FlipPub Example

Welcome
to MedStar Medical Group
version 10.17

Table of Contents

Letter to the MedStar Medical Group team.............................................................................................................. Pg 1
Vision, Mission, Values.................................................................................................................................................. Pg 2
MedStar Health At a Glance........................................................................................................................................ Pg 3
MedStar Medical Group…by the numbers............................................................................................................... Pg 4
MMG Organization....................................................................................................................................................... Pg 5
MMG Executive Team................................................................................................................................................... Pg 6
MMG Governing Council............................................................................................................................................. Pg 7
Clinical Practice Councils............................................................................................................................................. Pg 7
Quality Measures.......................................................................................................................................................... Pg 9
Patient Experience and Service Excellence............................................................................................................. Pg 10
Productivity and Financial Measures........................................................................................................................ Pg 11
Expectations of Performance and Behavior............................................................................................................ Pg 12
Safety and Risk Management.................................................................................................................................... Pg 14
MMG Policy on Patient Privacy and Confidentiality................................................................................................ Pg 18
Continuing Medical Education and Training........................................................................................................... Pg 20
Catalyzing Innovation/Advancing Health................................................................................................................ Pg 23
Information Systems................................................................................................................................................... Pg 29
Marketing, Communications and Physician Relations........................................................................................... Pg 32
Compensation and Benefits...................................................................................................................................... Pg 35
Equal Employment Opportunity............................................................................................................................... Pg 38
Accessing and Updating Payroll and Other Employee Information.................................................................... Pg 39
Notes............................................................................................................................................................................ Pg 41

Dear Colleague,
I am delighted to welcome you to the MedStar Medical Group (MMG) team.
As you join MMG, you enter a partnership and collaboration that will allow us to
provide the very best in patient care. With your help, MMG will continue to build
and nurture a culture based on mutual respect, shared values, commitment
to caring, and open communication with our patients, our community and
each other.
MMG is part of MedStar Health, the largest health system in Maryland and the
Washington, D.C., region. With a network of 10 hospitals and more than 6,500
employed and affiliated physicians, MedStar is a proven leader in delivering
excellent clinical care.
I am very pleased you have chosen to care for your patients at MedStar Medical
Group. Collectively and collaboratively, we are advancing the important work
of developing an integrated medical group that will seamlessly support
and connect MedStar Health’s Distributed Care Delivery Network across
Maryland and the Washington, D.C., region — all on behalf of the patients we serve.
We are committed to building the kind of medical group where providers want
to deliver care, where associates want to work and — most importantly — where
the patients of this region want to receive their care. Your engagement, your
insights, your energy, and your expertise are all of the greatest importance.
We pledge to provide you and your patients with high quality service and care.
If you have any questions or concerns, or if you need additional information
regarding resources available to you, please contact Ann Black in Physician
Relations at 443-725-8732 or you may reach me directly at 410-772-6729.

Sincerely,

Richard Goldberg, MD
President
MedStar Medical Group

1

Vision

To be the trusted leader in caring for people and advancing health.

Mission

To serve our patients, those who care for them, and our communities.

Values

Service
We strive to anticipate and meet the needs of our patients, physicians and co-workers.
Patient first
We strive to deliver the best to every patient every day. The patient is the first priority
in everything we do.
Integrity
We communicate openly and honestly, build trust and conduct ourselves according
to the highest ethical standards.
Respect
We treat each individual, those we serve and those with whom we work, with the
highest professionalism and dignity.
Innovation
We embrace change and work to improve all we do in a fiscally responsible manner.
Teamwork
System effectiveness is built on the collective strength and cultural diversity of everyone,
working with open communication and mutual respect.

2

At a Glance Who We Are

MedStar Health combines the best aspects of academic medicine, research and Hospitals
innovation with a complete spectrum of clinical services to advance patient care. MedStar Franklin Square Medical Center
As the largest healthcare provider in Maryland and the Washington, D.C., region, MedStar Georgetown University Hospital
MedStar Health’s 10 hospitals, the MedStar Health Research Institute and a MedStar Good Samaritan Hospital
comprehensive scope of health-related organizations are recognized regionally MedStar Harbor Hospital
and nationally for excellence in medical care. MedStar Health has one of the largest MedStar Montgomery Medical Center
graduate medical education programs in the country, training 1,100 medical MedStar National Rehabilitation Hospital
residents annually, and is the medical education and clinical partner of Georgetown MedStar Southern Maryland Hospital Center
University. MedStar Health is a $5 billion, not-for-profit, regional healthcare MedStar St. Mary's Hospital
system based in Columbia, Maryland, and one of the largest employers in the MedStar Union Memorial Hospital
region. Our 31,000 associates and 4,700 affiliated physicians support MedStar MedStar Washington Hospital Center
Health’s patient-first philosophy that combines care, compassion and clinical
excellence with an emphasis on customer service. Clinical Research and Innovation
MedStar Health Research Institute
MedStar Health Facts Fiscal Year 2015 MedStar Institute of Innovation

MedStar Health by the Numbers Home Health Care
MedStar Health Infusion
Total number of inpatient admissions and observation stays 204,528 MedStar Visiting Nurse Association
MedStar VNA Care Partners
Number of inpatient admissions 143,664
Services in our Community
Number of observations stays 60,864 MedStar Ambulatory Services
Hospice of St. Mary's
Total number of outpatient visits 4,332,707 MedStar NRH Rehabilitation Network
Number of home health visits 266,778 MedStar Pharmacy
Number of emergency department visits 547,472 MedStar PromptCare
Number of physician office visits MedStar RadAmerica
Number of ambulatory visits and surgeries 1,696,460
1,821,997 Managed Care Organizations
MedStar Family Choice
Net operating revenue $5.03 B MedStar Medicare Choice
Money spent caring for patients $4.87 B
Earnings from operations that were reinvested $160.8 M Nursing Homes and Senior Living
Investments in information technology Belvedere Green
Philanthropy $60 M Franklin Woods
$31.9 M MedStar Good Samaritan Nursing Center
Woodbourne Woods
Number of associates, residents and fellows 31,000
Nurses 8,700 Physician Practices in the Community
Residents and fellows 1,100 MedStar Medical Group
• Primary Care
Number of affiliated physicians 6,500 • Specialty Care
Employed physicians 1,800 • Surgical Care
Georgetown Physician Group

5565 Sterrett Place
Columbia, MD 21044
410-772-6500 PHONE
MedStarHealth.org

3

MedStar Medical Group…by the numbers

A clinical and operational cornerstone of the MedStar Distributed

Care Delivery Network

1/3 1/3 3,448 providers* MMG–A: 2,923 providers
MMG–B: 525 providers
medical surgical
2,389 employed physicians
1/3 1,059 advanced practice clinicians

primary
care

280More than

sites of care, covering
more than 85 zip codes

2,703,234** HOSPITAL-BASED

MMG–A: 1,707,254 patient visits
MMG–B: 995,980 each year

TELEHEALTH HOME CARE AMBULATORY

One of the largest More than 300 providers from
medical groups
in the country throughout the system involved in
governing MedStar Medical Group

PA
MD

400VA More than
physicians engaged
in research

More than 85 residency and fellowship programs

1,100 Supported by

residents 1,600 MedStar provider
and fellows
teaching faculty

MMG–A: 7,000 Approximately 8,000*
MMG–B: 834
non-provider associates

*Source: PeopleSoft and ECHO as of Jan. 2017; LEGEND
does not include residents and fellows MMG–A: Generally employed by MedStar hospitals
**Source: IDX — Jan. 1 to Dec. 31, 2016 MMG–B: Generally employed by MedStar Medical Group

Version 2.17

4

MMG Organization

MMG–A MMG–B
MMG Aligned MMG Business

MedStar Washington MedStar Good MMG Cardiology/ MedStar Shah
Hospital Center Samaritan Hospital Cardiology Medical Group
MedStar Harbor Hospital Associates Southern MD
MedStar Georgetown MedStar St. Mary's MMG II Physicians LLC
Univeristy Hospital MMG Radiology
MedStar Union Hospital (includes former
Memorial Hospital MedStar Montgomery MPP)
MedStar Southern
Medical Center
Maryland Hospital Center MedStar National
MedStar Franklin Square Rehabilitation Network

Medical Center

MedStar Medical Group Organization, also referred to as MMG–O, is what we call the entire medical group
for MedStar. All physicians and advance practice clinicians, regardless of business entity, are part of MMG–O.

