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Scope of Services


The following departments are an integral component of the organization and allow for optimal provision of patient care and services.

The scope of department services and care, including staff qualifications, hours of operation, staffing plans and additional information is referenced in individual departmental/service manuals.


Scope of Services:

The Admitting Department personnel are directly responsible for pre-admission, scheduling and registration of all inpatients and outpatients into the organization. Patient registration can occur in the Emergency Department, Admitting Department, Outpatient Registration Office or at bedside according to the assessed needs of the patient. The responsibilities of the department include preregistration and registration of patients to Acute, SNF, ED, OPS and outpatient ancillary services. This department provides patients with information regarding their right to make decisions regarding their healthcare (according to the PSDA), conditions of admission, patient rights and financial responsibilities which the patient may have. Whenever possible and appropriate to the patient condition, signatures required by law or regulation are obtained. The department is staffed 24 hours per day. The department provides for translation and communication needs of those patients/visitors requiring admitting services who are not fluent in the English language.

Skill Levels of Personnel:

The Admitting Department personnel must possess an accurate understanding of applicable policies and procedures, organizational regulations including patient rights and a thorough knowledge of the computerized registration system.


The Anesthesia Department provides complete anesthesia services, including general, spinal, major regional, moderate and deep sedation and pain management.

Anesthesia services are available to all inpatients and outpatients on an emergent, urgent and elective basis, Monday through Friday, with on-call coverage after hours and on weekends and holidays. Anesthesia services are available immediately when anesthesia is determined necessary for all emergency and obstetric cases.

The Anesthesia Department is directed by a board-certified anesthesiologist and staffed by qualified physicians and certified registered nurse anesthetists.

Cardiology services:

The Cardiology Department provides cardiac diagnostic therapeutic services for the inpatient and outpatient population.

The patient population served by the department consists of newborn, pediatric, adolescent, adult and geriatric patients requiring cardiac, testing or treatment to maintain optimum physiological maintenance of the cardiac system. Procedures performed by the department include but are not limited to ECGs, treadmill and thallium stress testing, nuclear cardiology, diagnostic and therapeutic coronary catheterizations. The department also covers all cardiac surgeries including grafting, value, and heart beating cardiac surgeries. The department also covers 24 hours consultations services and CCU coverage. Multispecialty outpatient's clinics are also covered.

All staff are certified clinicians and technologists

Clinical Laboratory:

The Clinical Laboratory Department provides comprehensive testing and blood bank services for all patients utilizing the facility.

The Clinical Laboratory is open seven (7) days per week, 24 hours per day to inpatient and outpatient patient population. Microbiology, Bacteriology, Hematology, Chemistry, Urinalysis, Serology, immunology, molecular biology, and Blood Bank services are available. Relationships with outside reference laboratories allow for completion of any laboratory test in a timely manner via computerized interface. All outside reference laboratories are approved by the medical staff.

The Clinical Laboratory personnel include personnel certified in medical technology and phlebotomy. Assignments within the department are based upon the complexity of the testing requirements. All personnel evidence proficiency with the Clinical Laboratory computer system and all chemistry and laboratory equipment. All personnel have an understanding and are able to demonstrate knowledge of the laboratory specific safety and infection control policies and procedures, as well as, the organizational safety management and utilities management programs. The physician director of the Clinical Laboratory is board certified in Clinical Pathology.


The Communications Department is responsible for the operation of the organization's communication system. Personnel are responsible for answering all incoming calls in a timely and professional manner and to accurately disperse all calls to their final destination. Staff is also responsible for activating the facility's overhead paging system, the internal and external pocket pager system and monitoring all of the organization wide emergency systems. The department is staffed seven (7) days per week, 24 hours per day.

