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KEEPING PHYSICIANS ABREAST OF THE LATEST NEWS AND INFORMATION AT DIGNITY HEALTH – ST. JOHN’S HOSPITALSMAY / JUNE 2023Medical DialogueSt. John’s Hospitals Nationally Recognized for Patient SafetyPatient safety remains a top priority at Dignity Health - St. John’s Regional Medical Center and St. John’s Hospital Camarillo. As such, it is with great pleasure to announce that both of our hospitals have received two esteemed national patient safety awards. We once again received an “A” Safety Grade from Leapfrog for the second consecutive year, and Healthgrades’ Patient Safety Excellence Award™.The “A” Hospital Safety Grade from The Leapfrog Group for Spring celebrates our achievements in prioritizing patient safety by protecting patients from preventable harm and errors. Most notably, this recognition reects our performance primarily during the height of the pandemic.The Leapfrog Group assigns grades to general hospitals across the country based on over national performance measures reecting errors, accidents, injuries and infections, as well as systems hospitals have in place to prevent harm. Additionally, Healthgrades Patient Safety distinction places us among the top of all short-term acute care hospitals. During the - study period, Healthgrades’ analysis revealed that patients treated in hospitals receiving the Healthgrades Patient Safety Excellence Award were, on average:• less likely to experience an in-hospital fall resulting in hip fracture than patients treated at non-recipient hospitals*• less likely to experience a collapsed lung resulting from a procedure or surgery in or around the chest than patients treated at non-recipient hospitals*• less likely to experience pressure sores or bed sores acquired in the hospital than patients treated at non-recipient hospitals*• less likely to experience catheter-related bloodstream infections acquired in the hospital than patients treated at nonrecipient hospitals*“Earning these awards on the heels of receiving several quality recognitions is a trend and a testament to our physicians’ and sta’s continued dedication to patient safety and quality care,” says Barry Wolfman, President & CEO of St. John’s Hospitals. “This culture of safety is made possible by the commitment and accountability of every single person who works here.”*Statistics are calculated from Healthgrades Patient Safety Ratings and Excellence Award methodology based primarily on AHRQ technical specications Version for MedPAR data years through and represent three-year estimates for Medicare patients only.
2 St. John’s Medical DialogueCompliance Corner – Patient Choice & Conflict of Interest DisclosureCommonSpirit Health’s Corporate Responsibility Program CRP partners with you to ensure that our patients receive individualized, informed, and the safest care possible. By providing our patients and/or their representatives with a choice of which post-hospital care provider works best for them, you are ensuring compliance with the Medicare Conditions of Participation CoP. More importantly, you are partnering with our patients and their loved ones to make decisions that are right for them. Patient Choice – Care CoordinationOering every patient available and appropriate options is a patient right during the discharge process. Medicare’s CoP requires the Care Coordination Team to be the rst to oer Patient Choice. Care Coordination must document in the patient’s medical record that the choice list, including the quality and outcome data, were provided to the patient and/or representative. The hospital must inform the patients and/or representatives of their freedom to choose and must respect their preferences when expressed. In addition, providers physicians, hospitals, etc. must disclose to our patients any nancial interest in a home health agency, skilled nursing facility, hospice, rehab, etc., to which the patient is being referred.Medical Staff Conflict of Interest Statement“All applicants, members and practitioners with privileges are required to report material nancial interests; ownership or leadership positions in any entity including practice groups which may have an interest in decisions taken by the Medical Sta or in any facility, clinic, post-acute care facility or practice entity which may be involved in the care of current or past patients of SJRMC or SJHC.” Compliance with Health Care Laws and StatutesIn order to stay in compliance with the Centers for Medicare & Medicaid Services guidelines, CommonSpirit Standards of Conduct, and Health Care Law, it is important that our physicians disclose any relationships with post-acute care facilities. The CRP supports our physicians and acknowledges the important roles you may have in other entities. Help us partner with you to ensure our patients receive the Patient Choice they deserve, while protecting our physicians and the organization from any potential risk. When in doubt, disclose or reach out to Kendra R. Duvall, SJRMC and SJHC Corporate Responsibility Ocer, for guidance. She can be reached at -.Thank you for all of the great work you do!Reference links and QR Codes:CommonSpirit Health Standards of Conducttinyurl.com/CSH-ConductDischarge planningtinyurl.com/DH-DischargePlanOffice of Inspector General – Roadmap for New Physicianstinyurl.com/DH-FraudTakeaway:Physicians may not mention specific post-acute options until Care Coordination has spoken to the patient and provided Patient Choice.Takeaways:1. A disclosure must be on file with the Medical Staff Office for any relationships with entities as defined here. 2. A written notice must be provided to the Medical Staff within 14 days of any changes to the disclosure.
