medical staff October 2014NEWSLETTER volume 52, issue 10 Inside this issue: From the President Flu Season 2014: "Without feelings of respect, Vaccinate or Wear From the President 1, 5-6 what is there to distinguish a Mask Flu Season 2014: Vaccinate 1 men from beasts?" or Wear a Mask Confucius - 551BC to 479BC From David Man, MD, Chair, Infection Control Committee Summary of the Minutes 2-4 "If we are peaceful, From the Health 7 If we are happy, The Hospital’s Influenza Vaccination Science Library we can smile and blossom Plan was designed in response to like a flower, an advisory issued by the Pasadena From Physician Informatics/IT 8-9 and everyone in our family, Public Health Department under our entire society, the authority of §120175 of the IT Physician Champion 9 will benefit from our peace." CA Health and Safety Code. In Vivity Message from President 10 December 2013, the Director or- Thich Nhat Hanh, 1978 - Monk, Zen Master and CEO, Steven A. Ralph dered the Hospital to implement a plan to prevent the transmission Physician’s Disruptive Behavior – Celebrating Milestones 10 of influenza virus to patients Part 2 including the provision of free Save the Date 10 flu vaccination to all healthcare At Huntington, there were 229 incident CDI Corner 11 report cases filed at the Medical Staff workers, along with measures to Office from May 2013 to April 2014, among be taken for those who decline to Outpatient Nutrition Services 12 which, 115 cases (50.2% from total) are be vaccinated. The Plan requires Huntington Bike Club 12 reports against physicians’ inappropriate healthcare workers who decline the vaccine wear a surgical mask behavior. On the average, there were CME Corner 13 10 incident reports on disruptive physician when they are in within three (3) behavior per month. All these behaviors feet of patients during the in- Medical Staff Services Corner 13 are seriously dealt with by all physician fluenza season. The definition Medical Staff 14 leaders. A formal investigation with due of healthcare workers includes Meeting Calendar process could be warranted followed by physicians and all healthcare actions ranging from no action, warning, providers who have direct con- CME Calendar 15 counseling, requesting apology to be tact with patients. The influenza made, referring to the Physician Well Being season has been defined as Committee, initiating corrective action November 1 – March 31. Medical according to the Medical Staff Bylaws, Staff members must provide Flu shots are coming! and imposing summary suspension. documentation of vaccination Keep an eye out for or will be offered flu vaccination more information. Managing disruptive physicians as noted at the hospital. Please watch for by many health providers requires planning more information to come. continued on page 5 medical staff newsletter Board Meeting As provided by the Bylaws of the Governing Body and as the designated sub-committee of the Governing Board the following items were presented and approved by the Medical Executive Committee of July 24 and September 8, 2014 and by the Governing Board on September 25, 2014 Administrative Reports Announcements The following raffle tickets were selected • An exclusion to the Board Certification for the July and August 2014 meeting requirements has been recommended attendance awards: for members of the new “Associate” staff category. • Kaveh Najafi, DO – Trauma Committee • A recommendation to decrease the • Jonathan Tam, MD – Obstetrics & Patient activity requirements for Active Gynecology Committee Staff members from 20 encounters • George Tang, MD – Orthopedic Section every two years to 12 encounters every two years which would include • Kathy Walker, MD – Obstetrics & admissions to observation status as Gynecology Committee well as inpatient status. Medical Staff Bylaws Amendments • Modification of the entire section addressing “Disaster Privileges” to The recent amendments to the Medical meet regulatory requirements. Staff Bylaws have been recommended • Addition of specific qualification for for approval by the Medical Executive Nominees for President and President- Committee and the voting members Elect (having served as a member of the Medical Staff. The proposed of the Medical Staff Leadership in amendments will be forwarded to the the capacity of Department Chair, Board for final approval. Credentials Chair or Chair-elect, Quality Management Committee The following is a summary of the proposed Chair or Chair-elect, Section Chair or revisions: Medical Staff Secretary/Treasurer). • Addition of an “Associate” staff category • Streamlined the election process for to consist of practitioners who want Department Chairs. The slate from the to maintain Medical Staff membership Department Nominating Committee but who do not meet or maintain the will be presented once to the Depart- levels of hospital patient care activity mental Committee to solicit additional to qualify for membership in other staff nominees as opposed to presenting categories. Practitioners appointed to the slate four times. the Associate Staff category will not • Addition of the election process and have clinical privileges. timeframes for Section Chairs. continued on page 3 2 medical staff newsletter Medical Staff Rules & Medical Staff Appointments Regulations Amendment • Credentials Committee Description Babakhanian, Zaree, MD Removal of the requirement that the Gastroenterology Credentials Committee must review 50 Bellefontaine Street Suite 409 requests for Temporary Privileges. (to Pasadena, CA 91105 be consistent with the requirements 626-817-9149 (office) outlined in the Medical Staff Bylaws) 626-817-9150 (fax) • Cancer Committee Description Chang, Elisa, MD Revised the reporting structure of the Infectious Disease Cancer Committee. All reports will be 959 E. Walnut Street Suite 120 submitted to the Quality Management Pasadena, CA 91106 Committee. 626-795-5718 (office) 626-795-8603 (fax) Departmental Rules & Regulations Amendment Chu, Kevin, DO Family Medicine Surgery Department Rules & Regulations Lotus Clinical Research The following amendment has been 100 W. California Blvd. recommended to the Surgery Department Unit 25 Rules and Regulations: Pasadena, CA 91109 626-397-2396 (office) Section 10 – ELECTIVE SURGERY 626-397-2165 (fax) In all instances of elective surgery with Hertzog, Hans Dieter, MD the exception of Cardiac Surgery the Ophthalmology Fellow surgeon of record must be physically Doheny Eye Center on Huntington Hospital Campus before 622 W. Duarte Road anesthesia is induced. For patients under- Suite 101 going elective cardiac surgery anesthesia Arcadia, CA 91007 may be induced if a Cardiac Fellow who 626-254-9010 (office) 626-254-9019 (fax) is either boarded in or eligible to take board examination for General Surgery is Hou, Jack, MD on the Huntington Hospital Campus and Urology there is a designated back-up cardiac 600 N. Garfield Avenue surgeon available, and the perfusionist Suite 308 is physically on the hospital campus.” Monterey Park, CA 91754 626-288-0889 (office) Privilege Sheet 626-288-1129 (fax) Thoracic Surgery – Addition of criteria and Kang, Kiandra, MD privileges for TAVR Pediatrics 50 Alessandro Place Please go to SharePoint Medical Staff Suite 200 Pasadena, CA 91105 Services Board Approved→ Items 2014 626-696-1234 (office) and select→ September 2014 to see: → 626-696-1230 (fax) • Administrative Policies and Procedures • Miscellaneous Items • Department Specific Policies and continued on page 4 Procedures volume 52, issue 10 3 medical staff newsletter Karandikar, Kalyani, MD Savagian, Amy, MD Anesthesiology Internal Medicine Pacific Valley Medical Group 800 Fairmount Avenue 100 W. California Blvd. Suite 210 Anesthesia Department Pasadena, CA 91105 Pasadena, CA 91109 626-381-9598 (office) 626-628-3132 (fax) Kaufmann, Sonia, DO Family Medicine Sims, Jessica, MD Huntington Medical Foundation Emergency Medicine 10 Congress Street 100 W. California Blvd. Suite 208 Emergency Department Pasadena, CA 91105 Pasadena, CA 91109 626-792-2166 (office) 626-397-5111 (office) 626-795-0740 (fax) 626-397-2981 (fax) Lee, Olivia, MD Singh, Gagandeep, MD Ophthalmology General Surgery Doheny Eye Center City of Hope 622 W. Duarte Road 1500 E. Duarte Road Suite 101 Duarte, CA 91010 Arcadia, CA 91007 626-359-8111 (office) 626-254-9010 (office) 626-301-8113 (fax) 626-254-9019 (fax) Yang, David, MD Lewis, Aaron, MD Interventional Cardiology General Surgery HealthCare Partners 1333 S. Mayflower Avenue 988 S. Fair Oaks Avenue 2nd Floor Pasadena, CA 91105 Monrovia, CA 91016 626-799-4194 (office) 626-359-8111 (office) 626-799-4913 (fax) 626-408-3911 (fax) Yung, John, MD Lu, Kenneth, MD Internal Medicine Ophthalmology HealthCare Partners Doheny Eye Center 440 E. Huntington Drive 622 W. Duarte Road Suite 200 Suite 101 Arcadia, CA 91006 Arcadia, CA 91007 626-405-7260 626-254-9010 (office) 626-254-9019 (fax) Ruhge, Kevin, MD Plastic Surgery Medical Staff Resignations 50 Alessandro Place • Kim, David D., MD – Obstetrics & Suite 300 Gynecology – effective 8/31/14 Pasadena, CA 91105 626-397-9095 (office) 626-397-9099 (fax) 4 medical staff newsletter From the President continued from page 1 from the health care organization to establish which have been left unresolved or untreated appropriate strategies and policies as since childhood resulting in diminished opposed to responding to a crisis when it self-esteem and confidence. In addition, emerges. Failure to institute appropriate physical illness can directly or indirectly procedures and policies is known to lead contribute to a physician’s disruptive to organizational