MERCY MEDICAL CENTER Cedar Rapids, Iowa Cardiovascular ...p.mercycare.org/app/files/public/74/pdf-020713-Agenda.pdf · Cedar Rapids, Iowa Cardiovascular Medicine Department of the

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MERCY MEDICAL CENTER Cedar Rapids, Iowa

Cardiovascular Medicine Department of the Medical S taff

Thursday, February 7, 2013 0700 – Mercy Katz Conference Room

I. Call to Order II. Approval of October 4, 2012 Minutes (pg. 2-5) III. Guest Speakers:

i. Criteria for Cardiology Comfort Care – Dr. Cearl ock (pg. 6-11) III. Committee Reports

a. MEC Excerpts (December 2012 & January 2013) – Dr . Hodgman (pg. 12-21) b. Administrative Report (January/February 2013) – Dr. Valliere (pg. 22)

i. Influenza Memo (pg. 23) ii. Joint Commission Memo (pg. 24)

V. Quality Reports a. ACC-NCDR – Michelle Wehr b. Heart Failure Data and Protocols in ED – Chad Wa re c. New Reportable VTE Measures – Sue Dawson (pg. 25-26)

VI. Old Business

a. Credentialing Criteria Review – Drs. Campbell & Langager (pg. 27-37) b. Vice Chair Needed (January 2013 – December 2014) – Dr. Hodgman c. Meeting Frequency – Dr. Hodgman (pg. 38)

VII. New Business

a. Policy Updates – Dr. Hodgman i. Admitting, Attending, Consulting (pg. 39-41) ii. Physician Notification, Escalation (pg. 42)

b. Rhonda Bridgewater Introduction – Eric Voss / Dr . Hodgman c. Outpatient Telemonitor data and process – Sue Da wson / Margie Pence (pg. 43) d. Restraint Training – Rita Malloy / Catherine Kan e (pg. 44-45) e. Case Review Criteria – Dr. Hodgman (pg. 46-51) f. Diabetes Education (Deb Kucera) – Sue Dawson (pg. 52-53)

VIII. Next Meeting Thursday, April 4, 2013, 0700 i n Mercy Katz Conference Room IX. Adjournment

Date: October 4, 2012

Discussion/

Leader

Expected

Result

Content/ Agenda Item Meeting Notes/Decisions/Actions or Assignments

Dr. Pospisil Action Call to Order Dr. Pospisil called this regularly scheduled meeting of the Cardiovascular Medicine Department of Mercy Medical Center, a peer review committee, to order at 7:10 am. Dr. Pospisil is here to appoint a temporary chair to run the meeting today due to there not being an officer available. Dr. Campbell volunteered.

Dr. Campbell Action Approval of August 2, 2012 minutes. The minutes were reviewed and approved as distributed.

Committee Reports

Dr. Pospisil and Dr. Valliere

Information Medical Executive Committee (August & September 2012)

Included in packets. It was noted, effective on or about November 6th the Bylaws on overdue records will be enforced. Physicians with incomplete records (beyond the 30 days) will have their privileges suspended until the records are complete. It was noted the Credential Committee has stated the criteria for Cardiovascular Medicine needs to be met or changed as the Bylaws will be enforced. Dr. Valliere reviewed the Value Based Purchasing and discussed how the reimbursement is calculated. He noted that collectively the Heart Failure patients fell below the national average. A Heart Failure team was put together in February 2012 and due to their processes this measure has improved significantly.

Mercy Medical CenterCedar Rapids, IA

Meeting Minutes for: Cardiovascular Medicine Department MeetingChair: Dr. McMahon / Recorder: Suzette Sabatino

Quality Assessment & Improvement Reports Quality Assessment & Improvement Reports Quality Assessment & Improvement Reports Quality Assessment & Improvement Reports

Present: Drs. Campbell, Langager, Payvandi, Riter. Also present: Drs. Pospisil, Valliere, Aucutt, Hilliard, Sue Dawson, Kyle Miller, Eric Voss, Lauren Cumings, Becky Quijano, Brian Boots, Lisa Ridge, LeAnn Tatman and Penny Glanz

Call To OrderCall To OrderCall To OrderCall To Order

Approval of MinutesApproval of MinutesApproval of MinutesApproval of Minutes

Start Time: 0700




Present: Drs. Campbell, Langager, Payvandi, Riter. Also present: Drs. Pospisil, Valliere, Aucutt, Hilliard, Sue Dawson, Kyle Miller, Eric Voss,

Start Time: 0700

Dr. Campbell Information P & T News (July 2012) Included in packets. It was noted there is a shortage on Levofloxacin IV, patients that meet the criteria will be given Levofloxacin PO. It was also noted patients admitted with PRN erectile dysfunction medications will have these orders automatically discontinued while the patient is in the hospital.

