March 2010 - Trident Health System

BUSINESS PLANMARÇO 2014

From 2008 to 2009, these results are attributed to the numberof core measures missed was reduced by 50 percent. Thanks tophysician engagement, peer review, open dialog, concurrentmonitoring and reporting and physician-lead processimprovement teams.There are more than 30 million surgeries performed in theUnited States each year. Despite the evidence that VTE is oneof the most common postoperative complications and prophylaxisis the most effective strategy to reduce morbidity andmortality, it is often underused.Of the 75 Summerville and Trident Medical Center surgerypatients that fell into this measure for fourth quarter2009, 12 did not receive VTE prophylaxis. Either it was notordered or it was ordered and not timely. These 12 cases havebeen thoroughly reviewed with each surgeon.AMI HF PNAcute MyocardialInfarctionAMI1 Aspirin at ArrivalAMI3 ACEI/ARB for LVSDAMI4 Smoking CessationAMI5 BB at D/CAMI8a PCI w/in 90 minsHeart FailureHF1 DischargeInstructionsHF2 LVF assessmentHF3 ACEI/ARB atfor LVSDHF4 Smoking CessationPneumoniaPN2 PN vaxPN3b BCs prior to AbxPN4 Smoking CessationPN5c Abx w/in 6 hoursPN6 Appropriate AbxPN7 Flu vaxMeasure Q1 2008 Q2 2008 Q3 2008 Q4 2008AMI 98.48% 99.58% 99.62% 98.02%HF 89.95% 91.96% 94.05% 94.55%PN 96.08% 95.01% 98.41% 95.83%SCIP 94.30% 94.81% 95.21% 96.60%Measure Q1 2009 Q2 2009 Q3 2009 Q4 2009AMI 99.07% 99.58% 98.28% 100.00%HF 96.49% 98.88% 98.29% 97.83%PN 97.62% 98.00% 97.50% 98.28%SCIP 98.58% 97.89% 98.20% 97.77%Having made general, wide-sweeping process improvementsin 2009 as evidenced by the composite scores above, it isimperative that we now take a targeted approach with anindicator-specific focus.For example, the Q4 2009 composite SCIP score of 97.77 percent(below TJC/CMS 90th percentile) is much lower than theprevious three quarters of the year. Of the six indicators thatmake up the composite score for SCIP (see chart) the two thatmeasure Venous Thromboembolism (VTE) performance offerthe area for most improvement.SCIP VTE1 & 2 measures the number of surgery patients thathad the recommended Venous Thromboembolism Prophylaxisordered and administered in a timely manner.SCIPSurgical CareImprovement ProjectSCIP1 Abx 1hr priorto incisionSCIP2 Appropriate AbxSCIP3 Abx D/C w/in 24hrsSCIPVTE1 VTE OrderedSCIPVTE2 VTE ReceivedSTKStrokeSTK1 VTE OrderedSTK2 D/C w/AntithromboticTherapySTK3 Anticoag forAfid/FlutterSTK4 ThrombolyticTherapySTK5 AntithromboticTherapy by Day 2STK 6 D/C on StatinSTK8 Stroke EducationSTK10 Assessed forRehabIn 2010, Stroke core measures have been added as an additionalquality measure although Trident Health System doesnot currently publicly report this data via Hospital Compare.However our Stroke data is reported to TJC as part of ourStroke Accreditation Program. Our preliminary fourth quarterdata is trending in the 90th percentile for most of the 10measures, except for STK3 - Anticoag for Afib/Flutter, whichis currently at 80 percent. Final results were not available atthe time of publication.If you have any questions or concerns regarding core measures,please contact Alice Turner, AVP of quality in administration,at 843-847-4100.TridentHealthSystem.comMedstaff Communications MARCH 2010 9

Trident and Summerville Medical CentersNAMED HOSPITALS OF CHOICE BY DORCHESTER AND BERKELEY COUNTIESTrident and Summerville Medical Centers were named thehospital and urgent care/emergency facilities of choice inDorchester and Berkeley counties.“Over 80 percent of our patients residein Berkeley and Dorchester counties andit’s a great honor that so many put theirfaith in our outstanding staff, physiciansand volunteers,” said Todd Gallati,president/CEO of Trident Health System.“I have no doubt that receiving thisrecognition is a result of Trident HealthSystem’s tradition of providing quality carein our region and the numerous recentimprovements that we have made.”The Summerville Journal Scene’s 2009 Readers’ Choice AwardsCategory: Medical HospitalFirst place: Summerville Medical CenterRunner-up: Trident Medical CenterUrgent Care/Emergency FacilityFirst Place: Summerville Medical CenterThe 2009 Best of Berkeley County Awards and the SummervilleJournal Scene’s 2009 Readers’ Choice Awards gave readers achance to voice their opinions on their favorite businesses.During November and December, ballots were published inthe Summerville Journal Scene, Berkeley Independent andThe Gazette. Voting was also made available to readers onlineat JournalScene.com, BerkeleyInd.com and OurGazette.com.Hundreds of Berkeley and Dorchester county readers votedin more than 200 categories. As ballots came in, votes weretabulated and winners were declared.The Berkeley Independent and The Gazette’s 2009 Best ofBerkeley County AwardsCategory: Medical HospitalFirst Place: Trident Medical CenterUrgent Care/Emergency FacilityFirst Place: Moncks Corner Medical CenterTrident Health System Offers CondolencesTrident Health System would like to offer sincerest condolences on the recent loss of one of ourphysicians, Dr. Carl P. Troedsson. A physician on staff with us since 2004, we express our deepestsympathies to his family and staff during this difficult time.10 Medstaff Communications MARCH 2010 TridentHealthSystem.com

