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					Brooke Army Medical Center

Department of Surgery

Fort Sam Houston, Texas 78234


Otolaryngology – Head and Neck Services
(Ear, Nose, & Throat, Audiology, and Speech Pathology Services)




               Clinical Business Rules and Protocols
                        BROOKE ARMY MEDICAL CENTER     -2-


Table of Contents_______________________________
PREFACE

EXECUTIVE SUMMARY
     MISSION STATEMENT
     LEADERSHIP TEAM AND KEY PERSONNEL
     PHILOSOPHY OF THE CLINIC AND PROCEDURE AREAS
     HOURS OF OPERATION

ADMINISTRATION

AWARDS PROCEDURES
     C.A.R.E.S. Award
     Military
     Civilian
     Contract
     Volunteer

ORIENTATION OF PERSONNEL
      In-processing Checklist
      Out-processing Checklist
      Parking Policy

ALERT ROSTER

EMERGENCY PREPAREDNESS PLAN

OVERTIME / COMPENSATORY TIME POLICIES AND PROCEDURES

ON-CALL / STANDBY POLICY

LEAVE POLICY
      Emergency Leave
      Pass
      Permissive TDY
      Sick Leave (Calling in Sick)

PERFORMANCE RATINGS / COUNSELINGS
     Military
     Civilian
     Contract

UNION NOTIFICATION REQUIREMENTS

ADDRESSING ETHICAL DILEMMAS
                       BROOKE ARMY MEDICAL CENTER            -3-


UNIT INSERVICES PROGRAM

JOB DESCRIPTIONS / STATEMENT OF WORK
      Physician
      Head Nurse
      NCOIC
      ENT Technicians / 91WP2
      Medical Clerk
      Medical Coder
      Secretary


CRIME PREVENTION
      Key Control Procedures
      Clinic Closing Procedures
      After Hours Access to Clinic
      Security Badge Procedures
      Password Protection

SAFETY
      Fire Safety Procedures
      Hazardous and Toxic Chemical Communication
      Hazardous Spills Procedures
      Radiation Safety
      Housekeeping (Refrigerator)

BUDGET

SUPPLY OPERATIONS
     Ordering Office Supplies
     Ordering Medical Supplies
     PYXIS Management
     IMPAC Credit Card Procedures

EQUIPMENT OPERATIONS
      CEEP
      MEDCASE
      Medical Maintenance Procedures
      Care of Equipment
     *Insert* Department of Surgery Equipment Tracking SOP

CLINICAL OPERATIONS

CLINIC ACCESS PLAN
       Staff Scheduling Procedures
       Appointment Types Definitions
       Appointment Protocols
                        BROOKE ARMY MEDICAL CENTER                  -4-


       New Patients
       Walk-in Patients
       Patient Instructions
       Space A (Champus / Tricare Standard)
       Follow-up Patients
       Telephone Consults
       Prescription Refill Patients
       Appointment Conversion Process
       Unbooked APR Appointments
       Priority of Care
       Special Categories and Conditions
                MEPS
                Ft. Hood / Ft. Polk Long Distance Patients
                Reserve Component
                ROTC
                VIP Procedures (Notification of Chain of Command)
                Regional Referrals
       Checking in Patients
       Patient Out-processing
       Admission and Discharge of Patients into Procedural Areas
       Late Arrival Procedures
       No Show Procedures
       Nurse Triage Procedures
       Telephone Procedures
       Patient Education
       Budget
       Supply Operations
       Space Utilization / Floor Plan
       Appointment Reminder System
       Automatic Call Distribution (ACD) System

CLINICAL REPORTS
      CHCS End-of-Day processing
      Automated Data System (ADS)

SERVICES
      CPT Codes
      DRG Codes

Front Desk Operations
       Telephone Etiquette
       Wheelchair Use

Patient Complaint / Compliment Procedure

Waiting Area Responsibilities
Consult and Referrals
                          BROOKE ARMY MEDICAL CENTER               -5-



Telephone Procedures
       Automatic Call Distribution

Nurse Triage Procedures

Patient Education

Admission and Discharge of Patients into Procedural Areas

Space Utilization
       Floor Plan

APPOINTMENT TYPES DEFINITIONS
      ROUA
      ROUB
      ROUC
      FOLA
      FOLB
      FOLC
      APR
      PRO
      PROA
      PROB
      PROC

APPOINTMENT PROTOCOLS
      New Patients
      Walk-In Patients
      Patient Instructions
      Space A (CHAMPUS Standards)
      Follow Up Patients
      Telephone Consults
      Prescription Refill Patients
      Appointment Conversion Process
      Unbooked APR Appointments
      Priority of Care
      Special Categories and Conditions
               MEPS
               Ft. Hood / Ft. Polk Long Distance Patients
               Reserve Component
               ROTC
               VIP Procedures (Notification of Chain of Command)
               Regional Referrals

       QUALITY CONTROL PROCEDURES
                        BROOKE ARMY MEDICAL CENTER                                     -6-


       JCAHO CONSIDERATIONS

       Care and Handling of Specimens

PROCEDURES SPECIFIC

       Consent for Procedures

       Special Care Needs of Children

       Special Care Needs of the Elderly

       Physical Assessment Guidelines

       Nursing Documentation


INFECTION CONTROL

       Unit Infection Control SOP

       Duties of the infection Control Coordinator

       Parenteral and Mucous Membrane Exposure

       Basic Aseptic Technique

       Dirty Utility Room

       Washroom Procedures

       Sporox-Sterilizing and Disinfecting Solution

       QA / Risk Management

CHECKLISTS


GLOSSARY OF COMMON TERMS

REFERENCES
(ADDITIONAL INFORMATION TO THESE STANDARDS OF PRACTICE, THE FOLLOWING REFERENCES AND
INSTRUCTIONAL GUIDES ARE LOCATED IN THE CLINIC LIBRARY)



FEEDBACK FORM
BROOKE ARMY MEDICAL CENTER   -7-
                             BROOKE ARMY MEDICAL CENTER                                                          -8-


Preface____________________________________________________________

The implementation of any business initiatives requires a thorough knowledge of the multitude of variables that
impact this venture. This document attempts to consolidate and present these variables in a format that will assist
leaders and managers at making decisions. This document attempts to aid the management of several resources
that involves many different assets within Brooke Army Medical Center (BAMC). Given the nature of our military
system and the frequent turnover of staff, this document serves as continuity between the leaders of the past and the
leaders of the future. The focus of this document remains on the services we provide to our patients and their ability
to receive the appropriate care at the appropriate time. To accomplish this mission it is imperative to share
information and brainstorm solutions to any bottlenecks or trouble spots. That is the goal of this handbook.
                              BROOKE ARMY MEDICAL CENTER                                                            -9-


Executive Summary
Mission Statement__________________________________________________

1. To provide state of the are medical and surgical care for all disorders of the head and neck region to all military
   beneficiaries.

2. To provide the best training in Otolaryngology-Head and Neck Surgery to our SAUSHEC residents.

3. To maintain staff readiness and prepare residents for their military mission upon graduation.


Description of the ENT, Audiology, and Speech Pathology Services_________
Purpose:

The primary goal of our service is to provide relief and control of chronic and/or acute ear, nose, and throat illnesses,
within the guidelines of military medicine for all qualified beneficiaries.



Leadership Team and Key Personnel___________________________________
LTC Jeffrey Faulkner, Chief, Otolaryngology Services
LTC Eric Helling, Assistance Chief, Otolaryngology Services
Ms. Cynthia Harrison, Chief, Audiology Services
Ms. Karen Myers, Chief, Speech Pathology Services
SFC Robert Nelson, NCOIC, ENT, Audiology, and Speech Pathology Services
SSG Jacinta Gaskin-Paulsen, NCOIC, ENT Operating Room
SSG Angel Kinsey, NCOIC, ENT Clinic
Ms. Lucille Day, Head Nurse
SGT Annette Barron, NCOIC, Audiology Clinic
Ms. Edith Foutch, Hearing Conservation Technician
Ms. Sue Pearce, Secretary
Ms. Mary Morgan, Medical Clerk
Ms. Gladys Cromartie, Medical Clerk
Ms. Leonora Rangel, Medical Clerk




Philosophy of our Service and Procedure Areas_________________________
Ear, Nose, & Throat, Audiology, and Speech Pathology Services are referral-based sub-specialties that deal with the
evaluation and treatment of chronic and/or acute ear, nose, and throat illnesses.
                             BROOKE ARMY MEDICAL CENTER                                                     - 10 -


Hours of Operation_________________________________________________
Ear, Nose, & Throat, Audiology, and Speech Pathology Services hours of operation are from 0730 – 1630 Monday
through Friday. Our services are closed on weekends and federal holidays unless otherwise directed by the Chief of
each specific clinic. During non-duty hours patients requiring emergency treatment should report to the Emergency
Room. Emergency or 72 hour consults will not be seen without the provider’s approval, unless the consult is
referring an (IFS) Iraqi Freedom Soldier or a (MEB) Medical Evaluation Board Soldier.




Administration

Awards Procedures__________________________________________________
                              BROOKE ARMY MEDICAL CENTER                                                           - 11 -

C.A.R.E.S. Award
(Competitive, one-time award)
     AMEDD E-Form 4.7
     BAMC Form 660
     Local Forms
     Scroll 2-3 pages



You Make A Difference
(Non-competitive, on-the-spot award)

For further reference to the above awards, please call BAMC Department of Ministry and Pastoral Care at 916-1105.

Military
           AR 600-8-22

Civilian
           AR 672-20

Contract
        Unknown

Volunteer
        Unknown



Orientation of Personnel_____________________________________________

In Processing

DA Form 5123-1-R

All military personnel will in-process through the unit to which they are assigned. Once in-processed through the unit,
the NCOIC will make sure all enlisted soldiers are in-processed through the hospital, orientated to the clinic,
evaluated for skills assessment, assigned a preceptor, ad provided clinic specific training and evaluation(s). The
Chief of the specific clinic is responsible for the evaluation / training of all professional providers (i.e.- Physicians,
Audiologists, and Speech Pathologists).

The NCOIC will make sure that all civilian personnel are in-processed through the hospital to include obtaining all
necessary access badges, receiving Department of Nursing Orientation (DONO), and any clinic specific training and
evaluation(s).

Out Processing

All personnel will out-process the hospital by turning in all keys, access badges, etc. to the NCOIC, prior to out-
processing the hospital and any other necessary areas. All enlisted military personnel will remain under supervision
of the clinic NCOIC until completely out-processed (determined by out-processing check list obtained from the
                              BROOKE ARMY MEDICAL CENTER                                                        - 12 -


company of assignment), at which time the soldier will be placed on the appropriate transitional status i.e., PCS
Leave, Terminal Leave, etc.


Parking Policy

Parking spaces at BAMC are at a premium. All personnel assigned to the clinic, as all employees at BAMC, should
park in the last two outermost rows of parking lots A, B, C, or D during regular business hours. This will avail a
higher number of parking spaces to patients and visitors. Employees, unless authorized, should not park in spaces
designated for disabled persons. Additional parking is available at parking lot E, across the main thoroughfare to the
hospital.




Alert Roster______________________________________________________________

Each military staff member is issued an updated copy of the service’s Alert Roster upon arrival. The Service NCOIC
will then provide the staff with updates as needed. A list of contact numbers is also kept on the L Drive under the
Administrative Information folder. The contact list has the phone numbers of the civilian staff and Air Force personnel
as well as that of the Army personnel.




Emergency Preparedness Plan______________________________________________

The Emergency Preparedness Plan for Brooke Army Medical Center can be found on the Local Area Network (LAN),
under the following hierarchy:
     BAMC Programs
     Administrative Systems
     BAMCEPP. DOC

See your clinic NCOIC for any questions regarding the Emergency Preparedness Plan.




Overtime / Compensatory Time Policies and Procedures__________________

AFGE Local 1004 Labor Agreement (BAMC)
For policies and procedures regarding overtime, refer to Article 22, Overtime/On-Call, in the Labor Agreement
Handbook, an agreement between Brooke Army Medical Center and the American Federation of Government
Employees Local 1004.
                              BROOKE ARMY MEDICAL CENTER                                                         - 13 -


For policies and procedures regarding compensatory time, refer to ???, ??? in Labor Agreement Handbook, an
agreement between Brooke Army Medical Center and the American Federation of Government Employees Local
1004.


On-Call / Standby Policy_____________________________________________

AFGE Local 1004 Labor Agreement (BAMC)

For policies and procedures regarding On-Call/Standby, refer to Article 22, Overtime/On- Call, in the Labor
Agreement Handbook, an agreement between Brooke Army Medical Center and the American Federation of
Government Employees Local 1004.


Leave Policy_______________________________________________________

For information on civilian leave policies, refer to AFGE Local 1004 Labor Agreement (BAMC)

For information on military leave policies, please see Department of Nursing Administrative Protocols C-6 & C-7,
Reference: AR 630-5, FSH Memo 690-14.

Emergency Leave: Emergency Leave will be authorized by the Company Commander with the receipt of a Red
Cross message. A person may request normal leave under emergency circumstances without a Red Cross
message, but will be subject to approval by the supervisor and the Company Commander. If this type of leave is
requested on a weekend, the supervisor should notify the BAMC Staff Duty (916-1244) to get approval and a control
number for the DA31. The person requesting the leave will then need to sign out at the Staff Duty desk in the
barracks dayroom across from the BAMC track.

Pass: Passes will be granted for outstanding performance (score of 270 and above on the APFT with 90 in each
event, Re-enlisting, etc..) or be issued as compensatory time. Passes cannot exceed 4 days in length

Permissive TDY: Permissive TDY can be granted in 10 day increments when in processing or out processing.
Other TDYs must be professionally or mission related, and must be approved by the clinic chief and the Troop
Commander.

Sick Leave: Sick leave is authorized for civilian personnel and is subject to the rules and regulations outlined in the
AFGE Local 1004 Labor Agreement.




Performance Ratings / Counseling____________________________________

Military
                               BROOKE ARMY MEDICAL CENTER                                                             - 14 -


          O-1 and above
           AR 623-105

          E-6 and below are required to be counseled quarterly by AR 623-205, however, the Service NCOIC should
           encourage monthly counseling when time permits. E-7 and above will be counseled quarterly.
          E-5 and above will receive NCOERs.
               - Reference:
                   AR 623-205
                   FM 25-100

Civilian

          Reference Total Army Performance Evaluation System (TAPES) Chapter 4302 (DA PAM 690-400).

          For further information, contact one of the following in the BAMC Personnel Office, RM 713-14.

          Vicky Alvilar             295-0515

          Irene Jiminez             221-2420

          Carol Cain                221-0878

          Lou Ann Reiser            221-2489



Contract

          Contact Contracting Agency.