5

MMG Executive Team

Richard Goldberg, MD Jean Bunker Brad Hall John DeSimone, MD Jill Donaldson
President Vice President Vice President Vice President Vice President

Marketing, and CFO Medical Operations Operations
Communications &
Physician Relations

Bill Frohna, MD Brendon Furlong, MD Roby Hunt Joe Ugast James Welsh, MD
Vice President Vice President & Vice President Vice President Vice President
Medical Operations Chief Medical Human Resources
Operations Primary Care Services
Information Officer

6

MMG Governing Council

It is essential to have a forum for key physician and administrative leaders to engage in meaningful dialogue
around the governance and management of MMG. The MMG Governing Council has an integral role in how
care is delivered and achieving the organization's growth, quality improvement, and other strategies. The
Governing Council consists of members who work diligently to promote the long-term interests of MMG as
part of and in support of MedStar Health and its vision. The purpose is to advise, inform and bring consensus
for the betterment of MedStar Medical Group and MedStar Health.

MMG Governing Council

Melly Goodell, Chair, MedStar Franklin Square Medical Center
Steven Brick, MD, Vice Chair, MedStar Medical Group Radiology
Brad Chambers, Senior Vice President, MedStar Health; President, MedStar Union Memorial
and MedStar Good Samaritan Hospitals
Steve Epstein, MD, MedStar Behavioral Health
Frederick Finelli, MD, Chief Medical Officer, MedStar Montgomery Medical Center
Scott Krugman, MD, MedStar Franklin Square Medical Center
Robert Lager, MD, MedStar Cardiology Associates
Les Matthews, MD, MedStar Union Memorial Hospital
Kevin McGrail, MD, MedStar Georgetown University Hospital
Sharon Taylor-Panek, NP, MedStar Washington Hospital Center
Sam Wiesel, MD, MedStar Georgetown University Hospital
Richard Goldberg, MD, President, MedStar Medical Group
M. Joy Drass, MD, Executive Vice President and Chief Operating Officer, MedStar Health
Stephen Evans, MD, Executive Vice President, Medical Affairs, and Chief Medical Officer

Clinical Practice Councils

The purpose of MMG is to create an aligned and engaged provider enterprise that serves as an important
clinical and operational anchor for MedStar and, more importantly, the patients we serve. MMG, which is
composed of all the employed providers across MedStar Health, plays a compelling role in MedStar’s growth
as the provider of choice for patients and their loved ones in this region. Its thoughtful development and
evolution will allow us to collaboratively design and implement a system-wide, evidence-based, standardized
clinical care delivery model that is world-class.

To accomplish this, one of the primary charges of MMG is the activation, development and guidance of
specialty- specific clinical practice councils. The councils guide the professional practice of medicine and
create consistent models of care, focusing attention on information management, including the optimization
of the Cerner Electronic Health Record; quality and safety; clinical practice guidelines to reduce variation and
enhance outcomes; operational efficiency; and value analysis of medical and surgical equipment and supplies.
The work of the practice councils will advance our care delivery model, while providing a voice for MedStar
providers with respect to how they practice medicine.

7

It is important to underscore that MMG is an organization by providers and for providers. Our aim is to involve
clinicians, and the teams who work with them, in the meaningful development of how we consistently, effectively
and seamlessly deliver care across our Distributed Care Delivery Network. This is not a top-down push, but rather
an integrated matrix of feedback and action involving each of you. Our mission, together, will be to demonstrate
the tremendous value a seamless, connected medical group can have on our system and our patients.

Following is a list of the councils and their chairs:
• Hospital Medicine: Emmanuel ("Manny") Kokotakis, MD
• OB/GYN: Samuel Smith, MD
• Radiology: Steven Brick, MD
• Emergency Medicine: Bill Frohna, MD
• Neurology: Carlo Tornatore, MD
• Critical Care: Charles Read, MD (Co-Chair) Daniel Stoltzfus, MD (Co-Chair)
• Urology: Jonathan Hwang, MD
• GI: Nadim Haddad, MD
• Pediatrics: Scott Krugman, MD (Co-Chair) David Nelson, MD (Co-Chair)
• Primary Care: James Welsh, MD (Co-Chair) Melly Goodell, MD (Co-Chair)
• Community Cardiology: Robert Lager, MD
• Orthopedics: Sam Wiesel, MD (Co-Chair) Les Matthews, MD (Co-Chair)
• Neurosurgery: Kevin McGrail, MD
• Vascular Surgery: Edward Woo, MD
• Colo-Rectal Surgery: Thomas Stahl, MD
• Ophthalmology: Jay Lustbader, MD
• Rehab Medicine: Curtis Whitehair, MD
• Breast Surgery: Shawna Willey, MD
• ENT: Bruce Davidson, MD
• Anesthesia: David Mayer, MD
• Behavioral Health: Steven Epstein, MD
• Thoracic Surgery: Tom Watson, MD
• Pathology: Moira Larsen, MD
• Oncology: Louis Weiner, MD
• Palliative Care: Chris Kearney, MD (Co-Chair) Kathryn Walker, PharmD (Co-Chair)
• Endocrine / Diabetes: TBD
• Plastic Surgery / Wound Care: David Song, MD

If you have questions about the work of the councils or would like to get involved, contact the chair
of your specialty, or you can reach out to James Welsh, MD, vice president, Primary Care Services for MMG,
at [email protected]; or John DeSimone, MD, vice president of Medical Operations for MMG,
at [email protected].

8

Quality Measures

In addition to providing a positive patient experience, MedStar Medical Group is committed to providing
patients with the highest quality of care. As such, we are working with our clinical councils to develop
standardized quality metrics and reporting, as well as system wide quality improvement initiatives to ensure
the highest quality and safety possible for our patients.
Primary Care:
In 2016, the Primary Care Clinical Council approved 14 quality measures for the care of adult patients
in the primary care setting. These quality measures will be collected system wide for all primary care providers
and regular reports will be available to providers, medical directors, and MMG leadership. These reports
ultimately are reported to MedStar Health’s Board of Directors to ensure progress towards ensuring the
highest quality of care delivery to MedStar patients.
For Fiscal Year 2018, the 14 adult primary care measures will include:
• Controlling High Blood Pressure
• Tobacco Use: Screening and Cessation Intervention
• Breast Cancer Screening
• Colorectal Cancer Screening
• Pneumonia Vaccination Status for Older Adults
• Diabetes: HbAic Poor Control (>9%)
• Diabetes: HbA1c Good Control (<8%)
• Adult Weight Screening and Follow-up
• Screening for Future Fall Risk
• Documentation of Current Medications in the Medical Record
• Influenza Immunization
• Diabetes Eye Exam
• Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
• Screening for Depression and Follow-up Plan
In MMG, Primary Care physicians and advanced practice clinicians will have 50 percent of their annual quality
bonus tied to meeting benchmarks for eight of the above measures. Please refer to the FAQ document on
Adult Primary Care Clinical Quality Metrics for additional information on definitions of the measures and
methodology, as well as a list of the specific measures tied to quality incentives in the MMG primary care
compensation plan.
Specialty Care:
Quality measures are important for all clinicians in MMG. While MMG Primary Care is more mature in reporting
its measures, in FY18 our specialty physicians will begin receiving individual reports on these, along with their
“focus” measure on Medication Reconciliation.

9

Patient Experience and Service Excellence

What is CG-CAHPS?

• The Clinician and Group Consumer Assessment of Healthcare Providers and Systems.
• A national standard tool to measure the patient experience in the physician office setting.
• Developed by AHRQ and the CAHPS Consortium (Yale, Harvard, Rand Corporation).
• Released by AHRQ in 2007.
• Endorsed by National Quality Forum and Robert Wood Johnson Foundation.
• Expected to become part of CMS pay-for-performance.

