SCAN
NCH
March 2013

Medical Executive Committee Update: March 12, 2013

Dear Colleagues:

This is the first of what I hope will be regular reports of the MEC meetings.

Credentials Summary: 7 new physicians, 16 resignations.

New Business:

Chief Quality Officer: Dr. Benink announced the hiring of Dr. Lucy Hammerberg to the new position of Chief Quality Officer (CQO). Dr. Hammerberg is trained as an Emergency Physician with a background in quality management.

Delinquent Operative Reports: Dr. Loren, Chief of Surgery, reported on the problem of delays in the dictation of operative reports. The reports are required by JACHO to be dictated at the end of the procedure. Operative reports will be considered delinquent if not dictated by 72 hours post-procedure, at which time physicians will receive a delinquent letter. If still not dictated by 14 days, there will be a $100 fine. If not dictated by 30 days, the physician will be suspended from the staff.

"Time Out": Dr. Loren presented a request for the new Time Out process to be implemented in all surgical areas. The process was approved by the MEC and will be implemented in the next few weeks.

Code of Conduct: Dr. Benink presented a Code of Conduct statement which all new Medical Staff and Allied Health Staff will be asked to sign upon board approval. Current Medical Staff members will be asked to sign it as part of the recredentialing process. (Click here to see the attachment)

National Nurses Week: The MEC approved a donation of $10,000 from the Medical Staff Funds in support of nursing activities for National Nurses Week on May 6-13. We have supported this activity in past years.

Professional Code of Conduct: Dr. Benink presented a policy entitled Professional Code of Conduct which will replace the previous Disruptive Medical Staff Member policy. Of significance, the process removes the office of the VPMA and directs the process through the Medical Executive Committee. The policy was approved by the MEC. (Click here to see the attachment)

Amendment to Bylaws for Quorum and Manner of Voting: As you know, an electronic vote was sent out regarding a change to our Quorum and Manner of Voting section of the Bylaws. This amendment had previously been reviewed by the Bylaws Committee, Medical Staff Officers, Dr. Benink, and NCH legal counsel, Wendy Rubas. Because of significant negative feedback about the proposed changes, we stopped the vote. The MEC reviewed the proposed revision and agreed that it was not worded well. Some wording changes were suggested and the MEC asked that it be reevaluated by the Bylaws Committee, then brought to the Medical Staff for review and ultimately a vote.

ID Badges: It was noted that some physicians are not presenting their ID badges in the cafeteria when charging meals and in order to obtain the employee discount of 28% on food/drinks. Some people are apparently using other physicians names and the bogus charges are applied to their accounts. It is important that we wear our ID badges at all times as it is a JACHO policy.

Utilization Review Committee: Drs. Benink and Kleinman reported that the Utilization Review Committee is a Hospital Committee, but the Joint Commission requires it to be a Medical Staff Committee. MEC voted to create a Medical Staff Utilization Management Committee and medical staff members will be assigned to serve on this committee.

NCH Medical Group Report: Dr. Hersh reported that the Patient Centered Medical Home Program with BCBS has piloted for 6 months and received accreditation from NCQA. He reported that 95% of patients discharged from the hospital are following up with their primary care physicians within 3 days of discharge.

Next Staff Meeting: Dr. Soper announced the next Staff Meeting will be held Wednesday, April 17th at Maggiano's Restaurant in Schaumburg. This will be a new venue for us and if well received by the medical staff we may hold other meetings there in the future.

Treasurer's Report: Dr. Clark reported there is $279,270.16 in the Medical Staff checking account.

Respectively submitted,
William Soper, MD
President Medical Staff