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Welcome to South Austin Hospital

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1 Welcome to South Austin Hospital
New Physician Orientation

2 Topics ID Badge, Parking, Door Access, and other miscellaneous info
Safety and Infection Control Physician Relations & Marketing Leadership Our Staff Physician FAQ’s Physician Roster by Specialty Phone Directory Forms Mission and Values Because I Care Service Initiative Overview of Hospital Patient Services Admissions & Scheduling Case Management & Core Measures HIM & Quality Cancer Registry, Tumor Board, and Educational Programs Computer Access It’s important to us for our new medical staff members to be able to start work at South Austin Hospital immediately after being approved. We understand your need to have information immediately at hand to help make it a trouble-free experience. The information contained in this presentation as well as in your Welcome Kit will assist in this goal. The topics covered on this slide were identified as important to new physicians by a recent medical staff survey. If you still have questions after viewing this presentation and reviewing the information provided in your Welcome Kit, please contact the Medical Staff Office or Administration. We will be happy to assist you.

3 Integrity: Be honest and do what you say
South Austin Hospital MISSION: To provide exceptional care to every patient every day with a spirit of warmth, friendliness, and personal pride. VALUES: Integrity: Be honest and do what you say Compassion: Be sympathetic to the needs of others Accountability: Take ownership for how actions impact outcomes Respect: Value the rights of others and accept differences Excellence: Take personal pride in exceeding expectations At South Austin Hospital, our mission is to provide exceptional care to every patient every day with a spirit of warmth, friendliness, and personal pride. We accomplish our mission with the core values that every employee and staff member is expected to exhibit.

4 Because I Care Our vision is to be the BEST hospital in the country for physicians to practice medicine, for employees to work, and for patients to receive care! Because I CARE is a multi-faceted initiative aimed at improving and sustaining patient, physician and employee satisfaction. The mission and values of St. David’s HealthCare describe what we do and how we do it. Our vision is to be the BEST hospital in the country for physicians to practice medicine, for employees to work, and for patients to receive care! Because I CARE is a multi-faceted initiative aimed at improving and sustaining patient, physician and employee satisfaction. The mission and values of St. David’s HealthCare describe what we do and how we do it. We use evidence-based practice to build an engaged culture focused on accountability. We have performance standards in place for all employees and volunteers. We round for outcomes with patients, employees and other customers. We also use peer interviewing techniques to hire the best and brightest employees. Our open culture of communication and follow-through creates an outstanding environment for your patients. The Video Clip on the next slide will validate how South Austin Hospital has and continues to meets it’s mission and values….

5 Overview of Hospital South Austin Hospital is a licensed 251-bed facility, dedicated to serving Austin and surrounding communities with state-of-the-art medical technology and a warm, personal approach to health care. Established in 1982 and a member of St. David’s HealthCare, South Austin Hospital completed a major expansion in 2004 that doubled the size of the Emergency Department and added a comprehensive Heart Center, additional medical/surgical beds, and a new Intensive Care Unit. South Austin Hospital offers a comprehensive cardiac program, a fully renovated maternity unit with Level 1 and Level 2 nurseries, and 24-hour emergency care. The hospital was recognized through several different awards: Solucient, 100 Top Hospitals (2003), 100 Top Hospitals for Cardiovascular Care (2004, 2005) HealthGrades, Best in Austin for Cardiac Care (2002), Best in Austin for General Surgery (2006, 2007, 2008) Gastrointestinal Care Award of Excellence (2007) Women’s Services Award of Excellence (2007, 2008) For more information about South Austin Hospital services, please visit our website: We are a part of St. David's HealthCare which also includes Georgetown Hospital, Round Rock Medical Center, North Austin Medical Center, St. David’s Rehabilitation Hospital, St. David's Medical Center and several surgery centers.

6 Nursing & Patient Care Services
Inpatient Areas Outpatient & Support Areas Our facility consists of several inpatient and outpatient care areas. Our average inpatient census ranges from the 150’s to the 200’s depending on the season. Our emergency department has a census that often exceeds 52,000 patient visits per year, and 60,000 patient visits are projected for It is not uncommon to have in excess of 7 emergency physicians working at any one time with a full compliment of nursing and support staff. Our ED has been recognized as being in the top 10% of Emergency Departments in HCA. Our Cardiac program remains top in its class.

