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MONTHLY

MEDICAL

STAFF

NEWSLETTER ProgressNotesVOLUME 7

In This Issue

Physician ICD-10 Training…….....P 1

Stroke Gold Plus Quality Achievement Award…………...….P 2

Thank You to Medical Staff……....P 3

Reason is You Physician Award…P 3 Medical Executive Committee Approvals………….………..…...…P 3

HIPAA Tip………………….……....P 4

Medical Staff Calendar....….….....P 5

New Practitioners on Staff..…..….P 6

Physician Roster Updates....….....P 7

J u l y 2 0 1 5

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Physician ICD-10 Training

Effective October 1, 2015

FREE TMMC Onsite Physician ICD-10 Training

New Dates:July 28, 29 & 30, 2015August 12 & 13, 2015

View the specialty specific training calendar at:http://www.torrancememorial.org/Professional_Health_Care_Education/Physician_ICD_10_Training.aspx

“Claims that do not use ICD‐10 diagnosis and procedure codes cannot be processed.”

‐ Centers for Medicare and Medicaid Services (CMS)

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Stroke Gold Plus Quality Achievement Award

Torrance Memorial Medical Center has received the American Heart Association/American Stroke Association’s Get With The Guidelines®-Stroke Gold Plus Quality Achievement Award for the third straight year. The award recognizes the hospital’s com-mitment and success in ensuring stroke patients receive the most appropriate treatment according to nationally recognized, research-based guidelines based on the latest scientific evidence. To receive the Gold Plus Quality Achievement Award, hospitals must achieve 85 percent or higher adherence to all Get With The Guidelines-Stroke achievement indicators for two or more consecutive 12-month periods and achieve 75 percent or higher compliance with five of eight Get With The Guidelines-Stroke Quality measures. These quality measures are designed to help hospital teams provide the most up-to-date, evidence-based guidelines with the goal of speeding recovery and reducing death and disability for stroke patients. They focus on appropriate use of guideline-based care for stroke patients, including aggressive use of medications such as clot-busting and anti-clotting drugs, blood thin-ners and cholesterol-reducing drugs, preventive action for deep vein thrombosis and smoking cessation counseling. “More than anything, winning this award represents the consistency with which our program works every day collaborating with all departments to give patients the basic care needed to ensure the best possible chance for recovery,” said Ed Nazareth, RN, stroke coordinator, Torrance Memorial Stroke Program. “Because time lost is brain lost, we continue working to further commu-nity education about the signs and symptoms of stroke so patients understand the urgency of rapid treatment. We also continue working to expand our use of interventional treatments, such as clot-busting drugs and surgical interventions, to ensure the most advanced care is available right here in our community.” Torrance Memorial has met specific scientific guidelines as a Primary Stroke Center for its rapid diagnosis and treatment of stroke patients. “We are pleased to recognize Torrance Memorial for their commitment to stroke care,” said Deepak L. Bhatt, M.D., M.P.H., na-tional chairman of the Get With The Guidelines steering committee and executive director of Interventional Cardiovascular Pro-grams at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School. “Studies have shown that hos-pitals that consistently follow Get With The Guidelines quality improvement measures can reduce length of stay and 30-day readmission rates and reduce disparities in care.” For providers, Get With The Guidelines-Stroke offers quality-improvement measures, discharge protocols, standing orders and other measurement tools. Providing hospitals with resources and information that make it easier to follow treatment guidelines can help save lives and ultimately reduce overall healthcare costs by lowering readmission rates for stroke patients. For patients, Get With The Guidelines-Stroke uses the “teachable moment,” the time soon after a patient has had a stroke, when they learn how to manage their risk factors while still in the hospital and recognize the F.A.S.T. warning signs of a stroke. According to the American Heart Association/American Stroke Association, stroke is the number five cause of death and a leading cause of adult disability in the United States. On average, someone suffers a stroke every 40 seconds; someone dies of a stroke every four minutes; and 795,000 people suffer a new or recurrent stroke each year. About Get With The Guidelines® Get With The Guidelines® is the American Heart Association/American Stroke Association’s hospital-based quality improve-ment program that provides hospitals with the latest research-based guidelines. Developed with the goal of saving lives and hastening recovery, Get With The Guidelines has touched the lives of more than 5 million patients since 2001. For more infor-mation, visit heart.org/quality or heart.org/QualityMap.

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Thank You to Medical Staff

Medical Executive Committee Approvals

Items approved at the last Medical Executive Committee meeting can be viewed by using this website link and selecting the particular month: http://www.torrancememorial.org/For_Physicians/Medical_Staff/MEC_Approval.aspx . If you have any questions, please contact the Medical Staff Services Department at (310) 517-4616.

Steven Jensen, MD, Pediatric Intensivist,

received the first “Reason is You Physician Award” on Thursday, June 25, 2015.

