UNM Hospital Board of Trustees
Friday, January 31, 2014 9:00 a.m.
Barbara and Bill Richardson Pavilion Conference Room 1500
AGENDA
I.
CALL TO ORDER – Michael Olguin, Chair, UNM Hospital Board of Trustees
II.
ADOPTION OF AGENDA
III.
ANNOUNCEMENTS

Introduction to Dr. Raymond Loretto (Steve McKernan)
IV.
PUBLIC INPUT
V.
APPROVAL OF THE MINUTES

November 22, 2013 UNM Hospital Board of Trustees Meeting
VII.
CONSENT APPROVAL/ INFORMATIONAL AGENDA

Architect and Engineering Approval Items
 UNM Psychiatric Center (UNMPC) HVAC System (Approval)

Construction Approval Items
 UNM Hospital North Fourth Street Clinic (Approval)
 UNM Hospital Laboratory Renovation (Approval)
 UNM Hospital Radiology Request, Interventional Radiology CT Scanner (Approval)
 UNM Hospital Fire Sprinkler Project (Approval)

Purchasing Item
 GE Healthcare (Informational)

Clinical Privileging
 UNMH Medical Staff Bylaws (Approval)
 UNMH CNP Core Privileges (Approval)
 UNMH CNP_PA non-core Cardiology Privileges (Approval)
 UNMH Endocrinology Core Privileges (Approval)
 UNMH Infection Disease Core Privileges (Approval)
 UNMH PA Emergency Medicine Core Privileges (Approval)
 UNMH Pediatric Surgery Core Privileges (Approval)
 UNMY Radiation Oncology (Approval)
VIII.
BOARD INITIATIVES

UNM Hospital Finance Committee Policy (Approval)

UNM Hospital Audit Committee Policy (Approval)

2014 Infection Prevention & Control Plan (Approval)

Resolution on 2004 Bond (Steve McKernan)

ACA Update (Rodney McNease)
IX.
ADMINISTRATIVE REPORTS

Chancellor for Health Sciences (Paul Roth, MD)

CEO, University Hospitals (Steve McKernan)
X.
UPDATES

December Financials – Ella Watt
XI.
COMMITTEE REPORTS

Performance Oversight / Community Benefits Committee (William Lang)