7 Inpatient Services Surgical Services Endoscopy
Cardiac Cath Labs (Invasive Cardiology) Cardiovascular & Heart Center CVRU Neuro/Ortho/Renal Surgical Ctr. Diabetes Patient Education Program Women’s Services Nursery Levels I & II Post Partum Med Surg 2 Central 3 North (Observation Unit) 3 Central (Med Surg/Tele) 3 South 4 Central (Cardiac/Tele) ICU/IMC PCU (progressive care) Special Needs Unit (Direct Admits) We offer many patient care services to include those listed on this slide and the next. A comprehensive list is included in your Welcome Kit. We are especially proud of our Emergency Department which has been recognized in the top 10% of Emergency Departments in HCA. Our Cardiovascular Services program has been recognized as a top 100 hospital by Solucent.

8 Email.
Outpatient Services Outpatient Heart Center Outpatient Surgery Lithotripsy - Dornier system Hyperbaric Wound Care Cardiac Rehab Respiratory Care ISS (Interventional Short Stay) In-house CAP certified Laboratory Emergency Department MRI/CT as well as full radiology support services for patient diagnostics and treatment Hyperbaric and Wound Care is the latest program that has been added to Outpatient services. Outpatient Surgery services remains in the 90th percentile of HCA hospitals for patient satisfaction. Forms for referring your patients to SAH for outpatient services have been included in your Welcome Kit. These include: Short Stay History & Physical Disclosure and Consent for Medical, Surgical or Diagnostic Procedures Forms Women’s Services Pre-Admission Women’s Brochures X-Ray/Lab Order Forms Whenever you need a new supply, just contact the Medical Staff Office. Sharen Hardcastle, Administrative Assistant to CMO . Office. (512) Fax. (512)

9 Nursing Administrative & Patient Care Areas
Sally Gillam, RN, Chief Nurse Officer Nurse/House Supervisor avail. (24 hrs/day) Digital Pager *Bed assignment, Fax Orders, Direct Admits, Transfers, Resources for many issues. Printed Orders: Contact the Nursing Department Manger and he/she will facilitate the process for . Getting Acquainted: Nursing staff pictures are located on each floor to assist with the names and faces. Please feel free to ask for assistance with anything may need. Each department in the hospital has a director who is accountable for operational issues in the units; however, due to the nature of their jobs, they are less likely to be immediately available for you. The nurse/house supervisor is here at all times and can easily assist with day-to-day issues. They manage staffing matters as well as virtually all traffic control situations with patients. The directors or their designees are always available by pager through the hospital’s PBX operator. If issue resolution is still not able to be achieved, then there is an administrator on call who is one of the hospital Senior officers (CEO, CNO, CFO, COO). It is our sincere intent to meet your needs to the best of our ability and for the good of the organization.

10 Admissions & Central Scheduling
Hospital‘s Main Number Central Scheduling Main Central Scheduling Physician's Line Hours: 7:30 to 5:00 pm (After hours, contact the Operating Room or House Supervisor) Registration/Admissions Normal Hours Registration/Admissions After Hours House/Nurse Supervisor Physician's Direct Line to PBX operators In order to take advantage of the services we can provide to you and your patients, all procedures and pre-op appointments are scheduled through Central Scheduling. Contact numbers are listed on this slide. The policy for scheduling is attached behind this slide. Information on afterhours is also included. All Outpatient, Emergency, and Inpatient Registrations and Admissions are completed in our central Registration/Admissions area. Direct admits are arranged by contacting the House Supervisor. Managed Care, Billing and Central Verification Services South Austin participates in all major insurance Managed Care Preferred Provider Programs. If you have any questions regarding managed care providers or your patient would like to discuss their coverage with our facility, please call Darla Schwabe at SAH has a centralized Shared Services Center (SSC) for all billing and follow-up processes. This office is located in San Antonio. If a patient has questions about their bill they can call and a customer service representative can assist them. Our market Central Verification Office (CVO) verifies and precerts surgical and clinical procedures. It is located at 3601 S. Congress, Bldg. G, Ste. 600, Austin, TX Cardon Healthcare is available on site during normal business hours to assist patients with screening for governmental assistance programs. This service is offered free of charge and Cardon can screen the patients prior to the service. If patients need assistance ask them to call Other Resources for Hospital Contacts For additional contact information on specific departments or person (s) refer to the South Austin Hospital’s Phone Directory. For procedures on central scheduling see attachments, under the admissions and central scheduling section. With help finding or searching for a physician a “Find A Physician” link is available at

