Physicians—Update Your Medicare Enrollment Information by ...

VOLUME 2
ISSUE
10
OCTOBER
2010
ProgressNotes
MONTHLY
MEDICAL
STAFF
NEWSLETTER
TORRANCE MEMORIAL MEDICAL CENTER
this issue
PECOS Deadline P.1
Medical Executive P.2&5
New Providers on Staff P.3&6
Medical Staff Calendar P.4
Roster Updates P.6
Physician Mixer P.6
Surgery Department News P.7
URGENT: Physicians—Update Your Medicare
Enrollment Information by October 18, 2010!!
General Staff Meeting P.7
If you enrolled in Medicare or updated your Medicare enrollment information within the past 5 years, your Medicare enrollment
information is stored in the Provider Enrollment, Chain and Ownership System (PECOS). This is an electronic system
in which Medicare contractors enter the Medicare enrollment information that you provided on the Medicare enrollment application.
Internet-based PECOS meets all required Government security standards—in terms of data entry, data transmission, and
the electronic storage of your Medicare enrollment information. Only authorized individuals can enter Medicare enrollment
information into Internet-based PECOS or view Internet-based PECOS data. These individuals are trained in security standards
and are bound by agreements to protect your Medicare enrollment information. PECOS does not disclose your Medicare
enrollment information to anyone except when they are authorized or required to do so by law.
If you enrolled more than 5 years ago and have not submitted any updates to your Medicare enrollment
information, you will need to update your Medicare enrollment information. Doing so will
ensure that your Medicare enrollment information is in PECOS. You can access Internet-based PECOS by using the same
User IDs and passwords that is used for the National Plan and Provider Enumeration System (NPPES).
Physicians and non-physician practitioners are required to report changes in their Medicare enrollment information. For
additional information about reporting changes, go to the download section of www.cms.hhs.gov/
MedicareProviderSupEnroll. Medicare also requires newly enrolling providers and suppliers to complete form CMS-588,
Electronic Funds Transfer Authorization Agreement, which will enable Medicare to send payments directly to a provider/
supplier’s bank account. If you are not receiving Medicare payments electronically, you need to complete this form and mail
it to your Medicare contractor. The form can be downloaded from www.cms.hhs.gov/cmsforms.

Medical Executive Committee Approvals
The following items were presented and actions were approved at the September 14, 2010 Medical Executive
Committee meeting:
Department of Anesthesia
A. David Kobayashi, M.D., nominated for Chief of Department of Anesthesia
Department of Family Practice
A. George D. Haas, M.D., nominated for Chief of Department of Family Practice
Department of Medicine
A. Revised ACC – National Cardiovascular Data Registry Required Documentation – changes to definitions
B. Patient Care Policy/Procedure entitled, “Nurse Runner Program”
C. Revised Department of Medicine – Cardiovascular Disease/Cardiology Privilege Card
Revisions:
Removal of the following privileges:
42.25 – Peripheral Angioplasty and other Percutaneous Peripheral Vascular Intervention includes Aortic Orifice Lesions
(Endovascular Procedures, such as Percutaneous Transluminal Angioplasty (PTA), implantation of stent and/or vena cava filter,
thrombolysis, embolization, stent graft repair, angiogram, angioscopy, and atherectomy)
42.26 – Carotid Stent Privileges
42.27 – Thoracic Endovascular Aortic Review (TEVAR)
Department of Obstetrics & Gynecology
A. Nursing Maternal/Child Services Policy/Procedures entitled, “Prevention of Peripheral Hepatitis B Virus Transmission to
Infants”
Department of Radiology
A. Revised Department of Radiology Rules & Regulations
Revisions:
ARTICLE II – PURPOSE, Paragraph 1. To ensure that all patients admitted to the Hospital or treated in the Outpatient Department
outpatient departments receive the best possible radiological services.
ARTICLE III – MEMBERSHIP, Paragraph C. Term of Appointment
The term of appointment shall be for two-years with reappointment every two years at the discretion of the governing Board.
Paragraph E. Temporary Privileges
Temporary privileges may be awarded as outlined in the Medical Staff Bylaws. In no case shall these privileges be for a period
greater than the term of regular appointments to the Department and these appointments are revocable at any time.