Dr. Jensen received this Torrance Memorial Medical Center Hero Award because of the compassionate care he provided to a badly burned little girl who was brought to Torrance Memorial after her apartment caught on fire. Dr. Jensen cancelled his Spring Break travel plans with his own daughters to be with this little girl and her family during an extremely critical time. Un-fortunately, this little girl’s mother perished in the fire. Dr. Jensen was extremely gentle and took a great deal of time with her father and remaining family to explain everything that was happening. Dr. Jensen remained on the Burn Unit when this little girl was in extremis, available for her, the staff and her family. The entire Burn Unit Team is so appreciative of Dr. Jensen’s heroic efforts.

Reason is You Physician Award

Thank You to Medical Staff for Staff Education Grants The Medical Staff is thanked for the generous 2014 contribution of $25,000 to support and promote additional staff education and advancement in the form of conference grants, certifications, and specialty training. A total of 23 grants were awarded, 9 for certifications and 14 awards for educational conferences. These conferences were specific to each recipient’s department and area of expertise and contributed significantly to improving practice and the provision of excellent patient care. Additionally, through the support of the Pay it Forward initiative, the Medical Staff contributed to the increase of Torrance Memorial’s nation-ally certified nurses and physical therapists to double our previous numbers! Thank you from the Staff of Torrance Memorial Medical Center.

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HIPAA Tip

QUESTION: IS IT A HIPAA OR PRIVACY VIOLATION IF STAFF WALKS AWAY FROM THEIR COMPUTER WORK STATION WITHOUT LOGGING OFF THEIR APPLICATION? ANSWER: Yes, it can be a HIPAA / Privacy violation if we have not;

Implemented reasonable safeguards in protecting patient PHI; Prevented users from accessing patient information from another employee’s user

account. Prevented unauthorized individuals from accessing our workstations or viewing and

accessing patient information displayed on our monitors.

We are required to protect patient PHI regardless of the form in which PHI is visible or accessible to unauthorized individuals (physicians, staff, patients, visitors etc). State and Federal Regulations mandate covered entities (TMMC) implement reasonable safeguards to protect patient PHI.

After use of any application, each employee (including physicians) must log off or suspend the application session.

Some safeguards implemented at TMMC to minimize incidental disclosures from computer workstations include:

Some clinical applications will log off the employee after a specific length of time of inactivity;

Screen savers automatically refresh on computer monitors; Privacy controls (filters, mirrors, etc.) have been installed on some computer monitors; Employees logging off or suspending the application after use; and Employees protecting their usernames / password (not sharing with anyone).

The following fines and penalties are associated with the “Misuse of PHI under False Pretense” (using another employee username / password to access PHI);

HIPAA: $100,000. fine / 5 years in prison; CA Law SB 541: Up to $25,000. fine to the Hospital; CA Law AB211: Up to $25,000. fine to the employee, possible jail time & lawsuits; HITECH Act: Civil fines from $100. to $ 50,000.; and HITECH Act: Criminal fines up to $100,000. / up to 5 years in prison. REFERENCE: State and Federal Regulations; 45 CFR 142.308(b)(4) & (b)(5) GUIDELINES ON WORK STATION USE POLICY # 1420.12 “COMPUTER WORKSTATION USE AND CONTROL

Monday Tuesday Wednesday Thursday Friday

1 7:00a CV Review Conf……….WT-D

2 7:00a Breast Tumor Board..WT-Aud 7:45a Lung/Thoracic Tumor Board…………...…...WT-Aud

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6 12:30p Cardiology……...……WT-D

7 8:00a TCU……………...….…..WT-C 12:30p Infection Control/P&T....WT-D

8 7:00a Anesthesia Dept…….WT-Aud 7:00a CV Review Conf……….WT-D 12:30p CME Conference….HCC-1&2

9 7:00a Breast Tumor Board..WT-Aud 7:00a Cardiac PI………………WT-D 7:45a GI Tumor Board….....WT-Aud 12:30p Pediatric PI……………..WT-D

10 7:30a IRB…………………..WT-A 8:00a Oncology………..…..WT-D

13 12:30p Credentials……….….WT-C

14 5:00p Professional Relations...WT-C 6:00p Medical Executive……..WT-D

15 7:00a CV Review Conf……….WT-D

16 7:00a Breast Tumor Board..WT-Aud 7:45a Lung/Thoracic Tumor Board…………...…...WT-Aud 8:30a Lung/Thoracic Subc..WT-Aud 9:00a Emergency Dept……….WT-D 12:30p Pediatric Dept……….WT-Aud

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20 12:00p Burn & Wound Surg...WT-C