11 Case Management Been in existence at SAH since 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   Case management is responsible for coordinating the care for patients across all aspects of the continuum. The goal of is to reduce the length of stay while providing proactive, safe discharge planning. They coordinate services and help patients/families find the available resources that they need. Education is a big component of what the case managers do to help the patients and their families understand discharge needs as well as the resources available. Case managers also obtain hospital certification for insurance companies. Interdisciplinary team meetings are held once a week on each unit and this helps with the coordination of care. These team meetings include nursing, social services, the RN case manager for the unit, pastoral care, patient educator and physical therapy/occupational therapy if necessary.  Both clinical and financial outcomes are reviewed and evaluated on a regular basis. The case managers monitor LOS, cost/case, patient outcomes, and track variances.

12 Your Role in Case Management
“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. Debra Amirault, Case Management Director Office Blackberry To ensure efficient patient care, the case manager will drive the discharge process. Your role is to keep the case manager informed of your plans for your patients so that delays in discharge do not occur. You may be asked to participate in a interdisciplinary team meeting or patient/family conference for those patients who offer greater challenges. Communication with case managers is key to moving the patients through the continuum in a timely way and to the next level of care. If you have any questions about case management please be sure and ask the director of case management for further assistance and clarification of the case manager's role.

13 AMI (Acute Myocardial Infarction) HF (Heart Failure) PN (Pneumonia)
Core Measures AMI (Acute Myocardial Infarction) HF (Heart Failure) PN (Pneumonia) SCIP (Surgical Care Improvement Project) As part of an ongoing process to improve delivery of patient care, South Austin Hospital participates in four Core Measures: AMI (Acute Myocardial Infarction) HF (Heart Failure) PN (Pneumonia) SCIP (Surgical Care Improvement Project) The Joint Commission, in conjunction with CMS, requires hospitals to participate in Core Measures. Reports on hospital compliance to core measure indicators are available through the JCAHO website and publicly through the CMS Hospital Compare website. CMS provides payments to hospitals that meet certain core measure requirements which allow hospitals to purchase equipment, hire more staff, etc.

14 Health Information Management
Hours of Operation Dictation Timeliness Requirements Health Information Management, also known as Medical Records, is open for 7 days a week from 7 a.m. to 11:30 p.m. (Sat./Sun. 8 a.m. ‑ 11:30 p.m.). We encourage all physicians to visit HIM weekly to complete patient records, pre-schedule one day a week so records will be pulled prior to your visit to save time. Dictation stations are located in all patient care areas throughout the hospital. We provide a 12-hour turnaround on H&Ps, Consults and Operative Reports and 24-hour turnaround on Discharge Summaries. We do bill back our transcription service for reports that are outside the contracted turnaround times. Dictation is charted on the floors 2 times daily and is available to immediately upon transcription in Meditech. The following rules and tips help to ensure accurate and compliant documentation: Verbal orders must be signed, dated and timed within 24 hours by the ordering physician. Dictate your H&Ps within 24 hours of admission and/or prior to surgery and operative reports prior to transfer to the next level of care. Discharge Summaries and signatures are due upon discharge of the patient. The use of Electronic Signature is strongly encouraged! 14 14

15 Health Information Management
Notification Process Coding Query Process Lounge Weekly reminders are sent out to let you know that you have records to complete. We are proud to maintain a delinquent record count at less than half the percentage allowed by JCAHO standards. You may probably be all too familiar with the Physician Query process which is sometimes needed in order to adequately substantiate your documentation for coding purposes. When are asked to answer a query, we will make every attempt to obtain your response as soon as possible for billing purposes. Physician Queries are generated to clarify documentation for coding purposes. The diagnosis needs to be documented on the form for policy. 15 15