Dr. Valliere and Dr. Hilliard

Information Administrative Report (September/October 2012) Included in packets. It was noted the Physician Survey has 46% participation. Action plans are being created and will be review at the next department meetings. The MS Website is being redesigned. Medical staff are encouraged to visit the website and provide feedback. Starting this year the hospital will be required to report not only the percentage of patients and employees vaccinated, it has expanded to volunteers, students, contractors and physicians. Physicians will be contacted for confirmation of vaccination. Dr. Valliere reviewed the upcoming CMS regulation on Deep Sedation. He noted physicians will not be able to use the specifically trained nurses to do EP cases and cardioversions, it must be a certified physician or anesthesiologist; if it is a physician it cannot be the one doing the procedure. It was noted that documentation needs to be very clear as to who covered sedation and who covered the procedure. A deep sedation course for certification will be available to physicians who are interested. Dr. Hilliard updated this group on the EPIC project. They have started Order set development. He will be contacting physicians to help with the development process. EPIC is evaluating our hardware needs and the number of workstations will be increased. Because of the difference in the EPIC versions between Mercy and St Luke's physicians will need to be re-trained on Mercy's system.





Start Time: 0700

Sue Dawson Information ACC-NCDR Cath Lab Data Ms. Dawson reviewed the ACC-NCDR Cath Lab Data for January 2010 through March 2012 and noted the national average Appropriate PCI use increased from 3% to 10%. She is checking into this.

Sue Dawson Information Heart Failure Data Ms. Dawson reviewed the Heart Failure data for January 2007 through August 2012. She reviewed some of the process issues and how they have been corrected.

Sue Dawson Information 30-Day Mortality Ms. Dawson reviewed the 30-Day Mortality. It was noted that a team met with the Palliative Care to come up with Comfort Care/Measures criteria.

Sue Dawson Information 30-Day Readmissions Ms. Dawson reviewed the 30-Day Readmissions data from January 2010 through December 2010. Discussed the readmission flows.

Dr. McMahon Discussion/Action Meeting Frequency DeferredDr. Valliere Discussion/Action Pre-Operative Process Updates Included in packet. Dr. Valliere reviewed the updated Pre-

Op Assessment Process. There are some issues that need to be worked out. Dr. Valliere asks for the physicians' feedback on the process.

Dr. Campbell Discussion/Action 2013 Vice Chair Elections Due Dr. Noreuil's departure the Vice Chair is open. Dr. Riter nominated Dr. Hodgman. Three in favor (Payvandi, Riter, and Campbell) none opposed. Dr. Hodgman is the Vice Chair for 2013.

Dr. Valliere Discussion/Action New OPPE Format Included in packet. Dr. Valliere presented the new OPPE format and asks the physicians to review it.

Dr. Valliere Discussion/Action INR Critical Values There was a discussion on when the INR level should be considered critical, currently it is 5.0, the physicians present were comfortable with this number.

New BusinessNew BusinessNew BusinessNew Business

Old BusinessOld BusinessOld BusinessOld Business





Start Time: 0700

Dr. McMahon Discussion/Action Credentialing Committee Update It was noted there have been too many waivers and extensions on CME requirements and procedure volumes for the Cardiologists. A committee will be formed to review the requirements. Dr. Valliere will send out the items not being met to the physicians to review and adjust.

Lauren Cumings Discussion/Action Pharmacy Recommendations for Bridging of Anticoagulation (2012 CHEST Guidelines)

Included in packet. Ms. Cumings presented the pharmacy's recommendations for Bridging of Anticoagulation per the 2012 CHEST Guidelines.

Dr. Campbell Discussion/Action ACLS Guidelines for Oxygen Administration (This item was added to today's agenda.)

Included in the packet. Reviewed the ACLS guidelines for Oxygen administration. It was noted these guidelines will be used throughout the hospital and EMS.

Lisa Ridge Discussion/Action Natalie Woederhoff, BSN (Assistant Nurse Manager Deferred

Dr. Campbell Information The next meeting will be held on Thursday, December 6, 2012, 0700 in Mercy Katz Conference Room.

With there being no further business, the meeting adjourned at 08:10 am.