Finance Committee (Michelle Coons)
XI.
OTHER BUSINESS
XII.
CLOSED SESSION: Vote to close the meeting and to proceed in Closed Session.
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a.
b.
c.
d.
Discussion and determination where appropriate of limited personnel matters pursuant to Section 10-15-1.H
(2), NMSA.
Discussion and determination, where appropriate, of matters subject to the attorney-client privilege regarding
pending or threatened litigation in which UNMH is or may become a participant pursuant to Section 10-151.H (7), NMSA.
Discussion of matters involving strategic and long-range business plans or trade secrets of UNMH pursuant
to Section 10-15-1.H (9), NMSA.
Vote to re-open the meeting
XIII. Certification that only those matters described in Agenda Item 12 were discussed in Closed Session; consideration
of, and action on the specific limited personnel matters discussed in Closed Session.
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Announcements
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Raymond Loretto, D.V.M.
P. O. Box 189
San Ysidro, NM 87053
(575) 834-7796 – Home
(575) 834-7410 - Work
OBJECTIVE:
To use my knowledge of medicine to assist in the development and provision of quality
medical care.
EDUCATION:
Doctor of Veterinary Medicine, Colorado State University, May 1986. Elective
courses/training: Equine Lameness, Herd Health, Ophthalmology, Equine Medicine,
Food Animal Ambulatory, Calving Management, Radiation Biology, Environmental
Epidemiology, and Breeding Soundness Testing in bulls.
Veterinary Preceptorship, United States Department of Agriculture, National Animal
Disease Center, Ames, Iowa. Investigation of the effect of pre- and post-natal exposure
of piglets to aflatoxin on Salmonella Choleraesius infection. September 1985 to
December 1985.
Master of Science, Colorado State University, August 1976 in Animal Nutrition. Paper:
“Economic Analysis Relative to Cost and Return for Alternative Combination of Major
Field Crops and Livestock Operation on the Jemez Pueblo Reservation.”
Bachelor of Science, New Mexico State University, December 1973 in Animal Science.
Interim term, January 1973: obtained Technician Certificate in Artificial Insemination
and Pregnancy Testing in cattle.
EXPERIENCE: Veterinarian, Loretto Veterinary Clinic, San Ysidro, New Mexico. Owner and sole
proprietor of veterinary medical clinic offering complete routine, surgery, dental, and
emergency medical care for large and small animals. Specialty area of veterinary
practice: provide veterinary medical care and assist in establishing herd management
program for bison herds managed by private owners in New Mexico and several
northern New Mexico Pueblo tribes. Only veterinary medical facility in this part of
Sandoval County serving northern rural communities within about 60 mile radius; also
set up special clinics for several Indian reservation communities. June 1987 to present.
(Went on one year sabbatical during my terms as Governor for the Pueblo of Jemez in
2003 and 1st Lieutenant Governor in 2001. I also hired another veterinarian to operate
my clinic when I took on the position as CEO of the Jemez Department of Health and
Human Services from 2007 to 2010.)
Chief Executive Officer (CEO), Pueblo of Jemez, Department of Health and Human
Services. I took on the position as CEO, of the Jemez DHHS on an Interim basis in
February 2007. I applied for the full-time position and was hired permanently in May
2007. As CEO, I managed 12 health and social services programs, including the Public
Health Program, Behavioral Health Program, Senior Citizen's Program, Social Services,
Vocational Rehabilitation, and Tribal Enrollment. The largest component of the Jemez
DHHS was the primary medical and dental care centers. We provided primary health
and dental care to all Jemez tribal members and as a PL-638 contract provider, we
provided care to all Indian peoples regardless of tribal affiliation. I supervised over 120
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employees, including a Deputy Director, Clinical Programs Director, Medical Director,
physicians, dentists, nurses, physician's assistants, pharmacists, counselors, and varied
medical technicians. The Pueblo of Jemez took over its PL-638 contract from the U. S.
Indian Health Services in 2000. As a member of the Jemez Health Board since 1999, I
was intricately involved in securing the PL-638. During this process, I developed close
relationships with the Albuquerque Branch of the Indian Health Services; a relationship
that became extremely viable during my tenure as CEO of the Jemez DHHS. This
relationship also proved viable during my tenure on the UNMH Clinical Operation Board
when UNMH was negotiating with IHS to continue contract health care delivery at
UNMH and critical during the building of the new Bill and Barbara Richardson's wing of
UNMH. In addition my responsibilities included: Preparing the annual budget; Planning
and working collaboratively with partners such as UNMH and IHS to increase services;
Insure compliance with all policies and procedures affecting the operation of a medical
facility-HIPAA; Insure that all medical staff are credentialed; Developing partnership
with other Tribal Agencies and agencies outside Jemez (BIA, IHS, UNMH, NMSU) to
increase resources available to the Department, access training, and limit duplication of
effort; and Conduct community assessment to ensure that DHHS was responsive to
meeting community needs. Critical was also my one-on-one meetings with patients and
consumers to resolve issues and to ensure we were providing quality care. 2/20076/2010.
Governor, Pueblo of Jemez, New Mexico. Following the cultural and traditional
practices of the Pueblo of Jemez, appointed as the Governor of Jemez for 2003. Along
