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Medical Staff Newsletter
Medical Staff Contacts:
Ashley McClellan, FACHE
Chief Executive Officer
972.420.1549
[email protected]
Mary Jo Sexton-Tosh, MSA
Director, Medical Staff Services
972.420.1586
[email protected]
Lora Jean Enty
Director, Physician Relations
214.236.8614
[email protected]
Stephanie Samuel
Medical Staff Manager
972.420.1557
[email protected]
Christine Bianco, CPCS
Medical Staff Coordinator
972.420.1507
[email protected]
Inside
Medical Staff Leadership ................ page 2
Crimson.............................................. page 2
Anticoagulation Consults ............... page 2
Alpha Jalloh Recognized................... page 2
Magnet Recognition........................ page 3
Tele-Psychiatry................................. page 3
Q1 2015
HCA NORTH TEXAS WELCOMES CARENOW
I am pleased to announce that
HCA has acquired Dallas-based
CareNow.
CareNow will become part of HCA Physician Services Group, adding an
exceptional network of 24 clinics and 130 physicians in the HCA North
Texas Division to complement our hospital, emergency and urgent care
services.
Founded in 1993, CareNow is a well-respected brand and a high-quality
provider in the DFW market that has grown to become one of the largest
independent providers of urgent care, family practice, and occupational
health in the United States. In 2013, the clinics served approximately nine
percent of the Dallas-Fort Worth population.
This transaction will substantially strengthen HCA North Texas’ primary
and urgent care base, and will help provide a seamless continuum of care
for our patients. It represents two trusted providers coming together to
deliver the quality health care services our community needs, when and
where they need them.
Together HCA and CareNow will be able to offer patients the expertise of
a proven network of primary and urgent care centers combined with the
broader resources of a large hospital system when a higher level of care
is required. I know you will join me in welcoming CareNow to the HCA
North Texas family.
Sincerely,
Erol Akdamar, President
HCA North Texas Division
Flu Documentation.......................... page 3
2014 Accomplishments................... page 4
2015 Goals......................................... page 6
Clinical Documentation Tip............. page 7
Upcoming Events............................. page 7
Staff Calendars.................................. page 8
Connect with us:
Our Mission: Above all else, we are committed to the care
and improvement of human life. In recognition of this
commitment, we strive to deliver high quality, cost effective
healthcare in the communities we serve.
w w w.lewisvillemedical.com
2015 Medical Staff Leadership
Crimson is Here!
Chief of Staff
Shirley Williams, MD
Chief of Staff Elect
Carl Menckhoff, MD
Secretary
Debra Naylor, MD
Crimson is a data reporting tool created by the Advisory
Board Company that is in use at hundreds of HCA facilities
around the country. It is now being implemented at all
North Texas HCA division locations.
Anesthesia Chair
Rishi Taneja, MD
CV Chair
Raul Santos, MD
Credentials Chair
Debra Naylor, MD
Critical Care Chair
Adekunle Adekola, MD
ED Chair
James Doyle, MD
Hospitalist Chair
Babar Zuberi, MD
Medicine Chair
Farrah Paracha, MD
NICU Chair
Maheshwar Thummala, MD
OB/GYN Chair
Thomas Fliedner, MD
PAC Chair
Stewart Coffman, MD
Pathology Chair
Michael Hew, MD
Pediatric Chair
Jason Buttles, MD
Radiology Chair
Joseph Chan, MD
Surgery Chair
Mathis Adams, MD
Crimson provides for data transparency and physician led
performance improvement by allowing physicians to view
their performance in patient care compared to their peers
for like cases. Crimson reports are not publicly reported,
but it does allow physicians to access the same types of
information that are being reported publicly by quality
rating providers such as CMS, Leapfrog and U.S. News.
As this year progresses, you will see more about Crimson
in your Departmental meetings and at the Crimson signon events that we will begin having once a month starting
in February. If you are interested in learning more about
Crimson or logging in for the first time, please feel free to
contact either Steve Adams at ext. 1555 or Holli Thornhill
at ext. 7533.
