December 2011, Volume 3, Issue 12 - Torrance Memorial Medical ...

Clinical DocumentationIntegrity ProgramCDIP, the Clinical Documentation Integrity Program is here to serve as a bridge between physicians and coding. Patient severity of illness isconveyed to quality organizations and payers through ICD 9 codes which are assigned by coders based only on what physicians and NPsdocument. Coding rules dictate what codes are assigned to which medical terms. Coders can not infer or assume a diagnosis. The ClinicalDocumentation Specialist, from the CDIP, can help by assessing the concurrent record to see if the medical terms, as they currently existtruly reflect the severity of that patient. If not, the CDS will clarify with the physician what terms might reflect the truest severity of illnessfor any given patient. Below is a sample of some commonly used terms and phrases:Unable to Code with High SeverityMulti‐system organ failureSevere respiratory distressWill rehydrateK + ↓ 2.0, will replete↓ Decreased↑ IncreasedCHF, EF = 15%Able to Code with High SeverityLiver failure, renal failure (acute, chronic or acute on chronic)Respiratory failureDehydration, hypovolemiaHypokalemiaHypo…Hyper…Acute systolic heart failure (acute or acute on chronic)For help or questions please call:Donna Kent ext.6884; Carolyn Ito ext.6691; Carmela Blanchard ext.6819ACOAccountable Care OrganizationTorrance Memorial will be forming an Accountable Care Organization(ACO) with shared ownership betweenphysicians and Torrance Memorial. This new ACO entitywill be available for investment in early 2012 and will bephysician driven and physician lead. More information willbe forthcoming. Please direct any questions to John McNamara,M.D., Chief Medical Officer atjohn.mcnamara@tmmc.com.

Medical Executive Committee ApprovalsThe following items were presented and actions were approved at the November 8, 2011 Medical Executive Committee meeting:The following items were approved at the November 8, 2011 meeting of the Medical Executive Committee:Treasurer’s ReportA. September 2011 Treasurer’s ReportB. Light Up A Life donation $10,000.00Obstetrics & Gynecology DepartmentA. Revised Clinical Privilege Application Card for Department of Obstetrics & Gynecology – PerinatologyRevisions:Documentation: For recent graduates, out of training less than two years, documentation must be submitted that supports the number listedin the column titled “# cases required Initial Application”. For recent graduates a case log for the (2-3 year) training period will be accepted ORan attestation letter from the program director of the residency and/or fellowship program that reflects the applicant has successfully met theinitial application activity requirements.For physicians out of training greater than two years, documentation must be submitted that supports the number listed in the “# cases requiredInitial Application” column. An activity report will need to be submitted from the hospital that is able to provide the number of procedures and/oractivity performed during the past 2 years.you are currently active, which list the number of procedures you have performed during the past 2years.52.00 – Perinatology CorePrivileges include the following: Consultation Perform history and physical exam Percutaneous umbilical blood sampling Ultrasound – targeted and limited obstetrical Placental biopsy Cerclage# of cases required reappointment: 30 15B. Patient Care Policy/Procedure entitled, “Code Neo, Code L&D, Code OB”Radiology DepartmentA. Intravenous Gadolinium and Nephrogenic Systemic Fibrosis (NSF) PolicyB. Radiology Online Policy and Procedure ManualsSurgery DepartmentA. Revised Clinical Privilege Application Card for Department of Surgery – UrologyRevisions:Addition of Rectal Procedures which include the following: Sigmoidoscopy; Polypectomy; Hemorrhoidectomy; Fissurectomy; Fistulectomy;Transvaginal pararectal rectal prolapse repair; Delorme rectal prolapse repair; Anal sphincteroplasty.Proctoring Requirements: 2# of cases required for Init App: 5# of cases required for Reapp: 1B. Revised Clinical Privilege Application Card for Department of Surgery – General SurgeryRevisions:Addition of Endoscopic Balloon Dilation of Colonic StrictureProctoring Requirements: 3# of cases required for Init App: 5# of cases required for Reapp: 5Credentials Committee – Approvals filed in Medical Staff Services – please see Toni Woodard.Continued on page 52

Medical Executive Committee ApprovalsThe following items were presented and actions were approved at the November 8, 2011 Medical Executive Committee meeting:Infection Control/P&T CommitteeA. Division of Nursing Policy/Procedure entitled, “Immediate Use Sterilization”B. Physicians will follow the same rules as employees for flu vaccinationsC. Pediatric Burn Pre-Printed OrdersD. Adult Burn Pre-Printed OrdersE. Formulary DeletionsF. Ativan and Dilantin for use in critical areasG. Revised Pharmacy Policy/Procedure entitled, “Poison Control”H. Revised Pharmacy Policy/Procedure entitled, “Communication to Staff”I. Revised Pharmacy Policy/Procedure entitled, “Licensure”J. Revised Pharmacy Policy/Procedure entitled, “Medication Usage Evaluation (MUE)”K. Revised Pharmacy Policy/Procedure entitled, “Overview of Pharmacy Services”L. Revised Pharmacy Policy/Procedure entitled, “Pharmacy and Therapeutics Committee”M. Revised Pharmacy Policy/Procedure entitled, “Planning Goals and Objectives”N. Revised Pharmacy Policy/Procedure entitled, Scope of Service”O. Revised Policy/Procedure entitled, “Accountability of Administration”P. Revised Pharmacy Services Policy/Procedure entitled, “Amiodarone (Cordarone®) Infusion Protocol”Q. Revised Pharmacy Policy/Procedure entitled, “Automatic Stop Orders”R. Deletion of Antidotes Policy/ProcedureS. Deletion of the Ativan Injectable Storage Policy/ProcedureT. Deletion of Hours of Operating and Staffing Policy/ProcedureU. Deletion of Patient Allergies Policy/ProcedureV. Deletion of Pharmaceuticals Waste Policy/ProcedureW. Adoption of a Standard Formulation for GI CocktailX. Proposed Changes for Smart Infusion Pump SettingsInstitutional Review Board – Approvals filed in Medical Staff Services – please see Yumi Lee.State of the Medical CenterAddress LuncheonHONORING THE PAST CHIEFS OF STAFF OFTORRANCE MEMORIAL MEDICAL CENTERWednesday December 7 th , 201112 Noon to 2pmTorrance Memorial Healthcare Conference CenterYou may RSVP to Robin Camrin at 310-784-4921 robin.camrin@tmmc.com orSusan Widem at 310-784-8792 susan.widem@tmmc.com by December 2, 2011.5

Medical Staff Services3330 Lomita BoulevardTorrance, CA 90505Phone: (310) 517-4616Fax: (310) 784-8777www.TorranceMemorial.orgProgressNotes Vol. 3 Issue 12 December 2011MONTHLYMEDICALSTAFFNEWSLETTERProgressNotesTORRANCE MEMORIAL MEDICAL CENTERTorrance Memorial’sPlanned New Main Tower