Union Notification Requirements______________________________________
AFGE Local 1004 Labor Agreements (BAMC)
The Union will be notified and be given the oppor1unity to be present and to par1icipate at any formal
discussion between one or more representatives of Management and one or more employees in the unit or
their representatives concerning any grievance, personnel policy or practice or other general condition of
employment. The Union will also be allowed to be present and represent an employee at any examination
of an employee in the bargaining unit by a representative of Management in connection with an
investigation, if the employee reasonably believes that the examination may result on disciplinary/adverse
action against the employee and the employee requests representation.

Any exceptions to this policy are detailed in the following articles: Article 24- Employee Counseling, Article 28 -
Actions Based on Unacceptable Performance, 29 -Disciplinary Actions, & 30 -Adverse Actions, of the Labor
Agreement Handbook, an agreement between Brooke Army Medical Center and the American Federation of
Government Employees Local 1004.
                             BROOKE ARMY MEDICAL CENTER                                                        - 15 -

Addressing Ethical Dilemmas_________________________________________
Ethical dilemmas on rare occasions, present themselves in the work environment, when an employee observes
another employee, basically and simply, doing something that should not be done or condoned, that demonstrates
immoral work ethics, or worse, is even criminal in nature. Examples are unfair/unauthorized absences from the work
place, malingering, abuse of sick leave, preferential treatment or harassment, repeated extended lunch periods,
unfair distribution of workload, questionably attending to personal business during duty hours, misuse of government
computers or other equipment, and questionable use of government funds.
Ethical dilemmas should be addressed in the following manner:

    1. Discuss the situation with the involved parties. One may find that the dilemma resulted from a
       miscommunication or misunderstanding.

    2. Discuss the situation with your immediate supervisor. Normally, this discussion should be the end
       point in an ethical dilemma.

    3. If the dilemma is not resolved after contacting your immediate supervisor, follow your normal chain of
       command to ensure prompt action is taken to assist you in correcting and/or dealing appropriately with the
       dilemma.

    4. A copy of the complaint may be forwarded to the applicable ethics committee for review and further
       assistance.



Unit In-Services Program____________________________________________
The BAMC Form 492 NS, Unit In-service Continuing Education Individual Record, parts A-D, will be maintained on
all Department of Nursing personnel. The forms should be kept in a three-ring binder on each nursing unit.

The Unit In-service Continuing Education Individual Record consists of the following documents:

         a. Form 492 NS: This is the Record Audit Sheet. This sheet will be placed in the front of the notebook. It
            will reflect audits of each nursing unit's CE records. Unit In-service Coordinators, Head
            Nurses/Wardmasters, and Clinical Supervisors and NETS staff should accomplish periodic audits.

         b. Form 492 A-D: These records will be maintained on each unit on each individual assigned to the
            Department of Nursing.

                  (1) Part A contains individual data and should be updated as information changes.
                             BROOKE ARMY MEDICAL CENTER                                                        - 16 -




Safety_____________________________________________________________
FIRE:
    a. Fire Prevention:
        (1) Smoking is prohibited within any BAMC facility.
        (2) Keep store rooms, hallways, and stairways free of trash and clutter.
        (3) Inspect for improper or unserviceable electrical wiring. Report problems to medical maintenance or
             building administration officer / NCOs.
        (4) Doors to hazardous areas such as trash room and dirty linen rooms should be kept closed.
        (5) Inspect electrically powered equipment before use.
   b. Procedures to follow in case of fire:
        (1) Remove patients from immediate danger.
        (2) Close doors.
        (3) Use manual fire alarm box and call Fire Depar1ment at 911, For1 Sam Houston Fire
             Department.
        (4) Attempt to extinguish the fire with appropriate equipment.
        (5) Disconnect electrical appliances.
        (6) Leave electric lights burning.
        (7) Do not call Information Desk to inquire where the fire is. The Information Desk will notify
            affected units adjacent to the zones.
        (8) Prepare to move to adjoining fire zone.
        (9) Notify appropriate nursing section supervisor for assistance to evacuate patients.

    Our Fire Zone(s):     2C1 – Clinical Area                 4M2 – Waiting Area

    See Appendix – 3.


BOMB THREAT:

1. Person receiving call will.
         (1) Attempt to keep the caller on the line and try to identify background noises
         (2) Attempt to ascertain location of the device.
         (3) Attempt to ascertain expected time of detonation.
         (4) Complete 'BAMC Bomb Data Card" (BAMC Form 902 (OT) dated Aug 2003.
         (5) Notify, DURING NORMAL DUTY HOURS BAMC Provost Marshal and
               Fort Sam Houston Military Police.
         (6) Notify, AFTER DUTY HOURS AOD.
         (7) Notify NCOIC, Chief of Service, and/or senior-ranking person in the immediate area at the time.
     b. NCOIC and/or Chief of service will notify the Department of Surgery when a bomb threat is received.
NOTE: The decision to evacuate patients will be made by the Commander or his designated representative and in
cooperation/coordination with Chief, Department of Surgery or his / her designee.
                             BROOKE ARMY MEDICAL CENTER                                                       - 17 -




Budget___________________________________________________________
The NCOIC, ENT Clinic, serves as the Resource Manager for ENT, Audiology, and Speech Pathology Services. He
receives budgetary guidance and monthly information from the Administrator, Department of Surgery.




Supply Operations__________________________________________________
All requisitions for supplies, services, and equipment must be officially approved. Regulations do not allow an
individual to obligate the U.S. government without official approval. These requisitions should be processed through
the Department of Surgery.
Normal hours for routine requests are Monday through Friday from 0730 until 1630.
Emergency requisitions will be processed at any time
Purchase requests may be forwarded to the Administrative Office, DOS at any time. All routine purchase requests
will be processed to Logistics in the order that they are received.
Points of contact regarding questions about these issues should be directed either to the Budget Assistant (Rachel
Patoja @ 6-4413, DOS or the Administrator (CPT Kim @ 6-5141), DOS.


Equipment Operation________________________________________________
The Hand Receipt Holder (NCOIC) is ultimately responsible for the accountability and maintenance of all equipment.
All staff members are expected to operate and maintain the equipment in the manner for which it was acquired. Any
deficiency and/ or violations of usage should immediately be reported to the NCOIC.

CEEP - Refer to Ms. Rose Slack, 6-45311 CEEP Manager, Logistics Division - Equipment with value under $1,00K

MEDCASE - Equipment with value over $1,00K.

Medical Maintenance Procedures-
        Preventive Maintenance
        Reference Medical Maintenance Branch. NCOIC, SFC Lee 916-2613.


        Automated Maintenance Request
        MEDCOM Form 643 to Medical Maintenance Branch


        Care of Equipment
        Individual training manuals / operators guides are located in the NCOIC’s office.
                              BROOKE ARMY MEDICAL CENTER                                                         - 18 -



Department of Surgery Equipment Tracking SOP {(Insert) as of 23 June 2004}


         “a. Department of Surgery Primary Hand Receipt Holders (PHRH) will execute positive control of equipment by:

             (1) Ensuring all doors leading to service area lock automatically and are secured at all times, 24 hours a
             day 7 days a week.

             (2) Highlighted labels will be placed on all equipment making identification of service specific equipment
             more easily recognizable (Ex. “PLEASE RETURN TO ANESTHESIA”).

             (3) Tracking patients and equipment by use of Operating Room Schedule obtained from Ms. Wildie
             (O.R. Scheduler). PHRH will biweekly search the Emergency Room, Wards, Clinics, etc. for missing
             equipment. Exchanging equipment once patients have reached end-state.

             (4) Increasing Frequency of Inventory Inspections. Hand Receipts will be divided into 6 (six) equal
             parts. Every month PHRH will inspect one part of their hand receipt identifying any missing or
             damaged equipment.”




Examination Room Requirements and Care____________________________
Each exam room will be equipped with an exam chair; a wall-mounted microscope; and a SMR unit (stocked with
nasal speculums, laryngeal mirrors, bayonet forceps, sweetheart retractors, suction tips, cerumen loops, rosen
picks, ear forceps, ear speculums, ear wicks, sterile and non-sterile tongue depressors, sterile and non-sterile cotton
tip applicators, band-aids, sterile and non-sterile 4x4 gauze, telfa pads, medical tape, gelfilm, gelfoam, culturette
tubes, xerofoam gauze, vaseline gauze, staple remover, surgical patties, coban, trach suction catheters, tonsil
sponges, bulb syringes, kerlix gauze, alcohol pads, cotton balls, anti-fog solution, medicine cups, pocket mask,
portable otoscope, insufflator bulb w/ magnifying lens, portable light source, bead-warmer, emesis basins, chux, and
stethoscope); and sani-clothe wipes. Each SMR Unit will be set up with a chux, paper towel, one nasal speculum,
two tongue depressors, and one non-sterile 4x4 for each patient. Once the patient’s examination is complete the
SMR Unit set up will be removed in discarding in the proper area, and the SMR Unit and chair will be completely
disinfected with the Sani-clothe wipes.




Medical Equipment Acquisition_______________________________________
All requests for new medical equipment begin with a request using DA Form 3953, and requirement justification as
indicated. Before any funds are expended for any equipment, a query for excess equipment within BAMC should be
made. Several funding mechanisms are in place and should be examined before proceeding. Point of contact within
DOS is the Administrator.
                               BROOKE ARMY MEDICAL CENTER                                                        - 19 -


Clinical Operations


Clinical Access Plan_________________________________________________

To ensure clinic access is maximized and that the clinic is working to meet clinic, BAMC, and MEDCOM missions,
the clinic access plan encompasses the following four areas:

Manpower
    Appropriate staffing levels in clinic (i.e. clerical, clinical)

    Staffing Scheduling Procedures

    The service chief is ultimately responsible for provider scheduling. The ENT, Audiology, & Speech Pathology
    Services appointment schedule will be established on a monthly basis and submitted to CHCS 30-60 days in
    advance. The service NCOIC and the Chief of that specific service will closely coordinate appointment types
    (SPEC, EST, WELL, and PROC) and their relative ratios. Access to care will be in keeping with DOD beneficiary
    guidelines.

Methods
     Increased communication between Department of Surgery clinics and Tricare Service Center
     Appointment templates/protocols
     Protocols for new patients, follow-up patients, prescription refills, telephone consults, consultation/referral
     Protocols for patient in-processing and out-processing, no-shows, and late arrivals.
     Patient complain/compliment procedures
     Nurse triage
     Telephone Procedures
     Patient Education

         Appointment Types Definitions

         ENT Clinic:
         SPEC                       New patient appointment (Patient being seen for the 1st time in clinic)
         EST                        Established patient appointment (Patient been seen in clinic before)
         EST$                       Established patient appointment (Physician book only for follow-up)
         WELL$              Pre-operative appointment (Patient scheduled for surgical procedure)
         PROC                       Procedure appointment (Patient is having a minor procedure in clinic)

         Speech Pathology Clinic:
         SPEC                    New patient appointment (Patient being seen for the 1st time in clinic)
         EST                     Established patient appointment (Patient been seen in clinic before)
         PROC                    Procedure appointment (Patient is having a minor procedure in clinic or
                                 in Radiology)
                     BROOKE ARMY MEDICAL CENTER                                                        - 20 -


Audiology Clinic:
SPEC                       New patient appointment (Patient being seen for the 1st time in clinic)
EST                        Established patient appointment (Patient been seen in clinic before)
WELL                       Hearing Aid(s) appointment (Patient is having hearing aid adjustments)
PROC                       Procedure appointment (Patient is having a minor procedure in clinic)



Appointment Protocols
1. APR slots will only be offered on Thursday's and will be booked at the physician’s request.
2. Only patients 18 years and older will be treated in the Pain Clinic.
3. If patient has had no contact with the Pain Clinic for a period of six months, patient will be
    considered a new patient and will require a new referral from their PCM.
4. All new patients need a referral from their PCM.
5. This clinic does not accept walk-ins unless it is a doctor to doctor arrangement.
7. All new slots are 60-minute in duration. Follow-up slots will be 30-minute in duration.
8. Seeing a patient who is 15 minutes or more late for an appointment will be seen at the
    discretion of the involved physician. A patient may be seen if it will not disrupt the remaining
    schedule for the day. Extenuating circumstances (medevac, long distance drive, bad weather,
    etc) will be taken into consideration but does not guarantee an appointment as scheduled.
    Rescheduling, if necessary, will be made with the physician's coordination to ensure the
    patient is not being placed at risk by waiting.
9. Give consideration to distances a patient has to commute when booking time and day of
   appointment. (i.e. Fort Hood bus schedule, and medevac aircraft schedule)
10. Initial and subsequent follow-ups are scheduled with the same physician to ensure continuity
     of care.
11. The patient automated reminder system will telephonically remind patients of their
     appointment two days prior to their appointment.

New Patients
New patients require a consult.

WaIk-In Patients
Walk-in patients are not accepted unless authorized through a doctor to doctor arrangement, and/or one of
the service providers instructed that patient to walk-in on a specific date.

Patient Instructions
Subject to provider disposition. Refer to patient education section.

Space A (CHAMPUS Standard)
Not accepted in the ENT, Audiology, and Speech Pathology Services.

Follow Up Patients
The number of follow-up visits is unlimited based on the provider. The provider will make the decision on
when follow-up care is no longer needed.

Telephone Consults
24 – 72 hours turnaround time.
Patient’s Prescription Refills
                             BROOKE ARMY MEDICAL CENTER                                                             - 21 -

       Patients are asked to call the front desk to leave a telephone consult for the physician to request a refill for
       medications.

       Priority of Care
       Active Duty, Tricare Prime, Tricare Senior Prime

       Special Categories and Conditions
       Everything will be handled with utmost privacy in this clinic because of the sensitivity of the patient and/or
       nature of diagnosis.

       Ft. Hood / Ft. Polk Long Distance Patients
       Long distance patients are given priority for appointments. However, the severity of the
       consult will determine the appointment date.

       VIP Procedure (notification of Chain of Command)
       These are dealt with on a case by case basis. The Chief of the specific clinic and the
       NCOIC will be notified.

       Regional Referrals
       Regional referrals will be coordinated through the Tricare Service Center. Urgent or 72 hour consults are
       conducted on a doctor to doctor basis.

       Checking in Patients
       See In/Out-processing checklists.

       Patient Out-processing
       See In/Out-processing checklists.

       Late Arrival Procedures
       Patients are given a fifth-teen minute grace period from their scheduled appointment time to check in with
       the front desk. However, if a patient shows up late, the provider will make every reasonable effort to see
       that patient on that same day.

