Report



Minutes

The University of Toledo Board of Trustees

Clinical Affairs Committee Meeting

July 10, 2012

|Committee Chair Mr. Gary P. Thieman was present, as well as members Dr. S. Amjad Hussain and Ms. Sharon Speyer; Ms. |ATTENDANCE |

|Susan E. Gilmore was absent. Faculty representative Dr. Sanford Kimmel was in attendance. Trustee Mr. William C. | |

|Koester also attended the meeting. Administrative Liaisons Dr. Jeffrey Gold and Dr. Scott Scarborough were present. | |

|Additional attendees included Mr. Dan Barbee, Ms. Lauri Cooper, Dr. Lloyd Jacobs, Mr. Chuck Lehnert, Dr. Carl Sirio | |

|and Ms. Joan Stasa. Special Guest, Ms. Britney Ward, also was at the meeting. | |

|The meeting was called to order at 7:30 a.m. by Committee Chair Thieman in the Faculty Club Room at the Toledo Hilton |CALL TO ORDER |

|Hotel. | |

|Committee Chair Thieman requested a motion to waive the reading of the minutes of the June 5, 2012 Committee meeting |APPROVAL OF MINUTES |

|and accept them as written. A motion for approval was received by Trustee Speyer and seconded by Trustee Hussain. The| |

|minutes were approved by the Committee. | |

|Dr. Jeffrey Gold, Chancellor and Executive VP Biosciences and Health Affairs/Dean of the College of Medicine and Life |HEALTH STATUS INDEX FOR NORTHWEST |

|Sciences, introduced Ms. Britney Ward, MPH, Assistant Director Health Planning at The Hospital Council of Northwest |OHIO |

|Ohio. Dr. Gold reported that he recently attended one of the Council’s meetings regarding an assessment of Northwest | |

|Ohio community health needs; he commented that the assessment provided good quality statistical information. Ms. Ward| |

|reported that the Council represents member hospitals and health systems in the Northwest Ohio area and provides | |

|opportunities to improve the health status of Northwest Ohio citizens. She shared with the Committee the names of | |

|those from the Council involved with project management, secondary data, data collection, and report development, as | |

|well as the physicians from UTMC involved with data collection and analysis. A timeline of the planned health | |

|assessments by county was reviewed from 2003 through 2013 and a map showing assessments completed and those yet to | |

|complete. Ms. Ward presented an overview of the areas assessed in the 165 page report and county rankings based on the| |

|Robert Wood Johnson Foundation. The Lucas County strategic planning process was discussed with the Committee and | |

|leading causes of death for each county. Ms. Ward compared adult health care coverage and access, adult chronic | |

|disease, adult risky behaviors, and adult weight control with several Northwest Ohio counties, the State of Ohio, and | |

|the nation, with data from 2009 through 2011. She also discussed obesity trends among U.S. adults for a 25 year | |

|period from 1985 through 2010. Lucas County adult priorities include economic stability and related health | |

|disparities, healthy living, and tobacco use. Youth weight control, injury-related behaviors, and risky behaviors | |

|were also compared by county, the State of Ohio, and the nation with data from 2009-2011. Ms. Ward reviewed the Lucas| |

|County youth priorities focus areas chosen. Children’s health insurance, access, utilization, and medical home were | |

|also compared for Lucas County with the State and nation for 2007 and 2011. Focus areas chosen for children’s | |

|priorities were also reviewed with the Committee. Dr. Gold thanked Ms. Ward for her presentation and stated that there| |

|is a very long list of items that UT is doing to assist with this program. | |

|Dr. Scott Scarborough, Sr. VP and UTMC Executive Director, gave the Committee a brief update on the UTMC Emergency |EMERGENCY MEDICINE SERVICES |

|Department patient experience. He reported that 57% of the hospital’s admissions come through the ED, which has |UPDATE/PATIENT EXPERIENCE |

|increased tremendously in the last three years. A pie chart was reviewed of the ED payor mix where Dr. Scarborough | |

|indicated that charity patient care continues to be a challenge. He discussed changes in the ED – facilities | |

|renovation, management change, process changes, and facilities expansion. Graphs showing UTMC ED visits were also | |

|reviewed with the Committee comparing data from 2010 through 2012. | |

|Dr. Gold provided the Committee with information about UT and The Patient Protection and Affordable Care Act. He |STATUS REPORTS AND UPDATES |

|reviewed with the Committee that Academic Medical Centers consist of the teaching hospital, the medical school and | |

|sound physicians focusing on access to care, cost of care, quality of care, and workforce for care. Discussion | |

