PINNACLE HEALTH HOSPITALS

1. PINNACLE HEALTH HOSPITALS MEDICAL AND ALLIED HEALTH STAFF ORIENTATION

2. Medical And Allied Health Staff Orientation Thank you for applying to the Medical/Allied Health Staff of Pinnacle Health System. I hope you will find the enclosed information helpful when you begin your privileges at Pinnacle Health. Please take the time to read through the information. Instructions on using Pinnacle Health’s digital dictation system are enclosed.A dictation number may be obtained from Medical Transcription at telephone number 782-4780. A Pinnacle Health Identification Badge and/or parking information may be acquired by calling Bob Beverlin at 782-3570. Access and training for the clinical information systems is provided during the onsite orientation. Physician Net Access is a service offered to physicians enabling you to view patient information from your private office. If you are interested in this service, further information and qualifications may be obtained by contacting Information Services at 231-8840. The Medical Staff Orientation Acknowledgement must be received in the Credentialing Office prior to your application being presented to the Credentials Committee. If you have any questions regarding the information, please do not hesitate to contact the Credentials Office at 231-8582/8583/8584/8585.

3. WELCOME TO PINNACLE HEALTH HOSPITALS A Tradition of Caring PinnacleHealth System The foundations of PinnacleHealth System dates to 1873, when Harrisburg Hospital was established. In 1909 another Harrisburg community hospital, Polyclinic Medical Center, was established to provide healthcare services and programs to the community. In 1995 the two organizations merged to form PinnacleHealth System, which included Harrisburg Hospital, Polyclinic Hospital and Seidle Hospital (another local hospital formed in 1936). In August 1998 Community General Osteopathic Hospital (1941), the area’s only osteopathic hospital, merged with PinnacleHealth System.

4. Our Mission . . .Our Vision . . .Our Values . . . Mission: PinnacleHealth System is a charitable organization dedicated to maintaining and improving the health and quality of life for all the people of central Pennsylvania. Vision: PinnacleHealth will be the most caring, innovative, disciplined and trusted health system in Central Pennsylvania. Values: • Concern for the total well-being of people in our community and our System family • Professionalism in dealing with our customers and each other • Respect for individual dignity and for the needs, talents and differences of others • Charity towards others and from others • Collaboration with and through our employees, affiliated physicians, other health providers and organizations • Satisfaction for those who entrust us with their care and for ourselves in fulfilling our mission • Accountability for the quality of care and the appropriate use of community resources • Safety in each act of care for our patients, our staff and our community and the design in the environment in which we work. 

5. Letter from the Pinnacle Health Hospitals Medical Staff President Dear Colleague: On behalf of the Medical Staff of the PinnacleHealth Hospitals, it is my pleasure to welcome you. The other Medical Staff Officers are Daniel Kambic, DO, president-elect, and, Harold Yang, MD, secretary-treasurer. The quarterly medical staff meetings are held on the fourth Tuesday in March at 6 p.m. in Conference Rooms 1, 2, and 3, Community General Hospital; and in June and September at 6 p.m. in the Seven Bridges Dining Room, 11th Floor, Harrisburg Hospital and the second Tuesday in December at 6 p.m. at the Harrisburg Hilton Hotel and Towers. It is my pleasure to introduce our new members at the September medical staff meeting. It is a good opportunity to meet your fellow colleagues at the dinner meeting. I hope you will be able to attend. The latest edition of our Medical Staff Bylaws, Rules and Regulations is available on the PinnacleHealth website for your perusal and reference. We would encourage you to familiarize yourself with this document. Our medical staff is composed of 11 departments – Anesthesiology, Cardiovascular Services, Emergency Medicine, Family Practice, Laboratories, Medicine, Obstetrics & Gynecology, Orthopedics, Pediatrics, Radiology and Surgery. Each department has a chairperson and most of the departments have sections and section chiefs. The medical staff organization is included within this manual for your reference. Our medical staff committee structure includes standing and special medical staff committees. Medical staff department chairperson may also form their medical staff department committees. In addition, many of our medical staff members either chair or serve on several PinnacleHealth Hospital committees. The medical staff committees are summarized in subsequent pages. Please notify me if you are interested in serving on any of the medical staff committees. Only two committees (Credentials Committee and the Medical Executive Committee) have 50 percent attendance requirements. All active medical staff members, however, are encouraged to attend the quarterly medical staff meetings, your department meetings, as well as any medical staff committees on which you have membership. A meeting schedule is enclosed as a separate document. Medical staff dues are assessed yearly with rates approved at the Annual Medical Staff Meeting. Currently the dues are $175 for active medical staff members; no dues are assessed for affiliate and honorary medical staff members. Dues are prorated for new members. Again, welcome to our medical staff. We look forward to your participation. Sincerely, Roger Levin, MD Medical Staff President