Adjournment & Next Meeting:Adjournment & Next Meeting:Adjournment & Next Meeting:Adjournment & Next Meeting:

AnnouncementsAnnouncementsAnnouncementsAnnouncements

Respectfully submitted by,Dr. Campbell


Medical Executive Committee

Excerpts December 4, 2012

Review of Department Minutes Dr. Pospisil reviewed the department meeting minutes for the Anesthesia, Family Medicine and Surgery. There were no action items for the Medical Executive Committee. In Anesthesia, the medication machine ballots were counted, and the medication machines were approved. Credentials Committee The Credentials Committee meeting report of November 20, 2012 was given. The following physicians were recommended for membership and privileges: • Jason Cogdill, MD – Internal Medicine/Nephrology joining Internists PC. • Kahlil Andrews, MD – Surgery/Plastic Surgery joining PCI Surgical Specialists. The committee reviewed the list of reappointments for the 4th quarter 2012. The following physicians were recommended for Advancements: • E. Christopher Outland, MD – Anesthesiology • Wei Zhang, MD – Internal Medicine • Edan Yodfat, MD – OB/Gyn • Brian Privett, MD – Ophthalmology • Kyle Switzer, DO – Orthopaedics • Gary Kummet, MD – Pediatrics • David Jensen, MD – Radiology The committee accepted the resignation of the following physician: • Richard Kozeny, MD – Internal Medicine • Mina Hanna, MD – Pediatrics The following physicians were recommended for withdrawal of all in-hospital privileges and move to Affiliate status: • Thomas Schroeder, MD – Family Medicine • Larry Richards, MD – Psychiatry

Naser Payvandi, MD – Cardiovascular Medicine was recommended for Moderate (conscious) Sedation and Deep Sedation privileges. The proposed revisions to the Sedation Administration for Non-Anesthesiologists privilege criteria were approved as presented. The Point of Care Diagnostic Ultrasound privilege criteria were recommended for approval as submitted.

Medical Executive Committee Excerpts December 4, 2012 Page 2

The Focused Professional Performance Evaluation documents were recommended for approval as submitted. The committee reviewed the table of outstanding 90 day and 6 month reappointment items. The committee recommended expiration of the noted privileges unless documentation of the required CME is received before December 31, 2012. Jody Harmsen, MD – Family Medicine provided documentation regarding proctored vaginal delivery cases. The Allied Health Practitioner Committee report of October 30, 2012 was given. Applicants recommended for approval: • Lori Colehur, DA – Morgan & Morio (Drs. Morgan & Morio) • Susan Enzle, PhD – Oncology Associates at Mercy Medical Center (Dr. Wiesenfeld) • Mackenzie Groteluschen, ARNP – Linn County Emergency Medicine (Dr. Aucutt) • Brian Knake, CA – Biotronic for Intraoperative Monitoring Services (Dr. Guyot) • Nicole Miller, ARNP – Oncology Associates at Mercy Medical Center (Dr. Wiesenfeld) • Lauren Trumm, ARNP – Internists PC (Dr. Paynter) • Lesley Vancura, ARNP – PCI Hematology & Oncology (Dr. Warren) Practitioners recommended for advancement: • Kevin Huddleston, CA – Biotronic for Intraoperative Monitoring Services (Dr. Maggio) • Jeffrey Miller, ARNP – PCI Surgical Specialists (Dr. Levett) • Matthew Pilsner, CA – Biotronic for Intraoperative Monitoring Services (Dr. Maggio) Practitioners recommended for re-registration: • Ann Aschoff, ARNP – Cedar Rapids Heart Center (Dr. Hopson) • Pattie Recker, PA – PCI Orthopaedics (Dr. Nassif) • Bonnie Seely, ARNP – Oldorf Hospice House of Mercy (Dr. Cearlock) • Lisa Shaffer, ARNP – Hall Perrine Cancer Center (Dr. Wiesenfeld) • Amy Valesh-Peterson, ARNP – Linn County Emergency Medicine (Dr. Pospisil) Practitioner resignations: • Allison Evertz, CA – Biotronic for Intraoperative Monitoring Services (Dr. Guyot) • Taralyn Holfen, CA – Biotronic for Intraoperative Monitoring Services (Dr. Guyot) • Anthony Fish, ARNP – Eastern Iowa Brain & Spine (Dr. Segal) • Heidi Barnhart, PA – PCI Hematology & Oncology (Dr. Fusselman) • Amy Ganske, ARNP – PCI Hematology & Oncology (Dr. Warren) • Scott Leaverton, ARNP – PCI Hematology & Oncology (Dr. Warren) • Beth Meyer, ARNP – Metropolitan Family Medicine & Chiropractics (Dr. Roes)


