The University of Toledo Board of Trustees
Minutes
The University of Toledo Board of Trustees
Clinical Affairs Committee Meeting
May 13, 2014
Committee Chair Mr. Gary P. Thieman was present. Other Trustees who attended included Mr. Seven M. Cavanaugh, Dr. S. Amjad Hussain, Ms. Susan F. Palmer, Ms. Sharon Speyer and Mr. Joseph H. Zerbey, IV who were all appointed by Mr. Zerbey as voting members of the Committee for this meeting. Student Trustee Dr. Laura E. Halpin attended this meeting and University Council Representative Ms. Marlene Porter was present. Additional attendees included Mr. Dan Barbee, Ms. Lauri Cooper, Ms. Karen Hoblet, Dr. Lloyd Jacobs, Dr. Ronald McGinnis, Mr. David Morlock, Mr. Peter Papadimos, Dr. Carl Sirio, and Ms. Joan Stasa. /ATTENDANCE
The meeting was called to order at 7:30 a.m. by Trustee Thieman in the Faculty Club Room at the Radisson Hotel on the Health Science Campus. / CALL TO ORDERMr. Thieman requested a motion to waive the reading of the minutes from the April 15, 2014 Committee meeting and approve them as written. A motion for approval was received from Trustee Palmer, seconded by Trustee Hussain, and approved by the Committee. / APPROVAL OF MINUTES
Mr. David Morlock, Executive VP Finance and Administration/UTMC CEO, reported that the Dashboard Report for the clinical enterprise is a work in progress particularly around long term and short term goals and how they should be displayed/reported. Principles applied in the development of the report were aimed at creating a balanced Dashboard around patient safety and quality, employees, and financials. Future reports will be focused across these three domains, which will include three in each group, as well as metrics. / DASHBOARD REPORT
Dr. Ronald McGinnis, Interim Dean for the College of Medicine, reported that the Academic Health Center Corporation was formed in 2010 between The University of Toledo and ProMedica to foster collaboration in research and medicine. The Corporation had a great beginning but, in recent discussions from both sides, it was recommended that they construct a Council to address the current problems in moving forward. The first meeting of this Council was held on May 6, and some excellent recommendations and conversation occurred in moving forward with education and research. Other individuals have been identified to be added to the Council membership. Dr. Jacobs reminded the Committee that a ProMedica Resolution was discussed at the February 11 Clinical Affairs Committee meeting to dissolve the Academic Health Center Corporation, which the Trustees recommended Dr. Jacobs not sign. Dr. Jacobs stated that ProMedica could pass this Resolution without his signature, especially since he is the only person who has not yet signed it. He was in agreement that now is the right time to sign. After further discussion, the Committee concurred with the decision and asked that the meeting minutes reflect that Dr. Jacobs would sign the ProMedica Resolution within the next couple days. / ACADEMIC HEALTH CENTER STATUS
Dr. Carol Sirio, VP Medical Affairs/Chief Operating and Clinical Officer, provided the Committee with the Ohio Department of Health (ODH) Preliminary Report on the radiation protection inspection conducted April 28-30, 2014. He stated that the purpose of the site visit is to ensure continued compliance with all ODH regulations relating to radiation safety. These surveys are conducted by the radiation safety arm of the ODH every other year, alternating with isotope management for nuclear medicine. Dr. Sirio reported that facilities are required to submit correction action plans within 30 days for any citations. Sanctions range from no required action to immediate suspension of all radiation services. UTMC preparation and responses for this visit were reviewed with the Committee. Seven findings were discussed with the Trustees and written notification must be received within 30 days that all findings have been resolved. Dr. Sirio reported that all findings were resolved at the time of the visit or shortly thereafter.
Mr. Morlock updated the Committee about the tri-annual visit of the Joint Commission. He reported that the senior management team is going through a structural process that touches on all aspects of the hospital and identifying strengths and weaknesses. The Joint Commission is a great way to keep the hospital focused over a three-year period to make sure all is done right. Mr. Morlock stated that by addressing “the now,” is a better way to keep building and moving forward with improvement in real time. Traditionally, UTMC has done very well with these accreditation visits. It has been reported that the Joint Commission has come under pressure over the last few years to ramp up their review process, particularly in the area of facilities. / ACCREDITATION UPDATES
In follow up to the Institute for Healthcare Improvement: The Role of the Board in Patient Safety and Quality seminar last month that Trustee Thieman, Mr. Morlock and Dr. Sirio attended in Boston, Dr. Sirio reported that one of the best practices that they learned was the importance of having an educational session periodically. Today’s meeting focused on the New Practitioner Onboarding Process/Re-credentialing: Due Diligence. The following handouts were distributed to the Committee prior to the meeting to assist with the presentation.