Central Service and Supply:

Central Service is directed by the Materials Management Department who assumes oversight responsibility for all Central Service functions. Central Service provides and routinely stocks inpatient units with certain items, as well as fills requests for sterilized non-chargeable and chargeable items and equipment. Stocked inpatient supplies are replaced daily to a centralized location on each patient care unit. Central Service personnel are responsible for checking dates of sterile supplies maintained in the central locations on each patient care unit. Special items are ordered via computer and charged to the individual patients. Patient care personnel are responsible for placing reusable dirty supplies in appropriate containers or areas within the dirty utility rooms. Central Service personnel make frequent rounds to areas to pick up reusable equipment/supplies that need to be decontaminated and sterilized. Patient care units are restocked by par levels. Central Service is responsible for assembly of reusable instrument sets, assembly of crash carts, to clean, decontaminates and sterilizes all reusable instruments. Central Service personnel maintain quality assurance tests and documentation for each sterilizer load.

Emergency Department:

The Emergency Department is a Level one emergency treatment facility which is open 24 hours a day, seven (7) days a week, fully staffed with licensed physicians and nursing personnel at all times.

The department provides evaluation and treatment to patients of various ages and varying levels of illness from minor to critical. All patients presenting to the facility requesting emergency treatment are medically screened by the Emergency Department physician. The Emergency Department patients are then evaluated for response to treatment and are admitted to the hospital, transferred for further necessary treatment not provided by the facility or discharged with follow-up instructions as appropriate.
The Emergency Department is staffed with registered nurses and licensed practical/vocational nurses, who are certified in ACLS, PALS and BCLS. All personnel, additionally, demonstrate competency in the performance of specialized ED skills.


Engineering is responsible for the organization's equipment management program, condition of the physical plant; including all grounds and equipment. All equipment is inspected and maintained as environment units, in accordance with the equipment preventive maintenance system, either directly through the Engineering Department or via outside vendor contracting. Engineering also assumes oversight responsibility for the safety and security of the organization, including the safety management program, physical condition of the plant and grounds and security of patients, personnel and visitors.

The Engineering Department is responsible for the organization's equipment management program. The program assesses and controls the clinical and physical risks of fixed and portable equipment used for the diagnosis, treatment, monitoring and care of patients. Equipment that is considered essential for life support, associated with a higher than normal incident risk during routine operation and requiring by reason of complexity a more intensive maintenance schedule, associated with utility systems that maintain a normal hospital environment are supplied or maintained and recorded on an individual basis within the system. Inspection, maintenance and repair of the following categories of equipment and documentation thereof is the responsibility of the following departments:

  • Imaging equipment - Imaging Services
  • Laboratory testing equipment - Clinical Laboratory
  • Anesthetic delivery equipment (including analyzers) - Surgery
  • Computer terminal equipment - Data Processing/Information Systems
  • Communication lines - Operator/Business Office
  • Personal computers - Desktop Publishing/Information Systems
  • Telecommunications equipment - Operator/Business Office
  •  Verification of oxygen purity and nitrous oxide at the point of delivery to the patient - Cardiopulmonary

The personnel in the Engineering Department possess the skill level in order to provide safe, competent and accurate care as defined under the scope of care. Personnel must possess knowledge of safety program policies.

Environmental Services:

Environmental Services personnel are responsible for the routine cleaning of patient care and public areas. Personnel are called to assist in the cleaning of unusual spills. Kitchen and appliance cleaning on units is the responsibility of the Nutritional Services personnel. The Environmental Services Chairman of the Department is responsible for ensuring that Environmental Services personnel remain knowledgeable and competent in infection control as well as their other environmental responsibilities.


Financial Operations is responsible for the following functions: accounts receivable, accounts payable, including patient refunds, payroll, financial statements, budgeting, financial regulatory reporting, including OSHPD and cost reports. This department also provides support to all patient care providers throughout the organization for all data related to the financial operation of specific units and how this interrelates with the organizational mission, vision, values and goals of the hospital.

Imaging Services Department:

The Imaging Services Department is a comprehensive service providing sophisticated clinical application of imaging technology 24 hours per day, seven (7) days per week. Services are provided to the inpatient and outpatient population of all ages, both within the Imaging Services Department and at the patient bedside. Diagnostic result reporting is continuously transmitted through the computer system with hard copy printing. Outpatient results are sent to the ordering physician's office. The department consists of Diagnostic Radiology, Interventional Radiology, Nuclear Medicine, CT, MRI, Mammography and Ultrasound services.