The Joint Commision SurveyTo All Members of the Medical Staff,The Joint Commission survey from late February was a tremendous success, with one of the surveyors noting that this was themost successful turnaround for any hospital he has seen in his 14 years as a surveyor. With only five Requirements for Improvements(RFIs) identified, this was over a four-fold improvement from three years ago and better than two times less than the average hospital.For the size and complexity of our system, this is a tremendous feat. We know that this would not be possible without the qualitydocumentation and care practiced by our medical staff.Through their review of charts, interviews with staff and physicians, the surveyors uncovered and saw direct evidence of great patientcare. The physician surveyor saw one physician and the ICU staff working day and night in what he called a “heroic effort” to save apatient’s leg. They saw great progress in our core measures, D2B times, infection rates and patient outcomes. Specifically recognizedwas the attention to detail shown by the medical staff, with no instances of unapproved abbreviations, unsigned orders or consentsand excellent and complete H&Ps.All the surveyors were extremely complimentary about the quality of patient care and the obvious dedication and professionalismevident in all our physicians and employees. Thank you for the great care you give to your patients every day and for your trust inTrident Health System.Todd Gallati, FACHEPresident/CEOTrident Health SystemLouis F. Caputo, FACHECEOSummerville Medical CenterLloyd Mandel, MDVP Medical AffairsTrident Medical CenterBeth Cook, MDChief Medical AdvisorSummerville Medical CenterNancy B. Stroud, MDChief of Medical StaffTrident Health SystemBetter ServicesFOR REFERRING PHYSICIANS IN 2009TridentHealthSystem.comIn 2009, we improved service andcommunication with our referringphysicians. And we’re not done yet;the entire team at Trident HealthSystem will continue to work withreferring providers to improve allaspects of communication in 2010.We launched our Consult-a-Nurse®health care referral program in early2009. During the latter part of the year,we provided more than 880 physician referrals to residents ofour communities.Just recently, we introduced a new “Lunch with the Doctor”lecture series. During a very short timeframe, and with yourhelp, we have provided community education to more than545 participants.Through 862 visits to your offices in 2009, we have respondedto your concerns, introduced new physicians and new programsto you.Would you please contact me with questions or suggestionsabout ways we can help our referring community providers?Thank you for your continued support and partnership withTrident Health System,Miriam Stanleymiriam.stanley@hcahealthcare.com843-847-3462Medstaff Communications MARCH 2010 11

Consult-A-Nurse®Just One Call Away.Looking for a physician for yourself or a loved one? Take advantageof our FREE physician referral service. Each of the 400 board certifieddoctors on staff at Trident Health System meets our uncompromisingstandards for training, experience and commitment to excellence. Andeach is backed by the latest technology and a wide range of services.Find a doctor who accepts your insurance, is conveniently located nearyou and who provides the service you need by calling Consult-A-Nurse;available 24/7 by calling 843-797-3463 (FIND).You can also register for classes, get health information or speak witha nurse about your health at no charge.Consult-A-Nurse ® 843-797-FIND (3463) | TridentHealthSystem.com