Bonnie Seely, ARNP has changed practice locations and is now employed at Mercy Hospice House under the supervision of Dr. Sommerfeldt. An updated collaborative practice agreement has been received. Dr. Valliere reported on the need for development of a privileging process for non-LIP within the hospital. Any LIP practitioners, employed by the hospital or an outside practice group, who manipulate live tissue (sutures, pap smears, biopsies, hemostasis, ligation, etc.) as part of their functions within the hospital will be required go through an evaluation of competency by the Medical Staff. The current equivalent processes that are being utilized through the Allied Health Practitioner Committee and hospital Human Resources departments will no longer be acceptable due to new CMS privileging requirements. Bylaws Committee Meetings continue to be held between Administration, the Bylaws Committee members and legal counsel. Nominating Committee The slate of officers for 2013 recommended by the Nominating Committee is: Deborah Wilbur, MD – President; Peter Pardubsky, MD – President Elect; and Gordon Baustian, MD – Secretary/Treasurer. Medical Record Suspensions Dr. Pospisil reviewed the list of medical record delinquencies and suspensions for the month of November included with the agenda packet. He congratulated the membership on their commitment to the issue and noted the great improvements that have been accomplished due to their diligence. Treasurer’s Report Dr. Pardubsky presented the Treasurer’s Report. Current savings account balance is $51,223.89 and checking account balance is $100.00. $39,100.00 was received in revenue from membership dues assessments. This revenue along with $3,736.22 from savings was dispersed to pay $10,000.00 for Medical Staff Officer Compensation, $21,041.59 for Medical Staff gifts and $11,655.00 in legal fees. Medical Staff Dues The Mercy Medical Staff annual dues continue at $100.00 per member. Charitable Giving • Sisters of Mercy 3,000.00 • Willis Dady House 1,500.00 • Tanager Place 1,500.00 • Catholic Worker House 1,500.00 • Madge Phillips Center 1,500.00 • St. Vincent DePaul 1,500.00 • His Hands Free Medical Clinic 1,500.00 • Community Health Free Medical Clinic 1,500.00 • Community Health Free Dental Clinic 1,500.00 • Mission of Hope 1,500.00 • H.D. Youth Center 1,500.00


• Catherine McAuley Center 1,500.00 • St. Luke’s Dental Health Center 1,000.00 Orientation of Medical Staff Department Chairs Orientation for new department chairs will be held Tuesday, January 8, 2013 at 5:00 p.m. Mercy Neuhaus Board Room followed by the regularly scheduled Medical Executive Committee meeting. Returning chairs are strongly encouraged to attend as well, to reacquaint themselves with the expectations and duties and assist in the orientation process. Medical Staff Leadership Compensation Dr. Pospisil reviewed his findings regarding the time obligations of Medical Staff Leadership roles and the compensation for these roles within the medical community. It was moved, seconded to compensate the Medical Staff Leadership as follows: • Medical Staff President $10,00 annually • Medical Staff Vice President $5,000 annually • Medical Staff Bylaws Committee Chairperson $1,250 annually • Medical Staff Credentials Committee Chairperson $1,250 annually


Medical Executive Committee

Excerpts January 8, 2013

2013 Committee Schedule and Department Chairs Dr. Wilbur drew attention to the listing of medical staff committees and department chairs included in the accompanying meeting materials. She noted that Cardiovascular Medicine, Internal Medicine and Orthopaedics are still searching for an assistant chair. Conflict of Interest Forms Dr. Wilbur reviewed the Conflict of Interest Policy forms for the 2013 Medical Executive Committee leadership and asked physicians to complete these and return them to the Medical Staff Office at their earliest convenience. 2013 Medical Executive Committee Goals Dr. Wilbur led the membership in a discussion of the goals for the coming year. Several goals were discussed including:

• Medical Staff Bylaws revisions • Medical Staff Rules and Regulations revisions • Medical Staff Policies review and revisions • Delineation of Privileges review and revisions • EPIC implementation • Meaningful Use • The Joint Commission Survey

Department Minutes Dr. Wilbur reviewed the department meeting minutes for the Dental, Emergency Medicine, Internal Medicine and Ophthalmology. In Ophthalmology, call schedule proportioning and accountability was discussed. Dr. Hall reported that this new policy has not been disseminated to all section members. Since the time of meeting a physician with previously documented unresponsiveness to call events has again not met call response expectations. It was moved, seconded and approved to suspend the practitioner for 30 days. Administrator’s Report Mike Trachta drew attention to the Administrator’s Report. Epic Update – The Medical Inpatient, Surgical and Outpatient Epic Physician Advisory Councils continue to meet. Work is progressing on order set development. Physicians are being asked to review order sets as their particular sets are developed. We are also having a panel of current users review the 2012 Epic version we will be using to give us recommendations on training. Considerations for how much training will be needed include a slight change in the look of the screen, incorporation of some new modules not currently in use locally and some workflow issues that are unique to Mercy. We will

