Welcome to St. David’sWelcome to St. David’s

South Austin Medical CenterSouth Austin Medical Center

New Physician OrientationNew Physician Orientation

2

Mission

To provide exceptional care to every patient every day with a spirit of warmth, friendliness and personal pride

3

Values

ICARE Values: –Integrity–Compassion–Accountability–Respect –Excellence

4

Goals

Exceptional CareCustomer LoyaltyFinancial Strength

Comprehensive, acute care hospital including emergency, heart, and women’s services

Established in 1982

Member of St. David’s HealthCare and Hospital Corporation of America (HCA) 5

South Austin Medical Center was built in 1982 Many people did not see the need for a

hospital “south of the river”Original planning meetings held at

Hill’s Café The Goodnight family, local business

owners, were very supportive and instrumental in the construction of the hospital

6

• Blood Cancer Treatment &Bone Marrow Transplant

• Robotic Surgery• Freestanding Emergency

Departments• Urgent Care Clinics• Wound Care/Hyperbaric Services• Sleep Lab• Transfer Center

7

Hospital ServicesHospital Services

Currently has approximately 40 beds

Observation area (called Fast Track)

In 2008, a helipad was constructed immediately adjacent to the ED to receive critically ill and/or injured patients

8

In 2010, SAMC had the busiest ED in Austin, with over 73,000 visits annually

Patients receive care based on a triage system

The majority of hospital admissions come through the ED

Major SAMC goal is to reduce wait times in ED and the time to release or admit patients

9

Triage station Walk-in and ambulance entrances

Several areas dedicated to surgical patients Orthopedic patients Post surgery patients Oncology patients Patients with illnesses

All floors have telemetry or heart monitor capability if required by patients (except L&D) 12

Levels of care

ICU – Intensive care unit (2nd floor)

IMC – Intermediate care unit (7th floor)

Full telemetry monitoring is done on

these patients, according to their

needs14

Patient room with telemetry equipment

Nurses station Family waiting area

Heart–related areas include

Cardiac cath labs and Outpatient Heart

Center

Special procedures area and EP Lab

CVRU (Heart-related ICU) on 4th floor

Two open-heart operating rooms

This unit has 8 beds 17

Procedure room & telemetry

Postpartum/2CentralPostpartum/2Central

22

Digital Mammography SuiteX-Ray Machine

Nuclear X-ray Cat-Scan

27

Chief Medical Officer:Al Gros, MD

Chief of Staff: Robert Northway, MD

Chief of Staff-Elect: Alex Esquivel, MD

Secretary: David Savage, MD

Medical Staff Leadership

Dr. Al Gros CMO, South Austin Medical CenterOffice: (512) 816-6112Mobile: (512) 294-7064 Fax: (512) 816-7278Email: Albert.Gros@stdavids.com

28

Senior Leadership

Sally GillamSally GillamCNOCNO

Sally GillamSally GillamCNOCNO

Nikki SikesNikki SikesAssociate Associate

AdministratorAdministrator

Nikki SikesNikki SikesAssociate Associate

AdministratorAdministrator

Todd StewardTodd StewardCEOCEO

Todd StewardTodd StewardCEOCEO

Brett MatensBrett MatensCOO/ECOCOO/ECO

Brett MatensBrett MatensCOO/ECOCOO/ECO

Dan HuffineDan HuffineCFOCFO

Dan HuffineDan HuffineCFOCFO

29

Governance & Peer ReviewGovernance & Peer Review

C red en tia lin g F u n c tion M ed ic a l C are E va lu a tion C om m ittee(M C E C )

Y ou r D ep artm en t

M ed ic a l E xecu tive C om m ittee(M E C )

B oard o f Tru s tees

Physician PI Coordinator

Variance Reports

Patient Complaints

Failed Measures

Fall-out from Screens

Prof. Liability Actions

Employee Complaints

Compliance Issues

Action

Clinical Issue: Competence,Core Measures, Outcomes

Indicator 'Fall-outs'

Department

Compliance / Social Issue:(i.e., Complaints, Non-compliance,

Behavior)

Egregious Event:(incl. Sentinel Events,

In-House Physician Quality Issues)

Rapid Review Team

Medical Director / Vice Chief of Staff

MCEC (Chief Medical Officer)

MEC(Chief of Staff)

BOT

Triage(Med Dir

& PIC)

Sentinel Events

Peer Peer Review Review ProcessProcess

Approved by MEC 2/08

31

OPPE & FPPE ReviewOPPE & FPPE Review

Core Measures

AMI (Acute Myocardial Infarction) HF (Heart Failure) PN (Pneumonia) SCIP (Surgical Care Improvement

Project)

SCIP Core MeasuresSCIP 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)

33

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

34

35

Physician and Patient Communication

36

Why Should You Care?

A 2004 Harris Interactive poll of 2,267 U.S. adults showed that “patients place more importance on doctors’ interpersonal skills than their medical judgment or experience, and doctors’ failings in these areas are the overwhelming factor that drives patients to switch doctors.”

Physician conduct and communication, not necessarily clinical outcomes, appear to be the principle predictors of malpractice risk.

HCAHPS

Hospital Consumer

Assessment of Healthcare

Providers and Systems

37

38

HCAHP Survey Questions

39

Key Stakeholders

The physician/patient interaction influences the patient’s experience and perception of care

CMS surveys patient on physicians:– Treating with courtesy and respect– Listening carefully– Explaining things in a way patients

can understand

40

Management Best Practices

AIDET and Key WordsConsistent approach to

communicationAcknowledgeIntroduceDurationExplanationThank You

Employee ForumsGlobal communication and

educationSenior Leader visibility

41

Case for Service

•Communication skills can heavily influence patient compliance and will impact clinical outcomes

•Studies have demonstrated that when a physician is approachable, gives serious consideration to the patient’s concerns, and communicates well, better patient compliance is likely.

42

Case for Service

Exceeding expectations with exceptional service keeps patients coming back.

