this issue - Torrance Memorial Medical Center

VOLUME 4ISSUE4A P R I L2012ProgressNotesMONTHLYMEDICALSTAFFNEWSLETTERTORRANCE MEMORIAL MEDICAL CENTERthis issueNew Tower/Joint Commission P.1Pneumonia Documentation P.2Medical Staff Calendar P.3Roster Updates P.4MEC Approvals P.5-6Torrance MemorialCelebrates Half-WayMark in Constructionof New TowerTo commemorate the midway point in constructionof Torrance Memorial Medical Center’snew $450 million patient tower, hospitalpatrons and staff gathered to celebrateplacement of the final piece of structuralsteel on the 398,350-square-foot facility witha Topping Out ceremony. Major donors,trustees, Foundation board of directors,medical staff and construction representativessigned the ceremonial steel beam,adorned with an American flag and an evergreentree. The beam was then lifted to thetop of the structure. The evergreen treesymbolizes growth, life and good luck. Theflag is a patriotic symbol that signifies thatunited effort of the project team. Constructionis scheduled for completion in November2014 with the tower opening in spring2015. Torrance Memorial has raised morethan $119 million, more than half of its fundraisinggoal of $200 million, to build the newtower.John McNamara, M.D., signs the beam at the Topping Out ceremony.Joint Commission RenewsTorrance Memorial'sAccreditationCongratulations are in order for last month's successfulJoint Commission Survey. After months of preparation,visits by mock survey teams and numeroustracers, the Joint Commission surveyors arrived onMarch 12. Staff from across the medical center andmany disciplines rose to the occasion during the thorough five-day survey. It wasreported during wrap-up sessions that the surveyors bestowed a multitude of complimentsand provided ideas on how to continue to uphold the standard of excellence incare for which Torrance Memorial is known. "I want to express my sincere appreciationand gratitude to all of you," said Craig Leach, president and CEO. "This was anamazingly rewarding week. It was great to listen every morning to the reports fromthe surveyors regarding the activities from the previous day. It is such a privilege tobe able to work with so many talented and committed people. Thank you for yourleadership and for your dedication. Congratulations to all of you." An independent,not-for-profit organization, The Joint Commission accredits and certifies more than19,000 healthcare organizations and programs in the United States. Joint Commissionaccreditation and certification is recognized nationwide as a symbol of qualitythat reflects an organization's commitment to meeting certain performance standards.

Torrance MemorialIntegrated PhysiciansOffering Meeting DatesOn March 6 th the Offering to buy a unit inthe Torrance Memorial Integrated Physicians(TMIP), a Limited Liability Company,became available. The documents to purchasea unit are available in the MedicalStaff office at TMMC. The Offering openedon March 5, 2012 and closes on April 30,2012. We will hold meetings on the followingdays to explain the Offering which bylaw is quite complex:DOCUMENTATIONSTRATEGIES TO SUPPORT SEVERITY OF ILLNESSREGARDING PNEUMONIATo properly reflect the true severity of illness and risk of mortality of your patient,to validate assignment of proper codes, and to support your professional profilein cases of pneumonia, the following steps will help:STEP1Evaluate patient’s risk of aspiration as the cause of the pneumoniafrom the perspectives of debilitating GERD, alcoholism, bed-riddenstatus, pharyngeal dysfunction, CVA with residual dysphasia, etc,Document if you suspect or think likely that this is likely a case ofaspiration pneumonia.DATE PLACE TIME4/3/12 Room D 12:30 PM4/5/12 Room D 7:00 AM4/10/12 Room D 12:30 PMSTEP2Evaluate the patient’s risk factors when the case likely representspneumonia due to aerobic gram-negative rods from the perspectiveof healthcare acquired or nursing home acquired pneumonia,pneumonia of the elderly, pneumonia in a diabetic or pneumonia in animmunocompromised host. This should appear either in the H&P orprogress notes4/11/12 Room D 6:00 PM4/13/12 Room D 7:00 AM4/19/12 Room D 7:00 AM4/23/12 Room D 7:00 AM4/25/12 Room D 12:30 PM4/25/12 Room D 6:00 PMWe hope to see you at one of the meetings.Please RSVP to Robin Camrin, VicePresident, Medical Staff Services/PI at310-784-4921 or robin.camrin@tmmc.com.STEP3If you are using antibiotics to treat specific organisms that you believemay be the likely cause of pneumonia, even in the absence of a positivesputum culture, document that.If in your judgment, the dehydrated patient who is not manifesting any infiltrateyet on chest xray, requires acute inpatient hospitalization and antibiotic treatmentbecause their symptoms make you suspect pneumonia is likely and that iswhat you believe you are treating, state that.2Thank you to all the physicians who attended the Doctor’s Day Celebration atTorrance Memorial on Friday, March 30th. The event was a success with manyphysicians attending to enjoy a great meal, music and prizes. Congratulations toDr. Vinh Cam, Nephrology, the lucky winner of the iPad 3 and the thirty-five physicianswho also won gift cards to Nordstroms, Amazon, Starbucks and iTunes.Torrance Memorial appreciates our physicians’ dedication and commitment to thehealth of our community.