16 Unacceptable Abbreviations
Intended Meaning Misinterpretation Expected Action U Units O, “4” Write out entire word “Units” IU International units Misread as IV (intravenous) or the number 10 Use the word “units” Trailing Zero (i.e. 1.0 mg) 1 mg Misread as 10 Do NOT use trailing zeros after a decimal point Lack of a leading zero 0.1 mg Misread as 1 or 11 mg ALWAYS use a zero before a decimal point MS MSO4 MgSO4 Morphine sulfate or magnesium sulfate Confused for one another. Can mean morphine sulfate or magnesium sulfate Write “morphine sulfate” or “magnesium sulfate” Q.D., q.d., qd Q.O.D, q.o.d, qod “Daily” and “every other day” Mistaken for each other. The period after Q can be mistaken for an “I” or the “O” can be mistaken for an “I” Write “daily” and “every other day” Your role in good record documentation includes using acceptable abbreviations. Health care practitioners widely use abbreviations with the intent of facilitating communication and simplifying documentation. However, the use of abbreviations can result in misinterpretations and actually contribute to medication errors. A review of the MEDMARX error reporting program from January 2000 to August 2004 found nearly 19,000 error reports from 498 facilities that cited abbreviations as a cause of error. Fortunately, only a very small percentage (0.55%) of these errors was categorized as harmful. The “do not use abbreviations” identified on this slide have also been listed as high-risk by several national organizations including, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Institute for Safe Medication Practices (ISMP). The goal is to reach 100% compliance in adhering to the “do not use” list. This is a very important multidisciplinary initiative that supports patient medical safety and takes a proactive approach. Your support and adherence to not using these abbreviatons is strongly encouraged.

17 Cancer Registry Cancer Registry Cancer Committee Tumor Boards
Patient Care Evaluation Studies Cancer Registry (HIM Dept.) coordinates all Cancer Program components ensuring compliance with national standards and provides data on cancer patients at SAH – Linda Rang is the Coordinator for Cancer Registry and her number is The Cancer Committee provides multidisciplinary leadership insuring excellence in cancercare for our patients through quality monitoring and improvement studies. Two Tumor Boards, held every first and third Monday at 12:30 pm in the Doctors Dining Room/Auditorium, provide discussion/presentation of treatment options for current cancer cases. (Approved for one Category I credit by AMA). Regarding documentation responsibilities, please be aware that Pink AJCC Staging forms on charts must be completed by the Managing Physician/Surgeon on ALL new cancer cases. The Medical record is delinquent until the staging form is completed and signed.

18 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 #: (HELP) Obtain Access, Schedule Training, & Report Problems 7 a.m.- 6 p.m. To assist you with medical record documentation, Meditech, aka CPCS, is the electronic computer system used for patient care information. This system is used market wide within the St. David’s Partnership. In Meditech, we have a fully integrated Clinical, Administrative and Financial System. In addition, all the information you need regarding your patients, including an automated Rounds Report, is available to you In-house, at your office or home. Through the PCI Module of Meditech you have immediate access to Lab results, any transcribed HIM/RAD/PATH/LAB reports, as well as your patients' demographic and billing information. If you would like to know more about our system and receive training, information about the system and forms needed to initiate the process is included in your Welcome Kit. You may also contact the Physician Help Desk. 18 18

19 ID Badge Obtain your ID badge from the Travis County Medical Society
4300 N Lamar, PO Box 4679, Austin, TX 78765 For badges contact Darla Blasingame –(512) Badge problems? Call Beth Case in Med. Staff Office (512) Physician ID badges are issued by the Travis County Medical Society. If you have not done so, please contact the TCMS to obtain your bade. Your badge will give you access to physician gated parking, elevators, and outside physician entrances (from parking lot, L&D, MRI). 19 19

20 Parking… There are dedicated physician only parking spaces located around the facility. Physician parking is located on the first floor of the parking garage. The physician parking lot at the SW corner of the building does require use of your TCMS security badge. There are various physician only parking areas around the facility. Although not required, “M-facility” stickers are helpful in identifying your vehicle belonging to a physician. These stickers can be obtained from the Travis County Medical Society at 4300 N. Lamar, , next to the blood and tissue center. These stickers are required for parking at some of the other area hospitals. There is also emergency physician parking in various locations near the front entrance. 20 20

21 Security Access Outside Entrances – use Physician ID Badge issued by TCMS Elevator & Exit doors – use ID Badge Internal Dept Entrances – For most, code is 5432 Including Physician lounge & dining room Badges will also allow you access to the second floor Women’s Services area via the elevator or stairwell exit doors. Most doors requiring a code use the same code: Some areas have a unique code as well, but are set by the department director of the unit. 21 21

