, its at mssmem.com

Archive for the ‘Admin’ Category

Office Based Surgery Adverse Event Reporting

This is a reminder that the state has strict regulations covering office based surgery (OBS) that include us in the mandate reporting of such events. The OBS laws are: Public Health Law (PHL) §§ 230-d and 2998-e and State Education Law § 6530(48). They include the following: “ reportable adverse events shall be reported to the NYSDOH Patient Safety Center within one business day of the occurrence of the event…. Failure to report this information falls within the definition of professional misconduct.” Mandated reporters include “ANY physician, PA and/or SA who believes or becomes aware of a patient complaint, complication, condition, emergency department visit, hospital admission or death that occurred status post an OBS procedure.”

If you become aware of such a case there are a few things to do.

1. Fill out the forms (attached) yourself and email/fax them to Jacqueline S. Lustgarten MD, Program Coordinator, Risk Management Fax: (212) 876-3191.

OR

2. Let me know. I will get the forms filled out to the best of my ability. (It is possible that by emailing me, if I’m away or post night shift, I won’t turn them around in the 24 hours mandate.)

In this recent case the gastroenterologist sent the state the forms and risk management here still felt the ED was obligated to report it as well.

This does NOT apply to adverse events from hospital based procedures.

Peter Shearer, MD FACEP

doh-4431_instructions
doh-4431 reporting form

Written by phil

July 7th, 2013 at 4:40 pm

Posted in Admin

Sinai Large Attachment Server

Written by phil

May 6th, 2012 at 3:42 pm

Posted in Admin

Research Updates – InfoEd, COI, CITI program

The GCO has changed the submission process of their paperwork.  They are not accepting any more paper copies, instead you have to do it via infoed.  Infoed is located through the Sinai Central System. Log on to:  https://sinaicentral.mssm.edu/ ; go to GCO.

Before you begin go to the following link which will help you understand how to fill out the GCO forms and other GCO forms: http://sinaiknowledge.mssm.edu/sinai_central/conflict-of-interest/gco/?searchterm=GCO..

Anyone that has a project that is coming to an end must fill out the “continuation” or “final” paperwork to the GCO again, via infoed.  If you do not close out your project(s) the GCO will not allow you to submit any other projects until you close them out.

C.O.I- Conflict of Interest form must be updated every year.  So even if you have done this already you have to do it again.  Go into the Sinai Central System at: https://sinaicentral.mssm.edu/, sign in and go to the GCO link and go to “List Forms” on the upper left hand corner.  This is mandatory for everyone that works on any kind of research.  Anyone who is named on a project has to fill this form out also.  Staff must fill also fill out this form.

EVEN if you have completed a Human Research Subject Protection you MUST read the information below and apply for a new certificate.  You will not be allowed to submit any projects until this is done.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Human Research Subject Protection

Education Requirement

Effective August 18, 2010, the only Human Research Subject Protection training course available through the PPHS office will be the CITI program. All personnel will need to complete the CITI program course requirement.

HOW THIS AFFECTS YOU

If the PPHS office has your information on file for having previously completed the Human Subjects in Research requirement, you have until December 31, 2010 to complete the CITI training. Beginning January 1, 2011, the PPHS office will not process any further submissions until this training has been completed. Please make sure all research faculty and staff complete this requirement. No one will want to spend New Years Eve doing these modules to avoid having a project be suspended on January 1, 2011.

If the PPHS office does not have your information on file for having completed the Human Subjects in Research requirement, or you are new to the Institution, you must complete the CITI training curriculum before you can engage in any human subjects research. The PPHS office will not process any submissions until this training has been completed.

If you have previously completed CITI training for any other project or institution, please log in to CITI and add “Mount Sinai School of Medicine NYC” as an affiliate in order for any of your credits to transfer. You will be required to complete the course curriculum for your credits to transfer.

HOW LONG WILL IT TAKE TO COMPLETE THE COURSE

The Basic Human Subjects course is expected to take 4-6 hours to complete. The average user breaks this down over 5 sessions. All modules must be passed and completed in order for you to fulfill the education requirement.