Medical Staff recognizes
Alpha Jalloh
Members of our Medical Staff recently came together
to recognize Alpha Jalloh, Sous Chef in MCL’s Food and
Nutrition Services. Alpha takes exceptional care of our
physicians daily in the physician lounge. Dr. Shirley
Williams (pictured with Alpha) and Dr. Farrah Paracha
presented Alpha with a token of appreciate from their
fellow physicians.
Anticoagulation Consults
The Clinical Pharmacy Department now provides
anticoagulation consults on a requested basis. An
order for “Coumadin Rx to Dose” may be entered
into CPOE ePOM, which will prompt a clinical
pharmacist consult. The clinical pharmacist will
review the patient’s medical history, indications for
anticoagulation and concurrent medications. The
pharmacist will dose and monitor the patient based
on the Medical Staff-approved nomograms, policies
and protocols. The pharmacist will enter progress
notes into the medical record and will communicate
with the medical team regarding any issues that
arise. We look forward to providing this additional
service to our medical staff and improving the quality
of care our patients receive!
2
Magnet Recognition Program
Magnet is considered the highest honor bestowed on hospitals to recognize the quality of nursing care. It is
outcomes-based and the standards are high – only 7% of U.S. hospitals (402) are Magnet designated. There are
proportionally more Magnet hospitals in Texas (34) and more in Dallas/Fort Worth than other Texas cities. When
MCL began this journey 3-4 years ago, there were less than 10 in Dallas Fort-Worth, there are now 16. It is a
point of differentiation in a highly competitive market.
3-Pronged Goals of Magnet Recognition
1.Identify excellence in the delivery of nursing services to patients
2.Promote a professional practice environment that supports quality care
3.Provide a mechanism for the dissemination of “best practices” in nursing services
35 years of research demonstrates that being a Magnet hospital makes a difference.
The standards are evidence-based and walk the organization through a roadmap to success that improves
engagement, clinical outcomes, and patient experience. We are excited to be on the journey to Magnet and
know that this designation will allow us to continue to provide Excellence Always!
Tele-Psychiatry
Green Oaks Hospital (GOH) is contracted with MCL to provide behavioral health and psychiatric consultation
services utilizing MCL’s telemedicine equipment. The utilization of the telemedicine equipment allows for a
psychiatrist to interface directly with patients and hospital staff to complete behavioral health assessments
or psychiatric consultation and it may decrease the time a patient would otherwise have to wait to see a
Psychiatrist. In some (but not all) cases, it may avoid the necessity to transfer patients to another facility or
expedite the discharge. One of the greatest benefits to our behavioral health patients is that this service may
be utilized at any point in the patient’s stay, rather than having to wait until the patient is medically stable for
discharge. For example, patients may benefit from early directed treatment with psychiatric medications that
could potentially impact the patient’s length of stay and discharge disposition.
The telemedicine consultation will be performed using FDA-approved video conferencing equipment controlled
by a licensed Psychiatrist that has privileges at MCL. Patients that have received Tele-Psychiatry assessments
similar to this often report very satisfactory experiences, and appreciate the ability to see a licensed Psychiatrist
timely. The Psychiatrist also feels confident and able to deliver the same level of services utilizing the equipment
compared to an in-person consultation. During the consultation, a representative of the facility’s clinical staff
(typically the nurse) will be present at all times.
Details regarding the Tele-Psychiatry process have been sent to all medical staff via fax/email. If you have not
received this information, please contact the Medical Staff office.
Flu Documentation
Employee Health and Medical Staff Services are requesting physicians turn in their flu vaccine documentation
if they haven’t already done so. Documentation can be faxed to Gina Harrison at 972.420.1805.
3
2014 Accomplishments
We enjoyed great success in 2014 thanks to your leadership and support, and look forward to continuing
the momentum striving for “Excellence Always” in 2015. In this newsletter you will find details on both our
accomplishments and 2015 goals (see pg 6). Thank you for your service and dedication to Medical Center of Lewisville.