22 There is a dedicated web site for the medical staff. The web site will provide current information about meetings, news updates, CME programs, bylaws, and other important information. Please take a moment to visit to see what information is immediately available to you. 22 22

23 Educational Programs Medical Grand Rounds Ethics Credit
Blood borne Pathogen & Tuberculosis Education CPR/ACLS Education Tumor Board Conferences Medical Grand Rounds Medical Grand Rounds is presented as needed on the second Thursday of a designated month from 12:30 p.m.-1:30 p.m. in the Doctors Dining Room. Announcements will be sent to you by and/or posted on The Participants will receive 1 hour Category I CME for attending the presentation. Ethics Credit programs are offered on occasion and can also be obtained from various website sources. For more information, please contact the Med Staff Office at Blood borne Pathogen and Tuberculosis Education Blood borne pathogen and tuberculosis training is available each month during hospital orientation and reorientation programs. For more information, please contact the Infection Control Practitioner at CPR/ACLS Education For more information please contact the Institute for Learning at Tumor Board Conferences Tumor conferences are held on the first and third Mondays of each month from 12:30 p.m. to 1:30 p.m. in the Doctors Dining Room. For inquiries regarding SAH Tumor Board, please contact Linda Rang, CTR, SAH Cancer Program Coordinator at or Leslie Dalton, MD, SAH Pathology Department at 23 23

24 On-line CME The Texas Medical Association offers a variety of on-line CME programs, even for Ethics Credeit. The website address is:

25 Emergency Call Responsibilities
Department and specialty specific requirements Most Active status members required to provide call coverage per medical staff bylaws Contact Medical Staff Office for assistance. If you applied for “active” status membership, you most likely will be required to provide Emergency Call coverage. Requirements vary by department and specialty and are outlined in specific department rules and regulations. If you are sure what your obligation is, medical staff office personnel can assist you. 25 25

26 Medical Staff Meetings
Monthly meeting calendars are posted on the MedWeb site and ed 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. Monthly meeting calendars are posted on the MedWeb site and ed to members. Meeting reminders are faxed to member offices. Please be aware of attendance requirements which exist to ensure medical staff participation in the necessary functions of the organization. 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. 26 26

27 Safety & Infection Control
OSHA: Practice Universal Precautions Fire: R A C E TB patients Codes (see attachments) Your Infection Control responsibilities include following Universal/Standard Blood and Body Substance Precautions and Transmission-Based Isolation practices. In order to comply with JCAHO standards, we are required to provide orientation information concerning Safety and Infection Control. It is important to know the steps to take if there was an emergency fire. R-A-C-E is the four step plan we follow at SAH: It stands for Rescue Alert Contain Extinguish The Nursing staff will place patients in isolation according to policy except for TB patients. An order for Airborne Isolation is required to place a known or suspected TB patient in a negative pressure room. If TB is suspected prior to admission, request a negative pressure room for Airborne Isolation when speaking with the Nurse/House Supervisor.

28 Physician Health Forms of Impairment Alcoholism and other drug use
Other psychiatric disorders Addressed by the TCMS Physician Health and Rehabilitation committee We are required by JCAHO to educate the medical staff about issues related to physician health. Our Medical Staff leadership normally engages the assistance of the Travis County Medical Society’s (TCMS) Physicians Health and Rehabilitation Committee in addressing physician health problems. More specific steps related to this process are addressed in the Medical Staff Bylaws. 28 28

29 Christin Cross, Corporate Communications & Marketing Director
Physician Relations & Marketing Services 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 Media Relations - proactive media for new procedures Educational Seminars Physician Newsletter Progress Notes Marketing and Corporate Communications is responsible for physician, public and media relations at the hospital. Specifically, for physicians, we provide several ways to help you market your practice: Media Relations Corporate and community outreach - We offer physician-taught educational seminars at various times throughout the year. We also offer hospital-based educational seminars on a wide variety of topics. Distribution of Progress Notes - our medical staff newsletter - is published quarterly and mailed to your office. The newsletter provides information that will be of interest to , such as new services at the hospital. If there is information that you would like to have included in the newsletter, contact Christin Cross. Christin Cross, Corporate Communications & Marketing Director Office. (512) Mobile. (512) Sarah Zamora, Physician Relations Director Blackberry. (512)