ARTICLE V – OFFICERS, A. Chief of Department of Radiology, paragraph 2. In the absence of the Chief, another radiologist
the Vice Chief shall be designated to act as Chief.
Paragraph 3, item a. He/she shall assume and discharge responsibility for professional direction of the Department under the
Bylaws of the Medical Staff of TMMC and for the administrative direction in cooperation with the Hospital Administrator Administration.
ARTICLE VI – MEETINGS, paragraph B. Attendance at Meetings
Active Staff members must meet the Bylaws requirements.
ARTICLE VII – DEPARTMENTAL RULES & REGULATIONS, paragraph B. Requisition for Radiological Consultation
Requests for radiologic services shall be written by attending physicians and contain a concise statement or reason for the examination.
This is the responsibility of the attending physician who shall discharge it personally or by delegation to competent
personnel. The important point is to provide orientation to the radiologist as to the clinical problem at hand. This is vital to the
maintenance of a high quality of radiologic service.
This responsibility is best discharged for:
1. In patients: by a signed request by the attending or house physician.
2. Emergency room patients: by a signed request by the physician in attendance.
3. Outpatients: by a signed request or telephone request from the physician’s office.
Bylaws Committee
A. Transitional Care Unit Rules & Regulations
Revisions:
Section III. MEDICAL DIRECTOR, paragraph 2 – The Medical Director shall uphold the requirements under CMS regulations
for the medical director defined in the State Operations Manual and enforce compliance with these standards and
conditions of participation to admit patients to the Transitional Care Unit.
Section IX. PATIENT SAFETY/PERFORMANCE IMPROVEMENT COMMITTEE
A. RESPONSIBILITIES
1. Safety Plan to Include:
a. A reporting system for patient safety events
b. A process to conduct analysis including but not limited to root cause analyses on reported patient events
c. A reporting process that supports and encourages a culture of safety
d. A process for providing ongoing patient safety training
e. A definition of a patient safety event including but not limited to all adverse events that are determined to
be preventable and health care associated infections that are determined to be preventable
2
f. See Patient Safety Plan Administration Manual #800.05_2 Continued on Page 5

Welcome New Providers On Staff as of September 30, 2010
No Photo
Available
SHANNON P. CALHOUN, D.O.
Radiology
Nighthawk Radiology Services
601 Front Ave., Ste. 502
Coeur d’Alene, ID 83814
Phone: (208) 292-2262
Fax: (208) 292-3130
ANJULI R. KUMAR, M.D.
Pediatric Gastroenterology
Miller Children’s Outpatient Center
3640 Lomita Blvd., Ste. 102
Torrance, CA 90505
Phone: (310) 378-1716
Fax: (562) 933-6743
JAMIE E. ETO, M.D.
Anesthesiology
Anesthesia Medical Group, Inc.
3330 Lomita Blvd.
Torrance, CA 90505
Phone: (310) 517-4759
Fax: (310) 517-4658
MARCIL M. MAMITA, M.D.
Internal Medicine
1403 W. Lomita Blvd., Ste. 303A
Harbor City, CA 90710
Phone: (310) 530-6900
Fax: (310) 530-6902
No Photo
Available
MAKI JERDEN, N.P.
Allied Health Professional
Wound & Ostomy Care
3330 Lomita Blvd.
Torrance, CA 90505
Phone: (310) 325-9110 Ext. 2363
Fax: (310) 891-6668
KAMRAN MATIN, M.D.
Cardiology
4201 Torrance Blvd., Ste. 790
Torrance, CA 90503
Phone: (310) 370-4558
Fax: (310) 540-0733
MYTIEN T. GOLDBERG, M.D.
Plastic Surgery
Hand and Wrist Institute
2808 Columbia Street
Torrance, CA 90503
Phone: (310) 618-9922
Fax: (310) 618-8445
No Photo
Available
DONALD NICELL, M.D.
Radiology
Nighthawk Radiology Services
601 Front Ave., Ste. 502
Coeur d’Alene, ID 83814
Phone: (208) 292-2262
Fax: (208) 292-3130
HSUAN-WEN C. HUANG, M.D.
Internal Medicine
HealthCare Partners Hospitalists
3330 Lomita Blvd.
Torrance, CA 90505
Phone: (310) 784-8770
Fax: (310) 784-4991
MARC SEDRAK, M.D.
