Actions Taken by Medical Executive Committee - April 14, 2009

The following actions were approved by the MHMH Medical Executive Committee and are pending Board approval for inclusion in its governing documents:

Obstructive Sleep Apnea Adult- (Revision to General Rules and Regulations)
Change to the guidelines for adult perioperative patients with OSA.

Peer Review Response Timeline - (Revision to Peer Review Plan)
This policy delineates the timeframe for responding to peer review and specifies that no extensions will be granted except for extraordinary circumstances.

Physician Assistant Scope of Privileges – (Revision to Credentials Plan)
Change to Credentials Plan stating that once every 7 days the supervising physician shall make a personal review of the historical and therapeutic data and shall so certify by signature. The following Delineations of Privileges were updated to reflect this change: Certified Physician Assistant, Certified Physician Assistant – Orthopaedics, and Certified Physician Assistant – Emergency Medicine.

Department Policy and Procedure and Performance Indicator Updates/Changes – (Changes to Department Rules and Regulations and to Peer Review Plan)
Annual department updates from February quarterly meetings were reviewed and approved.

IVC Filters - Endovascular DOP Addition – (Revision to Credentials Plan)
The Endovascular DOP was revised to include IVC filter placement as an additional privilege.

Also approved at MEC and pending Board approval:

Peer Review Oversight Committee Trending
PROC minutes and trending reports for cases reviewed, indicators, and proximate cause were reviewed and approved.

For information/discussion at all MHMH Senior Leadership Councils:

Case Logs - (update from Case Log subcommittee of Credentials Committee)
To have clinical privileges, the Joint Commission requires that we demonstrate “current clinical competency.” This is defined as having recently exercised the privilege successfully – with a good result. Clinical case logs are frequently required for privileges (especially procedural privileges) at appointment and reappointment. Many physicians have found specific DOP requirements to be vague, too restrictive, or too onerous. The Case Log subcommittee has been exploring opportunities for improving this requirement. Attached is the recent grid produced. This will require further input and modification from each department prior to Credentials, MEC, and BOD approval.

Regulatory Readiness
To align with CMS standards, the Joint Commission has recently issued several new standards that must be implemented by July 1, 2009. Several of these impact medical staff including the requirements that MEC approve the methods for handling tissue specimens as well as blood use criteria. Additionally, there is a change specifying that the hospital will attempt to secure autopsies in all cases of unusual deaths and of medical, legal, and education interest, and informs the medical staff (specifically the attending physician) of autopsies that the hospital intends to perform.

Performance Excellence Committee (PEC)
Drs. Maliot and Dilawari presented information on NSQIP at MEC. Other information presented at PEC included Part I of the National Perinatal Information Center data, an update on the Columbia Heart Source engagement, and an update on the ACC/STS database initiatives.

Patient Safety Committee (PSC)
A case involving an adverse outcome was presented along with improvement opportunities. There was active discussion of the need to have autopsies for unexpected deaths. Regulatory readiness update focused on the NPSGs and incomplete orders. Additionally, there were presentations on Grievances and Complaints, HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey Results, and the City-wide Hand Hygiene Initiative.

City-wide Hand Hygiene Update
The City-wide Hand Hygiene initiative continues with positive reinforcement in the intensive care units. In May, reminder cards will be distributed to those who are not exhibiting proper hand hygiene.

Pharmacy and Therapeutics Committee
A proposal was made to modify the reference start date/time default on orders entered into Cerner from current date/time to current date/time plus one hour (for everything except stat/now orders). A task force will convene to review this. The Warfarin/elevated INR and the category X rules will fire to physicians using CPOE. Pneumonia and CABG caretracks were approved as well as the hypothermia protocol. Rasburicase was added to the formulary (along with a prescribing protocol) with prescribing rights limited to hematology/oncology. Seroquel XR was NOT added to the formulary. A task force will be convened to address the cephalosporin/PCN allergy issue. Warfarin MUE was presented and importance of completing the warfarin monitoring form for all patients was emphasized. The high risk medication review was presented and lithium is deleted from the high risk medication list (no errors in 2008 because of safety mechanism interposed). Thrombolytics and high dose magnesium sulfate infusions were added to the high risk list. Because anti-EGFR antibody therapy is only effective with normal KRAS gene, it will be required that pathology reports document KRAS status for colon/rectal cancers for all new orders for cetuximab and panitumumab. Antibiogram data was presented. The action plan for incomplete orders was discussed.

Attachments: