November 2011 Volume 59, Number 11 It’s now about a month since the Joint Commission visited us for our triennial survey. Having been through a few of them now, I must say it is a very strange experience. First, because of what is at stake (the hospital’s ability to participate in the Medicare Program) no matter how many surveys we’ve been through before and passed, there is always a high degree of anxiety. The process feels somewhat akin to going for one of those Executive Physicals. It’s been 3 years since your last check up which went pretty well. You’re feeling reasonably well. As far as you know, all of your body parts are functioning the way they should. You think you’re OK, but the uncertainty is nerve wracking. You wonder what the examiners will be like. Will they be nice, or mean, or even weird? Ultimately, will they corroborate your sense that you’re alright, or will they find some life threatening disease? Will you need to take some medication, or will you need to submit to radical sur- gery? Fortunately, our survey went very well. The surveyors were very nice. Of course we were quite skeptical when they told us in their opening remarks that their goal was to work collabora- tively with us, but we soon came to real- ize that was true. They were not looking to play “Gotcha”. In fact, to paraphrase from Sally Fields at the 1985 Oscar presentations, they liked us, they really liked us. I think it’s fair to go so far as to say they were actually impressed by us. They even asked us to post some of our prac- tices on the Best Practice Portal of their website. Still, nobody’s perfect, and they did cite us for several issues. A few of those citations dealt with areas where the Medical Staff plays a key role. They include: 1. Use of prohibited abbreviations. This is an old nemesis and one where we have made a lot of progress, but still we’re all subject to falling into old hab- its every now and then. Specifically, we were cited for two instances of using the abbreviation qd, and one instance where we did not include a leading zero on a decimal. 2. Entries in the medical record must be dated and timed. This is another old nemesis. This includes not only orders but written notes as well. Even a brief written note indicating that you dictated a full note must be dated and timed despite the fact that the dictated note is automatically dated and timed. We did notice that some of our standard forms had a space for a date but not time, and they will be revised. 3. A period of focused evaluation must be implemented for each newly requested privileges. We have good, well defined processes to meet this requirement for procedural based privileges, but our process for non-procedural based privi- leges is not as well defined. 4. Updating of pre-operative H&Ps. It has been our practice to make sure pre-op H&Ps are updated within 24 hours of surgery. As we learned, to be fully compliant, that 24 hour window must start when the patient registers in the hospital the day of their procedure. Up- dates done the evening before in the doctor’s office don’t count. Continued on next page Editors Joan Bromm-DeForge e-mail: [email protected]Jean Flanagan e-mail: [email protected]Elizabeth Leahy e-mail: [email protected]Mitchell Rubinstein, M.D. e-mail: [email protected]INSIDE THIS EDITION: x Meetings/ Conferences x New Appointments x CPOE Newsletter x ChartMaxx Newsletter Feature Stories : x The Valley Hospital hosts Holistic Birth Reunion & Celebra- tion x Health Grades names The Valley Hospital top 100 in America Announcements : x Children’s Concert x 2011 Top Hospitals Survey Kumbaya with the Joint Commission
Transcript
November 2011 Volume 59, Number 11
It’s now about a month since the Joint Commission visited us for our triennial survey. Having been through a few of them now, I must say it is a very strange experience. First, because of what is at stake (the hospital’s ability to participate in the Medicare Program) no matter how many surveys we’ve been through before and passed, there is always a high degree of anxiety. The process feels somewhat akin to going for one of those Executive Physicals. It’s been 3 years since your last check up which went pretty well. You’re feeling reasonably well. As far as you know, all of your body parts are functioning the way they should. You think you’re OK, but the uncertainty is nerve wracking. You wonder what the examiners will be like. Will they be nice, or mean, or even weird? Ultimately, will they corroborate your sense that you’re alright, or will they find some life threatening disease? Will you need to take some medication, or will you need to submit to radical sur-gery? Fortunately, our survey went very well. The surveyors were very nice. Of course we were quite skeptical when they told us in their opening remarks that their goal was to work collabora-tively with us, but we soon came to real-ize that was true. They were not looking to play “Gotcha”. In fact, to paraphrase from Sally Fields at the 1985 Oscar presentations, they liked us, they really liked us. I think it’s fair to go so far as to say they were actually impressed by us. They even asked us to post some of our prac-tices on the Best Practice Portal of their website. Still, nobody’s perfect, and they
did cite us for several issues. A few of those citations dealt with areas where the Medical Staff plays a key role. They include:
1. Use of prohibited abbreviations. This is an old nemesis and one where we have made a lot of progress, but still we’re all subject to falling into old hab-its every now and then. Specifically, we were cited for two instances of using the abbreviation qd, and one instance where we did not include a leading zero on a decimal.