       No Show Procedures
       If the patient does not show for his/her appointment, that patient will have to contact the medical clerk to
       schedule another appointment.

       Patient Complaint / Compliment Procedure
       A. Every attempt will be made to handle all patient complaints locally by one of the specific clinic’s
           providers or NCOIC. If the patient(s) is/are still dissatisfied, the patient will be directed to the hospital’s
           Patient Representative Office.
       B. All complaints received through the Patient Representative Office or the BAMC Command will be given
           the highest priority.




Telephone Procedures
                             BROOKE ARMY MEDICAL CENTER                                                            - 22 -


        For patients, enter a TCON.
        For emergency cases, refer patient to Emergency Department / Urgent Care Clinic
        For physician to physician, inform the service physician before transferring the call.
        Obtain name, sponsor’s SSN, reason for the call, and a good return phone number for all phone calls.

Patient Education
Patient educational pamphlets, brochures, and handouts are displayed in the service’s lobby area.

Budget
For more information, contact the Department of Surgery’s Resource Technician or Administrator.

Supply Operations
All requisitions for supplies, services, and equipment must be officially approved. Regulations do not allow an
individual to obligate the U.S. government without official approval. These requisitions should be processed through
the Department of Medicine.

Normal hours for routine requests are Monday through Friday 0730 until 1630.

Space Utilization / Floor Plan
See Appendix A-1


Appointment Scheduling Systems:
    Appointment Reminder System
    Automatic Call Distribution (ACD) System

         Appointment Reminder System
         The appointment reminder system will call patients two days prior to their scheduled appointment(s). Using
         the last four digits of the sponsor's SSN as a password, the patient will be able to confirm or cancel a
         scheduled appointment.

         The system will attempt to call patients three times within three hours, and will not leave messages on
         answering machines.

         Daily reports will be generated informing the clinic staff of confirmed appointments, canceled appointments
         and patients who were not contacted.

         Clinics who wish to be excluded from the Appointment Reminder System should submit a memo/e-mail to
         the DCCS stating the wish to be excluded.

         Automatic Call Distribution (ACD) System
         Ear, Nose, & Throat, Audiology, and Speech Pathology Services are monitored by this system.




Clinic Reports______________________________________________________
                              BROOKE ARMY MEDICAL CENTER                                                          - 23 -



End of Day Report
The end-of-day reports are available in CHCS. Need not be printed, but must be reconciled / closed out on a daily
basis. Weekly, as a minimum, the NCOIC or front desk supervisor will ensure compliance by reviewing these reports
via CHCS.

KGADS Workload without ADS Records Report
NLT the 4th duty day of the month, print out the report for all providers. More frequent reports are to be printed on the
basis needed to ensure an acceptable BAMC standard as indicated in the CG MMR.

Clinic Workload Report
Monthly print from CHCS. Data should be compiled annually to reflect as a minimum, the total workload count for
the clinic. This data shows provider statistics by patient category and appointment type.

No Show Statistical Report
Monthly print from CHCS to obtain no-show rates by doctor or the clinic.

Appointment Utilization Report
Monthly print from CHCS

Clinic MMR
Prepare a monthly report that tracks the Service Chief’s selected items from the CG MMR, modified the report to
reflect individual provider statistics for the total service.

Defense Medical Human Resources System (DMHRS)
Monthly, complete the DMHRS report from compilation of surveys given to all employees reflecting workload type by
hours (See appendix for survey sheets).

Quality Improvement Report
This report is due to the Department of Surgery’s Quality Improvement Coordinator by the 7th of each month. The
final report compiled by Clinic Nurse with inputs on different M&Es from the Physicians, NCOIC, and clerical staff.
(Refer to 01 Plan maintained in Nurse's Office)

Budget Report
At the request of the Chief, or quarterly as a minimum, provide a report on the budget status/balances for the clinic
for TDY, Supplies (medical and office), overtime, etc.

Clinic Patient Base by Beneficiary Category
Annually prepare a breakdown of the clinic’s patient base by beneficiary category (Active Duty members, Active
Duty Dependents, Retiree, Retiree Dependents, and by service. The source for this program is CHCS.




Clinic Patient Base by Priority
Annually prepare a breakdown of the clinic’s follow-up patient base by priority designation
(Active Duty, Tri-care Prime, Tri-care Senior, Tri-care Space A, and others {TDRL, PDRL,
Foreigners, etc.}). The source for this program would be ADS Business Objects or clinic files.
                             BROOKE ARMY MEDICAL CENTER                                                      - 24 -



New Patient Appointments Report
As needed, report number of new patients seen per month by category (ROUA, B, C, B1 and MBP). The source for
this program is CHCS clinic workload report.

Special Reports
Periodically the Chief of the service or the NCOIC may request a special data/reports that are only accessible from
ADS Business Objects. Contact the ADS Systems administrator for special reports.




Ancillary Support__________________________________________________


Pharmacy Services
The clinic will maintain within locked supply closet the following items:
Phenol, Cortisporin Otic Suspension, Gentian Violet, Lidocaine Jelly 2%, Ophthalmic Bacitracin, Gentamicin Sulfate
Ophthalmic, Sodium Bicarbonate 8.4% (Inj.), Kenlog 10 (Inj.), Kenlog 40 (Inj.), Lidocaine 1:100,000 w/Epi (Inj.),
Lidocaine Viscus 2%, Lidocaine Topical Solution 4%, Hurricaine Spray (Benzoncaine 20%), Genasal
(Oxymetazoline 0.05%), Saline Mist (Sodium Chloride 0.65%), Silver Nitrate Applicators, Attachol, Detachol,
Benzoin Tincture, Hydrocortisone Cream 1%, Bacitracin Ointment, Hypodermic Needles and Syringes, and Surgical
Knives and Blades.

These bulk drugs are supplied by Inpatient Pharmacy. Supplies will be kept in stock and current with regular checks
for expiration dates by the NCOIC of the clinic. The Pharmacy also conducts monthly checks.


Radiology Service
Radiology is involved regarding MRI's and procedures performed under fluoroscopy. Patient requiring MRI's for Pain
procedures will be given consults. MRl's are all performed within the Radiology Department, 1s1 floor, BAMC.




Front Desk Operations______________________________________________

See Front Desk Checklist (In / Out Processing)

Waiting Area Responsibilities________________________________________
                              BROOKE ARMY MEDICAL CENTER                                                        - 25 -



The Medical Clerks at the front desk area along with the NCOIC monitors patient control in the waiting area.




Admission and Discharge of Patients into Procedural Areas_______________


For patients that are scheduled to have a procedure in the clinic, they are check into the clinic as normal. Once the
patient has been call and seating in the procedure room by the technician, the provider will then go over the consent
form with the patient and explain the possible risk of the procedure.

For patients that are scheduled to have procedures in the main operating room, they are scheduled to have a pre-
operative appointment with the provider at least 24 hours prior to the procedure in the clinic to discuss any concerns
and to have any questions answered. Once the patient has finished with his/her pre-operative appointment in the
clinic, they are scheduled to have another pre-operative appointment with the Pre-Admissions Department on the
first floor next to the Specimen Collection Area.




Procedures Specific_________________________________________________



SCOPE OF CLINIC OPERATIONS (Ear, Nose, Throat Clinic):

1. Patients will check in with the medical clerk(s) at the front desk upon their arrival to our clinic.
2. The patient’s chart will be removed from the front desk area and taken to the Tech Office, in order for the
   patient to be seen in the order of his/her appointment time.
3. The patient will be called by the technician (the technician will state the patient’s name and the physician’s
   name that the patient will be seeing) and taken to the exam room. The technician will complete the initial
   screening process of that patient, and brief the physician on the results. If any additional information is needed
   to assistance the physician at that time, than the technician will take action.
4. Once the patient’s exam is over and the patient has left the room, the technician will than remove the SMR Unit
   set up placing the items used in the proper receptacles. Wipe down the SMR Unit and exam chair with the
   Sani-clothe disinfectant wipes, and place a new SMR Unit set in place for the next patient to be seen.
5. Throughout the course of the day the technician will clean the instruments and scopes as needed.
   a. The technician will transport all dirty instruments and dirty scopes from the clinical area to the
       utility room inside a dirty container. (The technician will wear gloves while transporting the dirty
       containers.)
   b. Once inside the utility room, the technician will don the proper personal protective equipment in
       order to clean the soiled instruments and soiled scopes.
   c. The soiled instruments will be placed in the wash basin inside the sink and sprayed with Pro EZ
                              BROOKE ARMY MEDICAL CENTER                                                      - 26 -


       Foam (Foaming Enzymatic Spray) to disinfect and remove all proteins from the instruments.
       After soaking the instruments in the Pro EZ Foam for 20 minutes, the instruments are rinsed off
       with water; placed into the red container and taken to CMS for sterilization. The instruments are
       picked up from CMS on the next business day after being sterilized. (If the instruments have a
       high amount of protein before the cleaning process is started, then the instruments will be placed
       into the 11 gallon Ultrasonic cleaner for a 15 minute cycle.
    d. The soiled scopes will be placed in the wash basin inside the sink and sprayed with Pro EZ Foam
       (Foaming Enzymatic Spray) to disinfect and remove all proteins from the scopes. After
       disinfecting and removing all of the proteins from the scopes, the technician will rinse off the
       scopes and place them inside the System 83 Plus Ultrasonic Endoscope Washer to be sanitized.
    e. Once the scope has been sanitized, it will be returned to the tech room and stored in the clean storage
         cabinet ready to use.




SCOPE OF CLINIC OPERATIONS (Speech Pathology Clinic):

1. Patients will check in with the medical clerk(s) at the front desk upon their arrival to our clinic.
2. The patients chart will be placed in the chart bend and the Speech Pathologist will be informed of the patient’s
   arrival.
3. The Speech Pathologist will than call the patient from the wait area, take the patient into the exam room, and
   complete the examination.
4. Once the patient’s exam is over and the patient has left the room, the speech pathologist will than remove the
   items used and places the items in the proper receptacle. Wipe down the Video-Strobe Unit and exam chair
   with the Sani-clothe disinfectant wipes, and prepare the Video-Strobe Unit and exam room for the next patient
   to be seen.
5. Throughout the course of the day the speech pathologist will clean the scopes as needed.
   a. The speech pathologist will transport all dirty scopes from the clinical area to the utility room
       inside a dirty container. (The speech pathologist will wear gloves while transporting the dirty
       containers.)
   b. Once inside the utility room, the speech pathologist will don the proper personal protective
       equipment in order to clean the soiled scopes.
   c. The soiled scopes will be placed in the wash basin inside the sink and sprayed with Pro EZ Foam
       (Foaming Enzymatic Spray) to disinfect and remove all proteins from the scopes. After
       disinfecting and removing all of the proteins from the scopes, the technician will rinse off the
       scopes and place them inside the System 83 Plus Ultrasonic Endoscope Washer to be sanitized.
         c. Once the scope has been sanitized, it will be returned to clean storage cabinet ready to use.

SCOPE OF CLINIC OPERATIONS (Audiology Clinic):

    1. Patients will check in with the medical clerk(s) at the front desk upon their arrival to our clinic.
    2. The patient’s chart will be placed in the chart bend and the audiologist/technician will be
       informed of the patient’s arrival.
                             BROOKE ARMY MEDICAL CENTER                                                      - 27 -


    3. The audiologist/technician will than call the patient from the wait area, take the patient into the
       required area (Audiology booth, hearing aid fitting room, or hearing aid repair station), and
       complete the required examination, fitting, or repair.
    4. Once the patient’s exam is over and the patient has left the room, the audiologist/technician will
       than remove the items used and place the items in the proper receptacles. Wipe down the patient
       headphones, responding hand-switch, and the chair with the Sani-clothe disinfectant wipes, and
       prepare the equipment and exam room for the next patient to be seen.




OTHER PROCEDURES:

Examples of ENT Clinical Procedures:

1. Myringotomy / Myringotomy with P.E. Tube placement
2. Nasal Reduction
3. Biopsy of the head and neck area
4. Removal of Nasal polyps
5. Foreign body removal from ear, nose, or throat
6. Incision and drainage of a Peritonsillar abscess
7. Incision and drainage of an ear abscess
8. Control an epistaxis (nosebleed)
9. Patch an eardrum
10. Bronchoscopy
11. Tonsil hemorrhage
12. Cerumenectomy
13. Post-operative FESS Cleaning
14. Fine Needle Aspiration
15. Trach care management

16. The procedures listed below are not done in the ENT Clinic. They are done in the operating room,
    some are done in the ENT Minor Surgery Room:
    a. Tonsillectomy
    b. Adenoidectomy
    c. Septoplasty
    d. Septorhinoplasty
    e. Antral Window
    f. Caldwell-Luc
    g. Direct Laryngoscopy
    h. Stapedectomy
    i. Myringoplasty
    j. Middle Ear Exploration
    k. Otoplasty
    l. Exploratory Tympanotomy
                             BROOKE ARMY MEDICAL CENTER                                        - 28 -


    m. Blepharoplasty
    n. Tympanoplasty
    o. Radical Neck Surgery
(Note: For complete lists of procedures see Op-Log.)

Examples of Speech Pathology Clinical Procedures:

1. Laryngeal Videostroboscopy
2. Videofluoroscopic Swallowing Study - performed in the Fluoroscopy Suite in Radiology
3. Fiberoptic Laryngoscopic Swallowing Study - performed in the clinic or in inpatient room


Examples of Audiology Clinical Procedures:

1. Pure Tone Testing
        a. Air Conduction
        d. Bone Conduction
        e. Pure Tone Masking
        f. Pure Stenger
2. Speech Testing
        a. Speech Reception Threshold (& Masking)
        b. Word Recognition Test (& Masking)
        c. Performance Intensity Function for Phonetically Balanced Words – PIPB (& Masking)
        d. Speech Stenger
3. Acoustic Immittance Testing
        a. Tympanogram
        b. Acoustic Reflex Threshold
        c. Acoustic Reflex Decay
4. Earmold Impressions
        a. Assemble Equipment and Materials
        b. Explain Procedure to Patient
        c. Examine External Ear and Canal
        d. Take Impression
        e. Inspect Impression
        f. Pack and Ship Impression
5. Hearing Aids
        a. Hearing Aid Issue and Repairs
        b. Explain the Components of a Hearing Aid
        c. Common Problems with Hearing Aids and their solutions


CONSENT FOR PROCEDURES:
                             BROOKE ARMY MEDICAL CENTER                                                        - 29 -


The ENT Clinic has consent forms for different procedures. The original signed form will be placed in the patient’s
Health Record, while a copy will be place in the clinic’s training folder.




Infection Control Procedures_________________________________________

   Otolaryngology, Audiology, and Speech Pathology Services follows all Infection Control Procedures
   outlined in BAMC Pamphlet 40-2.