Loyal patients are greater revenue producers than acquiring new patients

43

Case for Service

Physicians can improve staff morale, performance, and retention through:

• Investing in relationships•Clear, constructive, respectful

communication•Specific reward and recognition•Modeling behaviors consistent with the

mission

44

RX Tool #1 – First Impressions Knock, then pause two seconds prior to

entry Smile, shake hands, and introduce yourself

to the patient and everyone in the room Sit and sustain eye contact LOOK as though you ENJOY what you do! Use a consistent opening dialogue for

established and new patients that creates comfort and approachability with you.

Tell patients about your training, your experience, and your personal approach to patient care.

45

RX Tool #2 – Exam Room Preparedness

What you know and don’t know when you enter the exam room creates or undermines the confidence patients will have in you.

Review interval events, consults, and what you did last prior to entering the exam room.

Specifically reference your “plan” that was established during the prior visit.

Communicate your awareness of interval medical events.

Leverage the information available to convey you are attentive and aware of every element of their care.

46

RX Tool #3 – The Physician Exam

Providing information on physician exam findings conveys thoroughness and a diligent effort to find the cause of a problem.

Review your physical exam findings as you perform the exam.

The more information you provide to patients about themselves, the greater value for the visit in the eyes of patients.

47

RX Tool #4 – Providing Patient Information

Explanation of diagnosis and treatment is the most important element of the patient visit

Effective communication improves recall of directions, compliance, and patient satisfaction.

Every condition and plan must include a simple explanation.

All explanations must be followed by query of the patients for their understanding.

Ask patients to repeat the plan as they understand it to ensure their understanding and identify areas needing further explanation.

48

RX Tool #5 – Collaboration with Patients

Establishing collaboration with patients improves compliance, outcomes, and patient satisfaction.

Collaboration can be established by asking patients if they have any reservations or concerns in regard to a treatment plan.

Collaboration is about specifically soliciting patient input regarding the treatment plan going forward.

49

RX Tool #6 – Patient Follow-Up

All patients must leave a visit understanding exactly what it is that will happen next.

Provide clear follow-up on the timing and purpose of patients’ upcoming visits.

Provide information regarding the timing of laboratory and radiographic tests and how the results will get to the patient.

Explain the purpose and timing for specialty consultation in terms of when, why, and who.

Position specialty physician colleagues well.

50

Steps in Effective Service Recovery

1. Apologize2. Let the patient speak3. Validate4. Correct the issue5. Take action6. Follow up with the patient

51

www.sahmedweb.comwww.sahmedweb.com

52

Medical Staff MeetingsMedical Staff Meetings

Monthly meeting calendars are posted on the Monthly meeting calendars are posted on the MedWeb site, faxed, and e-mailed to MedWeb site, faxed, and e-mailed to members.members.

There is a 50% meeting attendance There is a 50% meeting attendance requirement for Active members in the requirement for Active members in the departments of Medicine, Surgery, and departments of Medicine, Surgery, and Cardiology.Cardiology.

There is a 25% meeting attendance There is a 25% meeting attendance requirement at the quarterly General Medical requirement at the quarterly General Medical Staff meetings for all Active members.Staff meetings for all Active members.

53

Credentialing and Medical Staff ServicesCredentialing and Medical Staff Services

St. David’s and HCA structure regarding St. David’s and HCA structure regarding credentialingcredentialing

Standardized market formsStandardized market forms

Individual facility approvalsIndividual facility approvals

Qualification: Board certification or Qualification: Board certification or obtained within 5 years of initial obtained within 5 years of initial appointment. Certification must be appointment. Certification must be maintained.maintained.

54

Physician HealthPhysician Health

Forms of ImpairmentAlcoholism and other drug useOther psychiatric disorders

Addressed by the TCMS Physician Health and Rehabilitation committee

55

REDFIRE Hazardous Mat

GRAYTornado

WHITEDisaster

GREENEvacuation

Pull station/Extinguisher locations refer to safety charts/maps posted Rescue if possibleCall Security with location of fireActivate alarm pull stationClose doors & windowsIdentify fire doors & exitsEvacuate if necessaryIf fire is in an adjacent department or above or below, respond with available staff with fire extinguisherRemain alert for further instruction or “ALL CLEAR”R.A.C.E. – rescue alarm, contain/confine and extinguishP.A.S.S. – pull pin, aim, squeeze and sweep the base of the fire

InternalClear the area/close doorsStop the leak/spill if it can be done safelyPull MSDS sheetSecure the areaCall security with informationResponse team activatedIf there are victims, call EDNotify Director or supervisorAwait further instructions

ExternalDirect patients to outside of ED – NO entry to facilityPossible lockdown of facilityPatients triaged and decontaminated Remain alert for further instruction or “ALL CLEAR”

WATCHDirectors/Supv alert all staffCheck for supplies (flashlights, blankets, etc)Close blinds and drapesEnsure critical eqpt is plugged into red plugsRemain alert and listen for further instructionWARNINGClose all doorsMove away from windows, as much as possibleMove patients to inner hallwayEvacuate if necessaryRemain alert for further instruction or “ALL CLEAR”

Report back to your department PBX will page directors with instructions Assess staffing needs Hand carry staffing form to HR Assess bed availability & other resources

(blood, food, water, etc) Refer to staffing chart and assume your

assigned role Remain alert for further instruction or “ALL

CLEAR”

Partial EvacuationSupervisor completes quick head count of staffReport to your department if able. If not evacuate down, never go upRemain alert and listen for further instructionTotal EvacuationSupervisor completes quick head count of staffAll available staff report to nearest clinical area to assistevacuate to designated staging area, ambulatory patients go firstTake medical records if possibleDo not re-enter unless told to

BLACKBomb

PURPLE Threatening Person

YELLOWPerson Down

CODE ADAM Abducted Infant

DR. LEO/CODE BLUE Cardiac Arrest

Get all info you can from caller Try to keep caller on line while someone else

calls Security Refrain from alarming patients and visitors DO NOT use cell phones or radios Search areas for anything suspicious, if found