2. Entries in the medical record must be dated and timed. This is another old nemesis. This includes not only orders but written notes as well. Even a brief written note indicating that you dictated a full note must be dated and timed despite the fact that the dictated note is automatically dated and timed. We did notice that some of our standard forms had a space for a date but not time, and they will be revised.
3. A period of focused evaluation must be implemented for each newly requested privileges. We have good, well defined processes to meet this requirement for procedural based privileges, but our process for non-procedural based privi-leges is not as well defined.
4. Updating of pre-operative H&Ps. It has been our practice to make sure pre-op H&Ps are updated within 24 hours of surgery. As we learned, to be fully compliant, that 24 hour window must start when the patient registers in the hospital the day of their procedure. Up-dates done the evening before in the doctor’s office don’t count.
x� The Valley Hospital hosts Holistic Birth Reunion & Celebra-tion
x� Health Grades names The Valley Hospital top 100 in America
Announcements:
x� Children’s Concert x� 2011 Top Hospitals
Survey
���
Kumbaya with the Joint Commission
Kumbaya with the Joint Commission - continued
5. Post operative reports. The Joint Commission requires that a full operative report be submitted upon com-
pletion of the procedure and prior to the patient’s transfer to another venue of care. For our purposes, the full operative report is our Operative Dictation. An exemption to this rule is created when the surgeon writes a procedure note after the operation, in which case the full operative dictation can be completed within guidelines established by the hospital. The rules for the written procedure note are the same as for the full dictation; it must be written after completion of the procedure and before the patient is transferred to another venue of care.
6. Pre-sedation assessment. Although this may sound like an Anesthesia issue, it is not. The requirement is that any time anyone administers sedative medication to perform a procedure, they must specifically document a pre-sedation assessment.
7. Post sedation discharge instructions. This pertains to patients who receive sedation in an out-patient set-ting. Their transfer or discharge instructions must include items relating to having received sedation, not just relating to their underlying medical condition or the procedure performed.
8. Verbal orders must be authenticated (signed) within 48 hours. Although this is true of all orders, it is espe-cially important for verbal Admission Orders because Medicare uses lack of authentication as an excuse not to pay for the admission.
Having received the report, the hospital now must develop plans of action to correct these deficiencies. De-pending on the specific citation, those plans must be submitted to the Joint Commission either within 45 or 60 days. For items involving the Medical Staff, we will be working with Medical Staff leadership to develop some of those plans. Finally, I would be extremely remiss if I did not thank all members of our Medical Staff for their role in making this Joint Commission survey as successful as it was, and for making The Valley Hospital as excellent a hos-pital as it is.
Mitch Rubinstein, M.D. Editor
SAVE THE DATE: MEDICAL STAFF HOLIDAY PARTY WEDNESDAY, DECEMBER 7, 2011 7:00 P.M. SHERATON MAHWAH HOTEL
2011 MD COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE) LUNCHEON DATES
November 18 December 16
The luncheons are from 11:30 a.m. - 2:00 p.m. in the Medical Library.
NOTE: All but the November and December dates are the last Friday of the month. Call Susan Willey/CPOE at ext #3209 Spectra #1393 with questions.