St. John’s Medical Dialogue 3DEA Training RequirementsOn December , , the Consolidated Appropriations Act of enacted a new one-time, eight-hour training requirement for all Drug Enforcement Administration DEA-registered practitioners on the treatment and management of patients with opioid or other substance use disorders. Beginning on June , , practitioners will be required to check a box on their online DEA registration form—regardless of whether a registrant is completing their initial registration application or renewing their registration—arming that they have completed the new training requirement.Key Points Related to this Training . The training does not have to occur in one session. It can be cumulative across multiple sessions that equal eight hours of training. . Past trainings on the treatment and management of patients with opioid or other substance use disorders can count towards a practitioner meeting this requirement. In other words, if you received a relevant training from one of the groups listed below— prior to the enactment of this new training obligation on December , —that training counts towards the eight-hour requirement.. Past DATA-Waived trainings count towards a DEA registrant’s eight-hour training requirement. . Trainings can occur in a variety of formats, including classroom settings, seminars at professional society meetings, or virtual oerings.Free TrainingsFor your convenience, the list below includes several free training options. Simply click on the links, or scan the QR codes with your cell phone camera. Pain Management and Opioids: Balancing Risks and Benefits 2023ASAM eLearning: Pain Management and Opioids: Balancing Risks and Benets From CME Passport – Substance Use DisorderFundamentals of Substance Use Disorders and Identication and Management of Opioid Use Disorder – Module https://www.cmepassport.org/activity/searchAmerican College of Emergency Physicians Trainings oered by the American College of Emergency Physicians include:•Emergency Medicine Medication for Addiction Treatment: Core Training Free: CME hours•Buprenorphine Initiation and Pain Management Workshop Free: CME hours•EQUAL Opioid CME Collection Free: CME hours•ACEP Anesthesia & Analgesia Collection : CME hourshttps://www.acep.org/federal-advocacy/federal-advocacy-overview/regs--eggs/regs--eggs-articles/regs--eggs---march--Accredited Groups That Provide Trainings to Meet This New RequirementThe American College of Physicians ACP has a site dedicated to ongoing education acponline.org/painhub These groups may also provide trainings:•The American Society of Addiction Medicine ASAM•The American Academy of Addiction Psychiatry AAAP•American Medical Association AMA•The American Osteopathic Association AOA, or any organizations accredited by the AOA•To provide continuing medical education•The American Dental Association ADA•The American Association of Oral and Maxillofacial Surgeons AAOMS•The American Psychiatric Association APA•The American Association of Nurse Practitioners AANP•The American Academy of Physician Associates AAPA•The American Nurses Credentialing Center ANCC•Any other organization accredited by the Accreditation Council for Continuing Medical Education AACCME or the Commission for Continuing Education Provider Recognition CCEPR, whether directly or through an organization accredited by a State medical society that is recognized by the ACCME or CCEPR•Any other organization approved or accredited by the Assistant Secretary for Mental Health and Substance Use, the ACCME, or the CCEPR
4 St. John’s Medical DialogueSJHC Hosts Surgical Robot Open House to Meet MAKO and ROSA The St. John’s Orthopaedic Center at St. John’s Hospital Camarillo recently hosted an open house for the public and local students from the Oxnard High School District. Attendees learned about robotic-assisted orthopedic surgery from Dr. Ryan Quinn Dr. and Andrew Jeers (above photo l-r featuring the Mako Robotic System for knee replacements, and Zimmer Biomet’s ROSA® which provides specialized robotics for both hip and knee replacements. They also had the opportunity to participate in hands-on demonstrations with both models and speak with members of the surgical team. MAKO and ROSA made quite the impression! SJRMC Names da Vinci Xi Surgical Robots Thanks to our physicians and sta who participated in the “Name the Robots” contest. We tallied your votes and the votes we received on Instagram, and we are thrilled to share that our da Vinci Xi surgical robots now have names. Meet Leonardo and Wall-E! Both robots are housed at St. John’s Regional Medical Center and are designed to support our surgeons in performing the most complex procedures with unmatched precision.HELLOMY NAME ISHELLOMY NAME ISandCelebrating Our 100th TAVR CaseRecently, Dr. Omid Fatemi, Structural Heart Medical Director, and the Cardiac Cath Lab team successfully completed the th TAVR Transcatheter Aortic Valve Replacement procedure at St. John’s Regional Medical Center.TAVR is a minimally-invasive procedure during which a new valve is inserted without removing the old, damaged valve. The new valve is placed inside the diseased valve. Similar to placing a stent in an artery, the TAVR approach delivers a fully collapsible replacement valve to the valve site through a catheter. Once the new valve is expanded, it pushes the old valve leaets out of the way and the tissue in the replacement valve takes over the job of regulating blood ow.Dr. Fatemi is proud to have achieved this TAVR milestone alongside the team of physicians, nurses and technologists who work together to provide this innovative treatment to the communities we serve.