DO NOT TOUCH – call Security with exact location of object

If object found, evacuate area When area has been searched and cleared,

call Security Remain alert for further instruction or “ALL

CLEAR”

Call Security DO NOT attempt to challenge or disarm

individual Remain calm and maintain eye contact and

talk to individual NEVER attempt to physically restrain or

remove by yourself When response team arrives relay information Remain alert for further instruction or “ALL

CLEAR”

Call Security with exact location of person down

Remain with the person until response team arrives

Relay information Assist as needed Remain alert for further instructions

Go to closest exit and prevent anyone from leaving until help arrives

Report suspicious people to security If you see a person with an infant that looks

suspicious, STOP THEM, or follow them and call for help

If possible check outside doors Remain alert for further instruction or “ALL

CLEAR”

Call the Code based on your Facility (Dr. Leo/ Code Blue)

Call Security Bring the Crash Cart to the site If properly trained, begin CPR (check patient

for consciousness etc.) Each facility has a designated Code Team If not assigned to Code Team, clear the area

and manage traffic Have patient’s chart available

SPECIFIC SIGNALS - ISOLATED EVENTS

SPECIFIC SIGNALS - GENERAL SIGNALS

SAFETY CODESSAFETY CODES

Physician Satisfaction Team

The SAH Physician Satisfaction Team commits to partner with the medical staff to improve the environment in which they

work. We will strive to ensure that the highest level of service is consistently

provided to the physicians. We will act as a liaison to foster open communication

and will recognize our physicians as valued partners in the delivery of

healthcare.

•MVP of the Quarter•Doctors’ Day Celebration

•Veterans’ Day Celebration•Direct Physician Concerns to appropriate

leaders 56

Clinical Information Systems

Information Systems Access:MeditechhCare Portal

Decide which type of training will work for youWeb-based training (WBT)One-on-one sessionsOr a combination of training methods

Collect all of your clinical system passwords Plan to attend a training session to set up your account

57

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

58

For questions about Incomplete Deficiencies- please contact Health Information Management at 816-6308For questions about Portal or access- contact the help desk at 901-HELP or Ryder Bodoin at 632-1618

59

MeditechMeditech(Clinical Patient Care (Clinical Patient Care

System)System)

√ PCI (Patient Care Inquiry)PCI (Patient Care Inquiry)LAB, RAD, PATH and HIM reportsLAB, RAD, PATH and HIM reports

√ Demographic/Insurance Info.Demographic/Insurance Info.√ Access from hospital, office or homeAccess from hospital, office or home√ Physicians MUST write Consult Orders so consulting physician Physicians MUST write Consult Orders so consulting physician

will have access to the patientwill have access to the patient√ Electronically sign dictated reports remotelyElectronically sign dictated reports remotely√ Software provided by the hospital for remote installationSoftware provided by the hospital for remote installation

Physician Help Desk #: 901-4357 (HELP)Physician Help Desk #: 901-4357 (HELP) Obtain Access, Schedule Training, & Report ProblemsObtain Access, Schedule Training, & Report Problems 24/7 service24/7 service

60

Health Information ManagementHealth Information Management

Hours of OperationHours of Operation Monday-Friday 8:00 am Monday-Friday 8:00 am

to 4:30 pm.to 4:30 pm.

DictationDictationTimelinessTimelinessRequirementsRequirements

Electronic Health Record and Chart Completion for

Physicians

Select Dictation

Privacy and SecurityTerms and Definitions

PHI -Protected Health Information (Any information that can be linked to a patient) Name Address Dates (i.e. birth date, admission date, discharge date, etc.) Phone numbers; Fax numbers; Social security number; Medical record number; Health plan beneficiary number; Account

number; Certificate/license number; Vehicle identifier and serial number; Device identifiers and serial numbers; URLs; Internet protocol addresses; Biometric identifiers (e.g.; fingerprints); Full face photographic and any comparable images; Any other unique identifying, characteristic, or code; and Any other information about which you have actual knowledge that could be used alone or in

combination with other information to identify the individual

61

Health Information ManagementHealth Information Management

HIPAA – Heath Insurance Portability & Accountability Act (est. 1996) HITECH – Health Information Technology for Economic & Clinical Health (est. 2009).

Need to Know (Only access information that is needed for your job and only sharing sensitive and confidential information with other that’s have a need to know and are directly involved in the care of the patient.)Minimum Necessary (access, use or disclose the minimum information necessary to perform his or her designated role regardless of the extent of access provided to him or her.)De-Identify (Health information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual)Pass code Policy (Release of information to a patient’s immediate family member, other relative, or a close personal friend of the patient, or any other person to whom the patient has given his or her password (numeric code provided to patient at Registration). Sensitive Information: information that poses a significant or financial harm/risk to the patient. Examples: protected health information, social security numbers, employee human resources files) and restricted data (e.g., cardholder information, company passwordsBreach: Unauthorized acquisition, access, use, or disclosure of unsecured, unencrypted protected health information which compromises the security or privacy of such information and poses a significant risk of financial, reputational, or other harm to the individual.Wrongful Disclosure – wrongful release of protected health information (PHI) to an unattended recipient outside of our covered entity. Example: Faxing records to a church fax line instead of the attended physician office.Office of Civil Rights – OCR (Governing body for HIPAA & HITECH)

62

Health Information ManagementPrivacy and Security

Terms and Definitions

Health Information ManagementPrivacy and Security

Safeguarding Information Safeguarding= (Reasonable steps to protect PHI)

Following ‘need to know’ guidelines Employing ‘Minimum Necessary’ standards Verify documents are for the correct individual prior to providing services or releasing

documentation. Not removing PHI from the facility

Releasing of PHI = (Appropriate means for disclosing PHI) Utilization of the Pass code Policy

Obtaining a valid authorization for uses and disclosures outside of treatment, payment, and healthcare operations. Refer these requests to the Health Information Management

Department. (also see SAMC authorization on e-demand) Verbal Disclosure

Verifying appropriate audience (i.e. receive patient consent prior to discussing PHI in front of family members). * Clinicians should not assume the patient has agreed to have PHI verbally shared in front of their family members, friends or other visitors just because the patient did not request these individuals to leave when the clinician began speaking.

