Report - University of Toledo



Minutes

The University of Toledo Board of Trustees

Clinical Affairs Committee Meeting

April 15, 2014

|Committee Chair Mr. Gary P. Thieman was present. Other Trustees who attended included Ms. Linda N. Mansour, Ms. Susan|ATTENDANCE |

|F. Palmer, Ms. Sharon Speyer and Mr. Joseph H. Zerbey, IV who were all appointed by Mr. Zerbey as voting members of | |

|the Committee for this meeting. University Council Representative Ms. Marlene Porter was present. Additional attendees| |

|included Mr. Dan Barbee, Dr. Kristopher Brickman, Ms. Lauri Cooper, Ms. Karen Hoblet, Dr. Lloyd Jacobs, Mr. Chuck | |

|Lehnert, Dr. Ronald McGinnis, Ms. Stephanie Metzger, Mr. David Morlock, Dr. Carl Sirio, Ms. Joan Stasa, and Ms. Susan | |

|Wells. | |

|The meeting was called to order at 7:30 a.m. by Trustee Thieman in the Faculty Club Room at the Radisson Hotel on the |CALL TO ORDER |

|Health Science Campus. | |

|Mr. Thieman requested a motion to waive the reading of the minutes from the March 11, 2014 Committee meeting and |APPROVAL OF MINUTES |

|approve them as written. A motion for approval was received from Trustee Palmer, seconded by Trustee Speyer, and | |

|approved by the Committee. | |

|Trustee Thieman spoke of the conference he was invited to attend with Dr. Carl Sirio, VP Medical Affairs/Chief Medical|THE ROLE OF |

|IT Officer, and Mr. David Morlock, Executive VP for Finance and Administration/CEO of UTMC, held in Boston by the |THE BOARD IN PATIENT SAFETY AND |

|Institute for Healthcare Improvement April 3-4. The conference focused on the role of the Board in quality and safety.|QUALITY |

|Mr. Thieman reported that great discussions ensued about best practices regarding patient safety and quality. | |

|Approximately 50 people attended the conference composed of a combination of hospital chief executive officers, vice | |

|presidents of Nursing, board chairs and board members. Mr. Thieman mentioned a couple of the speakers at the | |

|conference and provided a few highlights. He learned that the best Boards spend at least 25% of their time on patient| |

|quality and safety matters. This reinforces the importance of what the Clinical Affairs Committee does each month at | |

|their meetings. Mr. Thieman stated that he would like to begin adopting best board practices to improve quality. In | |

|that regard Mr. Thieman asked President Jacobs, Mr. Morlock, and Dr. Sirio to continue their work in assessing | |

|opportunities for improvement in patient quality and safety and to bring forward a recommended action plan containing | |

|specific goals and targets for improvement. He further asked that a performance dashboard be constructed to report on | |

|a regular basis the most important indicators consistent with the institution’s specific goals for quality | |

|improvement. Mr. Thieman also suggested that each meeting include a board member education component. He also | |

|mentioned that the Committee has a responsibility to evaluate their performance to be able to reach the category of a | |

|high-performance Committee. | |

|Mr. Morlock reported that one of the overarching topics that the seminar stressed was that there are different ways to| |

|look at data. He indicated how important it is to drive hard on the safety aspects around patient care to prevent | |

|errors. Mr. Morlock stated work is continuing to bring forward a recommended set of quality goals and targets for | |

|improvement. The goals will not just be to meet national standards -- the aim should be zero errors. Dr. Sirio | |

|remarked that the bar should be set high for patient quality and safety goals by targeting perfection. Trustee Palmer | |

|stated that the Committee is pleased that the dashboard report will be reinstituted and that they would like to see | |

|the dashboard report prior to each meeting. She remarked that the Committee should be in agreement that zero is the | |

|goal for excellent quality. The Board should be aware of improvements with regard to those benchmarks on a regular | |

