MERCY MEDICAL CENTER Cedar Rapids, Iowa Cardiovascular ...p. · PDF file Cedar Rapids, Iowa...

Click here to load reader

  • date post

    03-Aug-2020
  • Category

    Documents

  • view

    4
  • download

    0

Embed Size (px)

Transcript of MERCY MEDICAL CENTER Cedar Rapids, Iowa Cardiovascular ...p. · PDF file Cedar Rapids, Iowa...

  • 1

    MERCY MEDICAL CENTER Cedar Rapids, Iowa

    Cardiovascular Medicine Department of the Medical S taff

    Thursday, February 7, 2013 0700 – Mercy Katz Conference Room

    I. Call to Order II. Approval of October 4, 2012 Minutes (pg. 2-5) III. Guest Speakers:

    i. Criteria for Cardiology Comfort Care – Dr. Cearl ock (pg. 6-11) III. Committee Reports

    a. MEC Excerpts (December 2012 & January 2013) – Dr . Hodgman (pg. 12-21) b. Administrative Report (January/February 2013) – Dr. Valliere (pg. 22)

    i. Influenza Memo (pg. 23) ii. Joint Commission Memo (pg. 24)

    V. Quality Reports a. ACC-NCDR – Michelle Wehr b. Heart Failure Data and Protocols in ED – Chad Wa re c. New Reportable VTE Measures – Sue Dawson (pg. 25-26)

    VI. Old Business

    a. Credentialing Criteria Review – Drs. Campbell & Langager (pg. 27-37) b. Vice Chair Needed (January 2013 – December 2014) – Dr. Hodgman c. Meeting Frequency – Dr. Hodgman (pg. 38)

    VII. New Business

    a. Policy Updates – Dr. Hodgman i. Admitting, Attending, Consulting (pg. 39-41) ii. Physician Notification, Escalation (pg. 42)

    b. Rhonda Bridgewater Introduction – Eric Voss / Dr . Hodgman c. Outpatient Telemonitor data and process – Sue Da wson / Margie Pence (pg. 43) d. Restraint Training – Rita Malloy / Catherine Kan e (pg. 44-45) e. Case Review Criteria – Dr. Hodgman (pg. 46-51) f. Diabetes Education (Deb Kucera) – Sue Dawson (pg. 52-53)

    VIII. Next Meeting Thursday, April 4, 2013, 0700 i n Mercy Katz Conference Room IX. Adjournment

  • Date: October 4, 2012

    Discussion/

    Leader

    Expected

    Result

    Content/ Agenda Item Meeting Notes/Decisions/Actions or Assignments

    Dr. Pospisil Action Call to Order Dr. Pospisil called this regularly scheduled meeting of the Cardiovascular Medicine Department of Mercy Medical Center, a peer review committee, to order at 7:10 am. Dr. Pospisil is here to appoint a temporary chair to run the meeting today due to there not being an officer available. Dr. Campbell volunteered.

    Dr. Campbell Action Approval of August 2, 2012 minutes. The minutes were reviewed and approved as distributed.

    Committee Reports

    Dr. Pospisil and Dr. Valliere

    Information Medical Executive Committee (August & September 2012)

    Included in packets. It was noted, effective on or about November 6th the Bylaws on overdue records will be enforced. Physicians with incomplete records (beyond the 30 days) will have their privileges suspended until the records are complete. It was noted the Credential Committee has stated the criteria for Cardiovascular Medicine needs to be met or changed as the Bylaws will be enforced. Dr. Valliere reviewed the Value Based Purchasing and discussed how the reimbursement is calculated. He noted that collectively the Heart Failure patients fell below the national average. A Heart Failure team was put together in February 2012 and due to their processes this measure has improved significantly.

    Mercy Medical Center Cedar Rapids, IA

    Meeting Minutes for: Cardiovascular Medicine Department Meeting Chair: Dr. McMahon / Recorder: Suzette Sabatino

    Quality Assessment & Improvement Reports Quality Assessment & Improvement Reports Quality Assessment & Improvement Reports Quality Assessment & Improvement Reports

    Present: Drs. Campbell, Langager, Payvandi, Riter. Also present: Drs. Pospisil, Valliere, Aucutt, Hilliard, Sue Dawson, Kyle Miller, Eric Voss, Lauren Cumings, Becky Quijano, Brian Boots, Lisa Ridge, LeAnn Tatman and Penny Glanz

    Call To OrderCall To OrderCall To OrderCall To Order

    Approval of MinutesApproval of MinutesApproval of MinutesApproval of Minutes

    Start Time: 0700

  • Date: October 4, 2012

    Mercy Medical Center Cedar Rapids, IA

    Meeting Minutes for: Cardiovascular Medicine Department Meeting Chair: Dr. McMahon / Recorder: Suzette Sabatino

    Present: Drs. Campbell, Langager, Payvandi, Riter. Also present: Drs. Pospisil, Valliere, Aucutt, Hilliard, Sue Dawson, Kyle Miller, Eric Voss,

    Start Time: 0700

    Dr. Campbell Information P & T News (July 2012) Included in packets. It was noted there is a shortage on Levofloxacin IV, patients that meet the criteria will be given Levofloxacin PO. It was also noted patients admitted with PRN erectile dysfunction medications will have these orders automatically discontinued while the patient is in the hospital.

    Dr. Valliere and Dr. Hilliard

    Information Administrative Report (September/October 2012) Included in packets. It was noted the Physician Survey has 46% participation. Action plans are being created and will be review at the next department meetings. The MS Website is being redesigned. Medical staff are encouraged to visit the website and provide feedback. Starting this year the hospital will be required to report not only the percentage of patients and employees vaccinated, it has expanded to volunteers, students, contractors and physicians. Physicians will be contacted for confirmation of vaccination. Dr. Valliere reviewed the upcoming CMS regulation on Deep Sedation. He noted physicians will not be able to use the specifically trained nurses to do EP cases and cardioversions, it must be a certified physician or anesthesiologist; if it is a physician it cannot be the one doing the procedure. It was noted that documentation needs to be very clear as to who covered sedation and who covered the procedure. A deep sedation course for certification will be available to physicians who are interested. Dr. Hilliard updated this group on the EPIC project. They have started Order set development. He will be contacting physicians to help with the development process. EPIC is evaluating our hardware needs and the number of workstations will be increased. Because of the difference in the EPIC versions between Mercy and St Luke's physicians will need to be re-trained on Mercy's system.

  • Date: October 4, 2012

    Mercy Medical Center Cedar Rapids, IA

    Meeting Minutes for: Cardiovascular Medicine Department Meeting Chair: Dr. McMahon / Recorder: Suzette Sabatino

    Present: Drs. Campbell, Langager, Payvandi, Riter. Also present: Drs. Pospisil, Valliere, Aucutt, Hilliard, Sue Dawson, Kyle Miller, Eric Voss,

    Start Time: 0700

    Sue Dawson Information ACC-NCDR Cath Lab Data Ms. Dawson reviewed the ACC-NCDR Cath Lab Data for January 2010 through March 2012 and noted the national average Appropriate PCI use increased from 3% to 10%. She is checking into this.

    Sue Dawson Information Heart Failure Data Ms. Dawson reviewed the Heart Failure data for January 2007 through August 2012. She reviewed some of the process issues and how they have been corrected.

    Sue Dawson Information 30-Day Mortality Ms. Dawson reviewed the 30-Day Mortality. It was noted that a team met with the Palliative Care to come up with Comfort Care/Measures criteria.

    Sue Dawson Information 30-Day Readmissions Ms. Dawson reviewed the 30-Day Readmissions data from January 2010 through December 2010. Discussed the readmission flows.

    Dr. McMahon Discussion/Action Meeting Frequency Deferred Dr. Valliere Discussion/Action Pre-Operative Process Updates Included in packet. Dr. Valliere reviewed the updated Pre-

    Op Assessment Process. There are some issues that need to be worked out. Dr. Valliere asks for the physicians' feedback on the process.

    Dr. Campbell Discussion/Action 2013 Vice Chair Elections Due Dr. Noreuil's departure the Vice Chair is open. Dr. Riter nominated Dr. Hodgman. Three in favor (Payvandi, Riter, and Campbell) none opposed. Dr. Hodgman is the Vice Chair for 2013.

    Dr. Valliere Discussion/Action New OPPE Format Included in packet. Dr. Valliere presented the new OPPE format and asks the physicians to review it.

    Dr. Valliere Discussion/Action INR Critical Values There was a discussion on when the INR level should be considered critical, currently it is 5.0, the physicians present were comfortable with this number.

    New BusinessNew BusinessNew BusinessNew Business

    Old BusinessOld BusinessOld BusinessOld Business

  • Date: October 4, 2012

    Mercy Medical Center Cedar Rapids, IA

    Meeting Minutes for: Cardiovascular Medicine Department Meeting Chair: Dr. McMahon / Recorder: Suzette Sabatino

    Present: Drs. Campbell, Langager, Payvandi, Riter. Also present: Drs. Pospisil, Valliere, Aucutt, Hilliard, Sue Dawson, Kyle Miller, Eric Voss,

    Start Time: 0700

    Dr. McMahon Discussion/Action Credentialing Committee Update It was noted there have been too many waivers and extensions on CME requirements and procedure volumes for the Cardiologists. A committee will be formed to review the requirements. Dr. Valliere will send out the items not being met to the physicians to review and adjust.

    Lauren Cumings Discussion/Action Pharmacy Recommendations for Bridging of Anticoagulation (2012 CHEST Guidelines)

    Included in packet. Ms. Cumings presented the pharmacy's recommendations for Bridging of Anticoagulation per the 2012 CHEST Guidelines.

    Dr. Campbell Discussion/Action ACLS Guidelines for Oxygen Administration (This item was added to today's agenda.)

    Included in the packet. Reviewed the ACLS guidelines for Oxygen administration. It was noted these guidelines will be used throughout the hospital and EMS.

    Lisa Ridge Discussion/Action Natalie Woederhoff, BSN