Highland Hospital, John George Psychiatric Hospital, Fairmont Hospital, Ambulatory Wellness Medical Staff Medical Executive Committee (MEC) Report to the Quality Professional Services Committee of the Board October 28, 2018 A. Credentials and Privileges Detailed discussion of credentialing and privileging activity occurred in a Closed Session Meeting of the QPSC. The Medical Executive Committee (MEC) reviewed and recommended approval for Medical Staff membership and clinical privileges as follows: • 10 Initial Appointments • 44 Temporary Privileges • 6 Reappointments • 1 Modification of Privilege • 12 Voluntary Resignations • 1 vRad Initial Appointment • 3 vRad Reappointments Additional Credentialing Actions: Medical Staff Provider Clinical Privileges (Exhibit 1) The following multi-facility forms were reviewed and approved. • OB/GYN Multifacility • Psychiatry Multifacility B. Professional Services/ Contracting The report continues to be presented. C. Quality and Outcomes Improving Patient Throughput • Surge Red / Patient flow o Improving Patient Throughput to Mitigate Surge Process o Patient Flow and System Utilization Strategies • AHS Core True North Metrics Dashboard FY201 o Dashboard was presented; reporting includes all 13 metrics • SAPPHIRE Report- Electronic Health Record o Monthly updates for project and ongoing systemwide efforts for standardization and alignment Page 1 of 2 Alameda Health System MEC Report to the Board of Trustees October 28, 2018 D. Other Issues • Alameda Health System, San Leandro Hospital, Alameda Hospital Medical Executive Committee Retreat, October 13, 2018 o Medical Staff Reporting Obligations, Strategies of Managing Disruptive Behavior, Care for the Caregiver, Wellness, Medical Staff Leadership Retreat objectives: Apply knowledge of ethics and law to medical staff governance Recognize the fundamental of medical staff leadership Assess the legal and ethical dilemmas if actions that can lead to license suspension or revocation/restriction of privileges Identify strategies for managing disruptive behavior • Orthopedic Department Annual Report What is quality in orthopedics? o Standard metrics are 30/90-day readmissions o Post op infections along with standard medical complications o Readmission rate 0.3%. Better than national average Orthopedic surgeons see another category of quality o Functional outcomes o Return to work o 5/10/15 year revision rates o Narcotic use/abuse • Wellness Program Individual-Free, Confidential, Flexible Schedule, In Person or Phone, Evenings Initial data from 8/8/2018-10/5/2018 o Total scheduled visits 48 Medical Staff Medical Executive Committee (MEC) Report to the Quality Professional Services Committee of the Board October 19, 2018 A. Credentials and Privileges Detailed discussion of credentialing and privileging activity occurred in a Closed Session Meeting of the QPSC. The Medical Executive Committee (MEC) reviewed and recommended approval for Medical Staff membership and clinical privileges as follows: • 5 Initial Appointments • 2 Proctoring Activity • 5 Resignations • 4 vRad Delegated Credentialing Additional Credentialing Actions: Medical Staff Provider Clinical Privileges (Exhibit 1) • Approval of Psychiatry Multifacility privileges B. Professional Services/ Contracting The following items are notable with regards to Professional Services/Contracting: • A new community general surgeon did not receive a contract with AHS to provide ED call coverage. This will discourage community surgeon involvement with the hospital. • Discussion was carried out with Dr. Jamaleddine and Dr. Yasumoto regarding the availability of certain radiologic procedures at San Leandro Hospital. The system is working towards a process for performance of those procedures. C. Quality and Outcomes • The FY 2019 True North Metric Dashboard was reviewed. • San Leandro Hospital hosted an AHS Simulation Center open house this month and this was well received. • Random chart audit demonstrated > 90% compliance with the moderate sedation policy and procedures. • Medical Staff Office continues to gather flu vaccination documentation for all providers. • The OPPE corrective plan and other plans pertaining to the Joint Commission Survey were approved. • Total surgery volume remains steady when compared with prior years and our endoscopy volumes demonstrated an increase. D. Other Issues • The rehab move to San Leandro Hospital and its implications was presented by Dr. Jamaleddine and was discussed at length. The Medical Staff urges the Board not to rush to a decision at the November meeting, and to allow more time to obtain input from the medical staff and to assess the potential ramifications. Page 1 of 1 Medical Staff Medical Executive Committee (MEC) Report to the Quality Professional