Closing Curtains in semi-private locations Use low voices & do not discuss PHI in public areas Verifying identity when speaking via phone When leaving messages do not disclose PHI or diagnostic information.

You can however leave your name, callback number, purpose for the call (e.g. “to discuss his or her treatment results”)

63

Health Information ManagementPrivacy and Security

Safeguarding Information

Accessibility Chart handling

Chart must not be left unattended in public areas Chart must not be readily available for unauthorized viewing (i.e. any customer, employee or

physician without need to know) Electronic Access

Screens/Monitors must be positioned away from direct view of general public• Privacy screens should be used in areas accessible to the public

Passwords must not be displayed or viewable Must log-out or lock workstation when leaving unattended (especially in public areas such as

corridors and patient rooms) Disposing securely

Documents must be shredded or disposed of in designated container.

FISO – Facility Information Security Officer = Covers Security (“Access to”) – e.g. Passwords, Encryption, Portable Media, etc.

SAMC FISO is Richard Lear – richard.lear@stdavids.com; 816-7336FPO – Facility Privacy Officer = Covers Privacy (“Appropriateness of Access”) – e.g. ‘Need to know’, ‘Minimum Necessary’, Confidentiality, SAMC FPO is Barbara Howard – barbara.howard@stdavids.com 816-7138Custodian of Medical records – HIM Director/FPO

64

65

Health Information ManagementHealth Information Management

• Notification ProcessNotification Process• Deficiencies color coordinated in portal Deficiencies color coordinated in portal

for your conveniencefor your convenience• BLUE: BLUE: Incomplete 0-15 daysIncomplete 0-15 days• RED: RED: Warning 16-29 daysWarning 16-29 days• YELLOW: YELLOW: Delinquent 30+ daysDelinquent 30+ days• Notification and Suspension Notification and Suspension

letters are faxed to physician letters are faxed to physician offices every Wednesday, as a offices every Wednesday, as a courtesy only.courtesy only.

• Coding Query ProcessCoding Query Process

Process Incompletesby 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

66

Unacceptable Unacceptable AbbreviationsAbbreviations

Intended Intended MeaningMeaning

MisinterpretationMisinterpretation Expected Expected ActionAction

UU UnitsUnits O, “4”O, “4” Write out entire Write out entire word “Units”word “Units”

IUIU International unitsInternational units Misread as IV Misread as IV (intravenous) or the (intravenous) or the number 10number 10

Use the word Use the word “units”“units”

Trailing Zero (i.e. 1.0 Trailing Zero (i.e. 1.0 mg)mg)

1 mg1 mg Misread as 10Misread as 10 Do NOT use trailing Do NOT use trailing zeros after a zeros after a decimal pointdecimal point

Lack of a leading Lack of a leading zerozero

0.1 mg0.1 mg Misread as 1 or 11 Misread as 1 or 11 mgmg

ALWAYS use a zero ALWAYS use a zero before a decimal before a decimal pointpoint

MSMS

MSO4MSO4

MgSO4MgSO4

Morphine sulfate or Morphine sulfate or magnesium sulfatemagnesium sulfate

Confused for one Confused for one another. Can mean another. Can mean morphine sulfate or morphine sulfate or magnesium sulfatemagnesium sulfate

Write “morphine Write “morphine sulfate” or sulfate” or “magnesium “magnesium sulfate”sulfate”

Q.D., q.d., qdQ.D., q.d., qd

Q.O.D, q.o.d, qodQ.O.D, q.o.d, qod

““Daily” and “every Daily” and “every other day”other day”

Mistaken for each Mistaken for each other. The period other. The period after Q can be after Q can be mistaken for an “I” mistaken for an “I” or the “O” can be or the “O” can be mistaken for an “I”mistaken for an “I”

Write “daily” and Write “daily” and “every other day”“every other day”

Clinical Documentation Improvement

Clinical Documentation Liaisons:

Betsy Woodhouse RN 512-816-6357 Betsy.Woodhouse@StDavids.com

Shawna Huskey RN 512-816-6043 Shawna.Huskey@StDavids.com

Juan Patino, RN 512-816-6422 Juan.patino@hcahealthcare.com

 

Insufficient, Incomplete, or Illegible Documentation How’s

this patient doing?

Good! Dated & Timed

Understand the Plan?

What is the medical complexity of this visit for billing?

Accurate Documentation

• Precise and detailed documentation reflects the complexity of our patients and the excellent care we provide

• Helps prevent HAC and RAC recoupment• Improves physician and hospital profiles

(MEDPAR, Healthgrades, CMS, etc.)• Comply with CMS rules and regulations• Receive proper reimbursement through

correct MS DRG assignment

Physicians Note

DRG classification is not only for purposes of reimbursement…

But captures the documentation necessary for quality of care analysis

and mortality predictions for both you…and the hospital!

Keep in Mind:

• Accurate representation of patients helps to justify cost, length of stay, and mortality statistics

• Coders have rules to follow. They cannot assume anything – they must code from what the physician has actually documented.

• Coders cannot use information from telemetry strips, lab reports, radiology reports, pathology, diagnostic reports, or nursing/ancillary notes for coding. The physician must address these findings in the medical record.