The Valley Hospital Hosts Holistic Birth Reunion and Celebration
The Valley Hospital recently hosted a Reunion and Celebration for parents who had given birth through the Center for Childbirth’s Holistic Birth Program. The event gave parents a chance to socialize with each other and with staff who cared for them during their delivery.
The party drew families from throughout the area and included remarks by program coordinator Heidi Z. Bren-ner, CNM, a certified nurse-midwife and advanced practice holistic nurse; nurses, a midwife and a physician. Families were offered complimentary family portraits.
The event was held on October 1 in the Terrace Room at the hospital.
Shown here (standing, left to right): Claire Grande, Assistant Vice President, Maternal Child Services; Joanne Simonetti, Manager, Labor & Delivery; Esther Nelson, Clinical Shift Supervisor, Labor & Delivery; Margaret Stewart, RN, Labor & Delivery; Heidi Z. Brenner, Holistic Birth Program Coordinator; obstetrician Aiman K. Shilad, M.D.; Martha Dell, RN, Labor & Delivery; Cris Giambalvo, certified nurse midwife; Jaclyn Smith, RN, Labor & Delivery; and Grace Ruth Qarmout, RN, Labor & Delivery.
Shown seated (left to right are): Kristy Florey, of Hewitt, NJ, with Sage; Tammie Schaffer, of Rochelle Park, with Ariana; Amanda Simco, of New Milford, with Hannah; and Leena Bhojawala, of Ho-Ho-Kus, with Sonya.
Valley Gastroenterologist
among Those Honored by Health Care Non-Profit
Mitchell J. Rubinoff, M.D., a gastroenterologist on the Medical Staff of The Valley Hospital, was recently honored by the Bergen Volunteer Medical Initiative, a Bergen County non-profit group that provides free medical care to county residents who are uninsured or do not have the means to pay for their care.
The Bergen Volunteer Medical Initiative, which celebrated the second anniversary of the opening of its Hackensack health center, presented awards to those individuals and companies that have helped the non-profit achieve its mission of providing primary and preventive care based on a “culture of caring.”
Since opening the center in November 2009, over 75 volunteer physicians, nurse practitioners, nurses, social workers, nutritionists, and others have treated over 800 patients with nearly 4,000 medical visits.
In addition to Dr. Rubinoff, those honored at the organization’s annual dinner and reception were: The Brach Eichler law firm; Medco Health Solutions, Inc., and Bernard Weinstein, MPH.
The Members of the Board of Trustees of the Bergen Volunteer Medical Initiative are Michael W. Az-zara, MBA, Chair; Gene Marsh, Vice Chair; Clifford Surloff, MBA,Treasurer; Rolf H. Henel, MBA, Secretary; Samuel A. Cassell, M.D., Founding Chair; Neil Abitabilo; Heidi Ahlborn, M.D.; Deborah Aronson; Rola Baddoura, Ph.D.; Janet Finke; Samuel Heller; Kenneth Herman, Ed.D., ABPP; Gladys Laden, Bergen County Section National Council of Jewish Women; Marilyn Schotz; Charlotte Sokol, M.D.; Bernard Weinstein, MPH; and Carl Wierum, M.D.
More information about the Bergen Volunteer Medical Initiative can be found at bvmi.org.
�
'R�<RX�:DQW�WR�,PSURYH�<RXU�3UDFWLFH·V�6WDQGLQJ�LQ�3XEOLF�5HSRUWLQJ�)RUXPV�6XFK�DV�+HDOWK*UDGHV"�����If so, effective patient documentation is the key.
Valley has contracted with DCBA, a consulting firm that will help the hospital and its physicians improve its clinical documentation.
Two representatives from DCBA -- Cesar Limjoco, M.D., Vice President of Clinical Services, and Kelli Estes, R.N., C.C.D.S. -- are now holding meetings for Valley physicians to introduce this important new initiative to the Medical Staff. Also attending each session will be at least one of Valley’s four, new Clinical Documenta-tion Specialists.
