Report - University of Toledo



Minutes

The University of Toledo Board of Trustees

Clinical Affairs Committee Meeting

October 15, 2013

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

|Mansour; Ms. Susan Palmer was absent. University Council Representative Ms. Marlene Porter was present. Trustees Ms. | |

|Sharon Speyer and Mr. Joseph H. Zerbey, IV also attended the meeting. Additional attendees included Mr. Dan Barbee, Dr.| |

|Mark Burket, Ms. Lauri Cooper, Mr. David Cutri, Dr. Jeffrey Gold, Dr. Lloyd Jacobs, Mr. Chuck Lehnert, Mr. Peter | |

|Papadimos, Ms. Jennifer Pastorek, Dr. Linda Rouillard, Dr. Scott Scarborough, Dr. Carl Sirio, Ms. Joan Stasa, and Ms. | |

|Norma Tomlinson. | |

|The meeting was called to order at 7:35 a.m. by Trustee Thieman in the Faculty Club Room at the Hotel at UTMC on the |CALL TO ORDER |

|Health Science Campus. | |

|Mr. Thieman requested a motion to waive the reading of the minutes from the September 17, 2013 Committee meeting and |APPROVAL OF MINUTES |

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

|approved by the Committee. | |

|Dr. Jeffrey Gold, Chancellor and Executive VP Biosciences and Health Affairs/ Dean of the College of Medicine and Life |FUTURE OF MEDICINE |

|Sciences, introduced Dr. Mark Burket. Dr. Burket, Chief of the UTMC Cardiovascular Division and Medical Director | |

|Cardiovascular Laboratories, was invited to the meeting as a member of the HSC College of Medicine Clinical Faculty to | |

|discuss acute myocardial infarction and quality of care at UTMC. He explained the anatomy of a heart attack and | |

|reported that there are approximately one million heart attacks in the U.S. annually. Heart attacks are a leading cause| |

|of mortality with chest pain the most common symptom. History of heart attack treatment since 1950 was provided as | |

|information and a complete artery blockage was displayed with an X-ray example. Another X-ray was displayed showing a | |

|guide wire that is advanced through the blockage with a third X-ray showing how the balloon is expanded in the blockage | |

|– this is referred to as “balloon time” and after inflation is when flow is reestablished in the artery. Dr. Burket | |

|explained that permanent heart damage starts within minutes and the faster the treatment the less permanent damage and | |

|lower chance of death. The door-to-balloon time guideline as measured by the American College of Cardiology and by the | |

|American Heart Association is considered less than or equal to 90 minutes. Dr. Burket reported that this is a core | |

|quality measure by the Joint Commission on Accreditation of Healthcare Organizations and that UTMC door-to-balloon times| |

|are better in comparison to ACC/AHA recommendations, UHC hospitals, national hospitals and local hospitals. The UTMC | |

|process that is used when a “STEMI Alert” is called was discussed. Committee Chair Thieman thanked Dr. Burket for his | |

|informative presentation and thanked him and his team for the great work they are doing. | |

|Dr. Gold was invited to present the Committee with information about year-to-date quarterly performance for the UT |UTMC QUARTERLY UPDATE |

|Medical Center and UT Physicians Clinical Faculty. | |

| | |

|For UTMC, he compared FY 2013 to FY 2014 to date against the FY 2014 budget in the following areas: | |

|Admissions | |

|Inpatient Surgeries | |

|Ambulatory Surgery Center / Operating Room Gross IP Revenue | |

| | |

|Information about days cash on hand for UTPCF for FY 2012, FY 2013, and FY 2014 was outlined and discussed. Dr. Gold | |

|also provided a comparison of July-September FY 2013 to July-September FY 2014 charges and collections. | |

|An update was provided about three projects on the Health Science Campus by Dr. Gold. |EXTERNAL PROGRAM RELATIONSHIPS |

| |UPDATE AND |

|Development of UT – Horizon Health relationship next steps to be |RESOLUTION |

|completed were outlined as follows: |NO. 13-10-18 |

|Facility architecture completion | |

|Facility construction completion | |

|Horizon agreement completion | |

|Faculty and staff recruitment | |

|Marketing and co-branding program | |

| | |

|Update on the addition of the second Varian Medical Systems linear | |

|accelerator at the Dana Cancer Center and development of next steps of the relationship will include: | |

|Cancer Center vault shielding | |

|Finalization of purchase agreement | |

|Equipment installation and testing | |

|Staff training and equipment calibration | |

|Marketing and co-branding agreement | |

| | |

|(3) Development of UT – Ernest Health relationship next steps will included: | |

|Academic program relationships | |

|Professional service relationships | |

|Auxiliary and laboratory relationships | |

|Clinical service purchase agreements | |

|Couglin Foundation relationships | |

|Ground lease agreement approval | |

| | |

|After discussion of the UT – Ernest Health relationship next steps, Dr. Gold presented Resolution No. 13-10-18: | |

|“Inpatient Rehabilitation Hospital at The University of Toledo.” For the State of Ohio to transfer real property, Board| |

|action is required to begin the process. After further discussion of the Resolution between Dr. Gold and the Committee | |

|members, Trustee Thieman requested a motion to forward the Resolution to the Consent Agenda at the November 18 Board | |

|meeting. A motion was received by Trustee Mansour, seconded by Trustee Hussain, and approved by the Committee for | |

|forwarding. | |

|Dr. Gold discussed the 2013 updates to the UT Medical Center and Clinics Compliance Plan for Healthcare Operations. The|UT COMPLIANCE POLICY UPDATE |

|Plan was last revised in 2006 upon the merger of UT with MUO. The 2013 revisions are consistent with best practices and| |

|are being made now to be consistent with recent changes in state and federal law. Material changes include health care | |

