sutures newsletter

PRODUCED BY AND FOR MEMBERS OF THE DEPARTMENT OF SURGERY November 2012 | Archived Issues

MEC 'Morning After' report

Highlights from the Nov. 5 Medical Executive Committee meeting include important announcements regarding CS-Link™ and changes in bylaws, rules and regulations.

CS-Link™ update

CS-Link was upgraded to the 2010 version. There are a lot of new features that should increase productivity.

There was one problem: Smartlinks were temporarily disabled. As a result, they did NOT refresh automatically. This has been corrected.

Do the following to ensure your documentation is correct:

  • Do not copy forward notes from either Nov. 4 or 5
  • Review any documentation you created on Nov. 4 and 5 to ensure that the smartlinks reflect the information intended to be communicated
  • Use fresh templates or smartlinks (these are highlighted green) for documentation to prevent pulling in smartlinks that are not refreshing

Bylaws revisions

You will be asked to vote on these amendments in a week or two.

  • Article VII – Executive Committee – redistributes membership on the MEC
  • Article XII, Section 12.1.1 – clarifies that loss of licensure results in termination unless request for review is granted
  • Article V, Section 5.1 and 5.3 – Removing references to "reapplication"

Rules and regulations

1. Provider Designation (Sections 1.1.1, 1.1.2, 1.1.8, 1.1.24, 1.3, 2.1, 3.2, 3.4, 3.6, 3.8, 4.5.3, 4.7, 4.10, 4.15, 4.16, 4.20.2, 4.21.1, 6.1, 9.6, 10.11, 16.2, and 16.3)

• From now on, when you admit a patient, you'll be asked to specify the name of the Admitting Physician and Attending Physician.
• The Admitting Physician is the person who made the decision to admit the patient. They are responsible for assuring that the patient has appropriate admission orders and documentation.
• The Attending Physician is responsible for oversight and problem solving. If you are listed as Attending Physician, expect to be called for critical or urgent lab results, Imaging results and other patient care issues. You can transfer this responsibility to another physician, by calling and getting their consent, and then changing this designation in CS-Link.
• If you admit a patient that you plan to manage in the hospital, you should list yourself as the Admitting Physician and Attending Physician.

For more information, click on the following PDF: Provider designations November 2012 (PDF)

2. Article II, Section 2.1.7 – Cedars-Sinai will be phasing out the Affiliate category. We will be contacting the 40 physicians in this category and helping them transfer to another category, if appropriate. For more information, click on the following PDF: Affiliate category November 2012 (PDF)

3. Article XXI, Section 21.3.4 – Medical Staff dues waiver – Medical Staff members who volunteer to work in our clinics supervising residents, but admit none of their own patients, may qualify for a dues waiver. For more information, click on the following PDF: Medical Staff dues November 2012 (PDF)

4. Article IV, Section 4.5.5 – Outside Reports – We continue to accept H&Ps and other reports from physicians who are not on our medical staff; however, they must be typed or dictated using the Cedars-Sinai dictating system.

5. Article III, Section 3.1 – Nondiscrimination language – You're not allowed to illegally discriminate against patients or staff.

6. Article XVI, Section16.6 – You don't have to be on our medical staff to order tests at Cedars-Sinai.

Physician hand-hygiene compliance

Physician hand-hygiene compliance was a bit lower in October – 95 percent.

The MEC approved a plan for cracking down on three-peat hand hygiene offenders:

Physicians who have taken the Hand Hygiene Class (after a second offense) and are then noncompliant for the third time (three-peaters) within a two-year period, will be referred to peer review. They also will be asked to meet with a panel including the chief medical officer, chief of staff, vice president of medical affairs, epidemiology medical director and possibly the chair from their department to discuss their noncompliance.

This panel will then determine appropriate interventions, which could include a temporary suspension from the medical staff.

Election update

The MEC formed a Nominating Committee to identify candidates for medical staff secretary and treasurer:

  • William Brien, MD – chair
  • Michael Alexander, MD
  • Jeff Caren, MD
  • Anthony Chin, MD
  • Daniel Margulies, MD

Department elections

  • Medicine:
    Department representatives to the MEC: Asher Kimchi, MD (second term) and Clement Yang, MD (second term)
  • Ob/Gyn:
    Clinical Chief – Ruth Cousineau, MD (first term)
    Department representatives to the MEC: Robert Katz, MD (first term) and Scott Serden, MD (first term)

Task Force on Civility

Last month, the MEC voted to create a Task Force on Civility. This month, it approved the initial members. The task force will be starting small, but adding members once it is up and running. Contact the chief of staff or vice chief of staff if you are interested in joining this task force.

The initial members are:

  • Scott Karlan, MD
  • Sarah Kilpatrick, MD, PhD
  • Steve Galen, MD
  • Joel Geiderman, MD
  • Chris Ng, MD
  • Michael Langberg, MD
  • William Brien, MD
  • Zab Mosenifar, MD
  • Paul Silka, MD
  • Harry Sax, MD
  • John Harold, MD
  • Andy Klein, MD
  • Paul Hackmeyer, MD

2013 list of committees/task forces approved for "committee service"

To run for MEC (and become chief of staff), you have to serve on several medical staff committees. All standing committees count. The MEC approved a list of additional committees for credit:

  • Readmission Task Force (reports to PEAC) HAI Task Force
  • Leadership Development Co-Chairs (this would allow for one additional year for the Co-Chairs who have already completed the Leadership Development Program)
  • IRB Panel
  • Medication Safety (Operations Committee)
  • MD/RN Collaboratives
  • CS-Medicine Working Group Committees
  • Patient Safety Committee and subcommittees
  • Pain Management Task Force
  • Falls Task Force
  • Task Force on Civility
  • Subcommittees of standing medical staff committees