Welcome to St. David’s South Austin Medical Center

1. Welcome to St. David’s South Austin Medical Center New Physician Orientation

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

3. 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: (512) 816-6112 • Mobile: (512) 294-7064 • Fax: (512) 816-7278 • Email: Albert.Gros@stdavids.com

4. Senior Leadership Wes Fountain CFO Todd Steward CEO Brett Matens COO/ECO Nikki Sikes Associate Administrator Sally Gillam CNO

5. 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

6. 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

7. 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

8. 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

9. Nikki Sikes Associate Administrator Worked at SDSAMC since January 2010 Picture here • From Georgetown, Texas • Departments include Rehab Services, • Laboratory, Environmental Services, • Nutrition Services, Spiritual Care, • Volunteers, Risk Management, Special Projects

10. 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)

11. Overview of Medical Center

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

13. 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 (<200 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. > 96.8o within 30 min. prior to 15 min. after Anesthesia End Time)

14. 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 <40% LVEF

15. Governance & Peer Review

16. 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) Variance Reports Physician PI Coordinator Prof. Liability Actions Patient Complaints Sentinel Events Failed Measures Employee Complaints Fall-out from Screens Compliance Issues Approved by MEC 2/08

17. www.sahmedweb.com 17

18. Educational Programs Medical Grand Rounds Ethics Credit CPR/ACLS Education Tumor Board Conferences 18

19. Medical Staff Meetings Monthly meeting calendars are posted on the MedWebsite, 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. 19

20. Credentialing and Medical Staff Services St. David’s 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.

21. Physician Health Forms of Impairment Alcoholism and other drug use Other psychiatric disorders Addressed by the TCMS Physician Health and Rehabilitation committee 21

22. Health Information Management Hours of Operation Monday-Friday 8:00 am to 4:30 pm. Dictation Timeliness Requirements Electronic Health Record and Chart Completion for Physicians Select Dictation 22

23. 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 23

24. 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 Electronic Medical Record (EMR) • What is the Clinician Portal? • Physician electronic access point for clinical information • Integrated systems • Simplified sign-on—one 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

25. 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 Initiative—and 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

27. 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 27

28. Cancer Registry Cancer Registry Cancer Committee Tumor Boards Patient Care Evaluation Studies

29. Case Management Department In existence at SAMCsince 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

30. 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 11:00 a.m. Case Management Office. 816-6260 Blackberry. 517-4342

31. 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

32. Admissions & Central Scheduling

33. One Call Patient Transfer Center

34. 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.