What does CG-CAHPS measure?

CG-CAHPS measures patient experience through 36 core questions in six (6) areas:
• Care coordination.
• Courteous and helpful office staff.
• Getting timely care, appointments, and information.
• Provider communication.
• Overall rating of the provider.
• Likelihood to recommend the provider.

CG-CAHPS has two tracks of survey administration:
• I nternal — for continuous performance improvement, covering all employed physicians who practice

in an office setting.
• External — for annual CMS public reporting, focusing on large medical groups.

National Research Corporation (NRC) is our system CG-CAHPS partner. CG-CAHPS surveys are mailed
to randomly selected MedStar patients following their appointments.

MedStar Medical Group publishes our patient experience survey results in the form of star ratings. NRC uses an
algorithm to convert CG-CAHPS scores pertaining to provider communication and overall provider ratings into the
star ratings most familiar to consumers. These results are specific to physician office visits, and can be found on our
Find-A-Doc pages on MedStarHealth.org, once a provider accumulates at least 30 complete surveys. Currently,
consumers may seek physician ratings from a variety of online sources, including Healthgrades, Vitals and Yelp.
However, these web-rating websites do not provide an accurate representation of patient satisfaction, as their
survey processes are unscientific and can be manipulated. Further, many physicians have only one or two consumer
reviews on these sites, and therefore a single negative review may result in an unsatisfactory and misleading rating.

By placing our providers’ MedStar patient experience data on MedStarHealth.org, we provide consumers with easily
accessible patient satisfaction scores obtained through a regulated survey process. Additionally, because of the
volume of patient survey data loaded on the website, our physician profiles will rank significantly higher than third-
party review sites and our competitors for any matching search on engines such as Google and Bing. This effort allows
us to amplify the positive visibility of our physicians and generate increased opportunities to engage new patients.

If you have questions about CG-CAHPS scores or need additional information and reports, please talk with
your Practice Manager or Director of Operations.

10

Productivity and Financial Measures

MedStar Medical Group will provide regular feedback to each physician, nurse practitioner and physician assistant
about clinical productivity. This is to ensure each provider is aware of his/her contributions to the team and to
the overall financial health of the organization, as well as to inform him/her about progress towards targets for
incentive compensation.
For most primary care physicians and advanced practice clinicians in MMG, monthly and quarterly dashboards
have been developed to provide clear and ongoing feedback around performance on a number of productivity
and quality measures. These reports are reviewed and shared with Facility Medical Directors and providers
on a monthly basis. Dashboards also are being developed for most specialists. A typical dashboard may
include the following:

MONTHLY DASHBOARD:

• Visits (total)
• New Patient Visits (number and percentage of total visits)
• Visits vs Budgeted Visits
• Work RVUs
• Work RVUs vs. Compensation Plan Incentive Targets
• Trendlines for visits, new patient visits, and Work RVUs
• Work RVUs vs. Budgeted Work RVUs

QUARTERLY DASHBOARD:

• Visits by month and for the quarter
• Average number of visits per scheduled clinic day
• Work RVUs by month and for the quarter
• Average Work RVU per visit by month and for the quarter
• Quarterly Work RVU compared to MGMA median and 60th percentile
• Quarterly Work RVU vs Compensation Plan Incentive Targets
• E&M Established Visit coding distribution vs. other MMG providers and national benchmarks
• Patient Experience Scores
• Quality benchmark comparison, meaningful use compliance, unsigned document compliance
• Trendlines for quarterly productivity and patient experience scores
Please ensure that you review these on a regular basis with your Facility Medical Director or Regional Medical
Director. If you have any additional questions or concerns, please contact James Welsh, MD, vice president,
Primary Care Services, or Bill Frohna, MD, vice president, Medical Operations.

11

Expectations of Performance and Behavior

Patient Care

• Show respect to every patient and family member.
• Achieve a level of clinical excellence through evidence-based practice that meets or exceeds the community

standard. See patients promptly and with enthusiasm.
• Knock on door before entering.
• Sit down during every visit.
• Execute the patient care plan.
• Give every patient his or her due.
• Ask “Do you have any questions?”
• Tell them “I'd like to see you back in _____”.
• Tell them to call if they have any further questions.
• Strive that every patient feels better in some way on leaving the practice than on entering.
• Keep the patient and family informed.
• Use diagnostic tests rationally.

Professionalism

• Show respect for professional staff colleagues, practice manager, front and back office staff, students,
and other staff members in the department.

• Arrive on time for shifts and ready to see patients – absolute punctuality.
• Arrive early or stay late when it is in the best interest of the patients or department.
• Chart completely and promptly.
• Behave and communicate professionally.
• Maintain a professional appearance.
• Manage your emotions.

Interpersonal Communication and Presence

• Demonstrate leadership in the clinical arena as a member of the professional staff.
• “Own” the department when you are working clinically; take the initiative in solving problems.
• Approach and offer assistance to all non-professional staff.
• Immediately, directly and honestly communicate to leadership any potentially damaging incidents, events,

or issues.
• See the work through the eyes and mind of the patient and his or her family.

12

Expectations of Performance and Behavior continued

Practice-Based Learning and Improvement

• Support the practice as a learning environment for staff, students, residents, and your colleagues.
• Be open to changing your clinical practice based on evidence or departmental guidelines.
• Make this a career and not just a job.

Relationship to MMG

• Attend and participate in organized MMG functions (e.g., staff meetings, special training sessions).
• Be a team player: help out your partners and the department when asked.
• Actively participate in the infrastructure activities of MMG (e.g., serve on Clinical Councils, committees).
• Find your niche.
• Find and make your unique contribution.
• Don’t wait to be told to make improvements.
• Partner with your FMD, RMD and practice manager.
• Share great ideas.
• Support MMG and departmental initiatives.
• B e accountable all of the time: take personal responsibility for mistakes and share with your colleagues

the benefits of successes.
• Demonstrate public support and adherence to departmental policies and practices.
• Discuss disagreement “behind closed doors.”
• Be loyal to the practice and be willing to place priorities of the practice above personal priorities.
• Respond promptly to requests for information from the department, hospital, or outside groups.

MedStar Medical Group’s Responsibilities to You

• Direct, consistent and timely communication
• Professional practice environment
• Practice support
• Resources and tools to be effective clinically and operationally
• Professional growth opportunities
• Respect for your personal time
• Fair compensation reflecting your contributions and experience
• Consistent feedback about performance: clinical, administrative, interpersonal and professional
• Communication about new policies, initiatives and programs
• Prompt attention to issues, concerns and complaints by MMG leadership
• Open door to MMG leadership

13

Safety and Risk Management

High Reliability Organization (HRO)

MedStar Health has long been committed to delivering the highest levels of quality and safety to our patients.
Now, as part of our good to great journey, MedStar strives to become a High Reliability Organization (HRO).
An HRO is an organization that succeeds in avoiding catastrophes in an environment where accidents are expected
due to risk and complexity. Air traffic control, airlines and nuclear power plants are some examples of HROs.
Within HROs, a culture exists where everyone is acutely aware that even small failures in safety protocols or
processes can lead to catastrophic outcomes.
Associates in these organizations are constantly searching for the smallest indication that the environment or
a key safety process has changed in some way that might lead to failure if action is not taken to resolve the
problem. Uncovering these safety concerns allows an organization to identify safety or quality problems before
harm occurs.