|basis and that they need to hear reality -- the good and the bad. | |

|Mr. Morlock provided the Committee with updated information about the Patient Safety System as was requested by |PATIENT REGISTRATION SYSTEM UPDATE |

|Trustee Hussain previously. He reported that the on-line registration portal is open and active, but changing because | |

|of different technology for meaningful use. Centralized scheduling and registration has been relocated to the | |

|basement of the Glendale Building. Mr. Morlock stated that there are eight clinics operational and that four will be | |

|added by year end. This will leave an additional 12 clinics to add in 2015. Work is being done with Cisco on phone | |

|upgrades with a plan pending by May 31. On-line scheduling is up and running for all 24 clinics. The payment portal | |

|is live on the internet, but not yet on the kiosks. The hardware is available for the kiosks, but they are not yet | |

|functional due to a software issue. | |

|As was also requested by Trustee Hussain, Mr. Morlock discussed how patients are addressed in clinical care |HOW PATIENTS ARE ADDRESSED |

|facilities. It was discussed that patients at UTMC be addressed by Mr., Miss, Ms., Mrs. or Dr. with their last name | |

|as opposed to using first names only. After further discussion, it was decided that the employee would ask the | |

|patient how they would like to be addressed as the preferred method. | |

|Mr. Morlock reported that the current information about the Family Medicine Clinic Project was discussed with the |FAMILY MEDICINE CLINIC PROJECT |

|Trustees at the Board meeting prior day. | |

|Since all Trustees present at today’s meeting were in attendance at the Board meeting, they were up to date with the | |

|current status of the project, so the same presentation was not provided again. | |

|Trustee Thieman requested a motion to enter Executive Session to discuss quality reporting and privileged information |EXECUTIVE SESSION |

|related to the evaluation of medical staff personnel appointments, medical staff disciplinary process and quality | |

|reporting. The motion was received by Trustee Mansour, seconded by Trustee Palmer, and a roll call of the Committee | |

|was taken by Ms. Stasa: Ms. Mansour, yes; Ms. Palmer, yes; Ms. Speyer, yes; Mr. Thieman, yes; and, Mr. Zerbey, yes. | |

|After discussion, the Committee exited Executive Session. | |

|Mr. Thieman requested a motion to approve and accept the Chief of Staff Report as presented in Executive Session. The|QUALITY REPORTING; CHIEF OF STAFF |

|Chief of Staff Report included one new medical staff applicant, three new Allied Health professional applicants, and |REPORT |

|six medical staff resignations. A motion was received from Trustee Speyer seconded by Trustee Mansour, and approved by| |

|the Committee. | |

|With no further business before the Committee, Trustee Thieman adjourned the meeting at 8:55 a.m. |ADJOURNMENT |

CHIEF OF STAFF REPORT

April 15, 2014

New Medical Staff Applicants

Kimberly Burkhart, Ph.D.

Pediatrics Service

Active Staff Status

Privileges in Psychology

New Allied Health Professional Applicants

Megan Flagg, MSN, CNP

Internal Medicine Service

Privileges as a Certified Nurse Practitioner

Sponsoring Physician: Marsha Paul, M.D.

Brandy Secory, NP

Emergency Medicine Service

Privileges as a Certified Nurse Practitioner

Sponsoring Physician: Kris Brickman, M.D.

Tracy Szirony, Ph.D., CNP

Internal Medicine Service

Privileges as a Certified Nurse Practitioner

Sponsoring Physician: Marsha Paul, M.D.

Medical Staff Resignations

Nasreen Bhumbra, M.D.

Pediatrics Service

Effective 06/30/14

George P. Engeler, M.D.

Radiation Oncology Service

Effective 04/05/14

David Ervin, M.D.

Orthopaedic Surgery Service

Effective 03/14/14

Ajay Jetley, M.D.

Emergency Medicine Service

Effective 03/06/14

Kenneth Muldrew, M.D.

Pathology Service

Effective 07/06/14

Khalid R. Siddiqui, M.D.

Radiation Oncology Service

Effective 04/05/14

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