|operations only, adoption of the compliance manual and employee training and attestation. Dr. Gold reviewed and | |

|discussed the important revisions with the Committee members, specifically mentioning that faculty and staff must be | |

|fully informed of laws and regulations. Mr. Thieman requested a motion to forward the Plan to the Consent Agenda at the| |

|November 18 Board meeting. A motion was received from Trustee Hussain, seconded by Trustee Mansour, and approved by the| |

|Committee for forwarding. | |

|Information was provided to the Committee about real time safety and quality reporting, as well as response tracking. |PATIENT |

|Dr. Gold reported that this is a collaborative project with the United Health Center Consortium and Patient Safety Net®.|SAFETY NET |

|As a “Club of 100” organization, a goal for UTMC is to have patient, visitor and staff safety and quality goals. Dr. | |

|Gold reviewed these established goals with the Committee. The UHC Patient Safety Net® is a real-time, web-based event | |

|reporting system. Membership includes 100 participating organizations, 47 patient safety organization participants, 12 | |

|multi-hospital members and 8 international members. This system allows any member to place an event or near-event into | |

|a database which uses standard nomenclature to collect information for inpatient and outpatient events, provides a | |

|proven data collection tool that allows for anonymous reporting, and alerts manager and quality/safety leadership. This| |

|comprehensive approach captures events involving patients and visitors, environmental hazards, equipment safety, | |

|inappropriate staff behavior, security issues and more. Intuitive dashboards are used and early focus is given to | |

|potential trouble spots. Patient Safety Net® will be easy to access with placement of an icon on all UTMC desktops. | |

|Triage of Patient Safety Net® entries and “closing the loop” include: | |

|Line managers see reports in real time 24 hours/day, 7 days/week | |

|Senior leadership receive daily batch reports of all incidents | |

|Events requiring immediate attention are dealt with in real time | |

|Events requiring further scrutiny/systematic “re-engineering” are tracked and | |

|followed by administrative leadership over time with shorter term amelioration steps as needed | |

|Dr. Gold reviewed improvements since implementation of the program in October 2012. Next steps will include daily | |

|notifications, a weekly safety huddle, reports and rewards/recognition. | |

|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. The motion was received by Trustee Hussain, seconded| |

|by Trustee Mansour, and a roll call of the Committee was taken by Ms. Stasa: Dr. Hussain, yes; Ms. Mansour, yes; and | |

|Mr. Thieman, yes. After discussion, the Committee exited Executive Session. | |

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

|Staff Report included new medical staff applicants, a medical staff request for additional privileges, medical staff |REPORT |

|reappointments from provisional to full staff status, new Allied Health professional applicants, addition to delineation| |

|of privileges form for clinical nurse specialist and certified nurse practitioner, addition to delineation of privileges| |

|form for wound care and the hyperbaric center, as well as resignations. A motion was received from Trustee Hussain, | |

|seconded by Trustee Mansour, and approved by the Committee. | |

|With no further business before the Committee, Trustee Thieman adjourned the meeting at 9:00 a.m. |ADJOURNMENT |

CHIEF OF STAFF REPORT

October 15, 2013

New Medical Staff Applicants

Matthew S. Currie, M.D.

Surgery Service

Courtesy Staff Status

Privileges in Ophthalmology

Effective 10/15/13

Tashelle R. Samuels, M.D.

Anesthesiology Service

Active Staff Status

Privileges in Anesthesiology

Effective 10/15/13

Medical Staff Request for Additional Privileges

Kenneth L. Muldrew, M.D.

Pathology Service

Privileges in Pathology

■ Class I – General Privileges

■ Privileges in Anatomic Pathology Limited to the Autopsy Service

Medical Staff Reappointments from Provisional to Full Staff Status

Anu Garg, M.D.

Internal Medicine Service

Active Staff Status

Privileges in Internal Medicine

Joseph L. Lach, M.D.

Surgery Service

Active Staff Status

Privileges in General Surgery, Wound Care & Hyperbaric Center, & Moderate Sedation

George V. Moukarbel, M.D.

Internal Medicine Service

Active Staff Status

Privileges in Internal Medicine, Moderate Sedation, Cath Lab I, Cath Lab II, Cath Lab III, & Cath Lab IV

New Allied Health Professional Applicants

Elizabeth Brashear, LISW-S

Internal Medicine Service

Privileges as a Licensed Independent Social Worker

Sponsoring Physician: Marsha Paul, M.D.

Effective 10/15/13

Allison Ovitt, MSN, CNP

Surgery Service

Privileges as a Certified Nurse Practitioner

Sponsoring Physician: Azedine Medhkour, M.D.

Effective 10/22/13

Lauren St. John, DNP, FNP-C

Family Medicine Service

Privileges as Certified Nurse Practitioner

Sponsoring Physician: Sanford Kimmel, M.D.

Effective 10/15/13

Additions to Delineation of Privileges Forms

Clinical Nurse Specialist & Certified Nurse Practitioner Form

New Section Titled, “Palliative Medicine”

■ Management of Palliative Sedation

■ Management of Ventilator Withdrawal

New Section Titled, “Vascular Surgery – Wound Care/HBOT”

■ Order & Manage HBOT & Related Diagnostic Tests

■ Supervise HBOT Treatments Under Supervision of Collaborating Physician

Wound Care & Hyperbaric Center Form

Add Class III – Nurse Practitioners & Physician Assistants

Resignations

Hammad Amer, M.D.

Surgery Service

Change Effective Date from 10/04/13 to 10/10/13

Alan P. Marco, M.D., M.M.M.

Anesthesiology Service

Effective 09/19/13

Mallory Williams, M.D.

Surgery Service

Effective 11/3/13

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