    Prior to each patient being seen within our service, that provider will wash his/her hands IAW
   BACM PAM 40-2. After each patient has been seen and has left the room/booth/area, the
   provider/technician will place all used items in the proper receptacles and wash his/her hands once
   again IAW BAMC PAM 40-2. The provider/technician will use Sani-clothe disinfectant wipes to
   wipe down all items used for patient care (i.e. SMR Units, otoscopes, headphones, responding hand-
   switch, chair, etc.) and prepare the equipment and area for the next patient to be seen.

    Throughout the course of the day the technician will clean the instruments and scopes as needed.
    a. The technician will transport all dirty instruments and dirty scopes from the clinical area to the
        utility room inside a dirty container. (The technician will wear gloves while transporting the dirty
        containers.)
    b. Once inside the utility room, the technician will don the proper personal protective equipment in
        order to clean the soiled instruments and soiled scopes.
    c. The soiled instruments will be placed in the wash basin inside the sink and sprayed with Pro EZ
        Foam (Foaming Enzymatic Spray) to disinfect and remove all proteins from the instruments.
        After soaking the instruments in the Pro EZ Foam for 20 minutes, the instruments are rinsed off
        with water; placed into the red container and taken to CMS for sterilization. The instruments are
        picked up from CMS on the next business day after being sterilized. (If the instruments have a
        high amount of protein before the cleaning process is started, then the instruments will be placed
        into the 11 gallon Ultrasonic cleaner for a 15 minute cycle.
    d. The soiled scopes will be placed in the wash basin inside the sink and sprayed with Pro EZ Foam
        (Foaming Enzymatic Spray) to disinfect and remove all proteins from the scopes. After
        disinfecting and removing all of the proteins from the scopes, the technician will rinse off the
        scopes and place them inside the System 83 Plus Ultrasonic Endoscope Washer to be sanitized.
       (The technician will wash his/her hands afterwards IAW BAMC PAM 40-2)
    e. Once the scope has been sanitized, it will be returned to the tech room and stored in the clean
        storage cabinet ready to use.


Reference: BAMC Pamphlet No. # 40-2
                           BROOKE ARMY MEDICAL CENTER                                                          - 30 -


Resident Supervision________________________________________________


      ALL RESIDENTS WILL BE SUPERVISED IAW THEIR APPROPRIATE SKILL LEVEL.

      PG 2 Level Skills
                  Clinical experience in the diagnosis and treatment of facial plastic, general, head and neck
      oncology, and pediatric otolaryngic conditions is the fundamental focus for this OTO-1 resident year. The
      solid general fund of basic science and clinical knowledge that was acquired in the PGY-I year is built upon.
      Principles of diagnosis and treatment are taught progressively and continuity of care is emphasized. The
      fundamental focus for this PG – II resident year is expanded clinical experience and depth in diagnosis and
      treatment of facial plastic, general, head and neck oncology, otology, and pediatric otolaryngology
      conditions. Principles of diagnosis and treatment are taught progressively and continuity of care is
      emphasized.
                  The otolaryngology resident will be supervised and instructed by staff otolaryngologists. When
      more senior residents are present on the service a hierarchical system will prevail, with the junior resident
      reporting to the senior resident or chief resident of the surgical team, who in turn reports to the attending
      staff. It is expected that, until delegated more authority, the junior resident will discuss all issues with the
      chief resident or attending staff. Senior residents and attending surgical staff will be available in a rapid
      reliable manner. Delegation of authority and responsibility for patient care will increase as the resident
      demonstrates increased competence in the delivery of safe, effective, and compassionate care. The
      otolaryngology staff will formally evaluate each otolaryngology trainee's performance after they complete
      their time on the staff’s service. Residents are expected to demonstrate progressive expertise over the five-
      year program.
                  While in the clinic, each resident will become thoroughly familiar with the use of otolaryngology
      equipment and diagnostic aids, perform history and physical examinations and will perform minor outpatient
      surgical procedures, under supervision as necessary.
                  Ward duties will consist of completing history and physical examinations on all patients admitted to
      the Otolaryngology – Head and Neck Surgery Department and following up on such patients both medically
      and surgically throughout their course of treatment.
                  In the operating theater, each resident will begin by doing minor otolaryngic surgical procedures
      under direct supervision of the attending staff or chief resident. These will consist of procedures such as,
      but not limited to, myringotomies with insertion of PE tubes, tonsillectomies, adenoidectomies,
      panendoscopies, neck node biopsies, septoplasties and removal of submandibular glands. Once the
      resident has demonstrated adequate surgical judgment and competence, he/she may be allowed to perform
      some of these procedures without a senior resident or staff directly in the operating room, but they must be
      within the surgical area. The clinical and surgical procedures at this PG II level are as follows:
  1. Closing a large wound using deep, subcuticular, and cutaneous sutures or staples.

  2. Place a flat suction drain and secure it.

  3. Tracheotomy

  4. Anterior endoscopic ethmoidectomy and opening of the osteomeatal complex.

  5. Tympanostomy tubes.

  6. Tonsillectomy or Adenoidectomy.

  7. Septoplasty.

  8. Drain a Peritonsillar abscess.
                              BROOKE ARMY MEDICAL CENTER                                                           - 31 -

    9. Pediatric laryngoscopy and bronchoscopy.

    10. Pediatric esophagoscopy

    11. Suturing wounds.

    12. Basic rhinoplasty

    13. Epistaxis management

PG 3 Skill Level
           The general fund of basic science and clinical knowledge that was acquired in the PG - II year is built upon,
with additional experience in the management of facial plastic, general, head and neck oncology, otology, and
pediatric otolaryngology. .
           The otolaryngology resident will be supervised and instructed by staff surgeons. The resident will discuss all
issues with attending staff until delegated more authority. Attending surgical staff will be available in a rapid reliable
manner. Delegation of authority and responsibility for patient care will increase as the resident demonstrates
increased competence in the delivery of safe, effective, and compassionate care. The otolaryngology staff will
formally evaluate each otolaryngology trainee's performance at the end of the rotation on the attending’s service.
           While in the clinic, the resident will see patients with more complicated otolaryngological
 problems and will assist in the training and supervision of younger residents and medical students.
           On the ward, the resident will be given a higher level of responsibility commensurate with his/her
level of training under the supervision of the attending staff and/or the chief resident. The resident will become
thoroughly familiar with temporal bone anatomy.
           In the operating theater, the resident will begin to operate as primary surgeon under direct
supervision of the attending staff in larger head and neck oncologic and pediatric procedures and will begin to do
major ear surgery. In addition, he/she will continue to develop skills in trauma surgery, as well as endoscopy and
sinus surgery. The surgical procedures at this PG III level are as follows:

         1.    Perform more complex sinus procedures.
         2.    Begin taking more junior residents through procedures such as tracheotomy and cervical biopsy.
         3.    Adult pan-endoscopies and staging of tumors.
         4.    Plan and mark the surgical incision for a thyroidectomy, parotidectomy.
               pharyngotomy, laryngectomy, and neck dissections.
         5.    Raise neck flaps.
         6.    Basic tympano-mastoidectomy.
         7.    Meatoplasty.
         8.    Complex closures of skin defects.
         9.    Skin grafts; split thickness, full thickness.
         10.   Facial resurfacing procedures using dermabrasion, lasers, or chemicals.
         11.   Open reduction and internal fixation of mandible fractures
         12.   Assisting with LeFort and NOE fractures.
         13.   Excision of branchial cleft cysts.
         14.   Excision of thyroglossal duct cysts.
         15.   Pediatric tracheotomy.
         16.   Assist in pediatric sinus surgery.


PG 4 Level
         Expanded clinical experience in diagnosis and treatment of facial plastic, general, head and neck oncology,
otology, and pediatric otolaryngology conditions is the fundamental focus for this PG – IV resident year, with
continued emphasis on principles of diagnosis and treatment. During this year the resident is expected to advance in
                              BROOKE ARMY MEDICAL CENTER                                                         - 32 -

the knowledge of all areas that have been covered thorough continued reading and participation in all the teaching
activities. The resident should do advanced reading for all operative procedures so that he or she has a thorough
knowledge of management of the disease and the associated indications, contraindications, complications, and
controversies and is prepared to discuss these items on rounds and in the operating room.
           The otolaryngology resident will be supervised and instructed by staff surgeons and the chief resident.
When more senior residents are present on the service a hierarchical system will prevail in which the junior resident
reports to the PG - IV resident who in turn reports to the chief resident or attending staff. Chief residents and
attending surgical staff will be available in a rapid reliable manner. The otolaryngology staff will formally evaluate
each otolaryngology trainee's performance at the end of the rotation.
           The resident by the end of this year should be able to manage the patient preoperatively, participating in
surgery, and manage the patient's recovery through the outpatient clinic.
           While in the clinic, the resident will see patients with more complicated otolaryngological problems and will
assist in the training and supervision of younger residents and medical students.
           On the ward, the resident will be given a higher level of responsibility commensurate with his/her
level of training under the supervision of the attending staff and/or the chief resident.
           In the operating theater, the resident will begin to instruct junior residents such as tympanostomy tube
placement and tonsillectomies. In addition, they will act as the primary surgeon under direct supervision of the
attending staff in larger head and neck oncologic, facial plastic, pediatric, and neurotologic procedures. In addition,
he/she will continue to develop skills in trauma surgery, as well as endoscopy and sinus surgery. The surgical
procedures at this PG 4 level are as follows:

           1. Open rhinoplasty.

           2. Endoscopic browlift.

           3. Blepharoplasty.

           4. Rhytidectomy.

           5. Tympanoplasty.

           6. Mastoidectomy.

           7. Ossicular reconstruction.

           8. Stapedectomy

           9. Endoscopic sphenoidethmoid ethmoidectomy

           10. Drain a deep neck abscess.

           11. Thyroidectomy

           12. Parotidectomy.

           13. Micro-laryngeal surgery.

           14. Lymph node biopsy

           15. Complex wound management.

           16. Assist in the design and harvest of microvascular flaps.

           17. Assist in the design and reconstruction of mandibular defects.
                        BROOKE ARMY MEDICAL CENTER                                                             - 33 -


    18. Assist in the design and transfer of myocutaneous flaps.

    19. Close surgical defects using local and regional flaps.

    20. Total laryngectomy

    21. Hemilaryngectomy

    22. Hemiglossectomy

    23. Composite resection of oral cavity tumor

    24. Maxillectomy

    25. Neck dissection

    26. Pharyngotomy

    27. Pharyngoesophageal reconstruction
PG 5 Level Skills

    The Chief Resident in his/her final year is expected to have in-depth knowledge of the diagnosis and
treatment of Facial Plastic, General, Head & Neck Oncologic, Otologic, and Pediatric conditions. During
this year the resident is expected to further refine an existing knowledge base by continued reading and
by taking an active role in the education of more junior residents.
    The resident should do advanced reading for all operative procedures so that he or she has a
thorough knowledge of the management of the disease and the associated indications,
contraindications, complications, and controversies and is prepared to teach these principles to more
junior residents, interns, and medical students.
    This year allows for continuity of care. The Chief Resident is responsible for preoperative
management of the patients with the most complex cases. Also, he or she is the primary surgeon for
such patients and manages their postoperative recovery through discharge and the outpatient clinic.
The Chief Resident also prepares monthly morbidity and mortality conference material, which should
include a thoughtful evaluation of the cases to enable a coherent analysis and a plan to avoid such
complications in the future. The Chief resident will present cases to the weekly combined H&N tumor
board.
    The Chief Otolaryngology Resident will supervise the more junior residents and interns and receive
instruction and guidance from staff surgeons. The Chief Resident is expected to manage all
administrative activities of the team such that quality care is delivered and documented. Attending
surgical staff will be available in a rapid reliable manner. The Otolaryngology staff will formally evaluate
each Chief Otolaryngology Resident trainee's performance during the quarterly resident review. The
surgical procedures at this PG V level are as follows:
    1. Liposuction

    2. Placement of facial augmentation prosthetics

    3. Botulinum toxin injection

    4. Reconstructive scalp surgery

    5. Extratemporal facial reamination

    6. Soft tissue expansion
                   BROOKE ARMY MEDICAL CENTER                                                            - 34 -


7. Mandibular reconstruction

8. Assisting in cleft lip and palate repair

9. Assisting in microtia repair

10. Reconstruction of soft tissue defects

11. Canaloplasty

12. Middle ear exploration

13. Typmanoplasty and myringoplasty

14. Tympanomastoidectomy

15. Endolymphatic sac surgery

16. Repair of perilymphatic fistula

17. Transtympanic installation of ototoxic drugs

18. Vestibular nerve section

19. Labyrinthectomy

20. Cochlear implantation

21. Assisting in the removal of vestibular schwannoma and other cerebellopontine angle tumors
22. Assisting in glomus tumor removal
    congenital middle ear reconstruction
23. Arterial ligation
24. Maxillectomy (with and without orbital exenteration /partial maxillectomy/intraoral resection/oral
    cavity resection/composite resection/glossectomy
25. Phonatory surgery/framework surgery
26. Laryngotracheoplasty / epigottoplasty
27. Management of laryngeal fractures
28. Repair of caustic injection injuries of the pharynx/esophagus and thermal injury of upper airway
29. Partial laryngectomy/ total laryngectomy/pharyngectomy
30. Artyenoidectomy/arytenoidopexy
31. Mandibulectomy/mandibular osteotomy
32. Excision of mass of parapharyngeal space (including chemodectoma, neurilemmoma removal
33. Excision of congenital cysts and sinus (branchial cleft, thyroglossal duct)
34. Resection of vascular malformations (lymphatic, venous, hemangioma
35. Paryngoesophageal reconstruction
36. Repair of penetrating injuries of the head and neck
37. Zenker's diverticulectomy
38. Treatment of laryngeal clefts and tracheoesophageal fistulas
39. Surgical voice restoration (TEP)
40. Tracheal resection
41. Skull base surgery
42. Ethmoid/ ethmoidectomy / forntoethmoidectomy
43. Maxillary / caldwell luc
44. Frontal trephination/obliteration/ablation
                             BROOKE ARMY MEDICAL CENTER                                                       - 35 -

           45. Sphenoid/ hypophysectomy
           46. Orbital decompression




APPENDIX – 1
Glossary of Common Terms

Account Processing Code (APC) - Four-digit alphanumeric code associated with a cost center, established locally by
the organization, reflecting its own accounting structure within the Army Management Structure (AMS).

Composite Health Care System (CHCS) - The clinic's electronic computer system, which allows for appointment
scheduling, laboratory work scheduling and look-up radiology reports, ordering medication for patients, and tracking
of patient’s medical records.