Medical Executive Committee Excerpts January 8, 2013 Page 2 be having separate classes for new and current users and plenty of practice time during which current users can add in their existing preference lists, smart texts, templates, etc. ahead of the Go-Live to make the transition smoother. Physician Survey – The Physician Liaisons continue to meet with physician groups to discuss results of the Physician Survey and present action plans. We are trying this new approach rather than presenting to Medical Staff Department meetings in hopes of generating more discussion. If you have not already had a meeting, please feel free to contact Andrea Ault at (319) 861-7684 to see when you are scheduled. Bylaws – The revised Medical Staff Bylaws are currently in legal review and hopefully will be available for general review in January. Please watch for announcements in the lounges. Influenza Vaccine Reminder – The Influenza season has arrived and is considered to be “widespread” in our community. If you have not been vaccinated, please consider doing so. You may get a vaccination at the Mercy Employee Health Clinic on the 2nd floor of the 8th & 8th Building. If for any reason you cannot receive a vaccine, please wear a mask to protect yourselves and the patients. PRACTICE GOOD HAND HYGIENE-FOAM IN & OUT TJC Reminders – We currently have The Joint Commission triennial survey on site. We appreciate your attention and assistance with some of the more common variances being found at other facilities being surveyed this year as well as focuses the surveyors are seeing on site:

1. Therapeutic Duplications – If you have more than one medication for the same indication, i.e. pain or nausea, please write which to use in what circumstance. For example-use drug A first, if not effective use drug B.

2. Please be sure and complete stickers for restraints and telemetry. Don’t let orders expire. 3. Please be sure and document informed consent discussions – risks/benefits/alternatives – in your

H&P or Preop Note. If you only include it in the Op Note itself, it is difficult to tell if the discussion took place prior to the procedure.

4. Time and Date orders 5. Time Out procedures

Physician Website – Work continues to upgrade the physician website. A new, simplified address has been created: www.p.mercycare.org. We welcome any suggestions as to what content you would like to see on the website. Credentials Committee The Credentials Committee meeting report of December 18, 2012. The following physicians were recommended for membership and privileges:

• Walid Behnawa, MD – Family Medicine/Hospitalist joining Hospitalist Medicine Physicians of Linn County.

• Thomas Serbousek, MD – Family Medicine currently practicing at MercyCare Marion. Dr. Serbousek is not requesting any inpatient privileges at this time, but intends to place orders in the outpatient treatment center and Wound Healing Center.

Medical Executive Committee Excerpts January 8, 2013 Page 3

• Sean Dow, MD – Internal Medicine/Pulmonology providing coverage for MercyCare Pulmonology and Intensive Care.

• Karim Nahra, MD – Internal Medicine/Neurology currently with Biotronic Neurophysiological Intraoperative Monitoring Services based in Ann Arbor, Michigan, providing remote intraoperative electrophysiological monitoring during orthopaedic spinal surgeries.

• Nora Royer, MD – Surgery joining the Mercy Medical Center General Surgery Clinic. Dr. Royer’s request for Bronchoscopy, with or without biopsy; Thyroidectomy, lobectomy; Thyroidectomy, subtotal; Thyroidectomy, total; Associated neck dissection with thyroid operations; Parathyroidectomy or exploration; Parathyroid transplantation and Tracheostomy privileges is pending documentation of training and experience.

Robert Keating, MD – Surgery was recommended for computer-enhanced laparoscopic surgery privileges. Keith Kopec, MD – Cardiovascular Medicine and Matthew McMahon, DO – Cardiovascular Medicine were recommended for moderate (conscious) sedation privileges. The draft delineation of privileges for the surgical assistant was approved as presented. The committee reviewed Dr. McMahon’s report of his reviews for the cardiologists that did not meet volume requirements in the 2nd quarter 2012 reappointment cycle. The committee recommended continuing the review of cases until privilege criteria volume requirements are met. Bylaws Committee Dr. Baustian updated the committee on the progress of the revisions. Tentatively planned rollout will be to the Medical Executive Committee membership prior to the February meeting and then a vote of sponsorship will be taken. Then the revisions will be rolled out to the Medical Staff as a whole for review and vote. Dr. Schweiger introduced himself to the new membership of the committee. He provided background on the bylaws revision process, the parties involved, highlights of the areas of focus, and the proposed rollout of the revisions. Joint P&T Committee The minutes summary of the December 11, 2012 Joint P&T Committee was given. Formulary interchanges: Medication Ordered: Interchanged To: Nitroglycerin 2% ointment- ½ inch Q8hr Nitroglycerin patch 0.2 mg/hr Q24hr (on 12 and off 12) Nitroglycerin 2% ointment-1 inch Q8hr Nitroglycerin patch 0.4 mg/hr Q24hr (on 12 and off 12) Nitroglycerin 2% ointment- 2 inch Q8hr Nitroglycerin patch 0.6 mg/hr Q24hr (on 12 and off 12) Lactobacillus any dose in adults patients Lactobacillus acidophilus/Lactobacillus Bulgaricus

