Checklists: Important tools for a complete orientation

"If you seldomly orient people, you need a checklist to cover your bases. There are a variety of things that need to be covered," says Dighton Packard, MD, FACEP, medical director of the ED at Baylor Medical Center in Dallas, TX. (See orientation checklist enclosed with this issue.)

"Checklists are an important tool," says Joel Stettner, MD, FACEP, assistant chairman of the department of emergency medicine at Summit Medical Center in Oakland CA, and chairman of the emergency medicine group management section of ACEP. "This should include a list of items, such as how you get your meals in the hospital, what to do if an oncall physician refuses to come in, and patient management issues."

The following should be included in orientation:

Hospital policies and bylaws. "When you become a medical staff member, it’s the hospital’s responsibility to make sure you are familiar with their bylaws and policies and procedures, says Packard. "That is often delegated to the ED director, and, when a new doctor comes on board, they are handed a copy of the bylaws. But they are very seldom asked to sign that they’ve read it, which is the right thing to do," says Packard.

"You need to cover chart flow, patient flow, documentation, idiosyncrasies of your processes, how to order tests, how the results will come to you, who to refer cases to, what your call list is, and referral for outpatients that may be different than your call list," says Packard. "How do patients get admitted to hospital, do you have residents or trauma teams?"

Hospital bylaws can differ significantly, says Packard. "One hospital’s bylaws may say that as a member of the medical staff, when you are on call, it is your responsibility to see that patient at least one time. Whereas other bylaws might not even speak to that," he notes.

If possible, a comprehensive presentation should be given. "We have five or six people who give an overview of the corporation, which is held at the corporate office," says Tim MacLean, DO, FACEP, an ED physician at Premier Healthcare Services, based in Dayton, OH. "A mini lecture series is also held in a single day, [including] COBRA, risk management, and documentation."

Differences in region. "You need to consider any significant change in environment, such as changing states or moving from a small rural to big urban facility," says Packard. "If somebody has only worked in Arkansas and they’re now working in New York State, you need to orient them to the local laws. It’s a different situation than if the physician has worked in New York all his life."

Hospital policy on writing of admission orders. A good orientation will alert physicians about appropriate admission order writing, says Daniel J. Sullivan, MD, JD, FACEP, chairman of the department of emergency medicine at Ingalls Memorial Hospital in Harvey, IL. "Physicians need to know the exact order writing climate in an institution," he stresses. "If they don’t know what to write, critical patient care may be omitted. Also, it can lead to terrible communication problems and animosity between the ED doctors and primary care physicians."

ED physicians must understand legal risks of writing admission orders. "In recent years, in front of large groups of people, straw polls tell me that at least 50% of ED doctors are writing admission orders," says Sullivan. "However, writing orders does increase exposure to liability. The more it looks like the ED doctor is responsible for admission care, the more likely it is that he or she will involved in a lawsuit related to the admission. The ED physician needs to understand that issue."

Policy for in-house resuscitations. This is a critical management issue which should be addressed during orientation, says Sullivan. "The range of responsibility should be very clear to new ED physicians," he emphasizes. "You must spell out exactly what is covered: resuscitations, deliveries, reading X-rays and EKGs, pronouncing patient deaths?"

It should be explained that care to ED patients should not be compromised, says Sullivan. "There should be an express agreement that the ED physician cannot leave a critically ill patient in the ED," he says. "The ED physician should stay with the critically ill patient, and someone else called in to care for the in house emergency."

Anything that is unique to your ED. "For example, we have disease reporting requirements which are a little different from other states," notes Stettner.

Individual hospital practices need to be explained, says Packard. "If you have a patient with hypertension that needs follow-up, in one hospital the patient will be sent to an oncall physician in internal medicine, but in another one that might be a strict no-no," he explains. "Instead, there might be a clinic, or a sub list of internists who take new cases."

Every EDs handles things differently, says Packard. "You may have a particular way to report risk management incidents, or if doctor has a problem with one of the medical staff physicians, maybe you handle it differently from most EDs," he explains.

Transfers. "Every hospital is different in terms of what kinds of cases your hospital cannot take care of and must be transferred, and where do they go," says Packard. "New physicians need to know what hospital they call for burns, pediatrics, and severe trauma cases."

EMTALA requirements. "Make sure physicians are thoroughly oriented in the requirements of EMTALA," says Stettner. "A new doctor who needs an ultrasound in the middle of the night needs to be told how to overcome resistance to radiologists."

Risk management concerns. "A new doctor might find himself involved in an incident which has potential risk. For example, there may be an untoward reaction to a drug where the physician might not have recognized an allergy and the patient deteriorates. That physician needs to know to report the incident early so risk manager gets involved," says Stettner. "This is usually embarrassing to a doctor, but in fact you can get some support which can be very helpful in determining what follow up steps to take."

Billing. "Many of us are billing independently for our services," says Stettner. "New physicians may not understand how to identify, document and charge accurately for their services. If physician has policy statements to read, then they can absorb it at their own speed."

The group perspective. "A physician from another group or part of the country needs to understand what the new affiliation means. We have a new partner orientation program so a new physician get oriented to the way our group operates," says Stettner. "That includes a series of presentations which address short and long term goals, culture, and management strategies. In addition, we give physicians a handout about the group’s philosophy and guiding principles." n

groups of people, straw polls tell me that at least 50% of ED doctors are writing admission orders," says Sullivan. "However, writing orders does not increase exposure to liability. The more it looks like the ED doctor is responsible for admission care, the more likely it is that he or she will involved in a lawsuit related to the admission. The ED physician needs to understand that issue."

Policy for in-house resuscitations. This is a critical management issue that should be addressed during orientation, says Sullivan. "The range of responsibility should be very clear to new ED physicians," he emphasizes. "You must spell out exactly what is covered, [for example] resuscitations, deliveries, reading x-rays and EKGs, [or] pronouncing patient deaths?"

It should be explained that care to ED patients should not be compromised, says Sullivan. "There should be an express agreement that the ED physician cannot leave a critically ill patient in the ED," he says. "The ED physician should stay with the critically ill patient, and someone else called in to care for the in-house emergency."

Anything that is unique to your ED. "For example, we have disease reporting requirements that are a little different from other states," notes Stettner.

Individual hospital practices need to be explained, says Packard. "If you have a patient with hypertension that needs follow-up, in one hospital the patient will be sent to an oncall physician in internal medicine, but in another one that might be a strict no-no," he explains. "Instead, there might be a clinic, or a sub list of internists who take new cases."

Every ED handles things differently, says Packard. "You may have a particular way to report risk management incidents, or if a doctor has a problem with one of the medical staff physicians, maybe you handle it differently from most EDs," he explains.

Transfers. "Every hospital is different in terms of what kinds of cases your hospital cannot take care of and must be transferred, and where do they go," says Packard. "New physicians need to know what hospital they call for burns, pediatrics, and severe trauma cases."

EMTALA requirements. "Make sure physicians are thoroughly oriented in the requirements of EMTALA," says Stettner. "A new doctor who needs an ultrasound in the middle of the night needs to be told how to overcome resistance [from] radiologists."

Risk management concerns. "A new doctor might find himself involved in an incident that has potential risk. For example, there may be an untoward reaction to a drug where the physician might not have recognized an allergy and the patient deteriorates. That physician needs to know to report the incident early so the risk manager gets involved," says Stettner. "This is usually embarrassing to a doctor, but in fact you can get some support which can be very helpful in determining what follow-up steps to take."

Billing. "Many of us are billing independently for our services," says Stettner. "New physicians may not understand how to identify, document, and accurately charge for their services. If a physician has policy statements to read, then [he or she] can absorb it at [his or her] own speed."

The group perspective. "A physician from another group or part of the country needs to understand what the new affiliation means. We have a new partner orientation program so a new physician gets oriented to the way our group operates," says Stettner. "That includes a series of presentations that address short- and long-term goals, culture, and management strategies. In addition, we give physicians a handout about the group’s philosophy and guiding principles."