Physician orders are entered into the computer order entry system with special needs of the patient identified at the time of ordering. Patients requiring transportation assistance will have this need met by Imaging Services Department personnel. Certain medical conditions may necessitate the accompaniment of a registered nurse based upon the assessment of the nursing personnel. Patient condition, or type of exam may require the procedure be performed outside of the department. This may occur on patient units, in the surgical suite, or any area where emergent imaging is ordered by a physician.

Scope of Services:

The Imaging Services Department provides services for the study of the anatomical processes of the human body by acquiring diagnostic images. Radiology diagnostic procedures are performed on patients of all ages, from the neonate to the geriatric patient. Nuclear Medicine provides for a study of the physiological and metabolic processes of the human body by acquiring diagnostic images after administering radioisotopes, either alone or tagged to chemicals normally utilized by the body. Isotopes are utilized as specified in the radioactive materials license.

Pregnant patients are assessed for risk, with denial of procedure when a potential for patient harm exists unless the risk from the suspected diagnosis outweighs the risk of radiation to the fetus, as determined by the referring physician and the nuclear medicine physician.

Skill Levels of Personnel:

The physician director of the department must be board certified in Radiology or possess equivalent experience and competence in the area of comprehensive diagnostic radiology services. The departmental personnel consist of licensed radiology technicians and other support staff who possess the skill level that allows for the provision of safe, competent and accurate care as defined under the scope of care.

Infection Control:

Pursuant to the organizational Infection Control Program Plan, the Infection Control Practitioner acts as the advisor and authority to each department in the hospital. The scope of services and goals of the infection control program are outlined in the Infection Control Program Plan and the Infection Control Performance Improvement Plan. The Infection Control Practitioner under the auspices of the Infection Control Committee maintains accountability for infection control and surveillance procedures. They, as well as appropriate chairman of the department and physicians, are appointed to the organizational Infection Control Committee, which determines and approves infection control policies and procedures for the hospital and considers issues impacting infection control and surveillance.

Information Management Department:

The Information Systems Department includes desktop publishing and is a critical component of the organization wide information. Information Systems Department provides for the software, hardware and support needs of the patient care providers. This support includes, but is not limited to, the installation of new software systems, along with the hardware and training necessary to utilize such systems, and ongoing maintenance of current hardware and repair of such hardware. The Information Systems Department is an important part of the decision team used in making selections of appropriate software systems to provide support in short and long-term planning for the patient care information needs of the organization.

Medical Specialties (see details in departmental Manual)

A large medical department provides integral patient care function

All medical specialties are covered including: Cardiology, Pulmonology, Gastroenterology, Rheumatology, Endocrinology, Neurology, Infectious Diseases, and Nephrology. 24 hours coverage of in patient's consultation is available as well as multi specialty out patients clinics during working hours.

All consultant physicians are board certified

Medical Records/Health Information Management Department:

The Medical Records/Health Information Management Department is responsible for overseeing the timely processing, completeness, and when necessary, the retrieval of all patient medical records.

The scope of services provided by the Medical Records/Health Information Management Department is based upon a collaboration and information sharing format to enhance patient care. Medical records services are provided to all areas of the facility, as appropriate to need and security levels. Medical record services include provision of an accurate patient record, with emphasis on the following:

  •  Record processing
  •  Record abstracting, analysis and coding
  •  Transcription of dictation for the medical record
  •  Correspondence
  •  Record retrieval, filing and storage

The scope of services also encompasses efforts made to provide:

  •  Improved data accuracy.
  •  Demonstrated balance of proper levels of security versus ease of access.
  •  Use of aggregate data, available through computerized reporting in the Medical Records/Health Information Management Department, to assist all  healthcare providers with information that allows for identification of opportunities to improve performance.
  •  Accessibility of the medical record at all times to only those authorized persons with a need to know for patient care.
  • Transcription service is available to all physicians on a 24 hours per day basis. All documents received will be placed in the chart as soon as possible to ensure timely access to this information.

Availability of Medical Records/Health Information Management personnel seven (7) days per week during regular business hours. During off hours, personnel are available by telephone. The house supervisor has access to the department and all medical records during off hours.