Neurosurgery
The Institute of Brain & Spine Surgery
21350 Hawthorne Blvd., Ste. 176
Torrance, CA 90503
Phone: (310) 540-0965
Fax: (310) 540-6721
KHA K. HUYNH, M.D.
Anesthesiology
Anesthesia Medical Group, Inc.
3330 Lomita Blvd.
Torrance, CA 90505
Phone: (310) 517-4759
Fax: (310) 517-4658
KAREN G. SOKOLOV, M.D.
Radiology/Oncology
TMMC Radiation Oncology Associates
3330 Lomita Blvd.
Torrance, CA 90505
Phone: (310) 517-4750
Fax: (310) 784-4886
Continued on Page 5
3

Torrance Memorial Medical Center
Medical Staff Calendar
October
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
1
7:30a IRB……………………...WT-D
12:30p Surgery Dept……….WT-Aud
4
5 6
7
8
7:00a Heart Failure………..WT-D
7:30a Cardiothoracic..…….WT-B
12:30p Cardiology…………..WT-D
5:00p Intensivist Program...WT-D
7:00a CV Review Conference…WT-D
8:00a Endocrinology……………WT-B
12:30p CME Conference……HCC-1&2
7:00a Breast Tumor Board….WT-Aud
7:30a Tumor Board….............WT-Aud
12:30p MSPI………………………WT-D
7:00a General Surgery……WT-C
11
12
13
14
15
7:30a MD Alignment………WT-B
8:00a Medical Staff Funds..WT-E
12:30p Credentials………….WT-C
12:30p Infection Control P&T….WT-C
6:00p MEC…..…………………WT-D
7:00a CV Review Conference...WT-D
7:00a Anesthesia PI..…..……WT-Aud
12:30p CME Conference……HCC-1&2
7:00a Breast Tumor Board….WT-Aud
7:30a Tumor Board……….….WT-Aud
12:30p Medicine PI……………….WT-B
18
12:00p Burn & Wound…..….WT-C
19
12:00p Radiology………..………WT-B
20
7:00a CV Review Conference...WT-D
8:30a TCU……………………….WT-C
12:30p CME Conference……HCC-1&2
21
7:00a Breast Tumor Board….WT-Aud
7:30a Tumor Board….............WT-Aud
7:30a Emergency Dept.………..WT-D
12:30p Pediatric Dept……..…..WT-Aud
22
7:00a Surgery Advisory……WT-D
25
26
27
28
29
7:30a Vascular Medicine…WT-B
4:00p Bariatric Surgery…….WT-C
12:30p Bioethics………………...WT-C
12:30p OB/GYN Dept……..…WT-Aud
7:00a CV Review Conference...WT-D
12:00p General Staff………….WT-Aud
7:30a Family Practice…………..WT-B
12:30p Credentials……………….WT-C
12:30p Utilization Mgmt………….WT-D
CME CONFERENCES
Wednesdays, 12:30 pm
Health Conference Center
Torrance Memorial Medical Center is accredited by the Institute
for Medical Quality/California Medical Association (IMQ/CME) to
provide continuing medical education for physicians. Torrance
Memorial Medical Center takes responsibility for the content,
quality, and scientific integrity of this CME activity. Torrance
Memorial Medical Center designates this live activity for a maximum
of 1 AMA PRA Category I credit. Physicians should only
claim credit commensurate with the extent of their participation
in the activity. This credit may also be applied to the CME Certification
in Continuing Medical Education.
For up-to-the minute conference information
call (310) 784-8776.
October 6, 2010
“Bacterial Endocarditis”
William Brenner, M.D.
UCLA School of Medicine
Commercial Support: None
October 13, 2010
“Prophylactic Antibiotics”
Samuel Wilson, M.D.
U.C. Irvine School of Medicine
October 20, 2010
“Integrative East-West Medicine: From Pain
Management to Patient Outcomes”
Eric Hsu, M.D.
UCLA School of Medicine
Commercial Support: None
October 27, 2010
NO CONFERENCE
Commercial Support: None November 3, 2010
“Providing Medical Care in a Disaster”
Andrew Shen, M.D.; Eduardo Anorga, M.D.;
and Judy Retter, R.N.