Services Committee of the Board October 19, 2018 A. Credentials and Privileges Detailed discussion of credentialing and privileging activity occurred in a Closed Session Meeting of the QPSC. The Medical Executive Committee (MEC) reviewed and recommended approval for Medical Staff membership and clinical privileges as follows: • 2 Initial Appointments • 8 Reappointments • 1 Proctoring Activity • 2 Resignations • 1 vRad Telemedicine Initial Appointment • 3 vRad Telemedicine Reappointments Additional Approved Credentialing Actions: Medical Staff Provider Clinical Privileges (Exhibit 1) • Provider Clinical Privileges o OB/GYN Multifacility o Psychiatry Multifacility B. Professional Services/Contracting Non-physician contracts continue to be reported. C. Quality and Outcomes Improving Patient Throughput • Patient Transfers o Recommendation to have multidisciplinary taskforce to develop and assess the current process key metrics/indicators for performance monitoring including the appropriateness / levels of care and availability of resources Specialty Coverage • GI • Urology D. Other Issues Page 1 of 1 Obstetrics and Gynecology Delineation of Privileges Applicant's Name: Instructions: 1. Click the Request checkbox to request a group of privileges such as Core Privileges or a Special Privileges. 2. Uncheck any privileges you do not want to request in that group. 3. Check off any special privileges you want to request. 4. Sign form electronically and submit with any required documentation. Required Qualifications Basic Education M.D. or D.O. Education/Training Completion of an ACGME or AOA accredited Residency training program in Obstetrics and Gynecology. Continuing Education Applicant must have [25] Category I CME credits per year (waived for applicants who have completed residency training during the previous 24 months). OR Applicant must be active in the MOC (maintenance of certification) program in obstetrics/gynecology. Certification Current certification or active participation in the examination process leading to certification in Obstetrics and Gynecology by the American Board of Obstetrics and Gynecology or in Obstetrics and Gynecology by the American Osteopathic Board of Obstetrics & Gynecology. Clinical Experience Recent clinical experience for initial appointment and reappointment is defined as having (Initial/Reappointment) performed at least 100 clinical services, procedures, or clinical consultations in a TJC-accredited hospital or hospital-based ambulatory setting in the last two years. The variety and type of clinical services must be sufficient to cover the scope of obstetrics/gynecology privileges requested. Additional Qualifications 1) Provider must submit documentation of successful completion of an AWHONN or ACOG for Providers Requesting endorsed Fetal Heart Monitoring class that includes current NICHD nomenclature prior to, OR for Obstetric Privileges within 3 months of date of initial appointment and annually thereafter. All documentation will be reviewed by the Department Chair of Obstetrics and Gynecology. AND 2) Provider must submit documentation of successful completion of Baby Friendly training prior to, OR within 6 months of date of initial appointment. All documentation will be reviewed by the Department Chair of Obstetrics and Gynecology. Published: 10/12/2018 Obstetrics and Gynecology Page 1 of 9 [applicant] Core Privileges in Gynecology Description: Evaluate, diagnose, provide consultation, treat and provide surgical and non-surgical management of reproductive health and pregnancy of female patients. Request Request all privileges listed below. AHS Core AH Click shaded blue check box to Request all privileges. Uncheck any privileges you do not want to request. - Currently granted privileges Admit to inpatient care or other level of care Perform history and physical examination Evaluate, diagnose, provide consultation and non-operative management of reproductive health and genitourinary system, including non-surgical treatment of injuries and disorders of the mammary glands. Moderate Conscious Sedation in Adults (current ACLS certification required) Procedures Minor GYN procedures including but not limited to: IUD insertion and removal, endometrial biopsy, Word catheter placement, and insertion and removal of contraceptive implants. Paracervical or pudendal block Marsupialization or excision of Bartholin's cyst or abscess Soft tissue biopsy of the genital-urinary tract or incidental biopsy of other lesions encountered in the course of a gynecologic procedure Simple vulvectomy Hymenotomy Dilation and curettage Dilation and evacuation (2nd trimester) Colpotomy, culdocentesis Colpocleisis Colposcopy Hysterectomy, abdominal, total or subtotal with or without BSO Hysterectomy, vaginal, with