Welcome to St. David’s

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• Welcome to St. Davids
• South Austin Medical Center

New Physician Orientation
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Topics

• WELCOME
• CMO OVERVIEW
• MEDICAL STAFF SERVICES
• HIM AND PHYSICIAN ACCESS
• INFECTION PREVENTION
• CASE MANAGEMENT
• PASTORAL CARE
• NURSING AND PATIENT SERVICES
• TOUR

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Medical Staff Leadership
Chief Medical Officer Al Gros, MD Chief of
Staff Robert Northway, MD Chief of
Staff-Elect Alex Esquivel, MD Secretary
David Savage, MD
Dr. Al Gros CMO, South Austin Medical
Center Office [phone] Mobile (512)
294-7064 Fax [phone] Email
Albert.Gros_at_stdavids.com
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Senior Leadership
Wes Fountain CFO
Todd Steward CEO
Brett Matens COO/ECO
Nikki Sikes Associate Administrator
Sally Gillam CNO
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Sally Gillam

• Chief Nursing Officer
• Worked at SAMC for 22 years with HCA for 24 years

• From Temple, Texas
• Married to Andy sons Kendall and Colby
• Departments include Emergency Services, Women's
  Services, Surgical Services, Telemetry (3S and
  4C), Med/Surg (2C and 3C), Quality, Critical
  Care, ISS, Endo, Outpatient Heart Center, Nursing
  Administration

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Todd Steward

• Chief Executive Officer
• CEO at SAMC starting April 5, 2010 with HCA for
  8 years.

• From Dallas, Texas
• Married to wife Toni daughters Sophia and Anna
• Departments include Human Resources, Surgicare,
  Marketing, Medical Staff and all Senior Managers

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Brett Matens

• Chief Operating Officer
• Worked at SAMC for 8 years with HCA for 12 years

• From Jackson, Mississippi
• Married to Christi daughters Macy Caroline and
  Sarah McClain and son McCord.
• Departments include Cardiovascular Services,
  Plant Ops, Pharmacy, , Physician Relations,
  Radiology, Pulmonary/ Neurodiagnostics,
  Hyperbarics/ Wound Care

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Wes Fountain

• Chief Financial Officer/Ethics and Compliance
  Officer
• Worked at SAMC for 5 years with HCA for 22 years

• From Atmore, Alabama
• Married to Melinda son David and daughter Sarah
• Departments include Accounting, HIM, Materials
  Management, Shared Services Group, Information
  Systems, Ethics and Compliance

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Nikki Sikes

• Associate Administrator
• Worked at SDSAMC since January 2010

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• From Georgetown, Texas
• Departments include Rehab Services,
• Laboratory, Environmental Services,
• Nutrition Services, Spiritual Care,
• Volunteers, Risk Management, Special Projects

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Physician Relations

• The Physician Relations Director is here for
  you!
• To help you get to know the facility, where
  things are and how processes work
• Help you with special requests, issue resolution,
  answer questions
• Help you meet other physicians in the area
• Physician Referral Line
• CME/Grand Rounds

Kathryn Scoblick, Physician Relations
Director 512-816-6113 512-897-0661 (cell)
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Overview of Medical Center
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Core Measures

• AMI (Acute Myocardial Infarction)
• HF (Heart Failure)
• PN (Pneumonia)
• SCIP (Surgical Care Improvement Project)

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SCIP Core Measures

• SCIP INFECTION QUALITY INDICATORS
• Prophylactic Antibiotic Received within 1 Hour of
  Incision (2 hrs for Vancomycin or
  fluoroquinolones)
• Recommended Prophylactic Antibiotic Selection for
  Surgical Patients
• Prophylactic Antibiotics Discontinued within 24
  Hours After Surgery End Time (48 hrs for Cardiac
  Surgery)
• Cardiac Surgery Patients with Controlled 6 A.M.
  Post-op Serum Glucose (lt200 mg/dL) post-op day 1
  2
• Surgery Patients with Appropriate Hair Removal
  (no razors)
• Urinary Catheter Removed on Post-op Day 1 or 2
• Surgery Patients with Perioperative Temperature
  Management (active warming intraoperatively or
  one body temp. gt 96.8o within 30 min. prior to 15
  min. after Anesthesia End Time)

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SCIP Core Measures

• SCIP VTE QUALITY INDICATORS
• Recommended Venous Thromboembolism Prophylaxis
  Ordered anytime from hospital arrival to 24 hrs
  after Anesthesia End Time
• Recommended Venous Thromboembolism Prophylaxis
  within 24 Hours Prior to Anesthesia Start Time to
  24 Hours After Anesthesia End Time
• SCIP CARDIAC QUALITY INDICATOR
• Surgery Patients on Beta Blocker Therapy Prior to
  Admission Who Received a Beta Blocker During the
  Perioperative Period
• SCIP HEART FAILURE QUALITY INDICATOR
• ACEI or ARB Prescribed at Discharge for Patients
  with lt40 LVEF