(Bacid) 2 caplets Daily Fluticasone/Salmeterol (Advair Diskus) No interchange

Medical Executive Committee Excerpts January 8, 2013 Page 4 100/50 1 puff BID Fluticasone/Salmeterol (Advair HFA ) 45/21 2 puffs BID

Fluticasone/Salmeterol (Advair Diskus)100/50 1 puff BID

Fluticasone/Salmeterol (Advair Diskus) 250/50 1 puff BID

Mometasone/Formoterol (Dulera) 100/5 2 puffs BID

Fluticasone/Salmeterol (Advair HFA ) 115/21 2 puffs BID


Budesonide/Formoterol (Symbicort) 80/4.5 2 puffs BID


Fluticasone/Sameterol (Advair Diskus) 500/50 1 puff BID


Fluticasone/Salmeterol (Advair HFA ) 230/21 2 puffs BID


Budesonide/Formoterol (Symbicort ) 160/4.5 2 puffs BID


Almotriptan (Axert) 6.25-12.5 mg PO at onset of headache, may repeat in 2 hours; NTE 2 tablets/24 hours

Sumatriptan 50 mg PO at onset of headache, may repeat in 2 hours; NTE 200 mg/24 hours

Eletriptan (Relpax) 20-40 mg PO at onset of headache, may repeat in 2 hours; NTE 80 mg/24 hours


Frovatriptan (Frova) 2.5 mg at onset of headache, may repeat in 2 hours; NTE 7.5 mg/24 hours


Naratriptan (Amerge) 1-2.5 mg PO at onset of headache, may repeat in 4 hours; NTE 5 mg/24 hours


Rizatriptan (Maxalt) 5-10 mg PO at onset of headache, may repeat in 2 hours; NTE 30 mg/24 hours


Zomitriptan (Zomig) 2.5 mg PO at onset of headache, may repeat in 2 hours; NTE 10 mg/24 hours


Formulary deletions: Medication Reason for Deletion Carbachol (Isopto Carbachol) 3% No longer available. Nystatin vaginal tablets No longer available. Phentermine (Adipex-P) No use. Morrhuate Sodium (Scleromate) Backorder and no use. Reserpine Back order and no use in 2 years.

Medical Executive Committee Excerpts January 8, 2013 Page 5 Pharmacists will use the table included with the agenda packet to make automatic conversions on medications that are being crushed or administered via a feeding tube. As directed by the conversion table, the pharmacist will contact the prescriber for recommendations if an approved automatic conversion is unavailable. The use of standard doses for oral Vitamin K was approved based on the chart below.

Dose Phytonadione (Vitamin K) PO Ordered Dose Dispensed 0-1.87 mg 1.25 mg

1.88-3.12 mg 2.5 mg 3.13-4.37 mg 3.75 mg 4.38-5.62 mg 5 mg 5.63-6.87 mg 6.25 mg 6.88-8.12 mg 7.5 mg 8.13-9.37 mg 8.75 mg 9.38-10 mg 10 mg

Quality, Safety, and Clinical Outcomes Dr. Valliere reviewed the Monthly Performance Scorecard included in the agenda packet: • Raw Mortality Scores above target. This may be attributed to a rise in the case mix index and the Risk

Adjusted Mortality Index reflects the more complex cases and is within target. • Average Length of Stay remains higher than budget. This may be attributed to the increase in CMI as

well as a small group of patients that have 100+ days on an inpatient stay. There have been difficulties placing these patients with facilities outside of the hospital due to co-morbid conditions.

• Safety event reports related to patient identification continues to not meet expectations. • The 1 miss on Acute Myocardial Infarction was due to an aspirin being missed both in the hospital and

the office setting. There had been a trend of three years of perfect scoring prior to this event. Dr. Valliere provided a brief explanation of the Value Based Purchasing program and how the withholding work and drew attention to the Value Based Purchasing reports included with the agenda packet. Dr. Valliere spoke regarding the differences in HCAHPS questions and Press Ganey exit surveys. He reviewed the HCAHPS reports included with the agenda packet: • Responsiveness of Hospital Staff continues to be a challenge. Light responses are recorded and the

hospital is averaging a response time within 2 minutes. • Communication about Medications is also a focus. The recent addition of Pharmacists to the floors is

expected to make a positive impact on this measurement. Physician Restraint Education Dr. Valliere reviewed the information included in the agenda packet. This information will be presented at each of the department meetings. This information was presented as part of the annual restraints education.