|involved how The Patient Protection and Affordable Care Act connects to the Academic Medical Center and the many | |

|different areas of interactive and moving parts related to the Act. Dr. Gold talked about health care reform and | |

|feedback of reform impact. He commented that all strategic initiatives are extremely important to health care delivery| |

|across the country. He also reported that on June 28 of this year, in a 5 to 4 decision, the U.S. Supreme Court | |

|declared the individual mandate of the Act constitutional. He then reviewed the status of many areas of UT and UTMC | |

|as it relates to compliance with The Patient Protection and Affordable Care Act. | |

| | |

|Dr. Gold briefed the Committee on the Accountable Care Organization of Toledo. He discussed the Centers for Medicare &| |

|Medicaid Services (CMS) and how they strive to lower insurance premiums and give consumers better information to make | |

|informed health care decisions, coordinate care and spread innovation. CMS provides health coverage for 100 million | |

|people. Dr. Gold reported that CMS is currently: | |

|Caring for our Community through Coordination | |

|Keeping as Many People Healthy as Possible | |

|Making Health Care More Affordable | |

|CMS has also established a Medicare Shared Savings Program (MSSP) to facilitate coordination and cooperation among | |

|providers to improve the quality of care for Medicare Fee-For-Services (FFS) beneficiaries and reduce unnecessary | |

|costs. Eligible providers, hospitals, and suppliers may participate in this program by creating or participating in | |

|an Accountable Care Organization (ACO), participation is voluntary. The Program is designed to improve beneficiary | |

|outcomes and increase value. The Program will reward ACOs that lower their growth in health care costs while meeting | |

|performance standards on quality of care and putting patients first. Dr. Gold also explained goals and measures of an| |

|ACO. He reported that approximately five months ago, UTMC entered into a partnership agreement with The Toledo Clinic| |

|regarding this Program. He then reviewed the June 21, 2012 letter to ACO of Toledo, Inc. from the Medicare Shared | |

|Saving Program indicating approval of their application to participate in the MSSP. | |

|Dr. Gold reported that the August 2012 issue of the magazine Consumer Reports contained the article, “How Safe is Your|CONSUMER REPORTS ARTICLE |

|Hospital?” This report rated the safety of approximately 18% of hospitals across the nation according to data | |

|published from a variety of state and federal agencies in 2010. UTMC did not score well in the report and Dr. Gold | |

|indicated that it was disappointing as employees at UTMC have been working hard over the last several years to change | |

|the culture of the institution and to focus efforts on what is best for the patients. In July of 2011, U.S. News and | |

|World Report recognized UTMC as the best hospital in the region. In November 2011, the Joint Commission gave UTMC a | |

|glowing accreditation report and just last month UTMC received the 2012 National Success Story of the Year Award from | |

|Press Ganey. Dr. Gold commented that UTMC is very proud of the progress they have made and a lot has been | |

|accomplished, but more still needs to be done. He, Dr. Scarborough and Dr. Jacobs have sent a letter to the | |

|University community today saying what he just reported. As UTMC has not yet been able to precisely define the data | |

|set included and the methodology used in the report, they hope to learn something from it. Much discussion ensued | |

|among the Trustees about the article. | |

|Trustee Thieman requested a motion to enter Executive Session to discuss privileged information related to the |EXECUTIVE SESSION |

|evaluation of medical staff personnel appointments and quality reporting. The motion was received by Trustee Speyer, | |

|seconded by Trustee Hussain, and a roll call of the Committee was conducted: Dr. Hussain, yes; Ms. Speyer, yes; and, | |

|Mr. Thieman, yes. After discussion, the Committee voted to exit Executive Session. | |

|Mr. Thieman requested a motion to approve the Chief of Staff Report – Attachment 1. A motion was made by Trustee |CHIEF OF STAFF REPORT |

|Hussain and seconded by Trustee Speyer. The report was approved by the Committee. | |

|With no further business before the Committee, Trustee Thieman adjourned the meeting at 9:17 a.m. |ADJOURNMENT |

Attachment 1

CHIEF OF STAFF REPORT

July 10, 2012

New Medical Staff Applicants

Yousef A. Al Ahwel, M.D.

Internal Medicine Service

Provisional Staff Status

Privileges in Internal Medicine & Moderate Sedation

Anjali Ambekar, M.D.

Radiation Oncology Service

Provisional Staff Status

Privileges in Radiation Oncology

David A. Banas, M.D.

Family Medicine Service

Provisional Staff Status

Privileges in Family Medicine & Moderate Sedation

Jason F. Bombard, D.O.

