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November 2013
Medical Staff Executive Committee

Medical Staff Executive Committee

Oct. 7, 2013 Meeting

William Jennings, President & CEO: August operating margin was slightly above budget. The ED is fully staffed and patient care treatments are ahead of budget. Surgery volume is up. Outpatient radiology revenue exceeds budget. Discharges are at plan and deliveries ahead of plan. Patient days remain low, due to reduced length of stay.

Year to date, net margin is ahead of budget. Cash on hand needs to increase before going to the bond market, where our rating remains excellent.

Maryellen Kosturko, RN, Senior Vice President, Patient Care Operations: The approach to shared governance will become more bottom-up and nursing-driven. The three health system chief nursing officers recommend a standardized, system-wide governance model. A consultant will help with the process.

Michael Ivy, MD, Senior Vice President, Chief Medical Officer: The search for a new chair of Medicine is ongoing, with a recommendation likely in November. Also, Medicare requires two midnights in the hospital to qualify as an inpatient, the first of which can be in the ED. All admits must have an admitting attending and a statement that admission is necessary. Michael Werdmann, MD, Senior Medical Director, IT: Allison Tighe, project facilitator/instructor, Library and Multimedia Services, was cited for registering more than 95 percent of staff for Epic training and Mark DeCapua, principal trainer, for being a superb resource. There was discussion about the process for medication reconciliation at discharge and theconsensus was that this is the same process already in place except it is now more formalized by the electronic medical record.

There was also discussion about how consultation requests through Epic have changed and how they can be improved; pending further discussion.

Peter Tortora, MD, President, Medical Staff: All medical staff members – both hospital-employed and community- based – should register online with Medicaid for OPR (order, prescribe, refer). Also, success of the Park Avenue site and the recruitment and nurturing of primary care practitioners will require the hospital’s full participation and referrals from primary care.

Ryan O’Connell, MD, Vice President, Performance & Risk Management: Medicare core measures showed typical fluctuation, with the pneumonia composite score reaching the goal of 100 percent. On value-based purchasing measures, there were no colon or hysterectomy infections and no MICU UTIs in July, although there was a bump in SICU bloodstream infections.

ED door-to-doctor time was 42 minutes, with door-todoctor for admitted patients at 36 minutes. Left without being seen was below the goal of 2 percent. As expected, door-to-floor increased following Epic go-live.

Norman Roth, Executive Vice President & COO: West Tower and Schine roof projects are complete, and upgrading the electrical switchgear continues. Final paperwork for the Park Avenue project will be signed in mid-October. A formal groundbreaking ceremony will be held in late fall with projected completion in early 2016.


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