WHAT TO DO WHEN THE COURSE HAS BEEN COMPLETED

Please retain your certificate. You do not have to send it to the PPHS. We will be notified by CITI when you have completed the course.

HOW LOW LONG THE COURSE WILL REMAIN VALID

Beginning in January 2011, ongoing education in human subjects research will be required every 3 years.

Refresher courses will be offered through the CITI program to meet this new requirement.

HOW TO BEGIN THE CERTIFICATION COURSE

1. Go to www.citiprogram.org

2.     Click on “New Users Register Here”

3.     Under “Select your institution or organization” , select “Mount Sinai School of Medicine NYC” in the  “Participating Institutions” drop down box.

4.     Create your own username and password and select the Learner group (Researcher)

5.     Make sure to keep a copy for your own file

Written by phil

September 17th, 2010 at 1:16 pm

Posted in Admin,Research

Deep Sedation

The Sedation/Analgesia (“Conscious Sedation”) Policy
 
The Sedation/Analgesia Policy was amended to delete the section on Deep Sedation.  Deep Sedation has been reclassified by CMS as “Anesthesia.”  Physicians and Dentists performing Deep Sedation must be credentialed specifically to perform deep sedation by their Chief of Service and maintain standards of care and documentation that are equivalent to the Department of Anesthesiology standards.  (Policy # A2-307)

Written by phil

July 14th, 2010 at 5:34 pm

Social Media Guidelines

Mount Sinai Medical Center Social Media Guideline

 

 Introduction

Social media are internet-based applications which support and promote the exchange of user-developed content. Some current examples include Facebook, Wikipedia, and YouTube. Posting personal images, experiences and information on these kinds of public sites poses a set of unique challenges for all members of the Mount Sinai community, including employees, faculty, housestaff, fellows, volunteers and students (collectively “Personnel”). All personnel have responsibility to the institution regardless of where or when they post something that may reflect poorly on Mount Sinai. Mount Sinai is committed to supporting your right to interact knowledgeably and socially; however these electronic interactions have a potential impact on patients, colleagues, Mount Sinai, and future employers’ opinions of you. The principal aim of this Guideline is to identify your responsibilities to Mount Sinai in relation to social media and to help you represent yourself and Mount Sinai in a responsible and professional manner.