Cooperative Administrative Support Unit (CASU) - A temporary-hire staffing service sponsored by the Department of
Labor.

DME -(Durable Medical Equipment) - reusable medical equipment used to facilitate treatment or rehabilitation for a
diagnosed medical condition or illness.

Element of Resource (EOR) – Four-digit alphanumeric code representing the different types of service, or item being
procured.
                             BROOKE ARMY MEDICAL CENTER                                                       - 36 -



Electronic Consult System -Computer-based consultation system allowing almost immediate consultation between
the patient's physician and various specialists regarding the medical care of the patient.

Foundation Health Care (FHP) -The company providing administrative contract support for TRICARE programs in
Region 6.

Full Time Equivalent (FTE) -One work year = 2080 hrs = 1 FTE.

Home Health Care -Full range of medical and other health related services such as physical therapy, nursing,
counseling and social services that are delivered in the home of a patient by a provider.

Patient Appointment System (PAS) -Used to make initial, follow-up and referral appointments to various providers in
the hospital.

Referral - The process of sending a patient from one practitioner to another for health care services. Referrals are
usually authorized by the beneficiary's insurance plan.

SMIR 1 and 2 - relates to Electronic Consult System

Transcription - Literally, the written word; a printed copy of the physician’s dictation.

TRICARE PRIME - A Health Maintenance Organization (HMO) type option where the beneficiary's care is managed
by a Primary Care Manager (PCM).

TRICARE STANDARD - An indemnity type option developed for active duty family members, retired military
members and family members of retirees on a cost-share basis whenever care is not available at a Military
Treatment Facility (MTF).

TRICARE EXTRA - A Preferred Provider Organization type option that offers lower out-of- pocket expenses, when a
network provider renders the care. The beneficiary does not have to complete claim forms when using the TRICARE
EXTRA option.

TRICARE SENIOR PRIME (TSP) - A health care program for Military Health System beneficiaries 65 years and
older. TSP-eligible beneficiaries are assigned a Primary Care Manager (PCM) at the Military Treatment Facility
(MTF). This program is available at selected MTFs. In addition, selected civilian providers were contracted to
supplement the TSP program. Please call (800)937-6093 for more information.
                          BROOKE ARMY MEDICAL CENTER                                - 37 -




APPENDIX – 2

References:

      Brooke Army Medical Center’s Safety Management Handbook
      Brooke Army Medical Center’s Infection Control Manual (BAMC Pamphlet 40-2)
      High-Level Disinfection of Endoscopes and Instruments
      Soldier’s Manual and Trainer’s Guide MOS 91WP2
                            BROOKE ARMY MEDICAL CENTER                                                - 38 -




APPENDIX – 3

                  OTOLARYNGOLOGY HEAD & NECK SURGICAL SERVICE

                                                    BAMC

                                      FIRE & EVACUATION PLAN

1. PURPOSE: To provide information and guidance in the event of fire within the Otolaryngology-
   Head & Neck Surgery Service, Audiology/Speech Clinic and Patient Waiting Area, Brooke Army
   Medical Center, FSH, TX.

2. SCOPE: Applicable to all personnel.

3. OBJECTIVES: Protection of patients and personnel within the confines of these three combined
   services.

4. RESPONSIBILITIES: The NCOIC, Otolaryngology-Head & Neck Surgery Clinic, NCOIC, Speech
   Pathology Clinic, and the NCOIC, Audiology Evaluation and Treatment Clinic, Bldg. 3600 had the
   overall responsibility in the event of fire in these areas.

5. PROCEDURES: Any person discovering a fire (regardless of type or size, odor of smoke, gaseous
   fumes, or other explosive hazards) will immediately alert or cause to alert all personnel in the
                           BROOKE ARMY MEDICAL CENTER                                                    - 39 -

respective clinic and will report the same to the Fire Department by the quickest means available. All
fires shall be reported including those extinguished upon discovery and those burned out prior to
discovery.

a. When an alarm sounds:

     1. NCOIC or individual in charge will inspect all areas in the clinic to
       determine if there is a fire or smoke.

     2. Assure that all interior doors and storage room doors are closed.

    3. If notified that the fire is in the clinic (Zone 2C1) or an adjacent fire zone (Zone 4M2) the
       NCOIC or individual in charge will keep the clinical staff informed so that preparations can be
       made for evacuation.


     4. Do not call the information desk to inquire if there is a fire. The clinic
       will be notified. Listen for the overhead announcement system
       for fire location.

b. When fire is discovered in the OTO-HNS, Speech and/or Audiology
   Clinic or adjacent fire Zone:

   1. Notify FSH Fire Department

      (a) Dial 911

      (b) Identify yourself and give the location of the fire (Zone 2C1) or
          Zone 4M2). Remain on the phone until released by the person
          receiving the call.

  2. Notify the Commo Center

     (a) After notification of the FSH Fire Department, report the location
         (Zone 2C1) or (Zone 4M2) to the Commo Center at telephone
         Number 916-1111.

  3. Verbal alarms:

    (a) Verbal alarms should be given to alert other personnel in the
        immediate and adjacent vicinity of the fire. DO NOT SHOUT
        “FIRE-FIRE”.

    (b) BAMC fire alarms are initiated by (1) detection devices
        (smoke/heat), (2) observation and reporting, and (3) Alarm Pull
        Boxes. To activate the Alarm Pull Box, push in and pull down to
        release the lever type fire alarm box located by back elevator 2nd
        floor OTO-HNS Clinic. Instructions are posted on the box.

   (c) If fire is located in the rear of the clinic, personnel would
       horizontally evacuate to the Dental Clinic area and pull 4M2 fire
      alarm. 4M2 Alarm Pull Box is located in breezeway between 2nd
                          BROOKE ARMY MEDICAL CENTER                            - 40 -

     floor clinic and the stairwell A3 toward Special Procedures and/or
     Dental Clinic.

4. Action after giving fire alarm when possible and safe to do so:

   (a) In the event of a fire within the clinic the NCOIC will shut-off
        the main Medical Gas Valve located by Room 258-9 and 259-5
        (Clinic O.R.).

   (b) If fire is small, fight, using proper extinguisher. See attached floor
        plan for fire extinguisher locations.

  (c) Close all doors in the immediate fire area.

  (d) Designated personnel to meet fire department personnel at front of
      Clinic and direct them to the fire.

5. Fire extinguisher type and location:

  (a) Class ABC Fire Extinguishers cabinets (4) are located in
      1. Speech Therapy corridor between Room 254-16 and 255-10
      2. Across from the Conference Room
      3. Otolaryngology corridor by 259-10
      4. OTO Exam Room 258-12, as noted as F on the enclosed floor
         plan.

 (b) Personnel must be initially trained in fire extinguisher use and
     annually thereafter. Fire extinguishers are operated using the
     PASS procedure:

      P - Pull the pin

      A - Aim near the base of fire

      S - Squeeze the handle

      S - Sweep with the hose to distribute the contents of the
          Extinguisher to the base of the fire.



 (c) The basic plan is based on the RACE concept:

      R - Rescue: Rescue anyone in immediate danger horizontally to
          Fire zone

      A - Alarm: Activate the fire alarm by pulling the nearest manual
           Alarm box and calling 911. After this action, call the Commo
           Center at 916-1111.

      C - Contain: Contain the fire and smoke. Shut all doors, place
          Smoke barriers (wet towels) at the bottom of the doors.
                             BROOKE ARMY MEDICAL CENTER                        - 41 -

              Keep the doors closed until the “ALL CLEAR” is made.

         E – Extinguish/Evacuate: Extinguish small fires if possible by
             using fire extinguishers (PASS) and with the help of the
             Automatic sprinkler system. If it is not possible to extinguish
             the fire, evacuate to the primary adjacent or vertical zone.

     (d) The Fire Alarm Box is noted as C on the enclosed floor plan.

   6. If evacuation is necessary:

     (a) Shut-off the main Medical Gas Valve located by Room 258-9 and
         258-5 (by O.R.)

     (b) Evacuate all patients and personnel, IAW evacuation plan for the
         clinic.

     (c) Evacuate and/or transport patients to an adjacent fire zone on same
         horizontal level (Ancillary Building by Dental, go through stairway
         if fire curtain has fallen).

      (d) DO NOT use elevators unless ordered by Fire Marshall.

     (e) Evacuate or transport patients to a lower floor ONLY when
         horizontal exits are blocked or when ordered by Fire Marshall



     (f) Evacuate the building only when ordered by the Fire Marshall, the
         Commander of BAMC, or their representatives

     (g) Assembly point for the clinical Ancillary Service Building will be
         the North Parking Lot C/D. Evacuation will be via the fire stairs,
         located in back and/or the front of the OTO-HNS Clinic. Refer to
         the attached map for location.

     (h) After evacuation, close doors

     (i) NCOIC and assigned fire point personnel will take a head count
         and report missing team members

     (j) A staff member will remain with patients throughout event

     (k) NCOIC of the Clinic is responsible for assigning Fire Point
         Personnel and for coordinating with the Fire Marshall for periodic
         check of all fire extinguishers.



REFERENCED: BAMC MEMO 420-3, Fire Protection & Evacuation Plan.
            BROOKE ARMY MEDICAL CENTER   - 42 -




APPENDIX - A-1

                   SEE ATTACHMENT
                                       BROOKE ARMY MEDICAL CENTER                                                         - 43 -


      APPENDIX – 4

INITIAL COMPETENCY ASSESSMENT OF UNIT SPECIFIC SKILLS
& PROCEDURES: Otolaryngology Service
Source of Performance Standard: Leadership --- Organizational Performance --- Patient Rights --- Human
Resources
1. Organization                                                    CRITICAL THINKING: Communicates this information to the staff and seeks every opportunity to make the vision a
                                                                   reality.
A. Verbalizes the mission, goals, and strategic plan for
   (1) MEDCEN
   (2) Department of Surgery
   (3) Department of Otolaryngology-Head & Neck Surgical
Service
   (4) Department of Nursing
B. Verbalizes understanding of roles & responsibilities of
   (1) Commander and Executive Group
   (2) Department Chief
   (3) Clinic Nurse Manager
   (4) Clinic NCOIC


2. Team Work                                                       CRITICAL THINKING: Communicates appropriate information to members of the team in a courteous, professional,
                                                                   and approachable manner. Maintains professional composure at all times, ensures thoroughness in work, and manages
                                                                   conflicts appropriately and in a timely manner.
A. Demonstrates ability to communicate and use effective
interpersonal skills with colleagues and other members of the
medical center
B. Ensures customer satisfaction oriented environment for both
patients, families, and other customers
C. Fosters a positive work environment and encourages team
work among staff
D. Demonstrates appropriate time management skills
E. Verbalizes knowledge and understanding of patient and staff
rights and responsibilities
F. Verbalizes clinic’s mission, philosophy, and scope of service
G. Verbalizes knowledge and understanding of scope of practice
for ENT and Audiology Technician

                                                                                                                                                                                 1
                                       BROOKE ARMY MEDICAL CENTER                                                               - 44 -

H. Ensures a safe environment for patients/families and staff,
identifying health/safety risks and takes appropriate and
immediate steps to alleviate the risk
I. Demonstrates knowledge of current status of MEDCEN,
Department, and Otolaryngology Head & Neck Clinic
Performance Improvement, Risk Management, and Patient
Safety programs and initiatives
J. Assist in the orientation of new personnel and shares expertise
K. Meets suspense without prompting

3. Telephone Courtesy                                                CRITICAL THINKING: Recognizes that older or English as a second language callers may demonstrate a delayed
                                                                     response to questions and politely allows them time to phrase an answer. Also clarifies the caller’s request to avoid any
                                                                     misunderstandings.
A. Correctly and politely answers the telephone and transfers
calls appropriately.
B. Correctly generates CHCS telephone consult
   (1) Verifies name, unit, SSN, phone number, address, DEERS
eligibility, and Tricare enrollment status
   (2) Obtains pertinent patient information and chief complaint;
documents in CHCS
   (3) Forward telephone consults to appropriate provider

4. Managing and Supervising for                                      CRITICAL THINKING: Appropriately delegates authority, accountability, and duties to staff. Assists with developing
                                                                     policies, procedures, and standards of care for all patients. Fosters interdisciplinary collaborative relationships among
Otolaryngology Head & Neck / Speech and                              other services to ensure provision of quality care. Prioritizes tasks and manages time schedules, personnel, and resources
Audiology Clinic                                                     to meet clinic’s goals and patient care standards.
A. Adheres to Society of Otolaryngology Head & Neck
Guidelines, JCAHO accreditation standards, Department
SOPs/policies, and BAMC policies
B. Ensures appropriate staffing levels, using qualified and
competent staff
CRITICAL THINKING: Recognizes when patient care exceeds available resources and takes appropriate action.
C. Leads by example
D. Delegates appropriately and follows-up on all delegated tasks
E. Ensures a safe environment for staff and patients
F. Ensures proper procedures are followed for reporting patient
and staff injuries
                                      BROOKE ARMY MEDICAL CENTER                                                              - 45 -


Source of Performance Standard:                             Surveillance, Prevention, and Control of Infection
Demonstrates ability to identify and reduce the risks of acquiring and transmitting infections between patients, employees, and visitors and
follows all guidelines per BAMC Infection Control Policy and Procedures Guide.
A. Refers to and implements the BAMC Infection Control Policy       CRITICAL THINKING: Understands the transmission of diseases and the application of disease prevention strategies

B. Correctly explains Standard Precautions
C. Identifies procedures for segregating/isolating patients with
suspected airborne, contact, and special droplet infections
D. Uses proper technique for
    (1) Handling linen
    (2) Blood safety devices (IV cannulas/needles, transfer
devices)
    (3) Disposing of sharps
    (4) Disposal of infectious and regulated medical waste
    (5) Storing clean and sterile supplies
    (6) Collecting and transporting lab specimens
E. States indications for and demonstrates proper use of personal
protective equipment (gloves, gowns, masks, and eye protection)
F Uses proper technique for managing blood and chemical spills
G. Demonstrates proper hand washing technique (before and
after treatments, between patients, and when needed)
H. Demonstrates proper cleaning and decontamination of
medical equipment using appropriate cleaning agents
I. Describes procedures for managing a needle stick or blood
borne pathogen exposure per BAMC MEMO 40-135

          Source of Performance Standard: Care of Patients-----Continuum of Care-----Assessment of Patients---
                          Management of Information---Patient Rights and Organizational Ethics
Demonstrates clinical competency related to specific skills and procedures IAW appropriate standards for care and within defined scope of
practice and manufacturer guidelines.
1. Patient Care/Screening ALL STAFF              CRITICAL THINKING: Recognizes normal and abnormal values for all age groups and takes appropriate action in a
                                                                    timely manner. Documents findings appropriately. Recognizes unique age and language appropriate communication
                                                                    needs of patients and responds appropriately. Recognizes normal variations in vital signs parameters associated with the
                                                                    aging process. Assures the confidentiality of patient information and their rights to privacy ( i.e., auditory and visual
                                                                    privacy).
A. Greets patient and family with professionalism and courtesy
B. Complete initial assessment based on patient’s status
                                        BROOKE ARMY MEDICAL CENTER                                                            - 46 -

C. Obtains vital signs as requested by the specialty provider
(pulse, BP, temperature, respiration, oxygen saturation) and
recognizes normal and abnormal values for the following age
groups:
 (1) Infants (1 month-18 months)
 (2) Toddlers (19 months-3 years)
 (3) Preschoolers (4-5 years)
 (4) School age (6-11 years)
 (5) Adolescents (12-17 years)
 (6) Adults (18-64 years)
 (7) Geriatric over 65 years
D. Inquire about presence of pain using age appropriate pain       CRITICAL THINKING: Recognizes the influence of age, language and culture on the perception of pain. Realizes that
scale (i.e. Wong and Baker FACES Scale, 0-10 etc) and              pain perception often changes with aging to include the minimization of normally acute symptoms (i.e., chest pain
documents on SF 600                                                associated with myocardial infarction, pain associated with broken bones) in the geriatric population. Inquires as to how
                                                                   the patient or family manages pain at home (medications, home remedies, restricting activities, etc) and documents. Alerts
                                                                   nursing staff and/or provider to the presence of pain.

