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					                                                                     NORTON HEALTHCARE
                                                      LOUISVILLE HOSPITALS SYSTEM MEDICAL STAFF
                                                                   Louisville, Kentucky

Committee: System Medical Executive Committee                           Date/Time/Location: Tuesday, March 25, 2008, Norton Audubon Hospital Community Room
                                                                          JAN    FEB     MAR      APR     MAY      JUN      JUL AUG SEP         OCT     NOV   DEC
Henry J. Walter, MD, President, System Medical Staff                       P       P      P
George Boatwright, MD, Audubon and Bylaws Committee                        P       P      P
William Bradford, MD, Ex-Officio, System Credentials Policy Committee      P       P      P
Stephen Cawood, MD, Suburban                                               E       P      P
Doug Ettin, MD, Alternate delegate, Audubon                                E       E      E
Mary Fallat, MD, Kosair                                                    P       P      P
Philip Fitzgerald, MD, Ex-Officio, Audubon                                 P       A      P
Bill Haney, MD, Suburban                                                   P       P      E
Steven Heilman, MD, Alternate delegate, Audubon                            E       P      E
Mary Ann Catherine Henry, MD, Norton and DAHP Committee                    E       P      P
Paul Kelty, MD, Norton                                                     P       P      P
Robert Powell, MD, Ex-Officio, Norton                                      P       P      P
Gerard Rabalais, MD, Kosair                                                E       E      E
George Raque, MD, Norton                                                   P       P      P
Jonathan Reinstine, MD, Suburban                                           P       P      A
William R. Schmidt, II, MD, Audubon                                        P       P      P
Gerard Siciliano, MD, Ex-Officio, Suburban                                 P       P      P
Jeb Teichman, MD, Kosair                                                   P       P      A
Stephen Wright, MD, Ex-Officio, Kosair                                     P       P      P
Robert Azar, Vice President and General Counsel                            P       E      P
Russell Cox, Executive Vice President and Chief Operating Officer          E       E      E
Robert R. Goodin, MD, Board Representative                                 E       E      E
Steven T. Hester, MD, VP, Medical Affairs                                  E       P      P
Thomas Powell, AVP, Assistant General Counsel                              E       P      E
Deve Vetter, AVP, Accreditation/Medical Staff                              P       P      P
Stephen Williams, President and Chief Executive Officer                    E       E      E
Tracy Williams, Vice President and System CNO                              P       E      E
Kenneth Wilson, MD, AVP, NHC Medical Affairs                               P       P      P
Lisa Poole, Manager, System Medical Staff Office                           P       P      P

Guests: Gregg Davis, VP, Ortho/Neuro/Spine Service Line, Carey O’Meara, Director, Physician Development.




SMEC Minutes – March 25, 2008
Page 1 of 8
AGENDA TOPIC             DISCUSSION                                                                      RECOMMENDATION / ACTION                 FOLLOW-UP

CALL TO ORDER            Dr. Henry Walter, President of the Norton Healthcare System Medical Staff,
                         called the meeting to order at 6:12 PM.

Opening Remarks                 Dr. Walter expressed appreciation to those in attendance.               Information only
                                Dr. Walter reminded members to complete their CME evaluation
                                 forms and to sign in to obtain CME credit.
                                Dr. Walter reminded members to update their contact information
                                 sheet if they have not already done so.
                                Dr. Walter reported that the SMEC will be going into more detail for
                                 Type II information on the Credentials Reports so the Board has a
                                 better understanding of the information being presented.
                                Dr. Walter reminded members of the confidentiality of discussions
                                 held at the SMEC meetings.
                                Dr. Walter reminded members that the May SMEC meeting will be
                                 held on Wednesday, 05/28 in conjunction with the Board of
                                 Trustees.
                                Dr. Walter reported that Doctors’ Day is being celebrated this week
                                 at the Norton Healthcare facilities.

Standing Service Line    Mr. Gregg Davis, VP, Ortho/Neuro/Spine Service Line, gave a brief update        No action required; information only.
Leadership Report        on Ortho/Neuro/Spine services within the Norton Healthcare facilities.