Guideline

The following Guideline outlines appropriate standards of conduct related to all electronic information (text, image or auditory) that is created or posted externally on social media sites by Personnel affiliated with Mount Sinai. Examples include, but are not limited to: text messages, media messaging service (MMS), Twitter®, Facebook®, Linked-In®, YouTube®, and all other social networks, personal and organizational websites, blogs, wikis, and similar entities. This Guideline applies to future media with similar implications. It also applies whether Personnel are posting to: Mount Sinai-hosted sites; social media in which one’s affiliation is known, identified, or presumed; or a self-hosted site, where the views and opinions expressed are not intended to represent the official views of Mount Sinai. Reference to Other Policies All existing policies of The Mount Sinai Medical Center apply to Personnel in connection with their social media activities. A list of relevant policies is included at the end of this Guideline. Best Practices Everyone who participates in social media activities should understand and follow these simple but important Best Practices: 1. Take Responsibility and Use Good Judgment. You are responsible for the material you post on personal blogs or other social media. Be courteous, respectful, and thoughtful about how other Personnel may perceive or be affected by postings. Incomplete, inaccurate, inappropriate, threatening, harassing or poorly worded postings may be harmful to others. They may damage relationships, undermine Mount Sinai’s brand or reputation, discourage teamwork, and negatively impact the institution’s commitment to patient care, education, research, and community service. 2. Think Before You Post. Anything you post is highly likely to be permanently connected to you and your reputation through Internet and email archives. Future employers can often have access to this information and may use it to evaluate you. Take great care and be thoughtful before placing your identifiable comments in the public domain. 3. Protect Patient Privacy. Disclosing information about patients without written permission, including photographs or potentially identifiable information, is strictly prohibited. These rules also apply to deceased patients and to posts in the secure section of your Facebook page that is accessible by approved friends only. 4. Protect Your Own Privacy. Make sure you understand how the privacy policies and security features work on the sites where you are posting material. 5. Respect Work Commitments. Ensure that your blogging, social networking, and other external media activities do not interfere with your work commitments. 6. Identify Yourself. If you communicate in social media about Mount Sinai, disclose your connection with Mount Sinai and your role at the Medical Center. Use good judgment and strive for accuracy in your communications. False and unsubstantiated claims, and inaccurate or inflammatory postings may create liability for you. 7. Use a Disclaimer. Where your connection to Mount Sinai is apparent, make it clear that you are speaking for yourself and not on behalf of Mount Sinai. A disclaimer, such as, “The views expressed on this [blog; website] are my own and do not reflect the views of my employer,” may be appropriate. 8. Respect Copyright and Fair Use Laws. For Mount Sinai’s protection as well as your own, it is critical that you show proper respect for the laws governing copyright and fair use of copyrighted material owned by others, including Mount Sinai’s own copyrights and brands. 9. Protect Proprietary Information. Do not share confidential or proprietary information that may compromise Mount Sinai’s business practices or security. Similarly, do not share information in violation of any laws or regulations. 10. Seek Expert Guidance. Consult with the Marketing & Communications Department if you have any questions about the appropriateness of materials you plan to publish or if you require clarification on whether specific information has been publicly disclosed before you disclose it publicly. Social media may generate interest from the press. If you are contacted by a member of the media about a Mount Sinai-related blog posting or Medical Center information of any kind, contact the Press Office, a division of the Marketing & Communications Department, at (212) 241-9200 or newsmedia@mssm.edu Failure to abide by Mount Sinai policies may lead to disciplinary action, up to and including termination or expulsion.

Applicable Policies:

These policies include, but are not limited to: Use or Disclosure of Protected Health Information (PHI) or Confidential Mount Sinai Materials; Computer Use Policy; Use of Mount Sinai’s Trademarks and Proprietary Information; Electronic Communications; Confidentiality of the Medical Record; Camera and Video Recorder Use; Portable Electronic Devices; Human Resources Policies 13.5 (Electronic Mail/Email) and 13.6 (Internet Use); and all professionalism policies and codes of conduct. Policies not listed above that are in the Human Resources Manual, the Faculty Handbook, the Housestaff Manual, the Student Handbook and the Bylaws of the Hospital Staff also apply.