Seven Characteristics of High Reliability Organizations

As MedStar Health drives to become a High Reliability Organization (HRO), we must adopt characteristics of
HROs in order to change our culture and the way we think, work and interact. Innovative healthcare organizations
striving for high reliability often possess the following seven characteristics. These characteristics will help provide
the framework required for MedStar to become a High Reliability Organization.
The seven characteristics include:
1. Transparency: involves open and honest communication between leadership, caregivers, staff, patients,

and families in all areas of care, including the publishing of all outcomes data.
2. P atient engagement: understanding patients’ needs, values, preferences and goals around care is at the

heart of better care at lower cost, as is finding ways for patients to take an active role in their care.
3. Reporting: safety cultures are dependent on knowledge gained from near misses, mistakes, and other

“free lessons.”
4. Interprofessional teamwork and collaboration: HROs employ team approaches in all they do and

successfully level the hierarchical “playing field.”
5. Measurement: HRO cultures use health information technology to measure everything. They know where

they stand relative to the best and act on it. They identify variation between departments, which spotlight
areas for standardization and opportunities to reduce harm.
6. R espect and support: in a HRO culture, the positive work of team members and individuals is noticed,
recognized, appreciated, and rewarded.
7. L eadership: leaders possess an innovative spirit that is driven by ideas, vision and action. They are fearless
and have an obsession for improvement.
Consider how we may apply these seven characteristics to our work. Be proactive. Be reliable. Be a hero.
For more information on HROs, visit http://starport.medstar.net/go/HRO.

14

Safety and Risk Management continued

Risk Management

MedStar’s Risk Management program is responsible for all of MedStar’s insurance programs, including medical
professional liability coverage. The risk management staff is responsible for managing all claims of medical
professional liability that involve any of MedStar’s entities, associates, and physicians employed by MedStar
Medical Group.
Critical to successful management of any medical professional liability claim is the early reporting to Risk
Management of any events or issues that have the potential for liability loss exposure. Once notified of such
events and/or issues, Risk Management personnel are available to provide immediate advice and support to
all MMG physicians and other MedStar associates.
Contact Information:
Jennifer Gonsalves, Claim Manager, Risk Management Services
Phone: 410 772 6918 (office) or 301 466 7314 (cell)

15

Safety and Risk Management continued

Compliance

The Corporate Compliance Department is responsible for educating the MMG and MedStar community about
the federal and local regulations affecting coding, billing, and documenting medical services, and for ensuring
that the regulations are followed.
Contact Information:
Lori Martin, MMG Compliance Officer 443-725-8713

Confidential Hotline to report any potential violations (24 hours per day)
202-877-2900 or 877-210-3320

Investigating Potential Compliance Violations

Corporate Compliance is required to investigate any possible violation of any regulations or policy associated
with the billing for services or transfer of funds, and to take corrective action if any violation is found.

Coding Resource

The staff of Corporate Compliance is available to answer any coding, billing or regulatory questions, and
to assist the physicians and staff in developing charge capture mechanisms and documentation templates.
Online coding training is available free with E&M University. For more details, see the Continuing Education
and Training section on page 19.

16

Safety and Risk Management continued

Patient Safety Event (PSE) Management System

As part of MedStar Health’s patient safety culture, our goal is to embrace a non-punitive response to error and
adopt a just culture approach to all we do when it comes to patient care. The implementation of MedStar’s
Patient Safety Event (PSE) Management System allows associates to report real or potential safety issues,
including patient harm, near misses and unsafe conditions.
The new PSE Management System, run by RL Solutions, is the system’s single reporting tool and replaces
all existing occurrence reporting tools. However, to report customer service compliments/complaints, please
use the Customer Service Report/Complaint section. This section will soon be incorporated into the PSE
Management System.

Procedures for reporting issues and concerns

Serious Injury
In the event of a serious injury – contact the practice manager or director of operations immediately.
Facility Safety Concerns
For urgent safety concerns involving the premises, please call 911.
Non-urgent Incident and Safety Concerns
For all other incidents and safety matters please complete an Incident or Occurrence report form. Staff with
knowledge of an incident, whether directly involved or not, are required to complete an occurrence report
online.
How to complete an Occurrence Report
Report all regardless of whether there is harm to a patient:
• Near Misses
• Medication Occurrences
• Identified Potential Errors

17

MMG Policy on Patient Privacy and Confidentiality

Definitions

HIPAA: Health Insurance Portability and Accountability Act of 1996 is a federal law that establishes minimum
safeguards to protect privacy of protected health information whether electronic, written, or oral form. This
law also establishes patient rights.
Protected Health Information: Any patient information created or received by health care providers or health
plans that relates to past, present, or future information related to the physical or mental health of the patient.
PHI identifies or could be used to identify an individual, is created or received by a healthcare provider, health
plan, employer, or healthcare clearinghouse.
Privacy: Control over the extent, timing, and circumstances of sharing personal health information with others.
Confidentiality: Pertains to the treatment of information that a patient discloses within the relationship of
trust with their health care providers and team members with the expectation that this information will not
be divulged to others in ways that are inconsistent with the understanding of privacy, without their express
knowledge and permission

Policy

Registration Area: As a patient presents for an appointment, every effort is made to conduct business in such
a manner as to protect the privacy of the patient. If it is necessary to discuss personal matters with the patient,
the patient should be directed away from the waiting area to maintain privacy and others present in the area
should be asked to step back to allow for privacy.
Exam Areas: All patient screening is conducted separately from the general waiting room. All patient visits/
rooming is conducted in private exam rooms.
Confidentiality: Patient specific information is not released or discussed with others unless it is authorized by
law, by the patient’s written/verbal consent, or by departmental policies. All federal and state laws regarding
HIPAA apply. All discussions with or about patients is conducted in strictest confidence and with an awareness
to maintain auditory privacy.
Written Materials: All written material concerning patients shall be secured and kept away from areas where
unauthorized persons could have access or exposure. This includes computer screens displaying patient
information that should be turned off, minimized, or privacy screens to protect unexpected exposure. MedStar
privacy brochures are to be available at the front desk and to be distributed to all new patients and anyone
who requests it.

Scope

Applies to all protected health information of all patients, caregivers, significant others in our care.

18

MMG Policy on Patient Privacy and Confidentiality continued

Requirements

Written consent of the patient is required for release of any protected health information. The compliance
office should be contacted for further instruction or information.

Exceptions

No exceptions to this policy.

Legal Reporting Requirements

Privacy and information security breaches must be reported to the Corporate Privacy Office or the MMG
Compliance Officer. After research, certain types of breaches must be reported to the individual affected, state
agencies, the U.S. Department of Health and Human Services, and potentially the media.

Right to Change or Terminate Policy

The MedStar Medical Group President has the final sign off authority on all policies. Changes in policy must be
reviewed and approved by the leadership of the disciplines affected s well as any applicable committees that
are responsible for oversight of the clinical practice prior to final sign off by the MMG President and the Chief
Privacy Officer.

19

Continuing Medical Education and Training

Continuing Medical Education (CME)

All MedStar Medical Group providers are eligible for CME benefits. Providers include physicians, nurse practitioners,
physician assistants, and other advanced practice clinicians (APC). Please refer to CME Policy for most the current
information and how to submit a request for reimbursement. All CME expenses must be approved in advance.
MedStar Medical Group provides the stated CME annual benefit for course tuition and related travel expenses
(as detailed below), books journals and educational programs. Dues, professional fees, society fees and licenses
are reimbursable items within certain limits as described below. These items are separate from the CME
allowance and not deducted from this account.

Coverage Period

CME Account will be available on July 1st of any given year and end on June 30th of the same fiscal year.
Funds must be used in the fiscal year or they will be forfeited. Any partial years of employment will be prorated
based on the portion of the year that the provider was employed by MMG. CME leave and allowance funds
are not to be used in the first 90 days of employment unless there is MMG business reason justified by the Regional
Medical Director.

CME Leave

In most instances, full time providers each will receive five days of CME time. Part-time providers will receive
CME hours equal to a usual work week. A provider would be entitled to the hours equal a usual work week.
For example, a 0.5 providers would be eligible for 20 hours of CME leave annually. For part-time providers,
CME leave may only be used for conferences that fall on usual workdays. A CME conference that falls on a
usual day off or weekend off is not considered CME leave, but the expenses to attend the conference are
covered under the CME policy.

CME Allowance

The annual CME allowance is determined by MMG Leadership and is based on many factors including economic
considerations. The current CME allowance per fiscal year is determined by policy. The amount is prorated for
start date of hire in the fiscal year.