E. Obtain weights on all Head and Neck Cancer patients and
documents on SF 600.
F. Reports abnormal findings to MD
G. Ensures Master Problem List is on chart (if available)
H. Documents allergy information (to include latex), medications
and other required screening on SF 600
I. Prepare patient, and set up equipment
J. Takes into consideration the specific needs of the following
age groups during all procedures and interactions:
   (1) Infants (1month to 18 months)                               CRITICAL THINKING for Infants: Explains to parents all procedures and provides reassurance. Never leaves infant
                                                                   unattended and keeps side rails of crib up. Keeps infant warm to minimize heat loss. Encourages parent to hold infant in
                                                                   arms if not contraindicated and if parent consents

  (2) Toddlers (19 months to 3 years)                              CRITICAL THINKING for Toddlers: Encourages parent to provide child with a security item (blanket, toy) and have
                                                                   parents stay with child. Gives toddler one- step directions at their eye level and maintains eye contact during procedure.
                                                                   Speaks in a slow and calm manner and praises toddler at completion of procedure.

  (3) Preschool age (4 to 5 years)                                 CRITICAL THINKING for Pre-schoolers: Involves child and parent in all decisions and encourages child to participate
                                                                   in procedures as much as possible (i.e. handling equipment to reduce fear and satisfy curiosity). Provides a safe
                                                                   environment, explains all steps using simple words the child can understand, and uses distraction technique such as songs
                                                                   or asking questions about favorite activities or pets. Provides minimal exposure due to particular modesty of this age group.
                                                                   Praises the child at the completion of the procedure.
                                       BROOKE ARMY MEDICAL CENTER                                                               - 47 -

  (4) School age (6-11 years)                                         CRITICAL THINKING for School Age: Involves child and parent in all decisions and encourages child to participate in
                                                                      procedure as much as possible (i.e., handling equipment to reduce fear and satisfy curiosity). Provides a safe environment,
                                                                      explains all steps using simple words the child can understand, and uses distraction techniques such as songs, video tapes,
                                                                      or asking questions about a favorite activity or pet. Provides for minimal exposure due to particular modesty of this age
                                                                      group. Praises child at the completion of the procedure.

   (5) Adolescents (12-17 years)                                      CRITICAL THINKING for Adolescents: Involves adolescent and parent in all decisions and encourages the adolescent
                                                                      to participate in procedures as much as possible. Supplements explanations with rationale. Provides a safe environment
                                                                      and maintains modesty. Allows adolescent to choose whether parent remains present if appropriate. Encourages
                                                                      adolescents to ask questions and express concerns/fears regarding procedure/illness. Talks directly to adolescent and
                                                                      allows them to answer questions even if parent is present. Does not treat adolescent like a child.


   (6) Adults (18-64 years)                                           CRITICAL THINKING for Adults: Addresses patient by name and/or rank per their preference. Explains procedures in
                                                                      clear and simple terms using correct terminology. Maintains safety and provides reassurance. Maintain a high level of
                                                                      awareness regarding patient’s current condition and contributing medical history as well as their potential future
                                                                      conditions and needs. Prepares accordingly.


   (7) Geriatric (65 plus)                                            CRITICAL THINKING for older Adults: Shows respect for patient and family and addresses patient by name and/or
                                                                      rank per their preference avoiding such terms as “honey, sweetie, or cutie”. Involves patient and family in all decisions
                                                                      and encourages the patient to participate in procedure as much as possible. Recognizes that older patients may
                                                                      demonstrate a delayed response to questions and allows them time to phrase an answer. Also adjusts explanations to
                                                                      accommodate short time memory loss. Explains procedures in clear and simple terms using correct terminology. Allows
                                                                      patient to describe their mobility capabilities and limitations in regard to positioning. Maintains safety and provides
                                                                      reassurance. Minimizes exposure to ensure modest and avoid unnecessary heat loss.


2. Patient Care: ENT Technicians (May also                            CRITICAL THINKING: Recognizes unique needs of patients of all ages and performs procedures accordingly. Gathers
perform the same procedures for Audiology Technician)                 age and diagnosis appropriate supplies and equipment. Explains all procedures in an age appropriate manner according to
                                                                      the level of understanding of the patient/family and the parent/guardian. Approaches patient in non-threatening manner
                                                                      and comforts or praises at completion.
A. Assist provider with procedures
  (1) Pulls and sets up instrument/equipment/supplies
  (2) Prepares patient appropriately
  (3) Practices proper Aseptic Technique
  (4) IV insertion (starting IV fluid therapy) under supervision of
MD or RN
  (5) Performs wound culture/care per MD orders under
supervision; applies, reinforce and removes wound dressings
using aseptic and sterile technique and assists with removal of
sutures/staples.
B. Uses proper steps and techniques in assisting physicians with
surgical procedures
   (1) Correctly identifies surgical/biopsy site(s)
                                      BROOKE ARMY MEDICAL CENTER                                                             - 48 -

  (2) Correctly identifies biopsy on specimen label with biopsy
specimen, physician and date.
  (3) Correctly places tissue in corresponding specimen bottle
and checks to make sure tissue is present in the specimen bottle
before transporting specimens to pathology with accompanying
pathology request
  (4) Documents specimen in clinic APV specimen log book
C. Maintains medication room stocking and ordering
D. Responsible for eye wash station
E. Makes appropriate use of Oxygen delivery systems                CRITICAL THINKING: Recognizes appropriate mode of oxygen administration based on the patient’s age and
                                                                   condition.
   (1) Nasal cannula                                                                                                                           Oxygen application must be verified
   (2) Face mask                                                                                                                               by licensed staff
   (3) Tracheotomy/collar
F. Administers medications as outlined within their scope of       CRITICAL THINKING: Administers the right medication in the right dose via the right route to the right patient at the
practice                                                           right time. Identifies patient identity per BAMC Patient Identifiers Policy. Understands the purpose of the medication and
                                                                   its intended effect. Recognizes signs and symptoms of anaphylaxis/overdose and acts appropriately. Recognizes and
                                                                   responds to unique medication needs of pediatric through geriatric patients. Responds appropriately by administering
                                                                   correct dose for age/weight and by monitoring medication effects. Verifies allergies before administration and documents
                                                                   medications given and the patient’s response.
   (1) Topical
   (2) Oral
   (3) Intranasal
G. Operating Room Performance
   (1) Preoperative
       a. Identifies and greets patient appropriately for age
       b. Insures patient comfort and safety
       c. Properly transports patient
   (2) Intraoperative
      a. Checks room, demonstrates preparation and maintenance
of sterile field set-up and supplies
       b. Opens sterile packs/instruments/solutions correctly
       c. Performs preoperative scrub to standard
       d. Uses appropriate Personal Protective Equipment
       e. Performs counts correctly (sharps/sponges)
       f. Labels all medication on field
       g. Identifies & correctly handles instruments
       h. Identifies, prepares and passes suture
   (3) Postoperative
        a. Properly handles & dispose of sharps & wastes
        b. Properly handles contaminated instruments
        c. Cleans, prepares instruments for sterilization
        d. Properly handles all specimens
                                       BROOKE ARMY MEDICAL CENTER                                                            - 49 -

H. Performs the following ENT Procedures
  (1) Perform ear irrigation’s
  (2) Cerumen impaction removal
I. Assists with minor biopsy/excision procedures (oral, nasal, ear,
facial, etc.) in the ENT Clinic operating suite
   (1) Epistaxis Control/Management
   (2) Myringotomy with PE Tubes
   (3) Endoscopic Sinus Surgery/Debridment
   (4) Septoplasty
   (5) Rhinoplasty
   (6) Blepharoplasty
   (7) Otoplasty (ear reconstruction)
   (8) Fine Needle Aspiration
   (9) Cautery Assisted UP3
   (10) Scar Revisions
J. Initiates Code Blue and performs infant, child, and adult BLS


3. Patient Care: Audiology Technicians (May                           CRITICAL THINKING: Recognizes unique needs of infant to geriatric patients and performs procedures accordingly.
perform the following to include all above procedures for             Gathers age and diagnosis appropriate supplies and equipment. Explains all procedures in an age appropriate manner
ENT Technicians)                                                      according to the level of understanding of the child and the parent/guardian. Approaches child in non-threatening
                                                                      manner and comforts at completion.
A. Perform Basic Audiometric Evaluation
   (1) Case History-record in subjective S.O.A.P.
       a. Age, Gender
       b. Who/ why referred
       c. Subjective impression of hearing ability
         1. History of ear infections, noises exposure,
ototoxicity
         2. C/O tinnitus (bilateral/unilateral) , vertigo, otalgia
   (2) Perform Otoscopic examination
       a. Impressions (i.e. WNL, Cerumen present)
   (3) Test Battery
       a. Speech Recognition Testing (Discrimination Threshold)
       b. Air/Bone Conduction Pure Tone Thresholds
B. Use proper techniques and record results in Prognosis of
S.O.A.P
C. Calibration of equipment daily
D. Explains possible treatment options and refers back to
physician as needed
E. Able to perform or assist with the following diagnostic
procedures
   (1) Acoustic Reflex
                                      BROOKE ARMY MEDICAL CENTER                                                           - 50 -

  (2) Automatic Brainstem Response
  (3) Caloric Vestibular
  (4) Electronystagmography
  (5) Ear mold Impressions
  (6) Hearing aid evaluation
  (7) Hearing Aid Buffer
  (8) Typanometry
  (9) Hearing Conservation

                                                                 CRITICAL THINKING: Recognizes unique needs of pediatric through geriatric patients and performs procedures
4. Patient Care: RN (May perform the following                   accordingly. Develops and implements nursing care, assesses patient’s response to care, and implements appropriate
to include all above procedures for ENT/Audiology
                                                                 changes. Coordinates appropriate consultations to support multidisciplinary care for outpatients being seen on an ongoing
Technician)
                                                                 basis for treatment.
A. Uses nursing process
  (1) Assessment
  (2) Planning
  (3) Implementation
  (4) Evaluation
B. Verifies patient’s readiness for surgery
  (1) Reviews Care-plan (DA5179) and Intraoperative report
  (2) Verifies patient’s NPO status and medication allergies
  (3) Verifies medications and pre-medication if ordered
  (4) Assess patient’s knowledge of impending procedure and
conducts patient education accordingly
  (5) Verifies Informed Consent and surgical site with patient
  (6) Maintain Operating Room equipment and supplies
  (7) Safely transports patient to and from surgery

C. Administers medications                                       CRITICAL THINKING: Administers the right medication in the right dose via the right route to the right patient at the
                                                                 right time. Identifies patient identity per BAMC Patient Identifiers Policy. Understands the purpose of the medication and
                                                                 its intended effect. Recognizes signs and symptoms of anaphylaxis/overdose and acts appropriately. Recognizes and
                                                                 responds to unique medication needs of pediatric through geriatric patients. Responds appropriately by administering
                                                                 correct dose for age/weight and by monitoring medication effects. Verifies allergies before administration and documents
                                                                 medications given and the patient’s response.