Clinical Documentation Liaisons’ Role

Concurrently review Medicare charts and query physicians for documentation clarification prior to patient discharge

Provide education to physicians and appropriate clinical staff about documentation improvement methods as indicated

Bridge the gap between clinical language and coding language

Physician Role

• Focus on patient care• Review any education from CDLs and

apply to documentation• Respond to all inquiries from CDLs

- Appropriate, timely responses will prevent

post-discharge queries from the coders- Physicians do not need to agree with the

inquiries, just respond

Clinical Language vs. Coding Language

APR DRG

Medical diagnoses and procedures are used to determine a patient’s APR DRG (All Patient Refined Diagnosis Related Group) – includes Severity of Illness (SOI) and Risk of Mortality (ROM) sub-classes

There are 4 sub-class levels for SOI and ROM:- Level 1: Minor - Level 3: Major- Level 2: Moderate - Level 4: ExtremeSOI and ROM are driven by secondary diagnosis.

Secondary Diagnoses

Definition – conditions that are monitored, evaluated and/or treated during the hospital stay.

Three classes:▪ Major complications and comorbidities (MCC)▪ Complications and comorbidities (CC)▪ Non-complications and comorbidities (NCC)

MCCs and CCs affect the DRG assignmentThe difference between an MCC, CC and NCC

can be the specificity of documentation

Be as specific as possible…● Congestive Heart Failure

Acuity – acute, chronic, acute on chronicType – systolic, diastolic, combinedPlease indicate both the type and acuity of CHF, if it is unknown please indicate that it is unknown. When type and acuity is determined, after testing, please make this note the chart.

● MalnutritionAcuity – mild, moderate, severeType – protein, protein calorie, marasmus, other unspecified

● Anemia Specific type and cause – acute blood loss anemia, iron deficient anemia, chronic blood loss anemia, anemia due to chronic disease, aplastic, etc.

● HypertensionEssential, benign, accelerated, malignantFYI – hypertension “urgency” or “emergency “ both code to plain hypertension

More Tips…● Home medications

Please provide corresponding diagnoses for ordered home medications. Remember that secondary diagnoses show the complexity of each patient and can affect SOI/ROM.

● Catheter associated UTIs (CAUTI)

Coders and CDLs are instructed to query for CAUTI anytime a UTI is diagnosed after a Foley catheter has been placed. This applies both to newly placed Foleys and chronic Foleys/suprapubic catheters. Please document whether or not the UTI is associated with the Foley.

● The attending physician is the one who will be queried for clarification even if the conflicting documentation originated from a consultant or partner. Once discharged, the coder will query the discharging doctor.

● Positive cultures (e.g. blood, urine, wound, respiratory)

Please link the organism to the infection (e.g. E coli UTI, MRSA sepsis, Pseudomonas pneumonia).

Please indicate the location of pressure ulcers and wounds as well as their etiology. Coders can take stages of wounds from nursing documentation.

Tips to Prevent a Renal Failure Query

ACUTE: ARF = acute renal failure AKI = acute kidney injury ARF = AKI to coders

ARI = acute renal insufficiency = disorder of kidney and ureter to coders

ARI ≠ ARF to coders ARI ≠ AKI to coders

CHRONIC: CRI = chronic renal

insufficiency CRF = chronic renal failure CKD = chronic kidney disease CRI = CRF = CKD to coders

If possible, please provide the stage of kidney disease. If not possible, please document that staging is being deferred at this time. 

CKD stage V = ESRD to coders Please document the stage of

CKD. If unknown-document unknown and later when determined document stage.

More Sepsis Tips “Urosepsis” codes as “UTI.” The coder will query to clarify the

doctor’s meaning of “urosepsis.” Septicemia or sepsis with a urinary tract source will code as sepsis

as Pdx. Bacteremia due to a UTI will code as a UTI as Pdx.

Please be specific-If a patient has a diagnosis of sepsis and a positive blood culture, link the sepsis to the organism – ex. Staphlococcal sepsis.

Definitions of sepsis terms (in regards to coding): Bacteremia – positive blood cultures; there are no significant

clinical symptoms; it will code to the underlying infection (not sepsis); physician can chart “bacteremia with sepsis (or septicemia or SIRS)”

Septicemia – systemic disease associated with the presence of pathological microorganisms in the blood; the coder is advised to query for “sepsis” when the physician documents “septicemia”

SIRS – systemic response to infection or trauma; not assumed to be sepsis

Sepsis is SIRS due to infection

Up/Down Arrows

From AHIMA Coding Clinic 1st Quarter 2011:It is not appropriate for the coder to report a diagnosis based on up and down arrows. Diagnosing a patient’s condition is solely the responsibility of the provider. Up and down arrows can have variable interpretations and do not necessarily mean "abnormal." They could simply be indicating change (including improvement) over past results. Therefore the provider should be queried regarding the meaning of the arrows and request that the appropriate documentation of a condition or diagnosis be provided.

For example, the coder cannot assume that “ ↑Na” refers to “hypernatremia” or “↓Mg” refers to “hypomagnesemia.” The entire word must be written at least once in the record. Subsequent documentation can contain up/down arrows.

End of Life Issues

Please clearly state the cause of death in your final progress note and/or death summary.

Please document “comfort care”, “hospice,” “end of life care,” or “palliative care” when further aggressive treatment is no longer appropriate and treatment is focused only on relieving pain and discomfort.

Please document secondary diagnosis such as coma, malnutrition, agonal respirations, shock, malnutrition, pressure ulcers. These require nursing care and monitoring and very often will affect the patient’s SOI and ROM calculation.

Malnutrition

Malnutrition is most simply defined as any nutritional imbalance.

People can suffer from overnutrition or undernutrition.

Malnutrition is a major contributor to increased morbidity and mortality, decreased function and quality of life, increased frequency and length of hospital stay, and higher health care costs.

On admission many critically ill patients, especially elderly patients, already are, or may be at significant risk of developing malnutrition and its related complications due to inflammation and or infectious process.

Old Malnutrition Query Form. The old malnutrition query form focused on protein / albumin levels.

“Research analysis indicated that these acute phase proteins do not consistently or predictably change with weight loss, calorie restriction, or nitrogen balance. They appear to better reflect severity of the inflammatory response rather than poor nutritional status.