Service Excellence
Physician Satisfaction: Employee Satisfaction: Top 10 in HCA for the 4th consecutive year
Clinical Quality
Sepsis: Reduced Sepsis mortality from 34% to 11% (79 lives saved)
Mortality: Reduced mortality rate to below HCA Division and National Average (0.83 to 0.39; Goal= 0.79)
Falls:1.46 YTD on a goal of 2.13
Core Measures: Significantly improved core measure performance over 2013
Accreditations/Designations:
• Magnet Application accepted
• Trauma IV
• Texas Hospital Quality Silver Award
• College of American Pathology (CAP)
• Joint Commission Top Performer
• Joint Commission Reaccreditations:
- Facility Overall
- Total Hip
- Total Knee
- Inpatient Diabetes
- Inpatient Stroke
4
Earnings Outperformance
Cardiovascular:
• Opened new, dedicated CVCU
• Introduced EP procedures and Cardiac MRI
• Maintained significant Cath and CABG volumes
Surgical Services:
• Significantly exceeded budgeted surgical volumes
• Acquired and installed DaVinci Robot (OR2D2)
• Invested additional capital into our ORs
Women’s & Children’s:
• Exceeded Budgeted Deliveries and NICU Days
• Ramped up Dr. Grubbs, Dr. Thomas and Dr. Banks
• Identified 2015 OB-GYN
Primary Care:
• Recruited full-time physician for Senior Health Clinic
• Initiated Primary Care Council Meetings
• Stabilized new Adult Hospitalists Physicians
• Recruited and opened Questcare Medical Clinic
• Identified 2015 FP
• HCA acquired CareNow (24 urgent care centers;
130 employed primary care physicians)
Oncology Services:
• Opened Solis Women’s Imaging Center
• Two oncology groups signed leases to move to campus
• Opened CLEAR Clinic- Low dose CT Clinic
• Hired Lung Navigator and New Breast Navigators
• Scheduled for ACOS Cancer Accreditation Survey Q3 2015
Rehabilitation Institute:
• Exceeded budgeted admissions and patient days
• Stroke Rehab Survey scheduled for Q1 2015
• Established quarterly meetings with referring hospitals
to discuss quality and referrals
• Dr. Jorgensen, Medical Director, appointed to
HCA Corporate Rehabilitation Committee
Emergency Services:
• Secured funding and initiated construction for new
Emergency Department to open Q4 2015
• Trauma IV Designation
• Grew EMS volume 3% over prior year (17% growth in 2013)
• Hired full-time EMS Liaison
• Decreased Door to Greet times to below 10 minutes in Q4 2014
• Successfully on-boarded new medical director, Dr. Doyle
5
2015 Goal Summary
Cardiology:
• Grow volumes (EP, CABG and Caths)
• Obtain Chest Pain V
Surgical:
• Grow surgical volumes via the robot and
additional new Surgeons
Women’s & Children’s:
• Onboard new OB-GYNs
• Evaluate pediatric surgery
• New Pedi ED Q4 2015
Oncology & Rehab:
• ACOS Accreditation
• Clear Clinic
• Grow Navigation
• Stroke Rehab Survey-2.5.15
Emergency Services:
• Open new ED in Q4 2015
• Obtain Trauma III
Access Points/ Network:
• Onboard new PCPs
• Maximize CareNow referrals
• Increase volumes in Senior Health Clinic
• Continue stability of hospitalists programs
Service:
• Increase MCL as a “Place to Practice” to
80th percentile for physicians
• Increase Employee Engagement to 81%
• Reduce turnover
• Improve HCAHPS & ED Overall Rating
Medical Executive Committee Goals:
• Reduce Sepsis Mortality
• Successful implementation of CPOE
• Coding Education for physicians
• Increase participation in Physician Satisfaction Survey
• Create “Past Chief of Staff Recognition Wall”
Quality:
• Reduce Sepsis Mortality
• Be “Green” for Core Measures
• Reduce Mortality Index to 0.58 (90th percentile)
• Reduce Complication Index to 0.70 (80th percentile)
6
Clinical Documentation Tip
AKI vs. ARF
• AKI (Acute Kidney Injury) and ARF (Acute Renal Failure) are both considered acute renal failure by
coding guidelines.
• Acute kidney injury and acute renal insufficiency are not interchangeable diagnoses.
• Consider documenting objective findings e.g. pre-renal azotemia, mildly elevated BUN/CR secondary
to dehydration for a modest/transient rise in BUN/CR
• Application of diagnostic criteria should be used only after an optimal state of hydration has been
achieved.