We ask that you please attend one of these sessions. Breakfast and lunch will be available at all 7 a.m. and 12:30 p.m. sessions respectively.
Each presentation will last approximately 20 minutes with additional time available for questions.
These sessions are a CME opportunity.
These presentations are an excellent opportunity for you to understand the reasons why this effort is so impor-tant and how your practice will be affected by these changes.
For more information, please call 201-447-8015.
Please see the schedule of sessions on the next page.
Clinical Documentation Physician Meetings
No RSVP required. Meetings are approximately 20 minutes. Breakfast and lunch available.
For more information on these meetings or Valley’s Clinical Documentation Ini-tiative, please call Mitch Rubinstein, M.D., at 201-447-8015, or John McConnell,
M.D., at 201-447-8614.
The Valley Hospital is accredited by the Medical Society of New Jersey to provide continuing education for physicians.
The Valley Hospital designates this live activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in this
activity.
NOVEMBER 2011 DEPARTMENT MEETINGS Anesthesia Tuesday, November 8 7:00 a.m. CC-7 Surgery Tuesday, November 8 7:30 a.m. Board Room Podiatry Tuesday, November 15 7:30 a.m. Medical Librarhy Pediatrics Tuesday, November 15 9:00 a.m. CC-7 Urology Wednesday, November 16 7:00 a.m. CC-2 Emergency Medicine Wednesday, November 16 6:00 p.m. Board Room Anesthesiology Tuesday, November 22 7:00 a.m. CC-7 Orthopedic Surgery Tuesday, November 22 7:30 a.m. Auditorium Surgery Tuesday, November 22 7:30 a.m. Board Room
NOVEMBER 2011 COMMITTEE/CONFERENCE MEETINGS Credentials Tuesday, November 8 12:00 p.m. Board Room Endoscopy Tuesday, November 8 12:00 p.m. CC-3 Palliative Care Wednesday, November 9 11:30 a.m. CC-5 IRB Thursday, November 10 12:00 p.m. Board Room Lung Mgmt. Conference Thursday, November 10 12:00 p.m. CC-5 GYN Cancer Conference Monday, November 14 9:00 a.m. Board Room Medical Board Monday, November 14 4:30 p.m. Board Room Cancer Committee Tuesday, November 15 12:00 p.m. Blumenthal Cancer Ctr. Patient Safety Tuesday, November 15 4:00 p.m. CC-7 Q/A Perinatal Wednesday, November 16 7:30 a.m. CC-7 Palliative Care Wednesday, November 16 11:30 a.m. Admin Conf. Room #1 Breast Mgmt. Conf. Wednesday, November 16 12:00 p.m. CC-5 QA&I /Orthopedic Surgery Thursday, November 17 7:00 a.m. Board Room Pharmacy & Therapeutics Tuesday, November 22 8:30 a.m. Board Room Palliative Care Wednesday, November 23 11:30 a.m. CC-7 Schwartz Ctr. Rounds Monday, November 28 12:00 p.m. CC-7 Hem/Onc Cancer Conference Tuesday, November 29 12:00 p.m. CC-5 Palliative Care Wednesday, November 30 11:30 a.m. CC-5
HAPPY ANNIVERSARY TO OUR ACTIVE STAFF PHYSICIANS!
CONGRATULATIONS ON YOUR MILESTONE! NOVEMBER CELEBRANTS:
PHYSICIAN DEPARTMENT YEARS
The Gamma Knife Center at The Valley Hospital.
Featuring the Leksell Perfexion System.
The most advanced tool on earth for Brain Cancer and Neurological Disorders.