30 Physician Satisfaction Team
Team Charter: 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. The Physician Satisfaction Team was created in It is committed to partner with the medical staff to improve the environment in which they work. It strives to ensure that the highest level of service is consistently provided to the physicians. The team also functions as a liaison to foster open communication and recognize physicians as valued partners in the delivery of healthcare. The team has had many accomplishment in the past two years. It: *Sends Birthday cards to physicians from the team *Operates a Physician Hotline which is *Compiled "Getting to Know the Docs" info/profiles for Doctors' Day 2007 *Synchronized the door codes for the nourishment and supply rooms on all nursing floors in 2007 *Surveyed at General Medical Staff meeting regarding what new physicians need to know and feedback for senior leaders *Will Presenting educational materials for physicians regarding ICARE standards and principles and other Because ICARE/Studer initiatives via articles in Progress Notes (Physician newsletter), making available the Flame (employee newsletter) in physician areas, and posting other information in the doctors dining room and lounges *Updated the physician links on the website and *Is updating the new physician orientation packets

31 Medical Staff Leadership
Chief Medical Officer: Al Gros, MD Chief of Staff: Richard DeBehnke, MD Chief of Staff-Elect: Robert Markus, MD Secretary: Amy Arrant, MD Dr. Al Gros CMO, South Austin Hospital Office. (512) Blackberry. (512) Fax. (512) . With the exception of the Medical Director, Medical Staff Leadership at South Austin Hospital is a group of elected physician leaders serving two-year terms for each position. These leaders are dedicated medical staff members who have actively served on various medical staff committees for several years and are well respected by their colleagues and the medical staff. Dr. Al Gros has come on board as our Medical Director, working in conjunction with Dr. Steve Berkowitz. Dr. Gros has served in key medical staff and board leadership roles at South Austin Hospital over the past two decades. Currently, he is president elect of the Texas Association of Obstetricians and Gynecologists; he also continues his OB/GYN practice in South Austin. Dr. Steve Berkowitz remains in his role as Chief Medical Officer for the HCA Central and West Texas Division. He continues to play an active role at South Austin Hospital on a part- time basis in addition to his other responsibilities. Under his leadership, we continue to make tremendous advances in Core Measures Performance, STEMI Performance, DVT Prevention, and Clinical Quality Management. Dr. Steve Berkowitz CMO, Central and West Texas Office. (512) Mobile. (512) .

32 Governance & Peer Review
There are two key committees involved in medical staff governance. The governing committee of the Medical Staff is the Medical Executive Committee, often called MEC. Membership includes the Medical Staff officers, immediate past Chief of Staff, Medical Staff Department Chiefs, Medical Care Evaluation Committee (MCEC) Chair and the CEO. The MEC is accountable to the hospital Board of Trustees and to the Medical Staff for the overall quality of medical care rendered to patients in this hospital. Key responsibilities include oversight of the Medical Staff Organization, credentialing functions, and Medical Staff Bylaws, Rules and Regulations. The Medical Care Evaluation Committee, often called MCEC, is comprised primarily of the vice-chiefs of the medical staff departments and is responsible for peer review and oversight of medical staff quality improvement activities. The MCEC may investigate, review and report on matters including the clinical or ethical conduct of any practitioner assigned or referred to it by the Chief of Staff, the Hospital Board or any individual responsible for patient care. The MCEC reports to MEC.

33 Credentialing and Medical Staff Services
Application for membership and privileges Qualification: Board certification or obtained within 5 years of initial appointment. Centralized application & verification process at St. David’s office Separate approval at each facility Website for Meetings, Bylaws, Rules and Regulations, and other information As a member of the St. David’s HealthCare, South Austin Hospital participates in the centralized application and verification process. It is very important to understand that the application and verification process is the only function that is centralized. Everything else is facility specific. Therefore, once the central office completes and collects all necessary documentation regarding your application, it is forwarded to each facility where privileges have been requested. Each facility will then take the application through its own committee approval process. Final approval is granted by each facility’s Board. To keep up to date on the latest Medical Staff activities, new, and information concerning meetings there is a website for your convenience. It is If you have any other questions, feel free to contact the medical staff office at or stop by in Administration which is on the first floor by the North lobby of the hospital.