20

Continuing Medical Education and Training continued

Acceptable CME Expenses

The CME Account is available for continuing medical education activities including attending accredited
CME conferences, purchasing medical periodicals, books, tapes, CD’s, software, journals and other medical
educational materials that generate CME credits.
For CME conferences, the account is available for related expenses such as tuition, fees, travel fares, mileage,
food and lodging. Taxi fares to and from an airport/train station, around the conference location or car rental
at the location are covered.
Please note that registration, reservations for accommodations and travel arrangements are the responsibility
of the individual Provider. The maximum nightly lodging allowance is $350. Lodging expenses more than this
amount are the responsibility of the Provider.
• The Provider’s CME balance will be determined by MMG Administration and can be requested by contacting

their Practice Administrator or Manager. If adequate CME funds are not available, MMG Administration will
contact the Provider.
• A dvanced payment of fees and tuition is available upon request provided the CME is approved by the Regional
Medical Director and adequate CME funds are available.

Professional Licenses and Fees

Fees associated with Maryland/DC/VA State Professional Licenses, Maryland/DC Controlled and Dangerous
Substance Permit, Federal Drug Enforcement Administration licenses and the fee to BPQA for Physician Assistants
will be paid by MMG and are not considered CME. ACLS and similar certifications area also paid by MMG.
These expenses are reimbursable up to 180 days prior to start of employment.
MedStar will assume the expense for board certification and re-certification after start of employment.

Hospital Dues

MedStar will pay for staff dues at MedStar hospitals if privileges are required. Under special circumstances,
staff dues will be paid at a non-MedStar hospital at the discretion of the Medical Director. These dues are not
paid from the CME account.

Professional Society Membership

MedStar will reimburse the cost of two professional society memberships (three memberships if a provider has
a subspecialty). The PAC (political action committee) contributions are not covered. Society membership dues
are not considered CME and will not be reimbursed from the CME account.

21

Continuing Medical Education and Training continued

Required Training
E&M University

Providers should complete online E&M University training on coding practices.
Coding and documentation is a high priority for all healthcare providers. We have partnered with E&M University
to provide online coding and documentation training. This program has been used by physicians throughout
MedStar and they have found it to be of value. E&M University features on-demand web-based E&M coding
courses developed by a physician who is also a certified professional coder. You can access the courses 24/7
from any computer connected to the internet. These web-based courses run directly in your browser as self-
paced video presentations. Physicians can earn CME credit for these courses. All new providers are required to
complete five modules. You can select the modules that are most appropriate to your clinical environment and
learning needs. If you have any questions about this program, please contact James Welsh, MD, or Bill Frohna, MD.

Login Instructions:
Click on the link below to access the web portal and enter the Registration Key: MMG:
http://emuniversity.com/Portals/MMG_Portal.html
Please create a new account in the system. You must enter the registration key – MMG at the bottom of
the form in order to access the courses. After you login click on the blue link in the middle of the page
with the course name – MedStar E&M Coding Courses. This will take you to the course page. Just click on
any of the courses you want to view. Once you create an account you can log back in anytime with your
email and password from the link or www.emuniversity.com<http://www.emuniversity.com>. Please note
you must enable pop ups on your browser to view the courses and they can be viewed on an Ipad. Once
you access the courses you just need to click on the course you want to view. There is a short quiz at the
end of the module and you need to pass by 70% to get either your CME or CEU certificate. If you are
taking CME credit you MUST complete the Yale CME Survey on the course to unlock your certificates.
You can start/stop the module at any time. The certificate will be located under the name of the course.

Annual Competencies – SiTEL Mandatories

ALL employees are required to complete specific competencies through the MedStar eLearning (SiTEL)
website. These competencies are required on an annual basis.

Mandatory Compliance Training

New providers are required to complete a Documentation and Coding compliance Course. This course is offered
online and the SiTEL website.

22

Catalyzing Innovation/Advancing Health

MedStar Institute for Innovation
MISSION

The mission of MedStar Institute for Innovation (MI2) is to catalyze innovation that advances health. Our mantra is
“think differently.” Chartered by MedStar Health’s President and CEO, Ken Samet, FACHE, in 2009, MI2 provides
a broad innovation infrastructure to help MedStar’s 31,000 associates and 4,700 affiliated physicians invent the
future. MI2 deploys a three-axis strategy to accomplish our mission:

CATALYZE

MI2 catalyzes innovation energy at MedStar Health by inspiring and equipping associates to unlock their
potential to create and improve.
Solving Problems by Seeing, Understanding and Thinking Differently
• Provides targeted consultations and in-depth “Think Sessions” on specific challenges
• Supports a distributed healthcare delivery network and the future of ambulatory care
• Offers an online curriculum with tools on influence and presence
• Convenes the innovations in…Thinking Differently Annual Forum and Monthly All Minds Meetings

MedStar Inventor Services
• Launched the Global Healthcare Innovations Alliance with Cleveland Clinic in 2011
• T ransforms MedStar associates’ ideas into commercial products through each stage of the inventor process

from concept to market

INNOVATE

MI2 develops deep technical capabilities—often in the “white space” where others have not gone before—
to solve problems and transform health care across MedStar Health and beyond.
National Center for Human Factors in Healthcare
• Largest group of human factors experts within a healthcare delivery system in the U.S.
• Designs systems to make patient care safer, more efficient and higher quality
• Assesses the design and use of products and processes for safety and effectiveness
• Engages in basic and applied research, internal and external safety and usability consulting

MedStar Simulation Training and Education Lab (MedStar SiTEL)
• Creates and delivers high-quality, innovative education and training
• Operates four simulation centers to provide high fidelity and virtual experiential learning
• Provides a mobile simulation program to offer in-hospital and on-site training
• Develops and maintains a custom online learning environment to deliver education, anytime and anywhere
• Creates innovative educational videos, programs, courses, and workshops

23

Catalyzing Innovation/Advancing Health continued

Center for Digital Health and Data Science
• Incubates initiatives around personal health, connected care and telehealth
• Creates web applications and social collaboration tools that improve healthcare delivery
• Develops information visualizations and data analytics to provide actionable insight
Center for Health Influence and Engagement
• Teaches the art and science of influence to encourage healthy decisions, promote behavior change in a

positive direction, help establish rapport and trust with patients and colleagues, and optimize constructive
communications

CONNECT

MI2 looks for better practices inside and outside health care, opens MedStar Health’s door to outside companies,
startup entrepreneurs and other entities in the innovation space, and forges strategic collaborations with them.
External Alliances and Consumer Digital Health Initiatives
• Formed MedStar’s Founding Partnership with global startup incubator and seed fund 1776
• Leads engagement with AARP’s Project Catalyst and the Innovation Learning Network
• Operates MI2’s Administrative Residency and Health for America Fellowship programs
For further information or to make a contribution to MI2, please visit MI2.MedStarHealth.org or contact MI2
Administrative Director and Director of External Alliances Jeff Collins at [email protected].

MedStar Institute for Innovation
3007 Tilden St., NW, Suite 7M
Washington, DC 20008
202-244-9800 PHONE
@Mi2Innovation TWITTER

24

Catalyzing Innovation/Advancing Health continued

MedStar Health Research Institute

MedStar Health Research Institute (MHRI), founded in 1963, is the research division of MedStar Health. MHRI
provides scientific, administrative, and regulatory support for clinical research throughout the MedStar Health
system. Led by Dr. Neil Weissman, MHRI supports more than 1,000 associates dedicated to advancing health
through research.
MHRI’s core services include a biostatistics and epidemiological center, clinical research centers, a research
pharmacy, two accredited pre-clinical laboratories, biochemistry and biomarker core laboratories, a core
platelet center, a cardiac and vascular pathology center, a genetics/genomics/proteomics research core, a
cardiovascular core imaging center, an institutional review board, and an office of research integrity. In the last
year, more than 1,000 active studies, involving thousands of patients, resulted in nearly 1,000 peer-reviewed
publications. MHRI is in the top 20% of U.S. institutions receiving funds from the National Institutes of Health
and other federal agencies, with approximately 60% of its studies being federally funded.
Wherever you look throughout the MedStar Health system, you're likely to find the highly qualified scientists
and investigators conducting leading edge clinical research. MedStar Health Research Institute researchers
cover many areas and types of research. From bench to bedside and into the community, associates across
MHRI work to advance the scientific understanding of disease and point the way toward better and more
effective treatments. As the research-focused entity of MedStar Health, this is our contribution to the healing
work performed throughout the system and in the communities we serve.
Learn more about our Principal Investigators and their research at MedStar Health Research Institute.
If you have any questions about research please contact us at [email protected].