Medical Executive Committee Excerpts January 8, 2013 Page 6 VTE Order Set Dr. Wilbur reviewed the information included in the agenda packet. Both the mechanical and pharmacologic sections need to be completed on each applicable patient. It was moved, seconded and approved for mandatory use of this order set. Physician Case Review Policy Dr. Wilbur reviewed the information included in the agenda packet. These criteria will be presented at each department meeting for review and possible revision, with the goal to have this completed by the end of the year. Epic and Meaningful Use Dr. Valliere reviewed his memo to the committee included in the agenda packet. Dr. Hilliard explained the purpose, reasoning and benefits behind the recommendation from the Epic Physician Advisory Groups. These items will be brought for vote at the next meeting. Flu Masking Dr. Wilbur reviewed the report included in the agenda packet. Mercy Medical Center has enacted a mandatory masking policy for employees. It was moved, seconded to adopt the same policy for Medical Staff members. Motion carried with one opposing vote.

ADMINSTRATIVE REPORT January/February 2013

Epic Update – The Medical Inpatient, Surgical and Outpatient Epic Physician Advisory Councils continue to meet. Work is progressing on order set development. Physicians are being asked to review order sets as their particular sets are developed. We are also having a panel of current users review the 2012 Epic version we will be using to give us recommendations on training. Considerations for how much training will be needed include a slight change in the look of the screen, incorporation of some new modules not currently in use locally and some workflow issues that are unique to Mercy. We anticipate having separate classes for new and current users and plenty of practice time during which current users can add in their existing preference lists, smart texts, templates, etc. ahead of the Go-Live to make the transition smoother. Physician Survey – The Physician Liaisons continue to meet with physician groups to discuss results of the Physician Survey and present action plans. We are trying this new approach rather than presenting to Medical Staff Department meetings in hopes of generating more discussion. If you have not already had a meeting, please feel free to contact Andrea Ault at to see when you are scheduled. Bylaws – The revised Medical Staff Bylaws are currently in legal review and hopefully will be available for general review in January. Please watch for announcements in the lounges. Influenza Vaccine Reminder – The Influenza season has arrived and is considered to be “widespread” in our community. If you have not been vaccinated, please consider doing so. You may get a vaccination at the Mercy Employee Health Clinic on the 2nd floor of the 8th & 8th Building. If for any reason you cannot receive a vaccine, please wear a mask to protect yourselves and the patients. PRACTICE GOOD HAND HYGIENE-FOAM IN & OUT TJC Reminders – We are currently within the survey window for our The Joint Commission triennial survey. We appreciate your attention and assistance with some of the more common variances being found at other facilities being surveyed this year:

1. Therapeutic Duplications – If you have more than one medication for the same indication, i.e. pain or nausea, please write which to use in what circumstance. For example-use drug A first, if not effective use drug B.

2. Please be sure and complete stickers for restraints and telemetry. Don’t let orders expire. 3. Please be sure and document informed consent discussions – risks/benefits/alternatives –

in your H&P or Preop Note. If you only include it in the Op Note itself, it is difficult to tell if the discussion took place prior to the procedure.

Physician Website – Work continues to upgrade the physician website. A new, simplified address has been created: www.p.mercycare.org We welcome any suggestions as to what content you would like to see on the website.

701 10th Street SE Cedar Rapids, IA 52403-1292 (319) 398-6144

MEMO

DATE: Mercy Medical Staff TO: Mark Valliere FROM: The Joint Commission Survey SUBJECT: January 17, 2013

As most of you probably know by now, The Joint Commission conducted its triennial survey at mercy during the week of January 7th. Thanks to all of you for your cooperation and participation. The survey went very well. The survey team stated this was their first survey of 2013 and the bar has been set very high for future sites. Our preliminary report cited 11 direct and 15 indirect findings. Some of these are duplicates as a single finding can show up in more than one standard. Nearly all were minor and many were fixed by the time the survey team left. I am pleased that we did very well on the Medical Staff standards. We have to make a minor working change on our application form, otherwise we were in full compliance. There were a few findings in other areas such as the timing of orders. This will largely go away once Epic is implemented in June. We also have to be sure that during procedural time outs, everyone in the room pauses and participates. Overall, we are very pleased that TJC has affirmed the quality of care that you provided at Mercy. I do not anticipate any significant changes in our current processes as a result of the survey.