These lab tests, while probable indicators of inflammation, do not specifically indicate malnutrition and do not typically respond to feeding interventions in the setting of active inflammatory response; therefore, the relevance of these acute phase proteins as indicators of malnutrition, is limited. “ A.S.P.E.N.

Dear Dr: ____ _ _______________ _____________ Date: ____________________ Please review the question below as clarification is needed to accurately reflect the severity of illness for your patient ___ ___________________________ __who was admitted on _ _________ .

Based on your clinical judgment, can you provide the known or suspected condition(s) that represent(s) the clinical indicators listed below?

Check here if indicator is

present

Clinical Indicator(s) Value(s), Location, and/ or date(s) in the medical record

which reflects the clinical findings

Visible wasting away of muscle/tissue

Enlargement/tenderness of liver/abdomen

Signs of circulatory collapse (i.e. cold hands/feet, weak radial pulses, diminished consciousness)

Dry, scaling or peeling skin

Severe pallor

Brittle nails and/or hair loss

Edema/fluid retention or edema

Low serum proteins

Documented weight loss

Dietary consult

Inability to consume adequate caloric intake

Physician/Dietician/Nursing BMI documentation: ______________

Albumin < 2.8

Other Clinical Indicator: ______________________ (Requires two of the above clinical indicators to be present in order to add an “other clinical indicator”)

If known, please document the diagnosis and acuity for which you are evaluating, treating, or monitoring this patient (e.g. marasmus, mild protein-calorie malnutrition, moderate protein-calorie malnutrition, severe protein-calorie malnutrition, other unspecified protein-calorie malnutrition, or other more appropriate diagnosis) in the box below and/ or within the medical record?

If no additional information is available please initial in or check the box, sign, date and time. If unable to determine, please initial in or check the box, sign, date and time.

____________________________________________ _____________ ____________

PHYSICIAN SIGNATURE DATE TIME

Thank you for your consideration of the query. In responding to this query, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected. If you have any

questions, please utilize the contact name below. Contact Name: _ ___ Phone Number: __ __ Fax Number: ________________

New Malnutrition QueryEffective September 2013

Since there is no single parameter that is definitive for adult malnutrtion, identification of two or more of the following six characteristics is recommended for diagnosis: •Insufficient energy intake•Wt loss•Loss of muscle mass•Loss of subcutaneous fat•Localized or generalized fluid accumulation that sometimes masks weight loss•Diminished functional status as measured by hand grips. A.S.P.E.N.

Albumin and prealbumin may still be used as an “other clinical indicator”.

Dear Dr: ______________________________ Date: _____________________ Please review the question below as clarification is needed to accurately reflect the severity of illness for your patient _ENTER PATIENT NAME HERE__who was admitted on ENTER ADMIT DATE HERE_ .

Based on your clinical judgment, can you provide the known or suspected condition(s) that represent(s) the clinical indicators listed below?

Check here if indicator is

present

Clinical Indicator(s) Value(s), Location, and/ or date(s) in the medical

record which reflects the clinical findings

Loss of muscle mass or subcutaneous fat or visible wasting away of muscle/tissue

Cachexia

Documentation of Infectious disease reducing dietary intake/absorption: __________________________________________

Diminished functional status as measured by hand grip strength

Deficiency with any of the following: iron, vitamins, minerals, zinc, iodine

Insufficient energy intake

Edema/fluid retention or edema

Unintentional Weight loss/Loss of Appetite

Dietary Consult

Inability to consume adequate caloric intake

Physician/Dietician/Nursing BMI documentation: ______________

Other Clinical Indicator: ______________________ (Requires two of the above clinical indicators to be present in order to add an “other clinical indicator”)

If known, please document the diagnosis and acuity for which you are evaluating, treating, or monitoring this patient (e.g. marasmus, mild protein-calorie malnutrition, moderate protein-calorie malnutrition, severe protein-calorie malnutrition, other unspecified protein-calorie malnutrition, or other more appropriate diagnosis) in the box below and/ or within the medical record?

If no additional information is available please initial in or check the box, sign, date and time. If unable to determine, please initial in or check the box, sign, date and time.

____________________________________________ _____________ ____________

PHYSICIAN SIGNATURE DATE TIME

Thank you for your consideration of the query. In responding to this query, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected. If you have any

questions, please utilize the contact name below.

Contact Name: ______________________ Phone Number: ____________ Fax Number: ________________

Questions?

Please feel free to contact a Liaison. We are onsite Monday through Friday.

Betsy Woodhouse RN 512-816-6357 Betsy.Woodhouse @StDavids.com

Shawnalee Huskey RN 512-816-6043 Shawnalee.Huskey@StDavids.com

Juan Patino, RN 512-816-6422 Juan.patino@hcahealthcare.com

Infection Prevention

Hand Hygiene – Most important tool in preventing infections.

We follow WHO guidelines for Hand Hygiene:

Both before and after touching patient Before performing clean/aseptic procedure After touching patient’s surroundings After body fluid exposure

Can use alcohol based hand sanitizer except in following circumstances:

Hands visibly soiled or patient has/or is suspected of having C. difficile infection. MUST use soap and water. Mechanical action removes spores from hands.

Isolation Precautions Standard Precautions used for all patients. Contact precautions for those entities spread by

direct or indirect contact: MRSA, VRE, C. diff, and other MDRO’s including ESBLs, localized Shingles, MDR Pseudomonas and MDR Acinetobacter baumanii. Must wear gown and gloves when entering patient room.

Droplet precautions for patients suspected or infected with diseases spread by large particle droplets: Meningococcal (Neisseria) meningitis, influenza, Pertussis, and Mumps. Must wear surgical mask.

Airborne precautions prevent the spread of infectious droplet nuclei which remain suspended in the air: TB, Chicken Pox, disseminated Shingles and Measles. N-95 mask and negative pressure room.