34 Medical Director / Vice Chief of Staff
BOT MEC (Chief of Staff) Peer Review Process Action MCEC (Secretary of Medical Staff) 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, Outcomes Indicator 'Fall-outs' Compliance / Social Issue: (ie, Complaints, Non-compliance, Behavior) Peer review at South Austin Hospital is designed to be an opportunity to review selected cases to improve patient care and physician performance. We have moved away from the previous grading model to a more open-ended approach to maximize the educational aspect of peer review and minimize the punitive connotations. Reviewers are usually Department Vice chairs and have a wide latitude of actions they may recommend. This may include presentation of selected cases at the department or Medical Care Evaluation Committee meeting in a collegial atmosphere. ************** Before we conclude this program, we’d like some of our hospital staff to share with you a little bit about who they are and why they’re here.... 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

35 Senior Leadership Wes Fountain, CFO Sally Gillam, CNO
Erol Akdamar, CEO Brett Matens, COO Laura Hotze, Assoc. Admin. The senior leadership at South Austin Hospital (SAH) includes five experienced professionals in the health care industry.

36 Erol Akdamar Chief Executive Officer
Worked at SAH for 3 years; with HCA for 13 years From New Orleans, Louisiana Married to Dara; son Ethan and twin daughters Ally and Emmy Departments include Human Resources, Surgicare, Marketing, Medical Staff and all Senior Managers Erol Akdamar is SAH’s third CEO. He began his career in Healthcare Administration in 1993 and came to SAH from Tulane University Hospital in November of Erol has a Masters Degree in Healthcare Administration from Tulane. Erol is a native of Louisiana.

37 Sally Gillam Chief Nursing Officer
Worked at SAH for 19 years; with HCA for 21 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 Sally Gillam has been CNO here since 1988 and is accountable for the practice of professional nursing and coordination of patient care for the hospital. Prior to this position, she had a progressive leadership track in critical care at Harris Methodist in Fort Worth and St. David’s Hospital in Austin. She has a B.S. in Nursing from the University of Mary Hardin Baylor and a Masters degree from St. Edwards University. Sally is a native Texan and has been an RN for over 22 years.

38 Brett Matens Chief Operating Officer/ Ethics and Compliance Officer
Worked at SAH for 5 years; with HCA for 9 years From Jackson, Mississippi Married to Christi; daughter Macy Caroline Departments include Cardiovascular Services, Engineering, Pharmacy, Risk Management, Radiology, Pulmonary/ Neurodiagnostics, Hyperbarics/ Wound Care Brett Matens began serving as the COO & Ethics and Compliance Officer (ECO) at South Austin Hospital in March of Prior to moving to South Austin, Brett was serving as Vice President of Operations at Rapids Regional Medical Center in Louisiana. He has a B.S. degree in Biological Sciences from Mississippi State University and a Masters degree in Healthcare Administration from Tulane University. Brett is a native of Mississippi.

39 Wes Fountain Chief Financial Officer
Worked at SAH for 1 year; with HCA for 18 years From Atmore, Alabama Married to Melinda; son David and daughter Sarah Departments include Accounting, HIM, Materials Management, Shared Services Group, Information Systems, Revenue Integrity Wes Fountain is SAH’s newest senior leader as Chief Financial Officer. He came to SAH from Gulf Coast Medical Center in Florida where he served as the CFO. Wes has been with HCA since He has an MBA from Auburn University.

40 Laura Hotze Associate Administrator/ Co-Ethics and Compliance Officer
Worked at SAH for 2 years; with HCA for 3 years Picture here From Houston, Texas Married to Patrick Departments include Rehab Services, Laboratory, Environmental Services, Nutrition Services, Spiritual Care, Volunteers, Patient Relations Laura Hotze began serving as Associate Administrator and Co-ECO at South Austin Hospital in December of Prior to this position, she was an administrative resident under St. David’s HealthCare President and CEO Jon Foster. Laura has a B.B.A. in Economics and International Business from Baylor University and a Masters of Science degree in Healthcare Administration from Trinity University. Laura is a native Houstonian.

41 Thank you for taking the time to view this orientation program
Thank you for taking the time to view this orientation program. We want your experience at South Austin Hospital to be the best in the city and we want to be your #1 facility of choice for your patients. Thank for taking the time to view this orientation program. We want your experience at South Austin Hospital to be the best in the city and we want to be your #1 facility of choice for your patients.

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