6. Letter from the President and CEO Dear Physician: Welcome to PinnacleHealth System. We hope this is the beginning of a long and mutually rewarding association for you. PinnacleHealth is the result of mergers between the area’s most respected health systems: Capital Health System, Community General Osteopathic Hospital and Polyclinic Health System. Together, we continue to serve the health needs of Central Pennsylvanians, as we have for over a century. In this totality, PinnacleHealth includes PinnacleHealth Hospitals (Harrisburg, Polyclinic, Seidle and Community General Osteopathic Hospitals); Fredricksen Outpatient Center; family practice and urgent medical care centers; home healthcare and hospice agencies; managed care entities and an array of healthcare services. We pride ourselves on the high caliber of physicians who join our Medical Staff. As a member of our Medical Staff, you should know that we’re serious about our mission in the community: “PinnacleHealth is a charitable organization dedicated to maintaining and improving the health and quality of life for all the people of Central Pennsylvania.” Our success in fulfilling that mission is dependent on the personal contribution of each and every member of our PinnacleHealth team. We look forward to working with you as we strive to strengthen both our organization and the health and quality of life for our neighbors and ourselves. Welcome aboard. Sincerely, Michael Young President and CEO PinnacleHealth System

7. Medical Staff Organization Medical Staff Officers July 1, 2012 through June 30, 2014 Roger Levin, MD – President Daniel Kambic, DO – President – Elect Harold Yang, MD – Secretary-Treasurer Senior Vice President of Medical Affairs Nirmal Joshi, MD

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15. Medical Staff Committees PinnacleHealth Hospitals Medical Staff Committees are constituted for two years. The current appointment period is from July 1, 2012 through June 30, 2014. Some committees have three-year appointment terms. Three voting members constitute a quorum except for the Medical Executive Committee where a 50 percent attendance is required for a quorum. There are eleven medical staff departments — Anesthesiology, Cardiovascular Services, Emergency Medicine, Family Practice, Laboratories, Medicine, Obstetrics and Gynecology, Orthopedics, Pediatrics, Radiology and Surgery. Medical staff committees include the Medical Executive Committee described in Article VI of the MEDICAL STAFF BYLAWS; Standing Committees of the Medical Staff described in Appendix 1, Section 3 of the MEDICAL STAFF RULES AND REGULATIONS; and Special Committees of the Medical Staff described in Appendix 1, Section 4 of the MEDICAL STAFF RULES AND REGUALTIONS. Special Committees cease every two years unless reconstituted by the Medical Executive Committee. Department chairpersons may also create department committees to expedite their responsibilities. In addition, active medical staff members are involved in several of the patient related hospital committees. These appointments are usually confirmed by the Medical Staff President. All medical staff committees submit written reports of their activities (via their meeting minutes) and any recommendations to the Medical Executive Committee. Relevant recommendations are then submitted by the Medical Executive Committee to the Board of Directors for action. Activities of the Medical Executive Committee are reported to the medical staff at every quarterly meeting by its chairperson (Medical Staff President). A 50 percent attendance requirement is required for members of the Medical Executive Committee and the Credentials Committee. Other members are encouraged to support the Medical Staff Committees to which they accept appointment. The Medical Staff Rules and Regulations identify the Medical Staff Committees, the chairpersons, main purposes and general constituencies. Please read the relevant section in the Medical Staff Bylaws and related documents for more information.

16. Forbidden and Approved Abbreviations FORBIDDEN abbreviations or Dose Designations PinnacleHealth System Approved Abbreviations/Symbols

17. Medical Staff Bylaws, Rules and Regulations The latest edition of our Medical Staff Bylaws, Rules and Regulations is available on the PinnacleHealth website for your perusal and reference. We would encourage you to familiarize yourself with this document. We also have a document, Medical Staff Bylaws for Dummies and very busy physicians, which is a condensed version of the Bylaws.

18. Credentialing Policies and Procedures The latest edition of our Medical Staff Policies and Procedures is available on the PinnacleHealth website for your perusal and reference. We would encourage you to familiarize yourself with these documents. For information regarding the processing of your application, please refer to Policy # 3, Initial Appointment Policy or Policy # 21, Allied Health Staff Initial Appointment Policy. Also, please review Policy # 17, Emergency Medical Staff Privileges.

19. Compliance Mission:  The Compliance Department is responsible to plan, design, organize, implement and maintain system-wide compliance programs to comply with all laws, regulations and internal policies. Our Services • Monitor compliance policies and procedures • Provide a resource for compliance related questions • Conduct compliance audits and monitoring services • Administer the Compliance Hotline • Conduct compliance education and training • Respond to detected compliance deficiencies and establish action plans • Perform voluntary disclosures (self reporting) to Office of Inspector General (OIG) for material compliance violations

20. Infection Control Mission: The PinnacleHealth Infection Control Department is committed to providing high quality patient care in a safe environment by reducing the risk of infection. Please review the Infection Control web page.