Medical Staff CalendarApril2Monday Tuesday Wednesday Thursday Friday345612:30p Cardiology………………WT-D8:00a TCU……………………...WT-C7:00a CV Review Conference.WT-D12:30p CME Conference…..HCC 1&27:00a Breast Tumor Board..WT-Aud7:30a Tumor Board………...WT-Aud12:30p MSPI…………………….WT-D7:00a Surgery Dept……...WT-Aud7:30a IRB…………………….WT-D9101112137:30a Physician Alignment…...WT-B12:30p Credentials……………..WT-C12:30p Medication Safety……...WT-C5:00p Professional Relations...WT-C6:00p MEC…………………......WT-D7:00a Anesthesia PI……….WT-Aud7:00a CV Review Conference.WT-D8:00a Endocrinology………….WT-B12:30p CME Conference…..HCC 1&27:00a Breast Tumor Board..WT-Aud7:30a Tumor Board………...WT-Aud12:00p Donor & Transfusion…..WT-D12:30p Ophthalmology……….WT-B16171819207:00a Cardiothoracic Surgery..WT-C12:00p Burn & Wound………….WT-C12:00p Radiology…………….WT-Aud12:30p Infection Control/P&T….WT-C7:00a CV Review Conference.WT-D7:00a Breast Tumor Board..WT-Aud7:30a Tumor Board………...WT-Aud9:00a Emergency Dept……...HCC-212:30p Pediatric Dept……….WT-Aud7:00a Surgery Advisory……..WT-D23242526274:00p Bariatric Surgery……….WT-C12:30p OB/GYN Dept………..WT-Aud7:00a CV Review Conference.WT-D12:00p Medicine PI……………..WT-E12:30p Bioethics………………...WT-B7:00a Breast Tumor Board..WT-Aud7:30a Family Practice………...WT-B7:30a Tumor Board………...WT-Aud12:30p Credentials………….….WT-C7:00a General Surgery……..WT-C30 1 2 3 4CME CONFERENCESWednesdays, 12:30 pmHealth Conference CenterTorrance Memorial Medical Center is accredited by the Institute forMedical Quality/California Medical Association (IMQ/CMA) to providecontinuing medical education for physicians.Torrance Memorial Medical Center designates this live activity for amaximum of 1 AMA PRA Category I credit TM . Physicians should claimonly the credit commensurate with the extent of their participation inthe activity.This credit may also be applied to the CMA Certification in ContinuingMedical Education.April 4, 2012“Falls Prevention in the Elderly”Steven Castle, M.D.UCLA School of MedicineCommercial Support: NoneApril 11, 2012“Conflicts in Bioethics”Stuart Finder, Ph.D.UCLA School of MedicineCommercial Support: NoneApril 18, 2012NO CONFERENCEApril 25, 2012NO CONFERENCEMay 2, 2012“Thyroid Cancer Update”Andrew Gianoukakis, M.D.UCLA School of MedicineCommercial Support: NoneMay 9, 2012“Advances in JointReplacement Therapy”Clive Segil, M.D.Cedars Sinai Medical CenterCommercial Support: NoneFor up-to-the minute conference information call (310) 784-8776.3