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Governance Peer Review
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BOT
MEC(Chief of Staff)
Action
MCEC (Chief Medical Officer)
Rapid Review Team
Egregious Event(incl. Sentinel Events,
In-House Physician Quality Issues)
Medical Director / Vice Chief of Staff
Department
Triage(Med Dir PIC)
Clinical Issue Competence,Core Measures,
OutcomesIndicator 'Fall-outs'
Compliance / Social Issue(i.e., Complaints,
Non-compliance,Behavior)
Physician PI Coordinator
Variance Reports
Prof. Liability Actions
Patient Complaints
Sentinel Events
Failed Measures
Employee Complaints
Fall-out from Screens
Compliance Issues
Approved by MEC 2/08
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www.sahmedweb.com
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Educational Programs

• Medical Grand Rounds
• Ethics Credit
• CPR/ACLS Education
• Tumor Board Conferences

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Medical Staff Meetings

• Monthly meeting calendars are posted on the
  MedWeb site, faxed, and e-mailed to members.
• There is a 50 meeting attendance requirement for
  Active members in the departments of Medicine,
  Surgery, and Cardiology.
• There is a 25 meeting attendance requirement at
  the quarterly General Medical Staff meetings for
  all Active members.

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Credentialing and Medical Staff Services

• St. Davids and HCA structure regarding
  credentialing
• Standardized market forms
• Individual facility approvals
• Qualification Board certification or obtained
  within 5 years of initial appointment.
  Certification must be maintained.

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Physician Health

• Forms of Impairment
• Alcoholism and other drug use
• Other psychiatric disorders
• Addressed by the TCMS Physician Health and
  Rehabilitation committee

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Health Information Management

• Hours of Operation
• Monday-Friday 800 am to 430 pm.
• Dictation
• Timeliness
• Requirements

Electronic Health Record and Chart Completion
for Physicians
Select Dictation
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Health Information Management

• Notification Process
• Deficiencies color coordinated in portal for your
  convenience
• BLUE Incomplete 0-15 days
• RED Warning 16-29 days
• YELLOW Delinquent 30 days
• Notification and Suspension letters are faxed to
  physician offices every Wednesday, as a courtesy
  only.
• Coding Query Process

Process Incompletes by selecting Process or
Process All
Queries are presented as Missing Text deficiencies
Press the PgUp key or click Page 1 to reference
the coding question
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Electronic Medical Record (EMR)
For questions about Incomplete Deficiencies-
please contact Health Information Management at
816-6308 For questions about Portal or access-
contact the help desk at 901-HELP or Ryder Bodoin
at 632-1618

• What is the Clinician Portal?
• Physician electronic access point for clinical
  information
• Integrated systems
• Simplified sign-onone username, one password
• Simplified Remote Access no more tokens
• User-friendly, intuitive interface
• Access to complete patient list
• Resources section
• Clinical references
• Training modules
• Facility-specific information
• Accessible from hospital, home, office, or while
  traveling

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Clinical Portal-Enhancements

• Electronic signature and record
• Post-discharge records available electronically
• These new features are available via Horizon
  Patient Folder (HPF)a new enabling technology
  supported by the Health Information Management
  Shared Services Initiativeand will be available
  from within the clinician portal.
• What you need to know
• Decide which type of training will work for you
• Web-based training (WBT)
• One-on-one sessions
• Or a combination of training methods
• Collect all of your clinical system passwords
• Plan to attend a training session to set up your
  account

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Meditech(Clinical Patient Care System)

• PCI (Patient Care Inquiry) LAB, RAD, PATH and
  HIM reports
• Demographic/Insurance Info.
• Access from hospital, office or home
• Physicians MUST write Consult Orders so
  consulting physician will have access to the
  patient
• Electronically sign dictated reports remotely
• Software provided by the hospital for remote
  installation
• Physician Help Desk 901-4357 (HELP)
• Obtain Access, Schedule Training, Report
  Problems
• 24/7 service

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Cancer Registry

• Cancer Registry
• Cancer Committee
• Tumor Boards
• Patient Care Evaluation Studies

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Case Management Department

• In existence at SAMC since early 1996
• Drives the discharge process
• Coordinate the care across the continuum,
  services and resources for patients/families
• Education of patient/family regarding continuum
  of care
• Conduct concurrent insurance reviews
• Plans and implements discharges with the
  interdisciplinary team
• Consists of both RNs Social Workers

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Your Role in Case Management

• Interqual Criteria
• Code 44
• Admit to Case Management
• Keeping the case manager informed of plans for
  the patient
• Communication with case manager is key to timely
  discharge/movement to next level of care
• Daily discharge of patients by 1100 a.m.
• Case Management
• Office. 816-6260
• Blackberry. 517-4342

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Spiritual Care Chaplain Services

• SDSAMC employs professional chaplains
• Available 24/7
• Provide information and assistance with Advance
  Directives
• Bioethics Committee is co-chaired by a physician
  and chaplain. Meets quarterly.
• Responsible for bioethical consults, edcuation,
  and policy recommendation.
• Texas Organ Sharing Alliance
• Digital Pager 512-205-1881, Office 512-816-7198

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Admissions Central Scheduling
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One Call Patient Transfer Center
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• Thank you for taking the time to view this
  orientation program. We want your experience at
  South Austin Medical Center to be the best in the
  city and we want to be your 1 facility of choice
  for your patients.