· UT Central Verification Office Credentialing Process
· Underwriting in the Credentialing Process: An Overview
· Credentialing Timeline
· Primary Source Verification
· Potential Red Flags
· UTMC Medical Staff Credentialing Summary for New Practitioners/Summary for Re-Credentialed Practitioners
Dr. Sirio discussed in detail the following four processes of the Central Verification Office (CVO) to get a new professional on board:
· UTMC medical staff (clinical privileges)
· UT Physicians credentialing (payors)
· UT Medical Assurance Company (malpractice coverage)
· Faculty Affairs (COM)
Prior to mid-2013, these four processes were separated in time and location. Dr. Sirio discussed the details of how the CVO was designed to incorporate, streamline and improve the process. He discussed the steps to the UTMC credentialing timeline, as well as the primary source verification process. Potential “red flag” issues were identified as adverse, unconfirmed, incomplete or discordant data in any piece of primary source or other components of an application. Modifications to the credentialing process for Allied Health professionals were also explained to the Committee, as well as the bi-annual reappointments of the clinical staff. Dr. Sirio reported that next steps include improved information flow to the Board of Trustees. / MEDICAL STAFF CREDENTIALING PROCESS
Trustee Thieman requested a motion to enter Executive Session to discuss quality reporting and privileged information related to the evaluation of medical staff personnel appointments and quality reporting. The motion was received by Trustee Zerbey, seconded by Trustee Hussain, and a roll call of the Committee was taken by Ms. Stasa: Mr. Cavanaugh, yes; Dr. Hussain, yes; Ms. Palmer, yes; Ms. Speyer, yes; Mr. Thieman, yes; and, Mr. Zerbey, yes. After discussion, the Committee exited Executive Session. / EXECUTIVE SESSION
Mr. Thieman requested a motion to accept and approve the Chief of Staff Report as presented in Executive Session. The Chief of Staff Report included three new medical staff applicants, two new Allied Health professional applicants, 43 Allied Health professional staff reappointments and 13 medical staff resignations. A motion was received from Trustee Zerbey seconded by Trustee Speyer, and approved by the Committee. / QUALITY REPORTING; CHIEF OF STAFF REPORT
With no further business before the Committee, Trustee Thieman adjourned the meeting at 9:00 a.m. / ADJOURNMENT
CHIEF OF STAFF REPORT
May 13, 2014
New Medical Staff Applicants
Joseph J. Rusin, M.D., D.P.M.
Orthopaedic Surgery Service
Courtesy Staff Status
Privileges in Orthopaedic Surgery
Neil E. Saunders, D.P.M.
Surgery Service
Courtesy Staff Status
Privileges in Wound Care & Hyperbaric Center
Michael Walkovich, D.P.M.
Surgery Service
Courtesy Staff Status
Privileges in Wound Care & Hyperbaric Center
New Allied Health Professional Applicants
Leena Hammuda, MSN, CNP
Emergency Medicine Service
Privileges as a Nurse Practitioner
Sponsoring Physician: Kris Brickman, M.D.
Ashley Sheskey, PA-C
Internal Medicine Service
Privileges as a Physician Assistant
Sponsoring Physician: Lorie Gottwald, M.D.
Allied Health Professional Staff Reappointments
Please see attached list.
Medical Staff Resignations
Mirza Baig, M.D.
Urology Service
Effective 04/06/14
Samih Bittar, M.D.
Internal Medicine Service
Effective 07/12/14
William R. Colyer, Jr., M.D.
Internal Medicine Service
Effective 06/30/14
Isam Daboul, M.D.
Internal Medicine Service
Effective 04/06/14
Charles L. Filipiak, M.D., M.P.H.
Internal Medicine Service
Effective 04/06/14
S. Zakir Husain, M.D.
Emergency Medicine Service
Effective 04/06/14
Karl J. Luketic, M.D.
Surgery Service
Effective 04/06/14
Paul Mitch, M.D.
Psychiatry Service
Effective 04/06/14
Robert J. Navarre, Jr., M.D.
Urology Service
Effective 04/06/14
S. John Pappas, M.D.
Emergency Medicine Service
Effective 04/06/14
Joseph J. Rusin, M.D., D.P.M.
Orthopaedic Surgery Service
Effective 04/06/14
Nanette C. Tertel, D.D.S.
Surgery Service
Effective 04/06/14
Jennifer L. Zoll, D.D.S.
Surgery Service
Effective 04/06/14
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