Welcome New Practitioners on StaffDong Wook Chang, M.D.Pulmonology/Critical CareHealthCare Partners Hospitalists3330 Lomita Blvd.—HCP 1st FloorTorrance, CA 90505Phone: (310) 784-8770Fax: (310) 784-4991PhotoNot AvailableRamprasad C. Dandillaya, M.D.Cardiology4201 Torrance Blvd., Ste. 790Torrance, CA 90503Phone: (310) 370-4558Fax: (310) 540-0733Physician Roster UpdatesChange of Address/Phone/Fax:Reinstatement from Leave of AbsenceJohn Brian Boyd, M.D.Plastic Surgery14650 Aviation Blvd., Ste. #210Manhattan Beach, CA 90250Phone: (310) 882-6261Fax: (310) 882-6260Premindra A. Chandrantna, M.D.Cardiology30932 Marne Dr.RPV, CA 90275Phone: (310) 541-4198Philip LoGiudice, M.D.General Surgery2274 Rue Le CharleneRancho Palos Verdes, CA 90275Phone: (310) 832-4225Fax: (310) 548-5034Katherine Miller, M.D.Internal Medicine3330 Lomita Blvd. TMHA 1 st FloorTorrance, CA 90505Phone: (310) 891-6623Fax (310) 891-6673David Slutsky, M.D.Orthopedics2808 Columbia StreetTorrance, CA 90503Phone: (310) 618-9922Fax: (310) 618-8445Princess Bordador, M.D.Internal MedicinePhone: (310) 793-4673Fax: (310) 793-4630Janice Hull, M.D.OB/GYNPhone: (310) 303-3175Fax: (310) 303-3174Mytien Goldberg, M.D.Plastic SurgeryFax: (310) 618-8445Saroj Bharatiya, M.D.Internal MedicineHealthCare Partners Hospitalists3330 Lomita Blvd.– HCP 1st FloorTorrance, CA 90505Phone: (310) 784-8770Fax: (310) 784-4991ResignationMazin I. Abdullah, M.D.InfertilitySharon F. Genato, M.D.Internal MedicineYuri Reznik, M.D.Family PracticeRyan Taban, M.D.Ophthalmology2080 Century Park East, Ste. #1202Los Angeles, CA 90067Phone: (310) 556-3937Fax: (310) 556-3930Emad Khaleeli, M.D.Cardiology4305 Torrance Blvd., Ste. #306Torrance, CA 90503The Medical Staff Newsletter Progress Notes is published monthly forthe Medical Staff of Torrance Memorial Medical Center.Thomas G. Simko, M.D.Chief of StaffRobin S. Camrin, CPMSM, CPCSVice President, Medical Staff Services & Performance Improvement4