Our MISSION

MedStar Health Research Institute is dedicated to supporting the academic platform of MedStar Health by
conducting high quality translational and health sciences research throughout the MedStar system.

Our VISION

To be the trusted leader in caring for people and advancing health.
MedStar Health is a not-for-profit, regional healthcare system with ten hospitals and more than 20 other
health-related services in the Maryland and Washington, D.C., region. More than a half-million patients trust
their care to MedStar Health each year.

25

Catalyzing Innovation/Advancing Health continued

MedStar Health Research Institute

MedStar Health Research Institute is the research arm of MedStar Health. It provides scientific, administrative
and regulatory support for research that complements MedStar’s clinical services and teaching programs.
The Research Institute conducts clinical, healthcare delivery and outcomes research in all of the hospital and
ambulatory settings, which are located throughout Maryland and Washington, D.C. To contact the Research
Institute, please send an email to [email protected].

26

Catalyzing Innovation/Advancing Health continued

MedStar Health Research Institute

Our Research Expertise

From bench to bedside to community, MedStar Health Research Institute investigators are involved in pre-clinical
investigation, investigator-initiated studies, early phase I/II clinical trials, large phase III multi-center trials, and testing
clinical application of new advances in clinical practice. As part of a multi-hospital academic medical system spanning
two cities, MedStar Health Research Institute is ideal for investigating healthcare delivery and outcomes research in
tertiary-, specialty- and community-based hospital settings that serve one of the most diverse patient populations in the
United States. The MedStar Health Research Institute’s areas of research strength include:

Cardiovascular Health Services Neuro-Rehabilitation
• Coronary and carotid interventions • Human factors engineering • Spinal cord injury
• Cardiac arrhythmia • Stroke
• Cardiovascular surgery • Patient safety and quality • Traumatic brain injury
• Electrophysiology • Upper extremity amputee
• Antiplatelet research center for PCI • Telehealth • Biomechanics and robotics
• Percutaneous valve implantation • SCI and stroke navigators
• Cardiovascular imaging • Healthcare-associated infections (HAIs) • Education and training
• Angiogenesis/myogenesis
• Gene discovery • Post-acute care Pulmonary Medicine and
• Vulnerable plaque Critical Care
• Stem cell therapy strategies • Healthcare delivery • Sepsis/shock
• Molecular diagnostic and therapeutic • Adult respiratory distress syndrome
• Healthcare payment
strategies (ARDS)
• Devices in peripheral vascular disease • Healthcare economics and policy • Venous thromboembolism
• Pharmacologic therapies • Heparin-induced thrombocytopenia
• Vascular biology and endothelial • Health IT • Pharmacoeconomic studies

function • Access to care Nephrology
• Lipoprotein and atherosclerosis • Kidney transplantation, including HIV
• Cardiac and vascular pathology • Comparative effectiveness/outcomes • Glucose metabolism
• Congestive heart failure • Immunotherapeutics
• Disparities • Chronic kidney disease
Oncology (Cancer) • Pregnancy-associated kidney disease
• Brain/Central nervous system • Palliative care • Vascular access
• Breast
• Gastrointestinal/Digestive Nursing Rheumatology
• Genitourinary • Evidence-based practice • Systematic Lupus Erythematosus (SLE)
• Gynecologic • Rheumatoid Arthritis (RA)
• Head and neck • Falls • Connective tissue disorders
• Hematologic/Blood • Autoimmune diseases
• Lung/Thoracic • Nursing outcomes • Fibromyalgia
• Melanoma • Lyme disease
• Quality of life • Wound healing • Steroid-induced osteoporosis
• Sarcoma/Musculoskeletal • Vasculitis
• Supportive care/Biosocial Orthopaedics and Sports Health • Gout
• Thyroid • Orthopaedic surgery • Musculoskeletal conditions
• Hand surgery
Gastroenterology and • Concussion Infectious Diseases
Digestive Diseases • Experimental drugs and devices • Transplant infections
• Colorectal surgery • Primary care sports medicine • Pulmonary Infections
• Motility disorders • Musculoskeletal disorders and novel • Sepsis
• Inflammatory bowel disease • HIV
techniques • Viral hepatitis
Endocrinology • Sport safety and policy
• Diabetes prevention and education Other
• Gestational diabetes Burn and Trauma • Medical education research
• Lipid abnormalities • Microvascular assessment • Eye surgery
• Obesity and metabolic syndrome • Shock • Epidemiology
• Thyroid disorders • Dermal substitutes
• Scarring, natural history and treatment 27
• Pathophysiology of electrical injury
• Mechanisms of burn and related wound

healing
• Nutritional requirements in trauma
• Sepsis and complications of trauma

Women’s and Infants’ Services
• Genetic and fetal medicine
• Incontinence
• Pelvic-floor disorders
• Adolescent medicine
• HIV and pregnancy

Catalyzing Innovation/Advancing Health continued

MedStar Health Research Institute

28

Information Systems

StarPort

StarPort is MedStar’s intranet site which has information and access to most of MedStar’s policies, collaboration
sites, Human Resources, etc.
StarPort is available only available within MedStar facilities or can be accessed via SERA (see below).

MMG StarPort

This is the home page for MedStar Medical Group information and policies. It is the home page on all pc workstations.

29

Information Systems continued

EMAIL

Contact your practice manager or director of operations to access your MedStar e-mail account.
Spam emails can be forwarded to [email protected].

MedStar E-mail Communication

All MedStar providers are required to use their MedStar email addresses for business related communications.
The email system employed by MedStar, Outlook Exchange, has built-in advanced security features that are
HIPAA compliant.
It is your responsibility as an MMG provider to check your MedStar email frequently. Your MedStar email is the
primary method to reach you regarding all department updates, announcements and various time-sensitive
compliance requests.

Secure Enterprise Remote Access (SERA)

Secure Enterprise Remote Access (SERA) provides you access to MedStar systems remotely (Off Campus).
SERA utilizes Two Factor Authentication to secure our network. This means that in addition to your ID and password,
you need a second thing or factor to identify you. This will be either your cell phone, a credential downloaded
to your phone, or a previously registered device. This is the same system that is used by Citrix for its remote
access. So if you have already set up Two Factor for Citrix, some of the steps in the instructions for your device
may be skipped.
There are two primary kinds of access.
• F ull Access connects you to our network just as you are at work. This also includes a menu of specific Web

Applications as well as the applications you normally access from your machine at work.
• Limited Access provides you a limited menu of Web-based Applications that you can access remotely.
The amount of access you receive will depend on two things: the access that has been granted to you based
on your role in the organization and whether you are using a MedStar device or a personal device
• P roviders, including clinicians who provide direct patient care such as physicians, nurse practitioners and

physician assistants who have been given access through the ASAP process, will have Full Access on MedStar
devices and non-MedStar Devices.

30

Information Systems continued

When you sign onto SERA you will have the option of choosing a Realm. In most cases you should choose
Associates and Providers and you will receive the appropriate access described above.
*In circumstances where you only need Limited Access regardless of what you are entitled to, for example of
you want to quickly check your email via OWA web access, choose Limited Access (Forced) and the system
will connect quicker without trying to check what kind of machine you are using which requires software to
be downloaded. Also Remote Access via Terminal Service will not be available.
SERA is usable on many different kinds of devices so you should review the appropriate documents available
on the Information Menu which explain how to register for SERA and access our systems.
Additionally, both kinds of access allow you to remote into your office machine if you have set it up properly
in advance. See the Remote Desktop Control Instructions for details.