Medical Staff:

All departments providing patient care have established lines of communication with the medical staff. Established mechanisms for communicating issues are described in the organizational wide Manual.

Scope of care and service of each member of the medical staff is delineated through the clinical privileging process according to the bylaws of the medical staff. The Emergency Department physician is onsite 24 hours per day, seven (7) days per week to meet patient care needs. Individual service committee scope of services is outlined.

Nursing Services:

Nursing Services is under the direction of the Nurse Executive of the organization. Nursing services are provided in all direct patient care nursing units. The Nurse Executive and the individual unit nurse managers are held responsible for the nursing professional standards of the organization, the responsibility for the standards of care and practice, performance assessment and improvement, policies and procedures, nursing staffing plans, personnel competency and nursing licensure within the Nursing Services Department. Collaborative activities have been established to ensure that these responsibilities are addressed in all areas throughout the organization where nursing care is provided.

The Nurse Executive assumes an active leadership role in the hospital's decision making structures and process.

The Nurse Executive assures the provision of nursing services, in the hospital, 24 hours a day, seven (7) days per week. At least one (1) on-premise registered nurse (RN) furnishes or supervises nursing services 24 hours a day, seven (7) days per week.

Nursing care is accomplished through the execution of the nursing process; patient teaching, administering, supervising, delegating and evaluating nursing care and practice. This includes implementation of nursing standards of care and practice.

All nursing care is under the direction of registered nurses and Nursing Aides. ECG monitoring technicians must evidence competency and completion of a certified EKG reading and interpretation program. Unit secretaries must display a thorough knowledge of unit specific as well as organization wide policies and procedures and be proficient in the computer order entry system.

Nutritional Services:

Nutritional Services is responsible for providing the highest quality food services possible to all patients (pediatric through the geriatric population), personnel and visitors. Cost-effective, nutritious, high quality meals are prepared and delivered daily to patient care and public dining areas. Physician meals and catered functions are also provided. Nutritional care is planned, administered and evaluated by the Registered Dietitian according to individual patient need.

The Nutritional Services Department provides cold sandwiches and nutritional supplements, including snacks to all patient care units to be served to those patients who request food after routine meal times. Changes in diet orders are carried out in a timely manner via the computer order entry system which allows for immediate notification of dietary changes and requirements.

The Nutritional Services Department Director is responsible to ensure that all personnel are knowledgeable and competent in infection control, safety and equipment management as this pertains to the Nutritional Services Department. Additionally, the registered dietitians, must evidence competency in those areas relating to clinical nutrition, including patient education and diet counseling. All other Nutritional Services personnel must possess a thorough understanding of infection control and safety management policies, procedures and requirements as they pertain to the Nutritional Services Department.

Pediatric Specialties (see details in Departmental Manual)

A large pediatric department provides integral patient care function

All pediatric specialties are covered including: Cardiology, pulmonology, gastroenterology, rheumatology, endocrinology, neurology, infectious diseases, allergy immunology, genetics, and nephrology. 24 hours coverage of in patient's consultation is available as well as multi specialty out patients clinics during working hours.

All consultant physicians are board certified


The Pathology Department provides for examination, diagnosis and description of all human tissue and cytology specimens received in the department.

The Pathology Department provides for examination, diagnosis and description of tissue and other specimens received in the Pathology Laboratory during routine departmental hours. The Pathology Department is open during routine business hours with availability via exchange beeper of department personnel in an emergency situation.

The Pathology Department operates under the direction of a physician licensed in anatomical and clinical pathology and run by certified pathologists and pathology technologists.

Performance Improvement:

The quality department coordinates the performance improvement program, which is designed to establish, support, maintain and document improvement in the process of delivering quality patient care.