Preventing Device Related Infections Bundles help ensure care on a consistent basis

IHI (Institute for Healthcare Improvement) Bundles

*Central line Bundle includes use of insertion checklist*

1. Hand Hygiene 2. Maximum barrier precautions during insertion 3. Use of CHG 4. Optimal site selection-AVOID femoral in

adults 5. Daily review of necessity- REMOVE

unnecessary lines

Preventing Device Related Infections

Ventilator Associated Pneumonia

1. Elevate head of bed 30 degrees, if possible maintain during transport.

2. Daily sedation vacation-assess readiness to extubate.

3. Peptic ulcer prophylaxis 4. DVT prophylaxis unless contraindicated 5. Oral care- including tooth brushing and

CHG rinse

Preventing Device Related Infections

Foley Catheter Associated Urinary Tract Infections

1. Daily review of need-OUT as soon as possible

2. Sterile technique for insertion. 3. Maintain closed drainage system. 4. Drainage bag below level of bladder at

all times, even during transport. 5. Secure catheter to prevent migration. 6. Daily catheter care.

What are Hospital Acquired ConditIons (HACs)?

Required by the Deficit Reduction Act (DRA) of 2005.

The Hospital-Acquired Conditions payment provision is a step toward Medicare VBP for hospitals

Conditions that are: high cost or high volume or both; result in the assignment of a case to a DRG that has a

higher payment when present as a secondary diagnosis, and

could reasonably have been prevented through the application of evidence based guidelines.

Infection Related Patient Safety

Mediastinitis after coronary artery bypass graft (CABG) surgery

Falls and fractures, dislocations, intracranial and crushing injury and burns

Vascular catheter-associated infections Pressure ulcers

Catheter-associated urinary tract infection

*Surgical site infections *Glycemic Control

*Ventilator-associated pneumonia *DVT/Pulmonary embolism

“Serious Preventable Adverse Event” Policy

Intra operative or immediate post operative death of ASA Class I patient

Wrong site/ body part surgery Wrong patient surgery Wrong procedure surgery Death or disability associated with device

use other than as intended Death or disability associated drugs,

devices, or biologics contaminated during use

Suicide or attempted suicide with disability while in facility

Death or disability due to elopement Discharge of infant to wrong person Death or disability due to spinal

manipulative therapy Stage 3 or 4 pressure ulcers, not present

on admission or a result of multi-system organ failure

Death or disability due to kernicterus Retained foreign object during surgery

• Death or disability from hypoglycemia with

onset while a patient• Maternal Death or disability associated with

labor and delivery• Death or disability due to hemolytic

transfusion reaction• Death or disability due to medication error• Death or disability related to restraints• Death or disability from fall• Death or disability due burn• Wrong gas delivered to patient• Death or disability due to electric shock• Death or significant injury of patient or staff

member due to physical assault• Physical or sexual assault within or on

facility grounds• Abduction of patient• Care ordered by or provided by person

impersonating a licensed healthcare provider

Vascular Catheter-Associated Infection

Diagnosing Short Term Catheter Infections in Adults

CDC/NHSN Surveillance Criteria CLABSI

For patients with suspected CRBSI:Collect blood cultures prior to initiating antimicrobial therapy.Two peripheral venous blood cultures (separate sticks) are preferred over paired blood samples drawn from the catheter and a peripheral vein.Do not routinely culture catheter tips on removal unless there are clinical signs and symptoms for infection.

Interpretation of Culture Results

A definitive diagnosis of CRBSI requires:•The same organism grow from at least 1 percutaneous blood culture and a quantity of >15 colonies from the catheter tip. •Paired blood cultures, either from two peripheral separate sticks or one drawn from a catheter hub and the other from a peripheral vein, growing the same organism in a patient with clinical signs and symptoms and no other recognized source. Growth of >15 colony-forming units (cfu) from a 5-cm segment of the catheter tip by semiquantitative (roll-plate) culture from short-term nontunneled catheters, without a positive peripheral blood culture, is not diagnostic by itself, and likely a contaminant. If a catheterized patient has a single blood culture that grows coagulase-negative Staphylococcus species, then draw additional paired blood cultures from the catheter and peripheral site to be certain that the patient has a true bloodstream infection and that the catheter is the likely source. If any organism, pathogen or skin contaminant grows from the line only and the venous culture is negative, this probably represents hub contamination. Treatment for CRBSIEmpiric antimicrobial coverage should be reevaluated when culture and susceptibility data are available and de-escalation of the antibiotic regimen can be done.

Criteria 1:

Patient has a recognized pathogen cultured from one or more blood cultures (at least one bottle), and organism cultured is not related to another site of infection. Recognized pathogen excludes organisms considered common skin contaminants

Criteria 2:

Patient has at least 1 of the following signs or symptoms: fever (>38oC), chills or hypotension AND signs and symptoms and positive laboratory results are not related to an infection at another site AND common skin contaminant is cultured from 2 or more blood cultures (at least one bottle from each set) drawn on separate occasions within two days of each other.

Organism sameness is defined by speciation or descriptive name, with or without antimicrobial susceptibility results

Purulent phlebitis confirmed with a positive semi-quantitative culture of a catheter tip, but with either negative or no blood culture is considered a vascular infection CVS-VASC, not a BSI.

Catheter-Associated UTI (CA-UTI)Diagnosing Catheter-Associated Urinary Tract InfectionsCA-UTI in Adults

Patient has at least one of the following signs or symptoms with no other recognized cause:•Fever (>38°C or 100.3°F) new onset or worsening•Altered mental status•Malaise or lethargy •Flank pain•Pelvic discomfort / costovertebral tenderness•Acute hematuria Or where catheters have been removed within the previous 48h:•Urgent or frequent urination•Dysuria•Suprapubic pain or tenderness

ANDPatient has a positive urine culture, that is >=103 microorganisms per cc of urine of one or more bacteria species.