21. Continuing Medical Education The CME mission of Pinnacle Health System is to provide diverse educational programs that improve the knowledge, skills and attitudes of the physicians and other clinical staff of the institution.  Such programs should enhance practice performance and ultimately improve overall health care delivered by the clinical providers.  These goals are integral to Pinnacle Health’s overall mission of improving health and quality of life for all people in the region. Purpose: The purpose of our CME programs is to provide diverse educational opportunities to improve the knowledge, skills and attitudes of the physicians and other clinical staff of the institution.  We will address core competencies such as patient care, communication skills, medical knowledge, practice-based learning and improvement, system-based learning and professionalism.  The Continuing Medical Education Committee, with the assistance of the Performance Improvement department, will work to ensure that the education it provides meets the specific patient care needs of the institution.  We will achieve this mission by the continued development, assessment, conduct and evaluation of our CME offerings.

22. Performance Improvement The Performance Improvement Department's mission is to improve performance in six key elements of quality care: . Safety - preventing harm. Effectiveness - evidence-based care that results in maximum benefit. Patient Centeredness - respectful and responsive to patient needs. Timeliness - reduce waits and delays. Efficiency - achieve best outcomes with least resources, avoid waste and overuse. Equity - quality care does not depend on gender, ethnicity, socioeconomic status, or location

23. Security The Department of Security Services has an office located at each hospital campus. Staff includes security supervisors and both full and part time Security Agents. Each hospital facility is staffed 24 hours daily, seven days a week. Please review the many services offered by security on their web page. A Pinnacle Health Identification Badge and/or parking information may be acquired by calling Bob Beverlin at 782-3570.

24. Level of Intensity The Pinnacle Health Hospitals has established procedures by which the attending physician, the patient, and the patient's family or legal representative may decide appropriate levels of medical care reflecting the patients wishes. Each patient upon admission to the Pinnacle Health Hospitals shall have a Level of Intensity (LOI) assigned. Please review Administrative Policy # 113, Level of Intensity of Care Assignment.

25. Infant Deliveries by Gestational Carrier PinnacleHealth Hospitals shall provide an appropriate environment for infant deliveries by gestational carries which responds to the medical needs of the patients and which acknowledges judicially recognized rights regarding deliveries by gestational carries. Please review Administrative Policy # 161, Infant Deliveries by Gestational Carriers.

26. The PinnacleHealth System maintains a full service clinical laboratory. The clinical laboratory is comprised of the following departments: blood bank, routine clinical lab (chemistry, coagulation, hematology, toxicology, urinalysis), and microbiology. Additionally, comprehensive cytological and tissue pathology services are offered by the department of laboratory medicine. The Commonwealth of Pennsylvania licenses this clinical facility and it is fully accredited by CLIA (Clinical Laboratory Improvement Amendments). The laboratory also maintains current accreditation from the following agencies: The College of American Pathologists (CAP) and the Joint Commission. The Blood Bank also maintains current accreditation status from the American Association of Blood Banks (AABB) as well as following Food and Drug Administration (FDA) regulations. The laboratory is staffed by highly trained professionals and adheres to a strict quality control program. Frequencyand cost are the main factors that determine whether tests are performed on site. For limited volume or technically demanding tests, PinnacleHealth uses appropriate reference laboratories. The laboratory strives to provide its patients with the best type of care and services available. Specimens are processed upon receipt, and test results are reported within the shortest possible period of time as dictated by the limits of the method used for the specific test that was requested. The laboratory information system consists of the Sunquest Flexilab and WindoPath software systems. The laboratory’s systems are interfaced with the hospital information system; Siemens Soarian. This allowsthe laboratory to receive orders for laboratory tests, as well as admission, discharge and patient transfer information. A results interface is responsible for the transmission of laboratory results back into Soarian, so that results are available through a result inquiry function from any hospital terminal. Laboratory results are also available on the intranet via Physician Net Access. A regularly scheduled courier service is available to pick up specimens and deliver reports directly to your office for your convenience. This service enables us to provide the fastest possible turnaround time for your test results. Couriers are also available on an as-needed basis. Many tests are available on a STAT basis. Results will be available within one hour after the specimen is received in the laboratory. Laboratory

27. Library Services The staff of PinnacleHealth Libraries provides professional Library services to meet the information, education, and research-related needs of PinnacleHealth medical staff, employees, and patients, and offers access and assistance to community members with health information needs.

28. Pinnacle Health Auxiliary The Auxiliary is an organization of men and women dedicated to volunteerism within Pinnacle Health Hospitals. They conduct many fundraising projects each year that benefit a wide variety of patient care programs and promote community awareness. Our Auxiliary membership is open to all those interested in giving of their time for these important services. For further information please visit Auxiliary web page.

29. Pain Management Pinnacle Health believes pain relief is an integral part of comprehensive care. Pain relief requires individualized treatment to total pain: physical, psychological, social and spiritual pain. Pain management involves collaboration among patients, families, and the health care team to facilitate healing and comfort, and improve the quality of life. A patient has the right to pain management through assessment, interventions and reassessment. Optimal pain relief facilitates the patient’s ability to cope and heal, thereby enhancing quality of life. Please review Administrative Policy # 327, Pain Management.

31. Thank you for completing the Medical and Allied Health Staff Orientation program. You are required to complete an orientation attestation found by clicking on the highlighted link.