The scope of the organizational performance improvement program includes an overall assessment of the efficacy of performance improvement activities with a focus on continually improving care provided, and patient safety practices conducted, throughout the hospital. The program consists of these focus components: performance improvement, patient safety, quality assessment/improvement and quality control activities. Collaborative and specific indicators of both key processes and outcomes of care are designed, measured and assessed by all appropriate departments/services and disciplines of the facility in an effort to improve patient safety and organizational performance. These indicators are objective, measurable, based on current knowledge and experience and are structured to produce statistically valid performance measures of care provided. This mechanism also provides for evaluation of improvements and the stability of the improvement over time. A summary of the significant findings is reported at the Medical Executive Committee and the Quality Council for further review, evaluation and action, if indicated. This process includes continuous quality improvement activities, based upon team management of identified issues, quality assurance activities conducted for medical staff and healthcare provider competency and quality improvement/assessment performance.

Management supports performance improvement activities through:

  • Leadership education and direction
  • Identification of problems/concerns
  • Training activities
  • Team participation
  • Referral of appropriate issues to the organizational CQI team and the hospital wide Performance Improvement Committee

Pharmacy Department:

Copies of all physician's orders for medications are provided to the Pharmacy for filling and appropriate processing. Pharmacist and pharmacy technicians routinely make rounds of the patient care units to retrieve copies once they have been removed from the patient's medical record. Orders are filled in the Pharmacy Department after screening is performed for duplication, interactions and allergies against each patient medication profile. The Pharmacy Department is open during the hours of 8:00 AM through 4:30 PM, Saturday to Wednesday for outpatient pharmacy while the inpatient and emergency pharmacy is open 24 hours 7 days a week. A limited set of medications, approved by the hospital, are available when the Pharmacy is closed. These medications are locked and secured in an area outside of the Pharmacy. Only trained, designated prescribers and nurses are allowed access to these medications.

A pharmacist is available on-call or at another location to answer questions or provide medications that designated staff cannot access.

The Pharmacy Department is designed to meet the primary needs of all customers. The customer base is composed of all patients, both inpatients and outpatients, who require medications, medication counseling and/or education. The customer base also includes the physicians prescribing medications and other healthcare providers who administer medications to the patient population. The Pharmacy Department's services includes dispensing of pharmaceuticals, appropriate inventory maintenance functions, drug monitoring, patient drug assessment functions, appropriate record keeping, drug information, education services and performance improvement functions. The Pharmacy Department also serves in an advisory capacity through the P&T Committee, Primary Care Committee and the administrative leaders to ensure the development, coordination and review of all professional standards, procedures, policies and controls relating to procurement, storage, dispensing and safe use of medications.

The Pharmacy Department is organized to provide services directed at meeting the needs of the patient population. Services are directed toward providing care to patients in all phases of development from newborn to geriatric states.

Pharmacy Department personnel must possess the skill level in order to provide safe, competent and accurate care as defined under the above scope of care for the Pharmacy Department. Pharmacists must be registered and, with training and experience that emphasizes an acute and long term care hospital environment. Technician personnel must meet the licensing/certification requirements and should possess national certification. Ancillary and support personnel must possess basic educational requirements and be trained to assist the professional personnel as appropriate. All personnel are provided with regular continuing education and training to maintain proficiency and competence. Technicians and Pharmacists are required to demonstrate active participation in continuing education courses as required by the State Board of Pharmacy by providing documentation of attendance.

Physical Therapy:

The Physical Therapy Department provides prescribed therapies/tests for the inpatient and outpatient population. Therapy is performed at the patient bedside or in the Physical Therapy Department. Physical Therapy personnel have the responsibility to transport patients to the department for treatment and services.

The Physical Therapy Department delivers comprehensive services to individuals with physical dysfunction secondary to disability, disease or injury in accordance with professional standards of practice, departmental policies and procedures and organizational standards. Services include comprehensive assessments, development of treatment plans, delivery and documentation of care, consultation, re-evaluation, discharge planning and patient/family education.

The personnel in the Physical Therapy Department possess the appropriate skill level to provide safe, competent and accurate care as defined under the scope of care. Physical Therapists must be licensed and possess a BS or MS from an institution that meets accreditation for physical therapy licensure requirements. Physical Therapy Assistants must possess licensure. Physical Therapy Aides within the department must evidence appropriate degree of competency in physical therapy practice.