Addendum to Social Media Guideline

The following are fictional use-case examples of social media and blogging activities and an explanation of their appropriateness as per the Mount Sinai Medical Center Social Media Guideline: 1. A patient attempts to “friend” an attending physician on Facebook. This is almost always inappropriate, unless the doctor-patient relationship has ended. Even after the doctor-patient relationship has ended, it would be inappropriate to discuss health-related information. (Best Practice 3) 2. A patient comments on a Mount Sinai physician’s blog and discloses protected health information with the expectation that the Mount Sinai physician will continue the discussion. Any health-related discussions by email with patients require a written consent. Similarly, social media discussion with a patient should not directly address health concerns of individual patients. (Best Practice 3) 3. A medical student “twitters” that he just finished rounds with the residents on a patient and describes the clinical findings of that patient. It is difficult to be certain that information disclosed in the Twitter® post is not identifiable to that particular patient. The best type of posting would include very general information. Other posts by the same student could indicate his/her medical school and current rotation, leading to circumstances that indirectly identify the patient, such as by naming a very rare disease. (Best Practice 3) 4. A medical student writes in her blog, naming an attending physician who did minimal teaching on rounds and recommending that other students not take clinical electives with that physician. Legitimate critique of an educational activity is appropriate, so long as professionalism is maintained. There are more effective and less public mechanisms for relaying this type of information, and the student may be counseled accordingly. (Best Practices 1, 2) 5. A graduate student posts to his “wall” on Facebook that half of the class was sleeping during Dr. X’s lecture on biostatistics. This is very similar to the use case above. (Best Practices 1, 2) 6. A pediatric resident posts (on her Facebook wall) a picture of a baby who was just discharged from her service, expressing joy, best wishes to the family, and congratulating everyone involved in this excellent patient outcome. Without written patient/representative consent, this is a clear violation of patient confidentiality, even if the patient is not named. (Best Practice 3) 7. A laboratory technician blogs that the laboratory equipment he is using should have been replaced years ago and is unreliable. The public disclosure of such information increases the liability for the Medical Center and is clearly unprofessional. There are legitimate and confidential mechanisms for improving quality at the Medical Center. (Best Practices 1, 2) 8. A medical student wearing a Mount Sinai t-shirt is tagged in a photo taken at a local bar and posted on a friend’s Facebook page. The medical student is clearly inebriated. The two issues are that: (1) the Mount Sinai logo identifies the affiliation to the institution; and (2) the unprofessional behavior of the student is available for all to see, including future employers and patients. The medical student did not post the photo, but should do everything possible to have the photo removed and remove the tagging link to the student’s own Facebook page. (Best Practices 2, 4) 9. A post-doctoral student blogs that her laboratory technician wears too much cologne, has terrible taste in clothes, and takes overly long lunch breaks. This is an inappropriate forum and set of comments and demonstrates unprofessional behavior by the post-doc student. There are legitimate and confidential mechanisms for addressing valid concerns in the workplace. (Best Practices 1, 2) 10. An oncology nurse practitioner uses an alias and blogs that Mount Sinai has the lowest bone marrow transplantation complication rate in the world. This may be a violation of Federal Trade Commission regulations that prohibit false or unsubstantiated claims, and does not disclose the employee’s material relationship to Mount Sinai. (Best Practice 6) 11. An applicant to the Medical School is given access to a MSSM blog to comment on the experience. The applicant writes that another medical school in NYC is obviously more prestigious and has better housing. Mount Sinai has no recourse against non-affiliated individuals. The administrator of the blog should have established policies and procedures for editorial procedures. If the blog posting meets these editorial guidelines, then the blog posting should remain. It is likely that others will debate the original comment and place MSSM’s reputation and housing status in context. 12. A medical student creates a social media website to discuss medical knowledge (e.g., “Cardiology Interest Group” on Facebook®) This is a learning community environment, in which medical knowledge is exchanged, shared and discussed. While the goal is laudable, there are still risks. A disclaimer is necessary, since postings may be incorrect, taken out of context, or improperly referenced. The moderator should take precautions to prevent the posting of information or photographs that are potentially identifiable to a particular patient. (Best Practices 1, 3 ,6, 7)

Written by phil

May 17th, 2010 at 3:02 pm

Posted in Admin

Office Based Surgery Complications

If you see a patient with a complication of Office Based Surgery, there is a provider obligation to report it in NYS. Please call Risk management for assistance in getting it reported as there is a one business day time frame. Below is a key excerpt from the FAQ.

Any physician, physician assistant or specialist assistant in a hospital setting who believes that a patient complaint, complication, condition, emergency room visit, hospital admission or death is related to an OBS procedure must report an OBS adverse event as soon as they suspect that there is some relationship to an OBS surgical procedure . In such a case, the reporter may not be able to complete the form in its entirety, but should submit as much information as possible.