ADDITIONAL TREATMENT INFORMATION•Neither presence of pyuria nor cloudy or odorous urine, in a catheterized patient, should be interpreted as a need for urine culture or antimicrobial therapy. •Absence of pyuria in a symptomatic patient suggests a diagnosis other than CA-UTI.•7 day tx duration for CA-UTI when symptoms promptly resolve.•14 day tx duration for CA-UTI with a delayed response•Consider 5 days of Levofloxacin in CA-UTI when patient is not severely ill •Consider 3 day tx duration in women age 65 years and less that develop CA-UTI without upper urinary tract symptoms after an indwelling catheter has been removed. •Antimicrobial prophylaxis with systemic or irrigation agents is not recommended

Important: Accurate documentation helps to assure correct coding and billing. Please use these guidelines to assist with documentation and treatment.

97

Case Management DepartmentCase Management Department

In existence at In existence at SAMC since early 1996 since early 1996 Drives the discharge processDrives the discharge process Coordinate the care across the continuum, Coordinate the care across the continuum,

services and resources for patients/familiesservices and resources for patients/families Education of patient/family regarding continuum Education of patient/family regarding continuum

of careof care Conduct concurrent insurance reviewsConduct concurrent insurance reviews Plans and implements discharges with the Plans and implements discharges with the

interdisciplinary teaminterdisciplinary team Consists of both RNs & Social WorkersConsists of both RNs & Social Workers

98

Your Role in Case ManagementYour Role in Case Management

Interqual CriteriaInterqual Criteria Code 44Code 44 Keeping the case manager informed of plans for the Keeping the case manager informed of plans for the

patientpatient Communication with case manager is key to timely Communication with case manager is key to timely

discharge/movement to next level of caredischarge/movement to next level of care Daily discharge of patients by 11:00 a.m.Daily discharge of patients by 11:00 a.m.

Case Management Case Management Office. 816-6260Office. 816-6260

Blackberry. 517-4342Blackberry. 517-4342

99

Spiritual Care – EthicsSpiritual Care – Ethics

Mark Elder, DirectorMark Elder, Director SDSAMC employs professional chaplainsSDSAMC employs professional chaplains Available 24/7Available 24/7 Provide information and assistance with Advance Provide information and assistance with Advance

DirectivesDirectives Bioethics Committee is co-chaired by a physician Bioethics Committee is co-chaired by a physician

and chaplain. Meets quarterly.and chaplain. Meets quarterly. Responsible for bioethical consults, education, and Responsible for bioethical consults, education, and

policy recommendation.policy recommendation. Texas Organ Sharing AllianceTexas Organ Sharing Alliance DNR Order SheetsDNR Order Sheets

Digital Pager #512-205-1881, Office #512-816-7198Digital Pager #512-205-1881, Office #512-816-7198

Nursing Structure

Led by the Chief Nursing Officer – Sally Gillam

Over 700 nurses employed Each nursing unit consists of a Nursing

Unit Director, Nursing manager, Unit Supervisors, and unit shift charge nurses

Support staff to include Patient care Technicians and unit clerks on each unit

Service Lines

SAMC consists of major service lines:Emergency DepartmentSurgical ServicesMedical Surgical/TelemetryWomen ServicesOncology

Nursing Units/Representation

2 North/Post partum Labor & Delivery NICU

Tina Mendiola

2 CentralNoel DeSapio

3 Central 5 Central

Rick Claycamp

3 South 4 Central

Tricia Casler

ICU CVRU IMC

Toni Fuller

6th Floor - Oncology

Nursing Units/Representation

24/7 Nursing Representation

The House Supervisor is available 24/7 by calling 68888

The House Supervisor is the Air traffic controller, aka Bed Czar, and is responsible for all patient placement and transfers

All incoming and outgoing will be through the House Supervisor

The House Supervisor in addition to each nursing floor charge nurse is available to assist with anything

105

Physician Relations 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 Director512-816-6113512-897-0661 (cell)

106

Educational ProgramsEducational Programs

Medical Grand RoundsMedical Grand Rounds

Ethics CreditEthics Credit

CPR/ACLS EducationCPR/ACLS Education

Tumor Board ConferencesTumor Board Conferences

107

Admissions & Central SchedulingAdmissions & Central Scheduling

Hospital‘s Main Number 447-2211Hospital‘s Main Number 447-2211

Central Scheduling Main 816-7340 Central Scheduling Main 816-7340 Central Scheduling Physician's Line 816-7464Central Scheduling Physician's Line 816-7464

Hours: 7:30 to 5:30 pmHours: 7:30 to 5:30 pm(After hours, contact the Operating Room or House (After hours, contact the Operating Room or House

Supervisor)Supervisor)

Registration/Admissions 24hrs/7day #816-Registration/Admissions 24hrs/7day #816-71167116

Director of Patient Access: Beverly Director of Patient Access: Beverly McFarland 816-7112McFarland 816-7112

House/Nurse Supervisor 816-7109House/Nurse Supervisor 816-7109

Physician's Direct Line to PBX operators 816-Physician's Direct Line to PBX operators 816-74977497

One Call Patient Transfer CenterOneCall Patient Transfer Team is comprised of Registered Nurses, Paramedics, and EMTs, all with critical care experience available 24 hours a day

 St. David’s HealthCare OneCall Patient Transfer Center is your one stop, one call resource for:

•Emergency Transfers or Direct Admits•Specialty Consults•IP admissions from physician office and/or referring hospitals for patients who need a higher level of care•Facilitation of ground and air transport•Housed at SDM at East 30th St.

108

One Call Patient Transfer Center

To Transfer a Patient:

1)Call 1888-989 89852)The One Call Patient Transfer Team will ask for basic patient information including:

•Patient’s Name•Referring Doctor/Hospital

•Reason for Transfer

109

110

Thank you for taking the time to view this Thank you for taking the time to view this orientation program. We want your experience at St. orientation program. We want your experience at St. David’s South Austin Medical Center to be the best David’s South Austin Medical Center to be the best in the city and we want to be your #1 facility of in the city and we want to be your #1 facility of choice for your patients.choice for your patients.