   (1) Administers IVPB medications
   (2) Intramuscular
   (3) Subcutaneous
   (4) Oral
   (5) Topical
                                       BROOKE ARMY MEDICAL CENTER                                                          - 51 -

D. Has completed Conscious Sedation Training and obtained
Certification.
E. Demonstrates ability to monitor conscious sedation patients
according to BAMC conscious sedation policy (RN or MD will
give IV Push medication)
      (1) Intra-procedural and Post-procedural monitoring to
include the following:
         a. Vital signs including: blood pressure, EKG, pulse
oximeter, IV drip, etc.) and record on anesthesia record
         b. Level of consciousness – using the recommended
numeric scale for neurologic status
          c. Patient responses to administered sedatives and
analgesics – monitor until vital signs returns to baseline values
and patient has normal or baseline cardiopulmonary and
neurologic status after completion of the procedure
          d. Observe patient for an hour after administration of
the last dose of reversal agent and the patient is continuously
awake and alert with naloxone or flumazenil
          e. Oxygen saturation every 15 minutes or more often if
patients condition warrants
          f. Respiratory rate, as well as overall adequacy of
patient’s airway and spontaneous ventilation every 15 minutes –
until returns to pre-procedural baseline for at least 15 minutes
without administration of medication antagonists of sedatives-
analgesics in the preceding 60 minutes
         g. Patient’s status relevant to any special baseline
condition (i.e., dialysis fistula- document presence or absence of
persistent “thrill”)
F. Checks out Narcotics, maintains used and wasted narcotic
protocol and documentation

5. Child, Spouse, and Vulnerable Adult Abuse                         CRITICAL THINKING: Treats patient and family with dignity and respect with emphasis placed on their psychological
                                                                     needs. Refer to AR 608-18 for additional information.
and Neglect
A. Able to identify high risk families or situations
B. Verbalizes signs/symptoms of the following:
  (1) Physical abuse
  (2) Sexual abuse
  (3) Physical neglect
  (4) Medical neglect
  (5) Emotional maltreatment
C. Notifies MD if family is high risk or signs and symptoms of
abuse/neglect are present
                                        BROOKE ARMY MEDICAL CENTER                                                              - 52 -


Source of Performance Standard:                                Education
Involves patient and family in the patient-education process and encourages their participation in the care and decision making process.
A. Assesses patient education needs based on physical, cultural,
religious, educational, language and age-specific criteria
B. Assesses the patient’s/family’s motivation and readiness to
learn and adapts teaching based on current needs
C. Documents education teaching per clinic BAMC policy
D. Familiar with various education materials to include other
languages, materials, in Braille picture books, etc and distributes
E. Informs MD of patients with additional educational needs to
included community resources
F. Provides verbal and written wound care instructions and
emergency procedures


To provide a safe, functional, and effective environment for patients, staff members, and other individuals in the organization.
1. Equipment                                       CRITICAL THINKING: Describes the capabilities, limitations and special applications of each item of equipment.
                                                                      Demonstrates basic operating and safety procedures for equipment items. Verbalizes importance of alarms and alarm
                                                                      settings and ensures they are on and operating correctly at all times. Reports routine problems with equipment. Identifies
                                                                      emergency procedures in the event of equipment failure. Describes the process for reporting user errors and/or patient
                                                                      incidents. Performs actions IAW unit SOP and BAMC Regulation.
A. ENT Clinic Procedures/Equipment
  (1) Defibrillator and crash cart, perform daily checks

                                    Source of Performance Standard:                Environment of Care

  (2) Vital signs monitors
  (3) Scales
  (4) Suction apparatus
  (5) Oxygen tanks/regulator
  (6) Video equipment
  (7) Microscope and maintenance
  (8) Fiber-optic light source/cords
  (9) Hot Bead Sterilizer
 (10) Ultrasonic Processor
 (11) High-Level Disinfecting (Cidex) test/document
 (12) Rigid endoscope
 (13) Flexible endoscope
 (14) Light source, indirect light with head mirror
 (15) Otoscope
B. ENT Clinical Operating Room
                                   BROOKE ARMY MEDICAL CENTER   - 53 -

 (1) Cardiac Monitor (BP, Pulse Ox, EKG Leads)
 (2) Electro-Surgical Unit
 (3) Ellman Coagulator
 (4) Facial Nerve Monitor
 (5) Wall Oxygen/Air
 (6) Wall Nitrogen
 (7) Instrument cart
 (8) Operating Table Positioning
C. Audiology Diagnostic Procedure/Equipment
  (1) Bone Conduction testing equipment
  (2) Electronystagmograph
  (3) Ear mold Impression equipment
  (4) Hearing Aid Repair/Buffer equipment
  (5) Otoscope
  (6) Rotary Chair
  (7) Typanometer
D. Speech Pathology Equipment
  (1) Videostrobe
  (2) Digital swallow analysis equipment
  (3) Rigid endoscope
  (4) Flexible naso-pharyngeal endoscope
  (5) Videofluroscopic (Radiology) equipment
                                       BROOKE ARMY MEDICAL CENTER                                                              - 54 -


2. Supplies                                                          CRITICAL THINKING: Ensures appropriate supplies are on hand and non-standard items are ordered in sufficient
                                                                     amount of time. Maintains a safe environment appropriate for the age specific population. Ensures that all supplies are
                                                                     secured to maintain a safe environment for children.
A. Restock exam/treatment/operating room supplies
B. Identifies unservicable equipment and report to NCOIC
C. Properly discard outdated material
D. Demonstrates proper procedure for cleaning, packaging and
exchanging instruments for sterilization in CMS
E. Delivers and receives CMS supplies/instruments IAW SOP
F. Demonstrates proper procedure for rotating supplies
G. Conserves supplies
H. Demonstrates proper procedure for exchange of Crash Cart

3. Security / Privacy                                                CRITICAL THINKING: Understands that adhering to established Security Policies and Procedures is imperative to
                                                                     maintaining a safe working environment for both employees and patients. Ensures that every employee supports
                                                                     established policies and is able to recognize and react to security breaches accordingly.
A. Ensures badge access for all staff & visitors to the immediate
work site
B. Ensures computer and patient records security
C. Stresses patient confidentiality (in both paper and electronic
formats)
D. Manages key control program
E. Manages security of equipment and supplies

4. Emergency Preparedness Plan (EPP)                                 CRITICAL THINKING: Understands BAMC’s EPP and procedures to follow in case of unexpected events. Able to
                                                                     function as a team player and ensure patient safety and staff wellbeing.
A. Demonstrates ability to respond to codes blue, red and pink
B. Demonstrates ability to respond to bomb threat
C. Know location of EPP in the clinic
D. Verbalizes correctly how to respond to a severe weather
warning, hazardous material spill and a facility systems failure
E. Verbalizes correctly how to respond to a fire; knows fire
alarm, extinguisher and exit evacuation plan
F. Responds appropriately to call light alarm system in the clinic
G. Responds appropriately to someone locked in the bathroom



      Preceptor’s Initials: _______ Printed Name: ______________________________________ Preceptor Signature: ______________________________________________________



      Preceptor’s Initials: _______ Printed Name: ______________________________________ Preceptor Signature: ______________________________________________________
                                 BROOKE ARMY MEDICAL CENTER                                                            - 55 -


Behavior                                                               *Self         Orientation          +Eval        Competency Validated by Supervisor       Comments
               (Source of Performance Standard)                        Assess     (Preceptor initials     Method              (Signature and date)
                                                                                       & date)
 INITIAL COMPETENCY ASSESSMENT OF SPECIFIC SKILLS AND PROCEDURES FOR Otolaryngology/Audiology Receptionists &
                                             Medical Clerks
     Source of Performance Standard: Leadership ---Organizational Performance---Patient Rights---Human Resources
Demonstrates competency related to specific skills and procedures IAW appropriate administrative and leadership standards.
1. Organization                                    CRITICAL THINKING: Communicates this information to staff and seeks any and all opportunities to make the vision a
                                                                      reality.
A. Verbalizes mission, goals, and strategic plan for
 (1) MEDCEN
 (2) Department
 (3) Clinic
B. Verbalizes understanding of roles and responsibilities of
 (1) Commander and Executive Group
 (2) Department Chief
 (3) Clinic Head Nurse
 (4) Clinic NCOIC

2. Team Work                                                          CRITICAL THINKING: Communicates appropriate information to staff members in a courteous, professional, and
                                                                      approachable manner. Maintains professional composure at all times, ensures that all work is completed, and manages
                                                                      conflicts appropriately and in a timely manner.
A. Demonstrates ability to communicate and use effective
interpersonal skills with colleagues and other members of the
medical center
B. Ensures customer satisfaction oriented environment for both
patients, families, and other customers
C. Fosters a positive work environment and encourages team work
among staff
D. Demonstrates appropriate time management skills
E. Verbalizes knowledge and understanding of patient and staff
rights and responsibilities
F. Verbalizes clinic’s mission, philosophy, and scope of service
G. Is familiar with BAMC services and their location: pharmacy,
radiology, nuclear medicine, MRI, out-patient records, lab, patient
administration, MEB office, patient rep, TRICARE center, health
promotion, CARES desk, ID office, health benefits advisor etc.
H. Ensures a safe environment for patients/families and staff,                                                                                                                              1
identifying health and safety risks and takes appropriate and
immediate steps to alleviate the risk
                                 BROOKE ARMY MEDICAL CENTER                                                              - 56 -

I. Demonstrates knowledge of current status of MEDCEN,
Department, and Clinic Performance Improvement, Risk
Management, and Patient Safety programs and initiatives
J. Assists in the orientation of new personnel and shares expertise
K. Meets suspenses without prompting


3. Telephone Courtesy & Customer Service                              CRITICAL THINKING: Recognizes that older or English as a second language callers may demonstrate a delayed response
                                                                      to questions and politely allows them time to phrase an answer. Also clarifies the caller’s request to avoid any
                                                                      misunderstandings.
A. Correctly and politely answers the telephone and transfers calls
appropriately
B. Correctly generates CHCS telephone consult
 (1) Verifies name, unit, SSN, phone number, address, DEERS
eligibility, and Tricare enrollment status
 (2) Obtains pertinent patient information and chief complaint;
documents in CHCS
 (3) Forwards telephone consults to appropriate provider


Source of Performance Standard:                               Surveillance, Prevention, and Control of Infection
Demonstrates ability to identify and reduce the risks of acquiring and transmitting infections between patients, employees, and visitors and follows
all guidelines per BAMC Infection Control Policy and Procedures Guide.
A. Refers to and understands the BAMC Infection Control Policy
B. Demonstrates proper technique for washing hands


                       Source of Performance Standard: Care of Patients-----Continuum of Care-----Management
                                        of Information---Patient Rights and Organizational Ethics
1. General Procedures                                                 CRITICAL THINKING: Recognizes the need for adapting communication skills and techniques to patients in different age
                                                                      groups. Demonstrates an awareness of varying safety needs for patients and maintains the work environment to ensure
                                                                      patient safety for all.
A. Greets all patients and family members with professionalism
and courtesy considering the following age groups:
 (1) Children (0-12 years)                                            CRITICAL THINKING FOR CHILDREN: Explains to parents all administrative procedures and provides reassurance.
                                                                      Encourages parent to provide child with a security item (blanket, toy) and have parent stay with child. Understands that
                                                                      parents should not leave children unattended and informs supervisor if this happens.

 (2) Adolescents (12-17 years)                                        CRITICAL THINKING FOR ADOLESCENTS: Involves adolescent and parent in all administrative decisions and
                                                                      encourages the adolescent to participate as much as possible. Supplements explanations with rationale. Talks directly to the
                                                                      adolescent and allows them to answer questions even if a parent is present. Does not treat adolescent like a child.
                                BROOKE ARMY MEDICAL CENTER                                                             - 57 -


 (3) Adults (18-64 years)                                            CRITICAL THINKING FOR ADULTS: Addresses patient by name and/or rank per their preference. Explains
                                                                     administrative procedures in clear and simple terms using correct terminology.

 (4) Geriatric (65 plus)                                             CRITICAL THINKING FOR OLDER ADULTS: Shows respect for patient and family and addresses patient by name
                                                                     and/or rank per their preference avoiding such terms as “honey, sweetie, or cutie”. Recognizes that older patients may
                                                                     demonstrate a delayed response to questions and allows them time to phrase an answer. Also adjusts explanations to
                                                                     accommodate short-term memory loss. Explains administrative procedures in clear and simple terms using correct
                                                                     terminology.

B. Demonstrates ability to print 600s for next day appointment and
arrange them with medical records per provider
C. Demonstrates end of day closure on CHCS pending entries
D. Works at a pace of typing at least 40WPM
E. Able to receive and handle all telephone calls, patients and
visitors in the clinic appropriately
F. Continually improve the use of medical terminology
(definitions, spelling)
G. Understands and contributes to FOCUS/PDCA efforts
H. Demonstrates knowledge of Outlook mail and checks mail on
daily basis
I. Participates in mock JCAHOs
J. Demonstrates understanding of prescription renewal process

2. Patient Processing: Check In                                      CRITICAL THINKING: Follows clinic guidelines for patient check-in and booking appointments and is sensitive to patient
                                                                     needs. Follows HIPAA and Patient Confidentiality rules to ensure patient privacy. Practices protection of patient information
                                                                     (conversations, exam rooms, rosters, schedules & medical documents).
A. Displays knowledge of specific paperwork that goes with
different appointment types or internal specialty clinics
B. Able to determine if patient needs a triage nurse immediately     CRITICAL THINKING: Recognizes situations that require RN intervention and reacts accordingly.
                                 BROOKE ARMY MEDICAL CENTER                                                          - 58 -

C. Ensures a parent or guardian with power of attorney                 CRITICAL THINKING: Shows respect for patient and elicits assistance from Administrator/NCOIC, or OIC while
accompanies patients under age 18. Exceptions to this include:         maintaining patient visual and auditory privacy

  (1) Patient is an emancipated minor with documentation
  (2) Patient is married
  (3) Patient is active duty military
  (4) Patient is the parent of a child
D. Verify patient eligibility (include reservist, NATO, foreigners,
etc. Check military ID and or health card stamp
  (1) Encourages patients to get medical card and record issued if
they do not have one
E. Determine need for patient certificate of eligibility
F. Verify / change patient demographic data in CHCS
G. Identify / coverage; third party information
H. Use CHCS to charge in or request outpatient records
I. Understand and implement late arrival policy. Marks time
patient presents at front desk.
J. Understands and enters walk-in process in CHCS
  (1) Prepares appropriate paperwork
K. Medical Records
  (1) Demonstrates medical record requesting, validation of receipt,
distribution, accountability and return
  (2) Assist in records location in all areas of Otolaryngology and
Audiology clinic and other clinics as needed
  (3) Ensures correct patient record location is entered in patient
demographics

3. Patient Processing: Check-out and/or                                CRITICAL THINKING: Shows respect for patient and elicits assistance from Administrator/NCOIC, or OIC while
                                                                       maintaining patient visual and auditory privacy
Booking Appointments Over the Telephone
A. Arranges for follow-up appointment as needed
B. Offer assistance with labs, instructions, etc.
C. Charge out patient records as appropriate
D. Demonstrates understanding of appointment types such as
established/follow-up appointments (EST), use of ACUT, PRO
and scheduling internal specialty clinic appointments
E. Demonstrates cancellation and rescheduling procedures
F. Adds, modifies, or deletes appointment times in the computer
G. Reschedules patient appointments as necessary efficiently
H. Notifies patients by telephone when appointments are moved
and rescheduled; opened or closed, or appointed off wait lists as
necessary
                                 BROOKE ARMY MEDICAL CENTER                                                             - 59 -


4. Spouse/Vulnerable Adult Abuse & Neglect                            CRITICAL THINKING: Treats patient and family with dignity and respect with emphasis placed on their psychological
                                                                      needs. Refers to AR 608-18 for additional information.
A. Able to identify high risk families or situations
B. Verbalizes signs/symptoms of following for vulnerable adults
   (1) Physical abuse and neglect
   (2) Sexual abuse and emotional maltreatment
C. Notifies physician or Charge Nurse if family is high risk or
signs and symptoms of abuse/neglect are present

To provide a safe, functional, and effective environment for patients, staff members, and other individuals in the organization.
1. Equipment                                        CRITICAL THINKING: Describes the capabilities, limitations and special applications of each item of equipment.
                                                                      Demonstrates basic operating and safety procedures for equipment items. Reports routine problems with equipment.
                                                                      Identifies emergency procedures in the event of equipment failure. Describes the process for reporting user errors and/or
                                                                      patient incidents. Performs actions IAW unit SOP and BAMC Regulations.
A. Call light system
B. Pneumatic tube system
C. Shredders
D. Printers
E. PCs
F. VTs
G. Telephone system
H. Typewriter
2. Supplies                                                           CRITICAL THINKING: Ensures appropriate supplies are on hand and non-standard items are ordered in sufficient amount
                                                                      of time. Maintains a safe environment appropriate for the age specific population. Ensures that all supplies are secured to
                                                                      maintain a safe environment for children.
A. Restocks front desk area with paper, pens, staplers, paper clips
etc.
B. Identifies unserviceable equipment and reports to supervisor
C. Fosters clean desk area environment to include emptying and
bagging shredded materials
D. Conserves supplies




    Source of Performance Standard:                Environment of Care
                                 BROOKE ARMY MEDICAL CENTER                                                            - 60 -


3. Security                                                           CRITICAL THINKING: Involves staff in all security measures and assists with the safeguard of all patient information.
A. Ensures badge access for all staff & visitors to the immediate
work site
B. Ensures computer and patient records security
C. Stresses patient confidentiality (in both paper and electronic
formats)
D. Manages security of equipment and supplies

4. Emergency Preparedness Plan (EPP)                                  CRITICAL THINKING: Understands BAMC’s EPP and procedures to follow in case of unexpected events. Able to function
                                                                      as a team player and ensure patient safety and staff wellbeing.
A. Demonstrates ability to respond to codes blue, red and pink
B. Demonstrates ability to respond to bomb threat
C. Know location of EPP in the clinic
D. Verbalizes correctly how to respond to a severe weather
warning, hazardous material spill and a facility systems failure
E. Verbalizes correctly how to respond to a fire; knows fire alarm,
extinguisher and exit evacuation plan
F. Responds appropriately to call light alarm system in the clinic
G. Responds appropriately to someone locked in the bathroom




Preceptor Initials: _________ Printed Name: _________________________________________Signature: __________________________________________________

Preceptor Initials: _________ Printed Name: _________________________________________ Signature: __________________________________________________
                                       BROOKE ARMY MEDICAL CENTER                                                            - 61 -


INITIAL COMPETENCY ASSESSMENT OF DUTY SPECIFIC SKILLS
& PROCEDURES FOR Otolaryngology Clinic Secretary
Source of Performance Standard: Leadership --- Organizational Performance --- Patient Rights --- Human
Resources
1. Organization                                                       CRITICAL THINKING: Communicates this information to the staff and seeks every opportunity to make the vision a
                                                                      reality.
A. Verbalizes the mission, goals, and strategic plan for
 (1) MEDCEN
 (2) Department
B. Verbalizes understanding of roles & responsibilities of
 (1) Commander and Executive Group
 (2) Department Chief
 (3) Department Staff

2. Team Work                                                          CRITICAL THINKING: Communicates appropriate information to members of the team in a courteous, professional,
                                                                      and approachable manner. Maintains professional composure at all times, ensures thoroughness in work, and manages
                                                                      conflicts appropriately and in a timely manner.
A. Demonstrates ability to communicate and use effective
interpersonal skills with colleagues and other members of the
medical center
B. Ensures customer satisfaction oriented environment for both
patients, families, and other customers
C. Fosters a positive work environment and encourages team
work among staff
D. Demonstrates appropriate time management skills
E. Verbalizes knowledge and understanding of patient and staff
rights and responsibilities
F. Verbalizes knowledge and understanding of scope of practice
for clerks, receptionists, secretaries
G. Ensures a safe environment for patients/families and staff,                                                                                                                            1
identifying health/safety risks and takes appropriate and
immediate steps to alleviate the risk
H. Demonstrates knowledge of current status of MEDCEN and
Department Performance Improvement, Risk Management, and
Patient Safety programs and initiatives
I. Assists in the orientation of new personnel and shares expertise
J. Meets suspenses without prompting
                                       BROOKE ARMY MEDICAL CENTER                                                               - 62 -


3. Telephone Courtesy                                                CRITICAL THINKING: Recognizes that older or English as a second language caller may demonstrate a delayed
                                                                     response to questions and politely allows them time to phrase an answer. Also clarifies the caller’s request to avoid any
                                                                     misunderstandings.
A. Correctly and politely answers the telephone and transfers
calls appropriately
 (1) Attempts to answer phone by third ring
 (2) Speaks clearly
 (3) Identifies self and unit when placing or receiving calls
 (4) “May I ask who is calling” will provide you with a name
which you can use throughout the call
 (5) Asks how may I help you
 (6) Listens carefully and attentively
B. Keeps messages accurate, brief, & concise
C. Retrieves and responds to messages in a timely manner
D. Forwards calls to appropriate staff members in a timely
manner
E. Receives visitors and phone calls for the Chief and staff
 (1) Determines nature of calls
 (2) Refers phone calls to appropriate staff
F. Correctly generates CHCS telephone consult
    (1) Verifies name, unit, SSN, phone number, address, DEERS
eligibility, and Tricare enrollment status
    (2) Obtains pertinent patient information and chief complaint;
documents in CHCS
    (3) Retrieves patient records and forwards telephone consults
to appropriate provider

          Source of Performance Standard: Care of Patients-----Continuum of Care-----Assessment of Patients---
                          Management of Information---Patient Rights and Organizational Ethics
Demonstrates clinical competency related to specific skills and procedures IAW appropriate standards for care and within defined scope of
practice and manufacturer guidelines.
1. Office Administration: Secretary              CRITICAL THINKING: Communicates appropriate information to staff in a courteous, professional, and approachable
                                                                     manner. Maintains professional composure at all times and manages conflict appropriately and in a timely manner.
A. Verbalizes comprehensive knowledge of the Department as it
relates to clerical duties and administrative support to perform
both routine and non-routine assignments
B. Demonstrates ability to use multiple computer systems to          CRITICAL THINKING: Ensures that all staff protects patient privacy as per HIPAA standards. Recognizes when
support the Department’s mission                                     standards are violated and takes corrective action (speak with staff, log off computers, etc).
 (1) Passwords, logging on and off
 (2) Various computer applications (email, databases, graphics,
word processing, internet and web pages, etc.)
                                       BROOKE ARMY MEDICAL CENTER                                                             - 63 -

    a. Windows NT, Microsoft Office Suite applications or
equivalent, (for example Word, Excel, Outlook, Powerpoint,
Access, etc.)
     b. CIS
     c. CHCS
     d. DCPS
     e. DMHRS
     f. AMEDD Forms
 (3) Generates reports and spreadsheets
    a. Completes ADMs by the fifth of each month and ensures
the ADM compliance report is printed
     b. Completes end of day reports
 (4) Help Desk use/CIS pager
 (5) Input weekly DMHRS
 (6) Input bi-weekly payroll
C. Maintains the Department Chief’s daily calendar
 (1) Responsible for making changes and adjustments and
appointments without prior approval
 (2) Prepare and distribute schedules
    a. Resolves scheduling problems and answers questions
regarding scheduling
    b. Ensure clinic schedule is prepared five weeks in advance
   c. Schedules all surgical cases
    d. Attends weekly conferences to maintain current
information
 (3) Makes travel arrangements for the Department Chief.
D. Develops and maintains professional contacts inside and
outside of the program that are important sources of information,
support, and collaboration.
E. Responsible for patient outprocessing (i.e., helping patients
with directions, copying, calling local and/or external services
when the patient is with the doctor or has just been seen)
F. Responsible for keeping the Practitioner Activity File in order    CRITICAL THINKING: Ensures that all staff records are for official use only. Protects documents IAW United States
and updated at all times                                              Code Title 10 Section 1102, Confidentiality of Medical Quality Assurance. Recognizes when standards are violated and
                                                                      takes corrective action.

G. Schedule physician's military training, adjust/cancel clinic and
contact patients accordingly
H. Ensures timely submission and participation in incentive
awards and annual and special ratings of civilian employees,
OERs, and NCOERs
                                       BROOKE ARMY MEDICAL CENTER                                                                - 64 -

I. Maintains and submits civilian time cards/automated records
for the department in accordance with official payroll program
J. Instruct and assist staff and Reservists who train annually on
administrative and procedural requirements
K. Maintain suspense file on official actions and follow-ups with
the supervisor and/or subordinates on status of suspense actions.
L. Demonstrates ability to write memos, SOP(s), and key
correspondence documents as appropriate
  (1) Receives and reviews all incoming messages and
correspondence
  (2) Prepares replies of an administrative or non-technical nature
M. Participate in staff meetings
  (1) Records minutes of Department meetings
  (2) Compiles, prepares, and submits recurring reports as
necessary
     a. New research protocols and data compilation
     b. Update protocol database
     c. Financial account status database
N. Demonstrates knowledge of current status of Department and         CRITICAL THINKING: Ensures that all staff records are for official use only protects patient privacy as per HIPAA
unit Performance Improvement, Risk Management, and Patient            standards. Recognizes when standards are violated and takes corrective action (speak with staff, log off computers, etc).
Safety programs and initiatives
  (1) Verbalizes understanding of methods available to monitor
and evaluate the quality of services & patient care
  (2) Pull charts for QA, patient satisfaction, pain assessment and
ensure suspense is met
  (3) Prepare the forms for QA and ensure suspense is met
  (4) Responsible for updating SOP and Scope of Service
  (5) Participate in the FOCUS PDCA
O. Establish & maintain department files/record keeping system
in compliance with organizational, departmental, and external
agency requirements
P. Verbalizes liaison role with BAMC departments
  (1) Assist departments with administrative requirements.
  (2) Assist departments with specialized needs
Q. Maintain Department Library
R. Responsible for Medical Records and patient confidentiality
  (1) Check and verify DEERS eligibility
  (2) Obtain authorization for release of medical information to
third parties
  (3) Handles third party insurance and ensures the proper
questions are asked regarding HIPAA (inquires if the patient has
received the pamphlet)
  (4) Retrieve patient data and input accordingly
                                      BROOKE ARMY MEDICAL CENTER                                                         - 65 -

 (5) Maintain all pertinent forms
S. Complete copying tasks as required
T. Post and update bulletin board information
U. Maintain clean & neat work area and personal appearance
V. Familiar with BAMC Infection Control Policy and procedures

2. Safety and Security                                             CRITICAL THINKING: Promotes safety and aggressively prepares staff to respond to dangerous or emergent situations.
                                                                   Involves staff in all security measures and encourages accountability for the security of all patient information.
A. Become familiar and demonstrate ability to respond to and
evaluate performance of:
 (1) CODE BLUE (cardiac arrest)
 (2) CODE RED (fire)
 (3) CODE PINK (pediatric abduction)
 (4) CODE YELLOW (bomb threat)
 (5) Severe Weather Warning
 (6) Hazardous Material Spill
 (7) Facility Systems Failure
B. Knows location of silent duress alarm
C. Performs end-of-day security checks (records, doors,
computers, etc.)
D. Describes unit safety plan
E. Describes Emergency Preparedness Plan and personal as well
as staff role

3. Child, Spouse, and Vulnerable Adult Abuse                       CRITICAL THINKING: Treats patient and family with dignity and respect with emphasis placed on their psychological
                                                                   needs. Refer to AR 608-18 for additional information.
and Neglect
A. Able to identify the characteristics of high risk families or
situations
B. Notifies PCM if family is high risk or signs and symptoms of
abuse/neglect are present


To provide a safe, functional, and effective environment for patients, staff members, and other individuals in the organization.


    Source of Performance Standard:               Environment of Care
                                       BROOKE ARMY MEDICAL CENTER                                                             - 66 -


1. Automated and regular equipment                                  CRITICAL THINKING: Describes the capabilities, limitations and special applications of each item of equipment.
                                                                    Demonstrates basic operating and safety procedures for equipment items. Reports routine problems with equipment.
operations and functions                                            Identifies emergency procedures in the event of equipment failure. Describes the process for reporting user errors and/or
                                                                    patient incidents. Performs actions IAW unit SOP and BAMC Regulations.
A. Operate Computer, laser jet, and track printers
B. Utilizes KG-ADS system to add or change patient’s insurance
information.
C. Utilizes Electronic Consult System
D. Operate Automatic File System, files organization and manual
operation
E. Demonstrate use of telephone features
  (1) Transfer calls
  (2) Call hold
  (3) Call forward
  (4) Call pickup
F. Operates label maker
G. Operate Copier
  (1) Copy schedules for Departments
  (2) Change toner cartridge
  (3) Change paper size, add paper when needed
H. Operate Fax Machine
  (1) Send fax, retrieve and distribute fax
  (2) Know how to verify fax by report
  (3) Knowledge on how to send fax by DSN
  (4) Knowledge on how to add paper
  (5) Knowledge on how to correct paper jam
  (6) Knowledge on changing ink cartridge
I. Knowledge on how to page key employees and knowing their
pager numbers
J. Be familiar with patient alarm panel (restrooms)
K. Reports defects or needs for maintenance
L. Ability to operate typewriter
  (1) Knowledge of keyboard
  (2) Change cartridge
M. Use Pneumatic Tube System


2. Supplies                                                         CRITICAL THINKING: Ensures appropriate supplies are on hand and non-standard items are ordered in sufficient
                                                                    amount of time. Maintains a safe environment appropriate for the age specific population. Ensures that all supplies are
                                                                    secured to maintain a safe environment for children.
A. Exercise prudent use of supplies
B. Maintains stock levels for front desk and administrative areas
C. Conserves supplies
                                       BROOKE ARMY MEDICAL CENTER                                                          - 67 -


3. Security / Privacy                                                CRITICAL THINKING: Understands that adhering to established Security Policies and Procedures is imperative to
                                                                     maintaining a safe working environment for both employees and patients. Ensures that every employee supports
                                                                     established policies and is able to recognize and react to security breaches accordingly.
A. Ensures badge access for all staff & visitors to the immediate
work site
B. Ensures computer and patient records security
C. Stresses patient confidentiality (in both paper and electronic
formats)
D. Manages security of equipment and supplies

4. Emergency Preparedness Plan (EPP)                                 CRITICAL THINKING: Understands BAMC’s EPP and procedures to follow in case of unexpected events. Able to
                                                                     function as a team player and ensure patient safety and staff wellbeing.
A. Demonstrates ability to respond to codes blue, red and pink
B. Demonstrates ability to respond to bomb threat
C. Know location of EPP in the clinic
D. Verbalizes correctly how to respond to a severe weather
warning, hazardous material spill and a facility systems failure
E. Verbalizes correctly how to respond to a fire; knows fire
alarm, extinguisher and exit evacuation plan
F. Responds appropriately to call light alarm system in the clinic
G. Responds appropriately to someone locked in the bathroom




      Preceptor Initials: ____________         Printed Name: ______________________________________ Preceptor Signature: __________________________________

      Preceptor Initials: ____________         Printed Name: ______________________________________ Preceptor Signature: ___________________________________

				
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