Risk Management:

The Risk Management component of the organizational performance improvement program provides direction and support to the medical staff, administrative and other healthcare providers throughout the organization. The Risk Management Coordinator is notified immediately of any significant occurrences to patients, visitors, volunteers or personnel which have the potential for serious harm. Risk management and performance improvement activities are a collaborative, blended effort due to the interrelationship of both entities. Appropriate documentation of unusual occurrences is performed within a 24-hour time frame of the occurrence.

Educational support is provided to all personnel and volunteers to ensure the provision of patient rights. Assuring patient rights is the responsibility of all hospital personnel, members of the medical staff and volunteers. Resolution and appeal processes of patient complaints are accessed through the Performance Improvement Department. Management and administrative leaders, medical staff committees with special emphasis on the multidisciplinary Ethics Committee are accountable for assuring that appropriate policies, procedures and activities are in place that ensure all patient rights are met.


The organizational safety and security program is provided for the purpose of maintaining a safe and secure environment for patients, visitors and hospital personnel. The program assesses risks through the multidisciplinary Environment of Care Committee, monitors sensitive areas and serves as a resource for security/safety information, equipment, supplies and training.

The program includes the following:

Access control to hospital facilities, motor vehicle parking control, traffic control and direction, response to calls for assistance in assaultive/combative behavior incidents, infant/child security personnel and visitor escort and a 24-hour patrol and monitoring function of the campus.

Clinical Social Work Department:

Referrals for all Social Service/Discharge Planning Services are accepted from physicians, hospital personnel, patients, families, outside agencies and other healthcare professionals as appropriate. Referrals may be made in person, by telephone or written contact. Treatment modalities of psychosocial services are available including crisis intervention, situational counseling, discharge planning and referral to appropriate community agencies. The Social Worker works closely with the interdisciplinary teams to develop a holistic plan of care for the patient. The plan is successfully executed by all team members working together with the patient/family.

The Social Service/Discharge Planning Department provides clinical social work services to inpatients, outpatients and hospital personnel. Discharge planning assistance is provided for all inpatients with follow-up referrals and assistance provided to outpatients as necessary and requested. Routine hours are from 8:00 AM through 4:30 PM, Saturday to Wednesday with Social Service access afterhours available through pager contact and Social Service response. Discharge planning activities are conducted after hours through the nursing personnel and administrative leaders, as appropriate. The Department coordinates coverage to ensure that the continuity of care needs of all patients are met in all service areas.

The Social Worker is a graduate from an accredited School of Social Work with oversight consultation and responsibility by a Licensed Clinical Social Worker.

Surgical Services:

The Surgical Services Department provides services for operative and other invasive procedures and immediate postoperative care on a 24-hour basis.

The Surgical Services Department provides a safe and comfortable environment for both patients and personnel in order to provide optimum assistance to the surgeons in meeting the emergency, preventive and restorative health needs of the patients. Procedures performed include general, ENT, ophthalmic, oral, neurological, thoracic, colorectal, cardio, vascular, urological, orthopedic, pain management, obstetrical and gynecological operative and other invasive procedures.

Patients are continually assessed throughout the peri-operative experience. Modifications to the plan of care are based on reassessment of the patient. In the immediate postoperative phase, the patient is under the direct supervision of the anesthesiologist/anesthetist who maintains responsibility for the needs of the patient until the patient has been appropriately discharged from the PACU.

Utilization Management:

Utilization management program is responsible for promoting appropriate quality patient care and effective utilization of available health resources along the continuum of care from pre-admission through post discharge. The Utilization Management Program is governed by the Utilization Management Committee with oversight responsibility for ongoing activities provided by the quality department.

Scope of Services:

Utilization Management provides services to assure appropriateness and necessity of admission at the most efficient level of care. Services are provided to assure that the level of continued care is appropriate to the patient need. Identification and analysis of patterns or trends which contribute to unnecessary or ineffective use of resources is performed. The Utilization Management Committee analyzes reviews and evaluates practices within the organization to promote and maintain quality patient care. Communication to the appropriate departments and/or committees of the results of committee findings for consideration and action is performed by the Utilization Management Committee and, as appropriate by the Utilization Management Coordinator and/or the Performance Improvement Team.



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