UpToDate

UpToDate Anywhere is available now to all MedStar associates. UpToDate is an evidence-based clinical decision
support resource used by healthcare practitioners to help them make the right point-of-care decisions. It is
proven to change the way clinicians practice medicine, and is the only resource of its kind associated with
improved outcomes. MedStar Health offered UpToDate in the past, but our new contract for UpDate Anywhere
gives users access from any Internet browser and the UpToDate mobile apps for iOS, Android and Windows 8
devices. To receive remote access you must first register from a MedStar computer. Eventually the product will
be accessible via the EHR. UpToDate Anywhere also provides physicians CME credit whenever they research
a clinical question – even if they do so from home on their mobile. Just go to www.uptodate.com and click
“log in/register” in the top right corner; sign-in using existing account information or register for an account
if you’re a new user; and then use the instructions below to install the mobile app. Once you’ve registered or
signed in from a MedStar computer, your “anywhere” rights will activate and you’re free to use the product
on-the-go.
To Install the Mobile App:
1. On your smartphone or tablet, search for “UpToDate” in your app store and install the free app.
2. Open the UpToDate Mobile App upon completion of download.
3. Long in with your UpToDate User Name and password. You only need to do this once – the app remembers

your username and password.

Find A Doc

On MedStarHealth.org, there is a link to MedStar's Find A Doc physician directory. This is one way to identify
possible physician colleagues for referrals.
You will also have a profile in Find A Doc. To help augment that profile, you will be receiving a link to complete
a Scope of Practice profile.

31

Marketing, Communications and Physician Relations

Contact Information:
10980 Grantchester Way, 7th Floor
Columbia, Maryland 21044
Main Department Phone: 410-772-6971
Jean Bunker, vice president, Marketing, Communications & Physician Relations

Newsletters

• M MGmail is a biweekly e-newsletter for the 1,200 providers and associates of MMG–B. It contains updates
about major topics of interest. The Practice Update is a biweekly e-newsletter for the physicians and
associates of MMG–A in the Baltimore region.

• C onnection is the bimonthly e-newsletter for the entire MedStar Medical Group enterprise (“MMG–O”).
The contents are topics of interest to this larger population of providers and the teams around them.

• M edConnect Minute and the Optimization Update are regular Information Systems update for MMG–O about
systems relevant to our providers and staff, notably our MedConnect EHR.

For more information about our publications, contact Tia Howard, director, Internal Communications,
at 410-725-8218 or [email protected].

Media Relations

All media calls are to be referred to Jean Bunker at 410-772-6972 or Laura Bossi, director, Marketing,
at 443-725-8704.

Physician Relations

• Assist all physicians encountering operational barriers
• New physician onboarding & introduction to system and non-system colleagues and referral sources
• Promotion of providers in strategic target areas
Physician Relations Contact:
Ann Black, director, Physician Relations
O: 443-725-8732 • Cell: 443-699-4530
[email protected]

32

Marketing, Communications and Physician Relations continued

Recognition

Recognition at MMG

MMG–B has an overarching recognition platform called . It is designed to reward and recognize

associates and providers who exemplify MedStar SPIRIT Values and Service Excellence, while also commemorating

milestone service anniversaries.

On-the-Spot Recognition

We're glad to have associates like you, who make MMG a successful organization and a great place to work.
We want you to be recognized for the great work you do, and to have a chance to give recognition to your
colleagues who demonstrate excellence.

With Give a WOW, you can:

• N ominate your coworkers to receive special recognition and awards when they demonstrate service
excellence.

• Stay up-to-date on achievements happening across MMG every day.
• Be appreciated and recognized for the great work that YOU do!
• Applaud the recognition given to others.
• Display the recognition you’ve received — with a printed certificate!
• S hare the recognition with your manager as a reference to show how you have exhibited SPIRIT values

All new hires will receive a Give a Wow welcome email with their username and temporary password on the
Friday of the week they start.

33

Marketing, Communications and Physician Relations continued

Annual Service Awards

Service anniversaries matter to us! As part of , associate and provider milestone anniversaries will

be recognized based on 5-year service increments. To ensure they are more timely and meaningful, directors

of Operations and practice managers will recognize associates and providers during staff meetings held in the

office. Honorees will still receive a service recognition letter and gift selection package.

Annual Awards

These awards recognize the best of the best across MMG for exemplifying MedStar’s SPIRIT values, celebrating
associatiates, providers and practices in the Central Maryland and Greater Washington regions. Annual

winners are honored at the Service Awards dinners.

Thank You Cards

The use of handwritten thank you notes is still a special way to let associates and providers know they have
been noticed! Providers are encouraged to send handwritten notes of thanks to fellow associates and providers.
MMG thank you cards are available at each practice.

Recognition Boards

“Thank You” Recognition Boards (whiteboards) are located at all MMG practices. Patients, associates and
providers are encouraged to write kudos on the boards. Kudos will be shared in MMGmail.

34

Compensation and Benefits

Compensation Principles for MMG Providers
Overview

MedStar’s goal is that all providers (i.e., physicians, nurse practitioners, physician assistants, nurse midwives,
etc.) working within MMG are paid fair market value for the work they do for our patients, their family members,
and the community at large. It is also important they understand how their compensation plan works. Most
MMG compensation plans have the following principles and components:

Guiding Principles
1. Establish a simple and transparent model
2. Reward greater levels of productivity without sacrificing quality
3. Pay competitive wages, enabling recruitment and retention
4. Incentivize high levels of patient satisfaction and access
5. Ensure flexibility to adapt as reimbursement models evolve

Standard Compensation Model
Compensation is made up of several components, each described in detail below:
• Base compensation
• Productivity Incentive compensation, based on the achievement of productivity targets
• Quality Incentive compensation, based on the achievement of certain performance metrics
• Facility medical directorship compensation (or administrative role)

Compensation plans often vary for various entities, specialties, and professional license.

Employment Benefits
Health Insurance

Physicians may choose either the CareFirst PPO Plan, MedStar Select Plan or Kaiser* Permanente HMO Plan.
The “PPO” or “Preferred Provider Organization” allows you to see any provider you choose, but you save
money on care when you see CareFirst PPO In-Network providers. The MedStar Select Plan offers comprehensive
medical coverage through the MedStar Select Provider Network. Many medical services provided by MedStar
facilities and physicians are paid at 100% or require minimal co-pay. You do not need to select a primary care
physician (PCP) to coordinate your care. The traditional Kaiser* HMO Plan allows members to obtain medical
services with participating providers located in Baltimore, the District of Columbia and Northern Virginia. Many
in-network services are covered at 100%, with the remainder calling for a minimal co-payment. The HMO Plan
requires the selection of a primary care physician and referral to see a specialist.

Coverage starts on the first day of the month following the date of hire, as long as the physician has completed
enrollment within 30 days after the date of hire. If you are hired on the first day of the month, your benefits are
effective on the date of hire. You must verify dependent eligibility in a timely manner to ensure dependent
coverage!

35

Compensation and Benefits continued

Dental Insurance
There are two plan options available: Cigna PPO and Cigna DHMO (you must designate a DHMO dentist).

Vision Care
You may choose to participate in the Group Vision Services Plan. The plan provides comprehensive vision
benefits from a network of providers.

MedStar Health 403(b) Retirement Savings Plan
• Newly hired associates may begin contributing to this plan immediately.
• 12 months and 1,000 hours of service are required to receive an employer match.
• The associate must be employed at the end of the year and have worked for 1,000 hours during the year.
• MedStar will match contributions at 50% of the first 6% of the associate's salary.
• Associates are 100% vested in their own contributions immediately.
• MedStar’s matching contributions will be vested after three years of service.

MedStar Health 457(b) Deferred Compensation Savings Plan
Physicians who have a minimum base salary of $150,000 are eligible to participate in the MedStar Health 457(b)
Deferred Compensation Savings Plan. The 457(b) Plan provides an additional way to save for retirement with
potential tax savings and earnings growth. Please note that Advance Practice Clinicians are not eligible for this
benefit. For more information, please contact Lorraine Proctor, AVP of Executive Benefits & Compensation, at
(410) 772-6766.