Michael C. Gartner, DO Plastic Surgery 5 Erin K. Lindenberg, MD Pediatrics 5
� � � � � � �� � � � � � � �
Pedramine Ganchi, MD Plastic Surgery 10 Douglas S. Holden, MD Orthopedic Surgery 10 Dante Implicito, MD Orthopedic Surgery 10 Amy M. Siegel, MD Gynecology/Obstetrics 10
� � � � � � �John R Capitanelli, MD Medicine 15 Arun Sehgal, MD Medicine 15 Lisa A. Steinel, MD Pediatrics 15
� � � � � � �Pedramine S. Grewal, MD Medicine 20 Deborah A. Lozito, DO Medicine 20
� � � � � � �Vishnu M Amin, MD Surgery 25
New Nonvascular Intervention Weekend Call Coverage
Radiology Associates of Ridgewood has partnered with 3 new Interventionalists: Drs. Bahramipour,
Lautin and Barone, to ensure appropriate weekend call coverage for our referring physicians. The
process for requesting a nonvascular intervention procedure for both the IR and CT departments will
remain the same. The Hospital Operations Resource Center (HORC), available at ext. 8075, will
maintain a current call list and can notify the Interventional team and the CT department can be noti-
fied directly at ext. 8215. We anticipate the addition will enhance coverage two-fold. The department
will be able to provide expedited intervention service as well as improve the body coverage by in-
creasing our resources.
Vascular Intervention call coverage will remain unchanged and will continue to be provided by the
vascular group.
Please Participate in the 2011 Top Hospitals Survey! �
Inside Jersey magazine has engaged Castle Connolly Medical Ltd. to conduct a survey of physicians in the state, asking them to select the top hospitals in various clinical service areas, for a special feature on the “Top Hospitals in New Jersey” to appear in the April 2012 issue of the magazine.
To participate, go to www.castleconnolly.com/insidehospitals by midnight, Sunday, November 20. The survey takes approximately five minutes to complete.
You will have the opportunity to vote for the leading hospitals as a function of size (less than 350 beds or more than 350 beds). Valley has 451 beds. The following medical conditions will be included in the survey: breast cancer; prostate cancer; pediatric cancers; coronary artery bypass surgery; hip and knee replacement surgery; congestive heart failure; stroke; high-risk pregnancy and birth; and neurological disorders. You will also be asked to vote for the overall top hospital in New Jersey.
Your consideration in completing this survey is appreciated. Thank you.
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36th Annual Medical Staff Picnic
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HealthGrades Names The Valley Hospital
One of America’s 100 Best Hospitals
for Cardiac Care and Orthopedic Surgery
Recipient of Multiple Clinical Care Excellence Awards
Ridgewood, NJ. (Oct. 18, 2011) – A report released today by HealthGrades, the nation’s most trusted, inde-pendent source of physician information and hospital quality ratings, named The Valley Hospital one of America’s 100 Best Hospitals for Cardiac Care and Orthopedic Surgery. Valley was also one of America’s 100 Best Hospitals for cardiac surgery, coronary intervention, joint replacement, and gastrointestinal care.
Choosing a hospital can be a life or death decision. The HealthGrades 2011 Healthcare Consumerism and Hospital Quality in America report found that patients treated at 5-star rated hospitals experience a 73 percent lower risk of mortality and a 63 percent lower risk of complications compared to 1-star rated hospitals. A quality comparison of doctors and hospitals in the New York area can be found online at HealthGrades.com.
“We are committed to clinical quality and patient satisfaction,” said Audrey Meyers, President and CEO of The Valley Hospital. “These outstanding recognitions are testament to the priority Valley staff and physicians place on achieving the highest-quality clinical outcomes, while delivering the most compassionate care.”
“Patients today have a wide array options when it comes to choosing a healthcare provider,” said Kerry Hicks, HealthGrades chief executive officer. “At HealthGrades, we are proud to have led the way for empowering patient choice based on objective clinical outcomes and access to actionable quality measures. We commend Valley Hospital for its superior quality and support of consumerism and transparency in the New York area.”