Medical Executive Committee ApprovalsThe following items were presented and actions were approved at the March 13, 2012 Medical Executive Committee meeting:Treasurer’s ReportA. January 2012 Treasurer’s ReportMedicine DepartmentA. Heart Failure UpdateEducational information was added to the discharge form in Powerchart to meet the CHF core measures and to helpidentify these heart failure patients. This information will be on the patient’s chart with the alert “Important Information.”Obstetrics & Gynecology DepartmentA. Division of Nursing Obstetrics Policy/Procedure entitled, “Obstetrical Emergency Medication Administration”B. Division of Nursing Policy/Procedure entitled, “Counts, Instruments, Sponges, Sharps and Miscellaneous Items”Radiology DepartmentA. Policy/Procedure entitled, “Scanning Patients with Revo MRI TM SureScan® Pacemaker”B. Revised Job Descriptions Radiology Technologist New Grad Radiology Technologist I Radiology Technologist II Interventional Radiology Technologist I Interventional Radiology Technologist II Interventional Radiology Technologist III Endovascular Technologist CT Technologist I CT Technologist II Nuclear Medicine Technologist Nuclear Medicine Technologist Level II Nuclear Medicine/PET SupervisorBioethics CommitteeA. Patient Care Policy/Procedure entitled, “Bioethics Committee”B. Bioethics Consultation GuidelinesC. Bioethics Committee Record of Patient Review SessionD. Bioethics Committee Criteria for the Early Recognition of Conflict Regarding Patient Care DecisionsCredentials CommitteeA. March 12, 2012 Credentials filed in Medical Staff Services – please see Toni Woodard.B. Revised Reappointment ApplicationC. Revised Allied Health Care Professional ApplicationInfection Control/P&T CommitteeA. Pediatric Crash Cart ListB. Revised Formulary Management Policy/ProcedureC. Revised Computer Systems Policy/ProcedureD. Revised Compounding Policy/ProcedureE. Revised Counseling Patient Policy/ProcedureF. Revised Discharge/Outpatient Prescriptions Policy/ProcedureG. Revised Drug Information/References Policy/ProcedureH. Revised Drug Recall Procedure Policy/ProcedureI. Revised Emergency Box Restocking Policy/ProcedureJ. Revised Rax/Omnilink Policy/ProcedureK. Revised Loaning and Borrowing of Pharmaceuticals Policy/Procedure5

Medical Executive Committee ApprovalsThe following items were presented and actions were approved at the March 13, 2012 Medical Executive Committee meeting:Infection Control/P&T Committee (continued)L. Revised Maintenance of Policy and Procedure ManualM. Revised Metric System Policy/ProcedureN. Revised Multivitamins, Parenteral Policy/ProcedureO. Revised Automated Dispensing Cabinets Policy/ProcedureP. Delete Percocet Orders Policy/ProcedureQ. Revised Pharmacy Management of Blood Components Policy/ProcedureR. Power of Attorney Policy/ProcedureS. Revised Productivity System Policy/ProcedureT. Revised Screening of Medication Process Policy/ProcedureU. Revised Scabies Exposure Prophylaxis for Employees Policy/ProcedureV. Revised Signature Verification/Physician Information Policy/ProcedureW. Revised Tube System Policy/ProcedureX. Revised Volunteers Policy/ProcedureY. Criteria for IV to Oral TransitionZ. Prophylactic Antibiotic Use ProtocolInstitutional Review Board – Approvals filed in Medical Staff Services – please see Yumi Lee.Patient Safety CommitteeA. Hand Washing Campaign Design wash your hands buttons, stickers or something that attaches to ID badges that displays the concept of“Foam In Foam Out”. For the purpose of positive reinforcement design a card that says thank you for following the recommended handhygiene processes. Set up Pledge boards on the various units and ask medical staff members to sign the pledge that they will washtheir hands and if they see another medical staff member not washing they agree to remind them to do so. Ask for physician volunteers to make rounds on the various hospital units auditing and talking to medical staffabout the pledge and reminding staff members to foam in and foam out.Torrance MemorialPhysicians, Nurses,and EmployeesRNs & Other HealthcareProfessionalsPre-Registration/On Site Registrationafter April 1, 2012$100$125Physicians $1506For details and to purchase ticketsplease visit our website:www.TorranceMemorial.org/cardiosymposiumor call 310-517-4177Torrance Memorial Medical Center3330 Lomita Blvd., Torrance, CA 90505

Medical Staff Services3330 Lomita BoulevardTorrance, CA 90505Phone: (310) 517-4616Fax: (310) 784-8777www.TorranceMemorial.orgMailing LabelProgressNotes Vol. 4 Issue 4 April 2012MONTHLYMEDICALSTAFFNEWSLETTERProgressNotesTORRANCE MEMORIAL MEDICAL CENTERTorrance Memorial’sPlanned New Main Tower