Cardiovascular Medicine Meetings

Mercy Medical Center

February 7, 2013

April 4, 2013

June 6, 2013

August 1, 2013

October 3, 2013

December 5, 2013

St. Luke’s Hospital

January 3, 2013

May 2, 2013

September 5, 2013

November 7, 2013


APPLIES TO: Hospital Wide

Page 1 of 1

SUBJECT TITLE: Physician Notification, Escalation STANDARD/REF #: NA

APPROVED BY: Medical Staff EFFECTIVE DATE: [Effective Date]

REQUIRED REVIEWERS: Provision of Care/NPSG REVIEWED DATE: [Reviewed Date]

Printed on: 11/6/2012

POLICY/PURPOSE: This document outlines the procedure for hospital staff to follow to resolve questions and/or concerns about the medical management of a patient. DEFINITIONS: PROCEDURE: For Patient Care Emergencies: Refer to the Medical Emergency Team Policy (includes Hospitalist).

For Non-Urgent Patient Needs: Staff should use the following steps for notification and escalation when needs remain unresolved at each level: 1. Nurse to Charge RN 2. Nurse or Charge RN to Physician

a. Nursing staff should make attempts of paging again and / or notifying the Answering Service for alternate contact numbers or contacting a partner.

3. Nurse or Charge RN to House Supervisor (or Department Manager/Director when available) 4. House Supervisor to Physician 5. House Supervisor to Administration (i.e. Administrator On-Call) 6. Administrator to Physician 7. Administrator to Department Chair, Medical Director, President of the Medical Staff, or CMO. RELATED DOCUMENTS: REFERENCES:

January 2013

Inpatient Diabetes Education Services

Referral Process:

How: Inpatient Diabetes Education Referral through Meditech.

Who: Anyone involved in the care of the patient can refer.

Cost: Not a billed service so no cost to patient.

General questions: Call 398-6663

Availability: Monday-Friday, time period variable based on number of referrals

Criteria for referral to the Joslin Diabetes Inpatient Educator: 1. New diagnosis of diabetes. 2. New oral diabetes medications in the hospital that they will be continuing at home. 3. New to insulin therapy who will be discharged home on insulin. 4. Patients with A1C > 9%. 5. Patients admitted with a diagnosis of ketoacidosis. 6. Patients requesting a review of anything related to their diabetes care and self-management. 7. Patients requesting general support for insulin pump use such as education about site

placement, rotation or basic button pushing skills. 8. Patients followed at the Joslin Diabetes Center for outpatient diabetes education, insulin

management or pump management.

Services Provided by Inpatient Diabetes Educators:

1. Education for Patients Newly Diagnosed with Diabetes: Survival skills diabetes education for patients newly diagnosed with diabetes.

2. Education for Patients Started on Insulin: Patients will be taught how to administer insulin injections with vial and syringe or pen (depending on insurance coverage). They will also be instructed on the prevention, identification and management of hypoglycemia, blood glucose testing recommendations and blood glucose targets.

3. Education for Patients with Poorly-Controlled Diabetes based on A1C > 9%: Educators will assess the patient’s diabetes self-management knowledge and practices and provide education and skills training as indicated.

4. Education for Patients Requesting a Review of Diabetes Self-Management: Educators will assess the patient’s diabetes self-management knowledge and practices and provide education and skills training as indicated.

5. Education for Patients Regarding New Medications other than Insulin Started During their Hospital Stay: Educators will review the dosing and administration, mechanism of action and side effects for new medications.

6. Support for Insulin Pump Patients: Educators can provide support and education related to set changes, management of hyperglycemia, and button pushing/programming on a pump.

January 2013

7. Review of Prevention, Identification and Management of Ketoacidosis (at home): Educators will assess a patient’s knowledge related to ketoacidosis and review prevention, identification and management of ketoacidosis, to include when ketones should be checked and when to contact the physician.

8. Courtesy Visit to any active Joslin patient: Educators would be interested in touching base with any active Joslin patient who is hospitalized if they would like a visit.

9. Follow-up Phone Calls after Discharge for Patients Eligible For and Interested in Outpatient Diabetes Education: Educators will contact patient by phone after they are discharged from the hospital to schedule them for outpatient education. Educators will contact the patient’s primary care provider to obtain appropriate referral for outpatient education if patient schedules an outpatient appointment.

Services that cannot be provided by inpatient diabetes educators:

1. Insulin Dose Adjustment/Pump Adjustment 2. Determining Specific Insurance Coverage for Diabetes Education and Supplies 3. Determining resources for obtaining medication and supplies due to financial or other

socioeconomic constraints.

Documents

MERCY MEDICAL CENTER Cedar Rapids, Iowa Cardiovascular ...p.mercycare.org/app/files/public/74/pdf-020713-Agenda.pdf · Cedar Rapids, Iowa Cardiovascular Medicine Department of the