Life Insurance
MedStar Medical Group provides eligible associates with Basic Life Insurance equal to one times your annual
base pay. Your coverage will be rounded up to the next higher $1,000. Basic coverage is provided at no cost to
the associate. Supplemental Life Insurance coverage is available in amounts equal to one, two or three times
your base pay, up to a combined (basic and supplemental) maximum of $1,500,000. If you do not enroll when
first eligible you may be required to provide evidence of insurability (EOI), which is a health questionnaire.

Disability Benefits
Short-Term Disability (STD)
• Full-time MMG associates are eligible for STD leave following 6 months of employment.
• Coverage is provided at no cost to you.
Note: Benefit premiums will continue to come out of your check while on STD. Maternity leave is treated as an
illness and allows 6 weeks for vaginal delivery and 8 weeks for C-section.
Long-Term Disability (LTD)
• After a 180-day waiting period, the LTD program replaces 60% of your base salary, at no cost to the associate.
• F ull-time associates receive a core LTD benefit of 60% of base salary up to a maximum benefit of $15,000 per month.
• You also have the option to select coverage options equal to 66 2/3% of pay. If you elect the LTD buy-up plan

you pay for the additional coverage via payroll deduction.

36

Compensation and Benefits continued

Family and Medical Leave Act (FMLA)
Our family care leave program enables an associate to take unpaid leave to care for a seriously ill family
member or child within the first year of birth, adoption or foster care placement. Associates may use medical
leave for their own serious health conditions, which will run concurrently with the short-term disability benefit.
To apply for Family Medical Leave, contact your supervisor.

Employee Assistance Program
Professional counseling is available for personal or health problems, including: stress, family conflicts, grief,
alcohol or substance abuse, financial, depression, anxiety, chronic illnesses and legal problems. You may
contact Business Health Services at 1-866-765-3277, 24 hours a day, seven days a week.

Capital Accumulation Plan (CAP)
Physicians may qualify for this voluntary after-tax program provides supplemental retirement income and
life insurance protection to full time associates with an FTE status of .75 or greater that meet the minimum
compensation requirements (a minimum base salary of $150,000 and a minimum total compensation
of $175,000.) MedStar Health will match 50% of after-tax contributions up to a maximum of 10% of total
compensation. Plan enrollment is conducted twice a year by MedStar’s plan administrator, Nolan Financial.
Please note that Advance Practice Clinicians are not eligible for this benefit. For more information, please
contact Lorraine Proctor at (410) 772-6766.

Wealth Management
Physicians are eligible to participate in our complimentary wealth management program. Personalized services
provided by our Merrill Lynch partners include risk analysis, estate and tax planning, concierge banking and
mortgage services, asset protection and much more. Please note that Advance Practice Clinicians are not
eligible for this benefit. To learn more please contact Andrew Meredith, Sr. Wealth Advisor, at 410-547-5039
or email at [email protected].

Bank of America
Associates can enroll in Bank of America at Work benefits. Services include checking accounts and discounts,
online banking, fixed rate IRAs and CDs, mortgages and more. To learn more, please call (800) 782-2265

Legal Plan
Associates may elect group legal coverage, which provides access to a network of attorneys who deliver legal
services via telephone or office visit. Examples of covered services are: will preparation, tenant/landlord disputes,
sale and purchase of real estate and traffic court representation. To learn more, please call (800) 728-5768.

MedStar Benefits Contact Information: MedStar Investment / Retirement Planning Contact Information:
For information about your provider For more information about your retirement
benefits contact: benefits contact:
Denise Busby at 410.933.2927 Brad Friedel at 410-933-2925
[email protected] [email protected]

37

Equal Employment Opportunity

Policy Statement
MedStar Health, Inc. is an Equal Opportunity (EO) Employer and is committed to equal opportunity for all
associates and candidates for employment. Where federal, state or local laws contain mandatory requirements
that differ from the provisions of this section, such legal requirements prevail for associates working in affected
locations.
Philosophy Statement
MedStar Health is committed to being an employer of choice by attracting, developing and retaining skilled
and engaged associates through the use of best practice employment procedures.
Procedure
In furthering its commitment to provide equal opportunities, it is MedStar Health, Inc.’s policy to:
• Comply with both the letter and the spirit of all applicable laws and regulations governing employment.
• Provide equal employment opportunity to all associates and applicants for employment.
• Prohibit unlawful discrimination or harassment in any employment decision or in the administration of

any Human Resources policy because of race, color, creed, religion, national origin, citizenship, sex, age,
physical or mental disability, veteran status, marital status, personal appearance, family obligations, political
affiliations, sexual orientation, gender identity or expression, or any other characteristic protected by federal,
state or local EO laws and regulations.
• M ake reasonable accommodations for the physical and/or mental limitations of qualified associates or
applicants with disabilities.
• P rotect associates’ right to refer possible violations of this policy to management, Human Resources, the
Compliance Department or any government agency or court without intimidation, coercion, discrimination,
harassment or retaliation of any form for exercising such rights.

38

Accessing and Updating Payroll and Other Employment Information

IMPAACT (PeopleSoft) Self-Service

IMPPACT (Integrating MedStar People, Processes, And Common Technology), also referred to as PeopleSoft,
is MedStar Health’s enterprise-wide management system.
Using the IMPPACT Employee Self-Service (ESS) module, associates can update their personal information
(name, address, etc.) and update tax and direct-deposit information.
IMPPACT can be accessed online at erp.medstar.net. Your log-in credentials are the same as your network
username and password (Cerner, etc.)
Send all updates to your practice manager in addition to making changes in PeopleSoft.

View and Edit Personal Information

Access the personal information summary page by following the path: Employee Self Service>Personal
Information> Personal Information Summary from the main menu.
Here, you can update personal information, such as names (legal / preferred), address (home / alternate),
phone numbers, email addresses, and emergency contacts. The Self-Service module will update the Human
Resources system.
Legal names will be used for all official documentations within MedStar. To change a legal name, provide
the required documentation to the Human Resources department.
When entering an address change, associates must remember to review and change Federal and State tax
forms if required.

Updating Tax and Payroll Data

Access the associate tax pages by following the path: Self Service > Payroll and Compensation> W-4 Tax
Information or View W-2/W-2c Forms from the main menu. Here, you can update your tax information, W4
and state tax deductions.

Payroll and Direct Deposit

Access your compensation history and direct deposit by the following path: Self Service > Payroll and
Compensation > Direct Deposit (OR) Compensation History. Here, you can view your compensation history
and update your direct deposit information. You can elect up to three bank accounts for direct deposit.

ePaystubs – Enrolling and Accessing Your Pay Details

With ePaystubs, you will have online, 24-hour access to their pay details. Providers enrolled in direct deposit
do not receive paper remittance. Pay details are available online one day before payday, and providers may
always print a hard copy of their paystub if necessary.

39

Accessing and Updating Payroll and Other Employment Information continued

Create your ePaystubs Account

Visit www.ePaystubs.org from work or home to create your ePaystub account. This one-time process should
take approximately 10-15 minutes to complete.
Enter Social Security Number (SSN), no dashes.
Click “Continue”
Enter your PIN. Enter the default PIN for the initial login, which are the last four digits of your SSN and the two-
digit month and two digit year of your birth date. Example: XXXXMMYY (If your SS is 555-55-5555 and birth
date is June 5, 1950, you will enter 55550650.)
Click “Login.” To begin the enrollment process, click “Enroll Now.” Follow the steps until your account is
confirmed.
You will then be asked to reset your current PIN with a personal PIN of your choosing. Your new PIN is
numerical only and must be eight to 16 numerals in length. Click “Save.”
Following enrollment in ePaystubs, in order to receive email notification of your online ePaystub deliver, visit
“Alerts and Settings” (in the upper right hand corner of website). Under “activate Alerts,” you must check the
box next to “paystub Alert.” If an email address is not present, select “Edit Email” and enter your email address
for paystub notification. Click “continue,” then “Save.” Place a check mark next to your email address confirming
that you wish to receive email alert notifications of ePaystub delivery. Additionally, to receive email notification
of PIN changes, select the box next to “Chance PIN Alert.” Also be sure to check the box next to your email
address under “Email Other Alerts.” During enrollment, if your birth date and/or Social Security Number are
incorrect in the system, contact Human Resources.

40

Notes

41