                         Mr. Davis provided the committee with a summary of the 2007
                         accomplishments for the Ortho/Neuro/Spine service line including physician
                         workforce development. Mr. Davis reported that education is underway
                         within the adult facilities to become certified stroke centers. Plans are for
                         Norton and Norton Audubon Hospitals to become certified stroke centers in
                         2008 and Norton Suburban Hospital in 2009.

                         Mr. Davis reported that there were 200 orthopedic visits per month in 2007.
                         For 2008, we are anticipating 550 orthopedic visits per month.

                         Mr. Davis also reported that a Seizure Monitoring Unit will be opening at
                         Norton Audubon Hospital this year.

Presentation             Dr. Steve Hester gave a brief presentation on the Physician Satisfaction        No action required; information only.
Physician Satisfaction   Survey Results from the Press Ganey survey recently conducted.
Survey Results           Approximately 600 physicians responded to the survey. Action plans will be
                         developed for the areas needing improvement.


SMEC Minutes – March 25, 2008
Page 2 of 8
AGENDA TOPIC               DISCUSSION                                                                        RECOMMENDATION / ACTION   FOLLOW-UP

Presentation (Continued)   Dr. Hester reported that he will be attending each DMEC meeting to present                                  Dr. Hester to attend
Physician Satisfaction     facility-specific results.                                                                                  DMEC meetings to
Survey Results                                                                                                                         present facility-specific
                           Dr. Hester gave a brief description of mean scores and percentiles. Common                                  results
                           areas of strength across the system for admitting physicians who completed
                           the survey included specialist availability. Overall assessment of patient care
                           received the highest score.

                           Opportunities for improvement include relations with leadership and
                           radiology professional services. Discussion ensued regarding radiology
                           services. It was reported that downtown radiology services rated high.
                           However, radiology services at the community hospitals did not rate as high
                           nor did radiology services at KCH.

                           It was felt that the issues identified may be attributed to the fact that the
                           radiology group at the community hospitals (Audubon and Suburban) started
                           at the same time as PACS was introduced. The issues with the radiology
                           group at KCH could be due to lack of communication between physicians and
                           radiologists since the radiologists reading films are off-site.
                           The Medical Directors will work with physician groups to assist in
                           developing action plans.

                           An informal survey regarding areas with opportunities for improvement may
                           be conducted in approximately one year to determine if improvements have
                           been made.

REVIEW AND                 The minutes of the February 26, 2008 SMEC meeting were reviewed.                  S/C                       Forward to the Board of
APPROVAL OF                                                                                                  Minutes approved.         Trustees Committee on
MINUTES                                                                                                                                Quality and Clinical
                                                                                                                                       Services for approval




SMEC Minutes – March 25, 2008
Page 3 of 8
AGENDA TOPIC                DISCUSSION                                                                      RECOMMENDATION / ACTION                    FOLLOW-UP

OLD BUSINESS

Policies/Standing Orders
Referral Laboratories       Ms. Vetter presented the Referral Laboratories Policy for final review. There   M/S/C                                      Forward to the divisions
Policy                      were no comments received from the divisions.                                   Referral    Laboratories          Policy   for implementation
                                                                                                            recommended for approval.

Laboratory Turn-Around      Ms. Vetter presented the Laboratory Turn-Around Policy for final review.        M/S/C                                      Forward to the divisions
Times Policy                                                                                                Laboratory Turn-Around Times Policy        for implementation
                                                                                                            recommended for approval.

STAT (Emergency_            Ms. Vetter presented the STAT (Emergency) Laboratory Testing Policy for         M/S/C                                      Forward to the divisions
Laboratory Testing Policy   final review. No comments were received from the divisions.                     STAT (Emergency) Laboratory Testing        for implementation
                                                                                                            Policy recommended for approval.

Skin Care Policy/Standing   Ms. Vetter presented the Skin Care Policy/Standing Orders for final review.     M/S/C                                      Forward to the divisions
Orders                      A copy of the Flexi-Seal Fecal Management System Standing Order, as it          Skin Care Policy/Standing        Orders    for implementation
                            appears in CareLink format, was distributed to members present.                 recommended for approval.