From Dr. Hill

Written by phil

March 10th, 2010 at 6:13 pm

Posted in Admin

2010 OSHA Class Schedule

DATES DAY START END LOCATION
January 5

January 21

Tuesday

Thursday

8:00am

3:00pm

9:00am

4:00pm

Goldwurm Auditorium

Goldwurm Auditorium

February 9

February 25

Tuesday

Thursday

8:00am

3:00pm

9:00am

4:00pm

Goldwurm Auditorium

Goldwurm Auditorium

March 9

March 25

Tuesday

Thursday

8:00am

3:00pm

9:00am

4:00pm

Goldwurm Auditorium

To be determined

April 8

April 27

Thursday

Tuesday

3:00pm

8:00am

4:00pm

9:00am

Goldwurm Auditorium

Goldwurm Auditorium

May 11

May 27

Tuesday

Thursday

8:00am

3:00pm

9:00am

4:00pm

Goldwurm Auditorium

Goldwurm Auditorium

June 10

June 22

Thursday

Tuesday

3:00pm

8:00am

4:00pm

900am

Goldwurm Auditorium

Goldwurm Auditorium

July 8

July 20

Thursday

Tuesday

3:00pm

8:00am

4:00pm

9:00am

Goldwurm Auditorium

Goldwurm Auditorium

August 5

August 24

Thursday

Tuesday

3:00pm

8:00am

4:00pm

9:00am

Goldwurm Auditorium

Goldwurm Auditorium

September 9

September 21

Thursday

Tuesday

3:00pm

8:00am

4:00pm

9:00am

Goldwurm Auditorium

Goldwurm Auditorium

October 5

October 21

Tuesday

Thursday

8:00am

3:00pm

9:00am

4:00pm

Goldwurm Auditorium

Goldwurm Auditorium

November 4

November 23

Thursday

Tuesday

3:00pm

8:00am

4:00pm

9:00pm

Goldwurm Auditorium

Goldwurm Auditorium

December 7

December 23

Tuesday

Thursday

8:00am

3:00pm

9:00am

4:00pm

Goldwurm Auditorium

Goldwurm Auditorium

Written by phil

December 8th, 2009 at 3:05 pm

Posted in Admin

Email Security

TO:                  All Faculty and Staff

 

FROM:            Aviva Halpert

Chief HIPAA Officer

The Mount Sinai Medical Center

 

Kenny Chu

Senior Director, Information Technology Security

The Mount Sinai Medical Center

 

DATE:              September 10, 2009

 

RE:                   Email Security

 

 

Email of Protected Health Information (PHI) or Other Confidential Information

Users of the Mount Sinai Medical Center email systems should review the policy on the Use of E-MAIL for communicating Protected Heath Information (PHI)and/or Personal Financial Information (Policy H-13).  Key points of the policy are:

· The minimum necessary amount of PHI should be disclosed via email.

· Messages that leave the medical center network that contain PHI or other confidential information must be encrypted.  Messages sent within The Mount Sinai Medical Center are not required to be encrypted.

· Encryption will not prevent misdirection or unintended forwarding of a previous string of emails.  Extreme caution must be exercised to prevent such risks.

· Unless the email is encrypted the patient’s name should not be used; if it is necessary to identify the patient the Medical Record Number should be used instead.

· If a patient wishes to communicate with his/her provider via e-mail regarding his/her care, the provider must obtain the patient’s consent.  Refer to Consent for Communication via E-mail (Physician-Patient) (Form MR-240).

The entire policy H-13 and form MR-240 can be found on the intranet-

http://intranet1.mountsinai.org/hipaa/policies/H-13.pdf

http://intranet1.mountsinai.org/MedicalRecords/pane.confidentiality/MR.pdf.240.pdf

Secure Messaging/Encryption

If you have to send PHI or other confidential information to an external recipient, you must use the email encryption option.  To activate the email encryption option, include the word [secure] within square brackets in the subject line of the message.  The recipient will be asked to self enroll when the message is opened.  The secure send mechanism can be used from any mail client (Outlook, Outlook Web Access, Blackberry.)

For certain destinations provisions have been made to ensure that all messages are encrypted using a mechanism called TLS.  For example, messages sent to Astra Zeneca and McKesson have been configured to auto encrypt so it is not necessary to manually activate encryption.

Beginning October 2009 the email system will automatically flag messages to external parties that contain confidential information but was not encrypted.

SPAM and Inappropriate Use

The use of Mount Sinai systems, including email, is intended for official business use.  Inappropriate use may result in the loss of access privilege and disciplinary actions.  Unsolicited mass emailing of material not related to medical center business is considered SPAM and may result in the loss of access privileges.  The entire policy HR 13.5 can be found on the intranet-

http://www.mountsinai.org/Education/School%20of%20Medicine/Computing%20Services/Network%20Access

 

Email Security and Phishing

Please remember to take care when opening attachments or following links contained in email messages.  Verify with the sender of the message if you receive an unexpected attachment or it contains suspicious links.  Be especially cautious of emails that have been quarantined by ProofPoint.  This product is very reliable in identifying SPAM. Unless a quarantined message is correspondence that you are expecting – do not release the email.