Torrance Memorial Medical Center
Commercial Support: None
4

New Providers on Staff (Continued)
ALEXANDER STEIN, M.D.
Cardiothoracic Surgery
1000 W. Carson St., Box 423, Ste. 3L2
Torrance, CA 90509
Phone: (310) 854-1904
Fax: (562) 435-7545
MEHDI TAHSINI, M.D.
Family Practice
2573 Pacific Coast Highway, Ste. B
Torrance, CA 90505
Phone: (310) 626-8037
Fax: (310) 626-6214
Physician Roster Updates
Change of Address/Phone/Fax
Amy Bandy, D.O.
Fax: (949) 574-0573
Specialty: Plastic Surgery
Alexandra Bujor, M.D.
3400 Lomita Blvd., Ste. 607
Torrance, CA 90505
Phone: (310) 530-5333
Fax: (310) 530-5363
Specialty: OB/GYN
Marc Colman, M.D.
3440 Lomita Blvd., Ste. 252
Torrance, CA 90505
Specialty: Otolaryngology
Payam Daneshrad, M.D.
Phone: (310) 453-6500
Fax: (310) 453-6681
Specialty: Otolaryngology
Roger DeFilippo, M.D.
3440 Lomita Blvd., Ste. 240
Torrance, CA 90505
Specialty: Pediatric Urology
Trevor Hayes, D.O.
Phone: (562) 426-3333
Fax: (562) 933-0125
Specialty: Family Practice
Chester Koh, M.D.
3440 Lomita Blvd., Ste. 240
Torrance, CA 90505
Specialty: Pediatric Urology
Anh Nguyen, M.D.
Fax: (310) 667-8779
Specialty: Pediatrics
Yutaka Niihara, M.D.
Phone: (310) 214-0065
Fax: (310) 214-0075
Specialty: Oncology, Hematology
Babak Shabatian, M.D.
23441 Madison St., Ste. 200
Torrance, CA 90505
Phone: (310) 909-8880
Fax: (310) 693-8091
Specialty: Ophthalmology
Resignation
Carol E. Davis, M.D.
Ophthalmology
Hans H. Kim, M.D.
Ophthalmology
Retired
Paul J. Gethner, M.D.
Dermatology
David C. Owen, M.D.
Otolaryngology
In Memory Of
Masashi Uriu, M.D.
It is with deep regret that we announce
the passing of Masashi Uriu, M.D. Dr.
Uriu was a General Surgeon at Torrance
Memorial Medical Center for over 50
years and brought much experience to the
hospital and his patients. He will be
greatly missed.
Physician Mixer is Great Success
On Tuesday, September 21 st , the medical center hosted a very successful physician
mixer in the West Tower Auditorium. Medical Staff members were treated
to an amazing wine tasting opportunity provided by JB and Adam of The Wine
House located in Los Angeles. A variety of imported and domestic wines were
available for tasting and delicious hors d’oeuvres were provided by Torrance Memorial’s
Catering Department. Speaking of variety, members of the medical staff
representing primary care, and multiple specialties were present to mix and mingle.
Hospital Executive Management was represented by Craig Leach, Sally
Eberhard, Mike Thomas, Debby Kelley, Peggy Berwald and Robin Camrin.
Comments received included “this was a great event, let’s do this more often,
and thanks for arranging for us to get together.” There was also the request
that this be a quarterly event. We are planning the next one now and hope that
you will plan to join us. Watch for your invitation after the first of the year.
5

Medical Executive Committee Approvals (Continued)
Bylaws Committee (Continued)
A. Transitional Care Unit Rules & Regulations (Continued)
Revisions:
A. RESPONSIBILITIES (Continued)
2. Function
a. Review and approve the safety plan
b. Receive and review reports of safety events
c. Monitor implementation of corrective actions for patient safety events
d. Make recommendations to eliminate future patient safety events
e. Review and revise patient safety plans, yearly or more often as necessary
B. Medical Records Committee recommendation to implement to the General Rules & Regulations, Section C. MEDICAL
RECORDS, paragraph 3A. “A Transfer Summary containing all the elements of a History & Physical and written
by a physician on the medical staff at Torrance Memorial Medical Center can be used as a History & Physical”
A three (3) month monitoring period will be performed.