Stroke Admission            Ms. Vetter presented the Stroke Admission Standing Orders for final review.     M/S/C                                      Forward to the divisions
Standing Orders             There were no comments received from the divisions.                             Stroke Admission Standing        Orders    for implementation
                                                                                                            recommended for approval

Oncology Admission          Ms. Vetter reported that the Oncology Admission Order Set is currently          No action required; information only.      Bring back to SMEC at
Order Set                   undergoing further review by Pharmacy and will be brought back to the                                                      later date
                            SMEC at a later date.

Other
SMEC Alternate              Ms. Deve Vetter presented the proposed revision to the Medical Staff Bylaws     M/S/C                                      Forward to the Board of
Delegates                   regarding SMEC Alternate Delegates.                                             SMEC       Alternate          Delegates    Trustees for approval
                                                                                                            recommended for approval.
                            Discussion ensued as to who is eligible to serve as a SMEC alternate
                            delegate.




SMEC Minutes – March 25, 2008
Page 4 of 8
AGENDA TOPIC             DISCUSSION                                                                      RECOMMENDATION / ACTION                FOLLOW-UP

SYSTEM
CREDENTIALS
POLICY COMMITTEE

Minutes                  The minutes of the March 12, 2008 SCPC meeting were presented for review.       M/S/C
                         Dr. Bradford reported that the minutes have been approved by the SCPC.          Minutes approved as presented.

                         Dr. Bradford reported that criteria is in the process of being developed for                                           Criteria to be presented
                         Balloon Kyphoplasty. Discussion ensued regarding the criteria for Balloon                                              to SCPC and SMEC
                         Kyphoplasty. It was felt that the criteria for non-surgeons performing this                                            once developed.
                         procedure should include a number of proctored cases.

                         Dr. Bradford also reported that laser privileges were also discussed at the                                            Further information
                         March SCPC meeting. Laser activity at the Norton Healthcare facilities will                                            regarding laser privileges
                         be reviewed as well as the current criteria for laser privileges. More                                                 will be forthcoming.
                         information regarding laser procedures will be forthcoming.

                         Dr. Bradford reported that the ED Call Task Force will hold its first meeting                                          ED Call Task Force to
                         tomorrow evening (03/26/08). A representative from each facility is on the                                             report back to SMEC at
                         task force.                                                                                                            April meeting.

                         Discussion ensued regarding core privileges. KCH requested assistance in                                               D. Vetter to work with
                         developing criteria for General Surgery core privileges.                                                               Dr. Fallat on general
                                                                                                                                                surgery core privilege
                                                                                                                                                form at KCH.

Medicated Treatment      Ms. Vetter presented the revised Medicated Treatment Protocol. It was noted     M/S/C                                  Forward to the divisions
Protocol                 that revisions were made to the step-up and step-down schedules.                Revised Medicated Treatment Protocol   for input
                                                                                                         recommended for approval.

Proposed Criteria for    The proposed criteria for Cardiac CT Angiography was presented. It was          M/S/C                                  Forward to the divisions
Cardiac CT Angiography   reported that a 64-slice CT is expected to be purchased by the end of 2008      Proposed criteria for Cardiac    CT    for input
                         and will be located at Norton Audubon Hospital.                                 Angiography      recommended     for
                                                                                                         approval.

NEW BUSINESS             There was no new business to discuss at this time.                              No action required.




SMEC Minutes – March 25, 2008
Page 5 of 8
AGENDA TOPIC              DISCUSSION                                                                        RECOMMENDATION / ACTION                   FOLLOW-UP

DIVISION REPORTS
TO THE SMEC

Appointments,             The March Credentials Report was presented and is attached to the original        M/S/C                                     Forward revised
Reappointments and        minutes. The recommendations for appointments, reappointments,                    All requests for appointments,            Credentials Report to the
Privileging               privileging and other membership issues were submitted for review and             reappointments, clinical privileges and   Board of Trustees
                          action, (*) attached.                                                             all other membership requests on the      Committee on Quality
                                                                                                            Credentials Report recommended for        and Clinical Services for
                          Type II information was discussed in detail. Dr. Walter reiterated the            approval with revision noted.             approval
                          confidentiality of the discussions held at the SMEC meetings.