21 12:30p Medicine Dept………….WT-D

22 7:00a CV Review Conf……….WT-D 12:30p Bioethics………………..WT-C 12:30p CME Conference….HCC-1&2 3:00p Ortho COE Hip&Knee...WT-C

23 7:00a Breast Tumor Board..WT-Aud 7:00a Surgery Advisory…...….WT-D 7:30a Family Practice Dept…..WT-B 7:45a Gen Tumor Board…..WT-Aud 12:30p Credentials……….….....WT-C 12:30p Health Info Mgmt……....WT-B

24 7:00a General Surg Subc..WT-C

27 12:30p Stroke Ad-Hoc……...WT-D 4:00p Bariatric Surgery…....WT-D

28 7:00a Breast Program Subc...WT-B 12:30p OB/GYN Dept……….WT-Aud

29 7:00a CV Review Conf……….WT-D 12:30p Antibiotic Stewardship……. Lundq Twr Pharm Conf Rm

30 7:00a Breast Tumor Board..WT-Aud 7:45a Gen Tumor Board…..WT-Aud 12:30p Medical Staff PI……..….WT-D

31 7:00a Surgery Dept…...…..WT-D

CME CONFERENCES Wednesdays, 12:30 p.m. Hoffman Health Conference Center

Torrance Memorial Medical Center is accredited by the Institute for Medical Quality/California Medical Association (IMQ/CMA) to provide continuing medical education for physicians.

Torrance Memorial Medical Center designates this live activity for a maximum of 1 AMA PRA Category I creditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This credit may also be applied to the CMA Certification in Continuing Medical Education. For up-to-the-minute conference information call (310) 784-8776 or visit: http://www.torrancememorial.org/For_Physicians/Wednesday_CME_Conferences.aspx

Medical Staff Calendar July 2015

July 29, 2015 NO CONFERENCE

July 1, 2015 NO CONFERENCE

July 8, 2015 “Sleep Problems” Alon Avidan, M.D. UCLA School of Medicine Commercial Support: Jazz Pharm

July 15, 2015 NO CONFERENCE

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August 5, 2015 “Cultural Perspectives of Medical Care” Patricia Lenahan, M.A. Univ. of Calif., Irvine School of Medicine Commercial Support: None

August 12, 2015 NO CONFERENCE

July 22 2015 “West Nile Virus” Laurene Mascola, M.D. Los Angeles County Department of Public Health Commercial Support: None

Welcome New Practitioners on Staff

Gilberto Bultron, M.D. Pediatrics Mindful Pediatric Gastroentology, Inc. 65 N. Madison Ave., Ste. 709 Pasadena, CA 91101 Phone: (626) 800-4059 Fax: (626) 800-3974

Deepti H. Chandran, M.D. Medicine Torrance Memorial Hospitalists Associates 3330 Lomita Blvd., TMHA 1st Floor Torrance, CA 90505 Phone: (310) 891-6623 Fax: (310) 891-6673

Craig A. German, M.D. Medicine HealthCare Partners 3565 Del Amo Blvd. Torrance, CA 90503 Phone: (310) 214-5741 Fax: (310) 793-4689

Ata Mazaheri, M.D. Surgery 20911 Earl St., Ste. 245 Torrance, CA 90503 Phone: (310) 303-5075 Fax: (310) 371-5351

Simone A. McKitty, M.D. Medicine 3440 Lomita Blvd., Ste. 442 Torrance, CA 90505 Phone: (310) 530-5451 Fax: (310) 530-3070

Carmen N. Morales, M.D. Family Practice Torrance Memorial Physician Network - Carson 824 E. Carson Blvd., Ste. 203 Carson, CA 90745 Phone: (310) 233-3203 Fax: (310) 316-5318

Reena Patel, M.D. Medicine UCLA Health Redondo Beach Primary & Specialty Care 514 N. Prospect Ave., 1st Floor Redondo Beach, CA 90277 Phone: (310) 937-8555 Fax: (310) 937-8556

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Phone/Fax Change Daniel A. DeUgarte, M.D. Surgery Phone: (310) 222-2709 Fax: (310) 206-1120 Resignation Sandra I. Vizireanu, M.D. Family Practice James M. Wilson, M.D. Medicine

The Medical Staff Newsletter ProgressNotes is published monthly for the Medical Staff of Torrance Memorial Medical Center. Thomas G. Simko, M.D. Chief of Staff Robin S. Camrin, CPMSM, CPCS Vice President, Medical Staff Services & Performance Improvement ANK-07/2015

Physician Roster Updates

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ProgressNotes Vol. 7 Issue 7 July 2015

ProgressNotesMONTHLY

MEDICAL

STAFF

NEWSLETTER

Medical Staff Services 3330 Lomita Boulevard Torrance, CA 90505 Phone: (310) 517-4616 Fax: (310) 784-8777 www.TorranceMemorial.org

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