St. John’s Medical Dialogue 5First Smart Knee Replacement in Ventura CountyDuring the rst week in May, our Orthopedic Surgery team at SJHC successfully performed the rst Smart Knee® Replacement on a patient in Ventura County. The procedure was led by Dr. Andrew Jeers, Medical Director of St. John’s Orthopedic Center, using the Zimmer Biomet’s ROSA® Robot. What is Smart Knee?This incredible Smart Knee technology oers personalization by taking into consideration the size, shape and t of a knee implant, while providing surgeons with more options to better match the patient’s bone anatomy. Unique to the Smart Knee, is a small “smart” stem extension that is attached to the bottom of the implant. This stem contains sensors that capture information, including the patient’s range of motion, stride length, walking speed, and step count. Data is collected throughout the day, and transmitted to the app, which is viewed by the surgeon–-think Fitbit in the knee. This remote monitoring of the patient’s functional progress helps to minimize complications, customize follow-up care and optimize recovery.We are excited to oer this technologically-advanced Smart Knee option to our patients.Top CDI Query Response Achievers High physician response rates help accurately reect patient severity of illness and intensity of service. We thank the following physicians for their diligence and commitment to St. John’s hospitals. Criteria for Top Clinical Documentation Improvement CDI Query Response Achievers: Only physicians with three or more queries and an answer rate of – are included. Below are the top achievers for February and March . Congratulations on a job well done!St. John’s Hospital Camarillo Hazel Abaya, MDAvan Patel, MDGarry Forkosh, MDSt. John’s Regional Medical Center Si Chen, MDLeah Grossman, MD Sulaiman Barkho, MDMary Piechowiak, MDSt. John’s High School Internship ProgramWe are happy to welcome our rst cohort to the St. John’s High School Internship program. The new program partners with students from the Oxnard Union High School District who are interested in pursuing a career in health care. With the guidance of their mentor, students are able to observe and learn from real-time health care experiences.St. John’s Hospitals’ administration welcome our first cohort from the Oxnard Union High School District.
6 St. John’s Medical DialoguePatient Safety Always a PriorityAcross Dignity Health’s Southern California Division, we are invested in the High Reliability Organization HRO journey to improve the care we provide with a focus on patient safety. Please take a moment to review our Safety by Choice, Not by Chance Universal Toolkit.Thank you for your ongoing commitment to ensuring the safety of our patients and one another.IntegrityExcellenceCompassionInclusionCollaboration
St. John’s Medical Dialogue 7Welcome New Physicians to St. John’s HospitalsCritical CareShyam Rao, MDFamily MedicinePatrick Kurt, MDJames Rohlng, MDGastroenterologyKeith Harris, MDHospitalistSarita Satpathy, MDNeurologyErika Lan, DONeurosurgeryAmit Goyal, MDOrthopedic SurgeryJerey Ballard, MDPathologyNeil Rawlinson, MDRadiologySean Novak, MDTele PsychiatryDebbie Chang, MDTele RadiologyAli Batouli, MDNew ABS CMEs Automatically Transfer by the ACCME PARS SystemThe American Board of Surgery ABS is pleased to announce that, as of July , , all CME credits will be automatically transferred to the ABS through the Accreditation Council for Continuing Medical Education ACCME® PARS system. This is part of our ongoing commitment to reduce the administrative burden on diplomates and enhance the value of the ABS Continuous Certication Program. As part of this improvement, the manual reporting feature the ability to individually input CME information in the ABS portal will no longer be necessary and will be retired on July , .Next Steps: As an ABS Diplomate, What Do I Need to Do?If you don’t see a previously completed CME activity already in your ABS CME repository:•You can manually upload those credits before July , , OR•Contact the CME provider and ask if they are able to send that information on your behalf to the ABS.•As of July , diplomates will no longer be able to manually report that information.Moving forward, when registering for a CME activity with an accredited CME provider, ABS diplomates can expect to provide the following information for the provider to report the CME credit:•First name•Last name•Month and day of birth•Permission to share this information with the ACCME and the ABS there will be a check box on every evaluation form that must be completed in order to get CME creditCME organizations are asked to report completed CME credits to ACCME within days of successful completion of the activity.There is nothing more that the diplomate must do. Once the data is transferred, the ABS will have a digital record of the diplomate’s participation in that activity, the number of credits earned, and the kind of credit. This information will automatically appear in the diplomate’s ABS portal.
8 St. John’s Medical DialogueCALL FOR ARTICLES: We encourage members of the St. John’s Hospital Camarillo and St. John’s Regional Medical Center Staff to submit information or articles for publication in the Medical Dialogue. We welcome your input! Please contact Tracie Gipson, Editor, at 818.522.4574 or tracie.cheesemangipson@CommonSpirit.org.EDITORIAL TEAMLynn Jeffers, MDCMO, St. John’s Hospital Camarillo and St. John’s Regional Medical CenterRenee ShimitzSenior Director, Medical Staff ServicesTracie GipsonMedical Dialogue EditorCamarillo ED Earns Geriatric Treatment Re-AccreditationThe Emergency Department at St. John’s Hospital Camarillo remains the only facility in Ventura County with a Geriatric Emergency Department Accreditation GEDA from the American College of Emergency Physicians. Our re-accreditation as a Level GEDA signals to the public that St. John’s is focused on the highest standards of care for our communities’ older adults. Congratulations to our ED physicians who played a signicant role in this achievement. Doctor’s Day RoundupThis past Doctor’s Day, St. John’s Hospitals hosted luncheons, distributed goodies and handed out “star” recognitions to celebrate our physicians to show appreciation for the meaningful work you do. We are grateful for you all, and Doctor’s Day was the perfect opportunity to celebrate your dedication, compassion and support.