C. Inclusion of various citations to the Rules & Regulations where appropriate to assist physicians with understanding
what regulatory agency was driving changes and where those requirements are found
D. Attribution Plan
E. New Medical Staff Policy/Procedure entitled, “Professional Relations Committee”
F. New Policy/Procedure entitled, “Proctoring”
Credentials Committee – Approvals filed in Medical Staff Services – please see Toni Woodard.
Infection Control/P&T Committee
A. Revised Post-Partum Orders
B. General Medicine Orders
C. Post Cardiac Device/EP Radio Frequency Ablation Orders
D. Cesarean Section Admit Orders
E. Labor & Delivery Routine Admit Orders
F. Mother Baby Newborn Admit Orders
G. Patient Care Policy/Procedure entitled, “Use of Erythropoesis – Stimulating Agents in Patients with Cancer”
H. Patient Care Policy/Procedure entitled, “Iron Dextran Dosing Service”
I. Iron Dextran Pharmacy Dosing Protocol
J. IV Medication Administration Guidelines
K. Revised Post Vaginal Delivery Orders
L. Labor & Delivery Routine Admission Orders
M. Entereg® Alvimopan Usage Criteria Order Set – Pilot
N. Formulary Reviews: Entereg; Curosurt; Pediarix; Ultiva
O. 3 Month Formulary Re-reviews: Lumizyme; Pepramen 1.5
Institutional Review Board – Approvals filed in Medical Staff Services – please see Yumi Lee.
Intensivist Program Ad-Hoc Committee
A. Change the rounding time requirement in the ICU from 13:00 to 11:00
Medical Staff Funds Committee
A. $120,000.00 Budget for 2011 Installation & Dinner Dance
Nomination Committee
A. Nominations for the 2011 Medical Staff Officers:
Secretary/Treasurer – Chan-Chou Chuang, M.D.
Assistant Chief of Staff – Eric Milefchik, M.D.
Chief of Staff – Thomas Simko, M.D.
Members-At-Large – Riad Adoumie, M.D.; Fikret Atamdede, M.D.; Steven Jensen, M.D.; Tonny Lee, M.D.;
Eric Nakkim, M.D.; Benjamin Rosin, M.D.; Deren Sinkowitz, M.D.
Physician Alignment Ad-Hoc Committee
A. Crimson Security Policy
6

Surgery Department News—Upgrading the
Peer Review Process
The Ongoing Professional Practice Evaluation (OPPE) is the continuous evaluation of the practitioner’s professional performance.
It identifies professional practice trends that may impact the quality of care and patient safety.
Torrance Memorial Medical Center has adopted this practice and the Department Chiefs have been evaluating physician
competencies based on data contained in the OPPE. Physicians have also received their individual practice data. Early this
year, the performance of all physicians between July to December 2009 was reviewed. One department chief, Dr. Riad
Adoumie, Surgery Department, suggested that all surgical complication cases should be reviewed and the results included in
the physician OPPE.
To facilitate this, Dr. Adoumie invited all surgical subcommittee chairs to a meeting requesting their involvement in understanding
how the information is collected and reported. The meeting was held this past August. Wayne Lyon, Manager, HIM
Coding, educated subcommittee chairs extensively. He also explained that physicians have the opportunity to oversee the
accuracy of the process. He reported that the administrative data coded by the hospital Health Information Management Department
is submitted to the Office of Statewide Health and Planning Department (OSHPD) every six months. This information
is eventually available to the public so the accuracy of the data is extremely important. Physician input and involvement
is invited.
Subcommittee chairs have been holding meetings educating surgeons and reviewing cases for accuracy, relevancy and competency.
Mr. Lyon has been included in these meetings to facilitate education and to assure accuracy of complication coding.
REMINDER:
General
Staff
Meeting
When: October 27, 2010
Where:
Torrance Memorial Medical
Center
West Tower—Auditorium
Time: 12:00pm
7

Medical Staff Services
3330 Lomita Boulevard
Torrance, CA 90505
(310) 517-4616 ph
(310) 784-8777 fax
www.TorranceMemorial.org
ProgressNotes Vol. 2 Issue 10 October 2010
MONTHLY
MEDICAL
STAFF
NEWSLETTER
ProgressNotes
TORRANCE MEMORIAL MEDICAL CENTER
Torrance Memorial’s Planned New Patient Tower