                          It was noted that Physician #39649 has complied with the TB policy and has
                          been removed from the report as a voluntary resignation.

                          It has been noted that all licensure is current, peer evaluations/hospital
                          affiliations and data bank reports were obtained and reviewed by the
                          appropriate clinical service chiefs/chairs, Credentials Chairpersons, and
                          Medical Executive Committee representatives and that the resources
                          necessary to support the privileges requested are or will be available. Quality
                          reviews have been conducted on all members being reappointed.

Dependent Allied Health   The Dependent Allied Health Committee minutes of 03/14/08 were                    M/S/C                                     Forward DAHP minutes
Committee                 presented. The March DAHP credentials list was reviewed.                          Minutes approved.                         and DAHP Credentials
                                                                                                            Requests for appointments,                List to the Board of
                                                                                                            reappointments, privileges and all        Trustees Committee on
                                                                                                            other membership requests pertaining      Quality and Clinical
                                                                                                            to the Dependent Allied Health Staff      Services for approval
                                                                                                            recommended for approval.

Division MEC Minutes      Division MEC minutes for February 2008 were included in the meeting               No action required; information only.
                          packet for review.

                          Dr. Philip Fitzgerald inquired as to whether the Central Line bundle
                          issues/concerns noted by the Audubon DMEC have been resolved.

                          It was reported that the order sets are being reviewed with those physicians
                          who have expressed concern. It was also reported that the anesthesia record
                          at Norton Audubon Hospital is being revised to reflect the sites in anesthesia.




SMEC Minutes – March 25, 2008
Page 6 of 8
AGENDA TOPIC               DISCUSSION                                                                           RECOMMENDATION / ACTION                 FOLLOW-UP

STANDING
SUBCOMMITTEE
REPORTS

Information Technology     There was no IT Advisory Committee report this month.                                No action necessary.
Advisory Committee

Information Technology     There was no IT Advisory Committee report this month.                                No action necessary.
Advisory Committee

Network Cancer Institute   There was no Network Cancer Institute Committee report this month.                   No action necessary.
Committee

System Pharmacy &          The 01/25/08 System Pharmacy & Therapeutics Assessment Committee                     No action required; information only
Therapeutics Assessment    minutes were distributed for review/information.
Committee
                           Discussion ensued regarding Phenergan IV and Zophran. It was reported that
                           a letter is being sent to the medical staff regarding the change in the order set.

Technology Assessment      There was no Technology Assessment Committee report this month.                      No action necessary.
Committee

STANDING REPORTS


Chief Nursing Officer      There was no CNO Report this month.                                                  No action required.
Report

VP, Medical Affairs        Dr. Steve Hester reported that Norton Brownsboro Hospital is slated to open          No action required; information only.   S. Williams & R. Cox to
Report                     in August 2009.                                                                                                              give a brief presentation
                                                                                                                                                        at the April meeting on
                           Dr. Hester reported that Mr. Steve Williams and Mr. Russell Cox would like                                                   the progress of the
                           to give a brief presentation at the April SMEC meeting regarding the progress                                                strategic plan
                           of the strategic plan.

AVP, Clinical Affairs      There was no AVP, Clinical Affairs Report this month.                                No action required.
Report

Other Committee Minutes    There were no other committee minutes for review at this time.                       No action required.

SMEC Minutes – March 25, 2008
Page 7 of 8
AGENDA TOPIC             DISCUSSION                                                                  RECOMMENDATION / ACTION                 FOLLOW-UP

OTHER BUSINESS           Dr. Walter reported that the next SMEC meeting is scheduled for Tuesday,    No action required; information only.
                         04/22/08.

                         Dr. Walter reminded members present that the May SMEC meeting date has
                         changed to 05/28/08 to be held in conjunction with the Board of Trustees.

ADJOURNMENT              There being no further business, the meeting adjourned at 7:30 PM.          M/S/C
                                                                                                     Meeting adjourned.
                         Henry J. Walter, MD
                                                                                                     Lisa K. Poole, CPMSM
                                                                                                     Manager, System Medical Staff Office




SMEC Minutes – March 25, 2008
Page 8 of 8

				
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