Please also take care with any messages that ask you to provide private information (Birthdays, Social Security Number, Credit Card numbers, User account passwords, etc.)  These messages may actually be a phishing attempt from a person pretending to be a legitimate company or organization.  If you have doubts please contact the party requesting the information for confirmation.  Users should not rely on the contact information contained in the email, but use the contact information typically found at the company website or on the back of the Bank or Credit card.

 

 

If you have any questions regarding any of the topics covered in this memo, please contact Kenny Chu – kenny.chu@mountsinai.org.

Written by phil

September 10th, 2009 at 5:21 pm

Posted in Admin

OSHA and Infection Control Training

As in the past, there are two training mandates:

* The first is OSHA blood borne pathogen training ANNUALLY.
* The second is NYS infection control training- EVERY FOUR YEARS
*

The attached report indicates the date upon which your current certificate for OSHA Blood borne Pathogen Training expires. Employees with expired certificates are indicated by a comment in the far right column of the table. YOU are responsible to keep your certifications up to date. Web sites are indicated below for on line training courses if you need.

Please let me know if you have any questions. Many thanks! Jill

1) OSHA-Required Blood borne Pathogen Training and NEW Joint Commission-Required Training ANNUALLY

. As of July 2009, the Mount Sinai Infection Control Department will be providing this additional training as part of the annual bloodborne pathogen and infection control training that is already required. This will allow our faculty and staff to fulfill both requirements by completing a single activity. Pre-registration is not required. The online course is available on the Infection Control website ( >>Infection Control). In order to receive credit for the online course, the post-test must be successfully completed after review of the slide presentation. The confirmation certificate generated after successful completion should be printed for the employee’s records.

2) New York State-Required Infection Control Training- EVERY FOUR YEARS

New York State requires that certain healthcare professionals receive training in infection control every four years. Information regarding an employee’s NYS certification status can be obtained from the appropriate Mount Sinai credentialing office. For a list of other approved New York State Infection Control course providers, visit http://www.op.nysed.gov/icproviders.htm. Licensed health professionals can also fulfill the course requirements online at www.proceo.com.

Written by phil

August 13th, 2009 at 2:11 pm

Posted in Admin

MountSinai.org Website

MountSinai.org Website
1) My name doesn’t appear in the Find-A-Doctor list or the information there is incorrect. What do I do? Simply fill out and submit the “Find-A-Doctor” application. You will also need to choose one or more items from this list of clinical interests.

2) My publications aren’t listed in Find-A-Doctor, what do I do? Send a list of your top ten (most recent/most important) publications to kristen.morales@mountsinai.org and webfeedback@mountsinai.org.

3
) How do I add an event to my “events” page on the Patient Care or Education Pages? Simply email the request to webfeedback@mountsinai.org.

Written by phil

July 15th, 2009 at 5:01 pm

Posted in Admin

Provider Data Lookup

Written by admin

June 10th, 2009 at 8:07 pm

Posted in Admin

Swine Flu Surge Coverage

It has been noted that a lot of attendings are behind in hours. Not as far behind as I, but behind non-the-less.

We have negotiated a “pot-sweetener”: if you are behind in hours to double- digits (that’s more than 10), you can be re-imbursed for swine hours at almost double. That’s right- 5 hours for 3.

Note that if you are ahead in hours, not behind, you are being paid at $150, which is higher than moonlighting rate. It seemed unfair to pay those ahead at a higher rate, while re-imbursing those behind at the base rate.

We are now re-imbursing both those ahead and those behind at higher, crisis pay rates.
Take another look at the spreadsheet now.

If you have a gmail account, you can add your name to the schedule yourself.

Written by admin

May 28th, 2009 at 7:47 pm

Posted in Admin,Swine Flu