• Consider documenting AKI or ARF after expected time frame for normal renal function to return
especially if Cr does not return to baseline or dialysis is required.
Upcoming Events
Friday, March 27
Thursday, April 2
Saturday, June 13
HortySpringer Seminar
1:00 – 5:00pm
Community Room
Doctors’ Day Celebration
5:30 – 7:30pm
2nd Floor Community Room
Speaker: Scott Robins, MD
2015 Medical Staff Gala
7:00 – 11:00pm
Dallas Arboretum –
DeGolyer Mansion
You and a guest are invited to join
us for a sophisticated evening of
smooth jazz under the stars as we
enjoy cocktails, dinner and dancing.
We will also recognize our physicians
for their years of service. Formal
invite with more details will arrive in
your mailbox soon. You won’t want
to miss it!
HortySpringer offers seminars and
workshops for medical staff leaders,
hospital and health system board
members and executives, legal
counsel, and other management
personnel. Medical Staff Leaders
are faced with many challenging
questions. This training will focus on
best practices for medical staff peer
review and the credentialing process.
4 hours of CME credit is provided.
Registration Required. Contact
Stephanie Samuel at 972.420.1557
for more information or to RSVP.
Doctors’ Day celebrates doctors
and recognizes their hard work and
commitment to their community.
Join us for a Doctors’ Day Celebration
and general medical staff meeting,
including a one-hour Ethics CME,
Value Based Purchasing and the
Patient Experience. Dinner will be
provided. Registration preferred.
Contact Stephanie Samuel at
972.420.1557 for more information
or to RSVP
7
MEDICAL CENTER OF LEWISVILLE - MEDICAL STAFF MEETINGS
MEDICAL CENTER of LEWISVILLE - MEDICAL STAFF MEETINGS
March 2015
MARCH 2015
Sunday
Monday
1
Tuesday
Wednesday
2
Thursday
3
12:15pm – Credentials
Committee (Admin
Board room)
8
9
15
th
16
6
7
11
7:30am – Grand
nd
Rounds (2 floor
Community room)
12
13
14
17
20
21
27
28
12:15pm – Cancer
th
Committee (4 floor
conference room)
18
19
12:15pm – Dept of
nd
OB/GYN (2 floor
Community room)
22
Saturday
5
12:15pm – Critical
th
Care Committee (4
floor conference
room)
10
12:15pm – MEC (4
floor conference
room)
Friday
4
12:15pm – Dept of
th
Pediatrics (4 floor
conference room)
23
24
12:15pm – PAC
th
Committee (4 floor
conference room)
25
12:15pm – P&T
th
Committee (4 floor
conference room)
26
7:30am – Dept of ED
th
(4 floor conference
room)
12:15pm – Tumor
th
Board (4 floor
conference room)
29
30
31
MEDICAL CENTER OF LEWISVILLE - MEDICAL STAFF MEETINGS
MEDICAL CENTER of LEWISVILLE - MEDICAL STAFF MEETINGS
April 2015
Sunday
Monday
APRIL 2015
Tuesday
Wednesday
Thursday
Friday
Saturday
3
4
9
10
11
16
17
18
23
24
25
1
2
DOCTOR’S DAY!!!
12:15pm – Critical
th
Care Committee (4
floor conference
room)
6pm – General
Medical Staff meeting
5
6
7
12:15pm – Credentials
Committee (Admin
Board room)
8
7:30am – Grand
th
Rounds (4 floor
conference room)
7:30am – Dept of CV
th
Med/Surg (4 floor
conference room)
12:15pm – Cancer
th
Committee (4 floor
conference room)
12
13
14
12:15pm – MEC (4
floor conference
room)
19
15
th
20
21
12:15pm – PAC (4
floor conference
room)
th
22
12:15pm – Infection
Prevention & Control
th
Committee (4 floor
conference room)
7:30am – Dept of
Emergency Medicine
th
(4 floor conference
room)
12:15pm – Tumor
th
Board (4 floor
conference room)
26
27
28
29
30
12:15pm – Dept of
th
Surgery (4 floor
conference room)
8