In addition to being named one of America’s 100 Best Hospitals for cardiac care, orthopedic care, and gastro-intestinal care, The Valley Hospital was also recognized for the following clinical achievements:
• Recipient of the HealthGrades Cardiac Care Excellence Award™ for 4 Years in a Row (2009-2012)
• Recipient of the HealthGrades Cardiac Surgery Excellence Award™ for 3 Years in a Row (2010-2012)
• Recipient of the HealthGrades Coronary Intervention Excellence Award™ for 4 Years in a Row (2009-2012)
• Recipient of the HealthGrades Orthopedic Surgery Excellence Award™ in 2012
• Recipient of the HealthGrades Joint Replacement Excellence Award™ in 2012
• Recipient of the HealthGrades Gastrointestinal Care Excellence Award™ in 2012
• Recipient of the HealthGrades Gastrointestinal Surgery Award™ in 2010 and 2011
• Recipient of the HealthGrades General Surgery Excellence Award™ in 2012
• Recipient of the HealthGrades Maternity Care Excellence Award™ in 2010/2011, 2009/2010
• Recipient of the HealthGrades Women's Health Excellence Award™ in 2011, 2010/2011, 2009/2010
HealthGrades Names The Valley Hospital
One of America’ s 100 Best Hospitals
for Cardiac Care and Orthopedic Surgery
Recipient of Multiple Clinical Care Excellence Awards (Continued)
• Ranked Among the Top 5 percent in the Nation for Overall Cardiac for 3 Years in a Row (2010-2012)
• Ranked Among the Top 5 percent in the Nation for Cardiac Surgery in 2012
• Ranked Among the Top 5 percent in the Nation for Coronary Interventional Procedures for 2 Years in a Row (2011-2012)
• Ranked Among the Top 5 percent in the Nation for Joint Replacement in 2012
• Ranked Among the Top 10 percent in the Nation for Overall Orthopedic Services in 2012
• Ranked Among the Top 10 percent in the Nation for Cardiology Services for 4 Years in a Row (2009-2012)
Key findings of the HealthGrades 2011 Healthcare Consumerism and Hospital Quality in America report in-clude:
Patients had, on average a 73percent lower risk of dying in a 5-star rated hospital compared to a 1-star rated hospital, and a 54 percent lower risk of dying in a 5-star rated hospital compared to the national average.
Patients had, on average, were 63 percent less likely to experience in-hospital complications than patients at 1-star programs, and had a 43 percent lower chance of developing an in-hospital complication than the national average.
If all Medicare patients from 2008 through 2010 had been treated at 5-star hospitals, 240,040 lives could have potentially been saved.
If all Medicare patients from 2008 through 2010 had gone to 5-star hospitals for their procedure, 164,472 in-hospital complications could have potentially been avoided.
Drug Interaction warnings display at the time of ordering. Click on the interaction displayed in Red for additional information about the interaction.
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5HPLQGHU����97(�'RFXPHQWDWLRQ�1RZ�2Q�$GPLVVLRQ�6FUHHQV�The VTE risk assessment tool is included on page 2 of the Cardiac, Medical, and Surgical admission orders. Indicate
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November 2011 page 2 of 2
From the ���� Mailbox
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A Physician asks: There are orders on my To Be Signed list that are not mine. Can I remove them?
The CPOE team’s response: Yes. From your To Be Signed List in either PCI or PCM, select the order you would like to remove. Click Reject Order, select the appropriate
rejection reason, and enter your PIN. The order will be removed from your list.
(QWHULQJ�0HGLFDWLRQ�$GPLQLVWUDWLRQ�,QVWUXFWLRQV�All medication administration instructions (ie: hold parameters) should be entered as part of the
medication order.
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Physician/Nurse Communication.
I nstructions entered on these orders
Do this…. Always enter instructions by clicking on the
instructions (INST) dropdown on the medication order. These instructions will be seen by the
Pharmacy as well as by the nursing staff on the
3K\VLFLDQ�6XSSRUW�7DEOH�Have questions? Need assistance?
A member of the Advanced Clinical Team is available outside the Caduceus Club on
Tuesdays and Thursdays from 10am-12pm and 1pm-2pm.