Clinician Portal UpdateTrident Health System has deployed an enterprise-wideelectronic health record (EHR) called hCare. A key componentof hCare is having a comprehensive, single view of a patient’sclinical data. The hCare Clinician Portal provides an electronicaccess point for physicians to view patient information,clinical data and access clinical information systems through auser-friendly, intuitive interface. You should be able to locateinformation quickly because all linked clinical data is accessiblefrom one location. In addition, you can also set preferencesfor how you’d like information and data to be displayed.The core hCare Clinician Portal integrates with MEDITECHto provide you with a single source of clinical data. Laterenhancements will include integration between the portal andadditional clinical systems to include: radiology and cardiology,imaging and reports, EKGs, fetal monitoring and CVIS.By the third quater, the portal will also include electronicsignature to allow you to sign off on reports.Through Simplified Remote Access (SRA), you no longer needto use tokens (or SecurIDs) to access the system. You willbe able to log in with a username or 3-4 ID and passwordthrough HCA’s secure Web site www.southatlantichcare.com,which will automatically log you into the portal.The hCare Portal can also be made available on your smartphone. HCare Mobility allows you to see patients’ records andclinical results on your smart phone from any location whereyou can receive cellular reception. Recently, the iPhone hasbeen added to the approved list of devices. The Blackberrycompatible version is expected for later this year. However,if you have a Palm OS or Windows OS phone, hCare Mobilitymay be compatible. For a list of compatible devices, pleasecontact your Physician Support Coordinator listed below.For access to hCare Portal or hCare Mobility, you will need tohave a user account set up and an assigned 3-4 user ID. Yourpassword will be the same for all three systems. However,in order to meet security standards, your password mustbe alphanumeric and contain at least seven characters, onenumber and one uppercase letter.To learn more about training opportunities and user set-upsessions for you or your staff, contact Janel Paulk MBA, PMPat 843-847-4837, Janel.Paulk@HCAhealthcare.com or JodiMadigan at 843-647-9910, Jodi.Madigan@HCAhealthcare.com.Trident Health System NursesReceive Certification through Grant FundAt Trident Health System, 38 local nurses have receivedcertification through the State of South Carolina IncumbentWorker Training Grant. Certification is a component forRegistered Nurses to express their dedication and commitmentto professional development.“In addition, certification contributes to improved patient safety,and indicates that a nurse is qualified and competent in his orher specialty area by meeting rigorous requirements to achieveand maintain this expert credential,” said Robin Phillips, staffdevelopment director for Trident Health System.The nurses who received this recognition from the AmericanAssociation of Critical Care Nurses, the American Nurse’sCredentialing Center and the Academy of Medical SurgicalNurses include:• CCRN – Critical Care Registered NursePatricia Holland, Amanda McNulty, Brandy Dempsey,Mary Gurganious, Julie David, Jessica Kruael, Leslie Williams,Auryelle Ascue, Erin Brister, Gail Dziamniski, Lisa Haltiwangerand Rachel Roxbrough.• PPCN – Progressive Care Certified NurseMargaret Ratcliff and AnnaLiza Timbol• BC – Board Certified Medical Surgical NurseEmma Ashcroft , Scott Bates, Kim Borgman, Jamielynn Droze,Stacey Godwin, Ashley Greenwalt, Jennifer Infinger,Sally Kredich, Mary Linder, Sara Martin, Kathy Sanders,Angela Stone, Beth Wallace and Beth Wilson• CMSRN – Certified Medical Surgical Registered NurseKatherine Blackburn, Lisa Duesterhaus, Melanie Godfrey,Opal Lord, Tamara Matthews, Patricia McGaskill, Colleen O’Neil,Dena Runyon, Jennifer Smith and Patricia Stone-BurbageTridentHealthSystem.comMedstaff Communications MARCH 2010 13

14 Medstaff Communications DECEMBER 2009 TridentHealthSystem.com

APRIL 2010 Medical Staff Services 843-847-4946Sunday Monday Tuesday Wednesday Thursday Friday Saturday1 234 5 6 12:00pm 7 7:00am 8 5:30pm 9 12:00pm 10EasterTumor Board Café AClinical Care ReviewConf. Room11 12 13 7:00am 14 7:00am 15 1:00pm 16 7:30am 17IRB Comm. Boardroom8:00amER/TraumaCafé A12:00pmTumor BoardCafé A18 19 20 7:00am 21 8:00am 22 23 2425 26 5:00pm 27 12:00pm 28 7:30pm 29BioethicsCafé AMed ExecBoardroom12:00pmTumor BoardCafé A5:30pm Dept Mtgs*6:30pm Qtrly Staff **Tumor BoardCafé AClinical EffectivenessCafé AInfec ControlCafé A5:30pmCritical CareCafé APerinatal M&MCafé ACredentialsBoardroomPatient SafetyCafé B30“New Drug Update”by Marlea Wellein,PharmDCafé AUtil MgmtResource MgmtConf RoomMedical Executive Committee ReportThe following actions were approved bythe Medical Executive Committee andthe Board of Trustees from November2009 through January 18, 2010. All currentpolicies are located on the Trident HealthSystem Intranet, or please contact TerriCoburn, director of medical staff services,at teresa.coburn@hcahealthcare.com or at843-847-4559 for a copy.• Revision of Delineation of Privileges: The Departmentof Medicine and the Department of Women’s and Children’sServices, along with the Credentials Committee, MEC andBoard of Trustees approved revisions of the followingdelineation of privileges:1. Emergency Medicine2. OB/GYN3. Pediatrics / Neonatology4. Certified Nurse Midwife• Internal Problem Resolution Policy: This policy clarifiesguidelines to be used by Medical Staff Leadership,and appropriate documentation, when holding informalconversations with Medical Staff membersregarding complaints in an attempt to rectifypotential disciplinary situations prior to theinitiation of formal actions being taken by the MEC.•MD Co-Signatures on APP Orders: Increased the timerequirement for sponsoring physicians to cosignAdvanced Practice Professionals (APP), including PAs,NPs and CNMs, orders from 24 to 48 hours.TridentHealthSystem.comMedstaff Communications MARCH 2010 15

Trident Health System9330 Medical Plaza DriveCharleston, SC 29406