Psychiatry Service

Provisional Staff Status

Privileges in Psychiatry

Mouhammad Jumaa, M.D.

Neurology Service

Provisional Staff Status

Privileges in Neurology

Ankush Moza, M.D.

Internal Medicine Service

Provisional Staff Status

Privileges in Internal Medicine and Moderate Sedation

Nicole M. Payne, M.D.

Emergency Medicine Service

Provisional Staff Status

Privileges in Emergency Medicine and Moderate Sedation

Ehsan Rafiq, M.D.

Internal Medicine Service

Provisional Staff Status

Privileges in Internal Medicine and Moderate Sedation

Mohammad Taleb, M.D.

Internal Medicine Service

Provisional Staff Status

Privileges in Internal Medicine and Moderate Sedation

Cherian Verghese, M.D.

Internal Medicine Service

Provisional Staff Status

Privileges in Internal Medicine, Hematology-Oncology, and Moderate Sedation

Dingding Xiong, M.D., Ph.D.

Pediatrics Service

Provisional Staff Status

Privileges in Pediatrics

Syed F.A. Zaidi, M.D.

Neurology Service

Provisional Staff Status

Privileges Neurology

Medical Staff Request for Leave of Absence

Nael Bahhur, M.D.

Family Medicine Service

Effective June 16, 2012

Revised Delineation of Privileges Forms

Urology

Added: Pelvic/Sacral Nerve Stimulation

Pathology

Added: Ultrasound-Assisted Fine Needle Aspiration of Superficial Lesions

New Delineation of Privileges Form

Endovascular Surgical Neuroradiology

Medical Staff Requests for Additional Privileges

Luis E. De Las Casas, M.D.

Pathology Service

Additional Privileges in Pathology – Ultrasound-Assisted Fine Needle Aspiration of Superficial

Lesions

Mouhammad Jumaa, M.D.

Neurology Service

Additional Privileges in Endovascular Surgical Neuroradiology

Syed F.A. Zaidi, M.D.

Neurology Service

Additional Privileges in Endovascular Surgical Neuroradiology

Medical Staff Resignations

Faheem Ahmad, M.D.

Radiation Oncology Service

Effective June 29, 2012

Rajender K. Ahuja, M.D.

Radiation Oncology Service

Effective June 29, 2012

Wayne S. Court, M.D.

Radiation Oncology Service

Effective June 29, 2012

Qais A. Farjo, M.D.

Surgery Service

Effective June 1, 2012

Shaneli A. Fernando, M.D.

Radiation Oncology Service

Effective June 29, 2012

Jeffrey A. Forquer, M.D.

Radiation Oncology Service

Effective June 29, 2012

James A. Fugazzi, M.D.

Radiation Oncology Service

Effective June 29, 2012

Kara E. Hertzfeld, M.D.

Radiation Oncology Service

Effective June 29, 2012

Wainwright A. Jaggernauth, M.D.

Radiation Oncology Service

Effective June 29, 2012

Ryan Y. Jin, M.D.

Radiation Oncology Service

Effective June 29, 2012

Ronald M. Kendrick, D.O.

Surgery Service

Effective March 30, 2012

Eric P. Kielhorn, M.D.

Radiation Oncology Service

Effective June 29, 2012

Roger Kucway, M.D.

Radiation Oncology Service

Effective June 29, 2012

Dhaval Parikh, M.D.

Radiation Oncology Service

Effective June 29, 2012

Steven J. Rubin, M.D.

Radiation Oncology Service

Effective June 29, 2012

Steven R. Zeidner, M.D.

Radiation Oncology Service

Effective June 29, 2012

Reason: End of contract between UTMC and Toledo Radiation Oncology

Kamal Yoakim, M.D.

Family Medicine Service

Effective May 14, 2012

Reason: No longer has UT COM faculty appointment

New Clinical Associate Staff Applicants

Theresa Cluse-Tolar, LISW-S, PhD

Pediatrics Service

Privileges as Licensed Independent Social Worker

Sponsoring Physician: Jeffrey Blumer, M.D.

Robert David Denyer, AA-C

Anesthesiology Service

Privileges as Anesthesiologist Assistant

Sponsoring Physician: Alan Marco, M.D.

Clinical Associate Staff Changes in Sponsoring Physician

Erica Krause, MSN, CNM

Obstetrics and Gynecology Service

From Nauman Khurshid, M.D. to Albert Payne, M.D.

Judith M. Malhotra, MSN, CNP

Internal Medicine Service

From Joseph Shapiro, M.D. to Shobha Ratnam, M.D.

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