with the 1st Lieutenant Governor and 2nd Lieutenant Governor, administer and manage
seven tribally-operated governmental departments—Health and Human Services,
Community Services, Public Works, Housing, Finance and Human Resources, Tribal
Enterprises, and Education—comprised of over 200 employees; negotiate with federal,
state, tribal, and local governments (including the Governor of New Mexico and New
Mexico Congressional leaders), and private entities on all matters affecting the Pueblo of
Jemez; make policy recommendations to the Tribal Council; meet with, listen to, and
assist tribal members (approximately 3,300 tribal members) in accessing services and
settling domestic issues; serve as Judge at Tribal Court hearings; represent the Pueblo
at functions outside Jemez; and provide leadership in community events. My areas of
expertise: negotiating contracts and services; developing the Pueblo’s energy resources;
overseeing the Jemez Health Clinic’s operations; developing the tribe’s enterprises and
initiating economic development; and negotiating with the State Highway Department
for highway and bridge construction and expansion. January 2003 to December 2003.
1st Lieutenant Governor, Pueblo of Jemez, New Mexico. Following the cultural and
traditional practices of the Pueblo of Jemez, I was appointed as the 1 st Lieutenant
Governor of Jemez for the 2000 year. Along with the Governor and 2nd Lieutenant
Governor, administered and managed six tribally-operated governmental departments—
Health and Human Services, Community Services, Public Works, Finance and Human
Resources, Tribal Enterprises, Education—comprised of over 165 employees; negotiated
with federal, state, tribal, and local governments, and private entities on all matters
affecting the Pueblo of Jemez; make policy recommendations to the Tribal Council;
meet with, listen to, and assist tribal members (approximately 3,300 tribal members) in
accessing services and settling domestic issues; served as Judge at Tribal Court
hearings; represented the Pueblo at functions outside Jemez; and provide leadership
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Page 3
and participated in community events. My areas of expertise: negotiating new
construction projects; developing the Pueblo’s energy resources; overseeing the Jemez
Health Clinic’s operation; and negotiating with the State Highway Department over
highway and bridge construction and expansion. January 2001 to December 2001.
NM State Fair Veterinarian, Albuquerque, NM. Served as a State Fair veterinarian
inspecting horses and other exhibition livestock coming onto the state fair grounds to
ensure that animals are healthy and that each had health certificates documenting
health status; also served as the Rodeo Veterinarian at each rodeo performance held.
Contractual services have been renewed each year from September 1996 to Present.
Relief Veterinarian, Los Lunas Animal Clinic (small and large animals), Los Lunas,
NM: Bosque Animal Clinic (small and large animals), Bosque Farms, NM; and Ponderosa
Animal Clinic (small animals), Albuquerque, NM. June, 1987
Pari-mutuel Ticket Seller, Cloverleaf Kennel Club, Loveland, Colorado. Part-time
position during years at veterinary medical school. Sold tickets at dog racing track.
Each spring season, 1982-86.
Ranch Assistant, Fossil Creek Farm, Fort Collins, Colorado. Part-time position during
years at veterinary medical school. Assisted in artificial insemination breeding of brood
mares; maintenance and care of 50 mares. December 1982 to April 1983.
Veterinarian Assistant, North College Veterinary Clinic, Fort Collins, Colorado. Small
animal exclusive. June 1980 to August 1981.
Research Assistant, Lovelace Biomedical and Environmental Institute, Albuquerque,
New Mexico. Determination of the acute toxic effect of sulfuric acid aerosols in guinea
pigs. Publication available. June 1978 to August 1978.
Research Assistant, Department of Animal Science, Colorado State University, Fort
Collins, Colorado. Obtain and analyze data to predict the extent of biological
degradation of forage fibers; analyze nutritive value of recycled manure obtained from
feedlots. September 1974 to August 1976.
CONTRACTS:
Technical Peer Reviewer, for Colorado State University and Risk Assessment
Corporation (RAC) - Reviewed Contemporary Risk Assessment, Risk Analysis,
Communication, Evaluation, and Reduction (RACER) at Los Alamos National Laboratory.
March 2004 to December 2004.
PROFESSIONAL
MEMBERSHIP: Board of Trustees, Valles Caldera National Preserve
The Board establishes policies and guides operations of the Valles Caldera National
Preserved. I was appointed to the Board of Trustee by President George W. Bush in
June 2005 for a four-year term. I was the first to be reappointed in 2009. I served as
Chairman of the Board, September 2010 to September 2012. Term ended in December
2012.
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Clinical Operations Board, University of New Mexico Health Sciences Center.
The Board establishes policies and guides clinical operations of the University of New
Mexico Hospital and the UNM School of Medicine. Appointed in October 2003 for a
three-year term and re-appointed for another four-year term. My term ended in 2010.
Jemez Pueblo Tribal Council. This is a lifetime appointment following my
completion as Governor of the Pueblo of Jemez. Council makes policy decisions over all
aspects of the governance of the Pueblo.
Jemez Pueblo Health Board. Appointed by the Jemez Pueblo Tribal Council in 2000.
The Board establishes policies and guides program direction for the Jemez Department
of Health and Human Services, which includes the Jemez Comprehensive Health Clinic.
Serve as Chairman of the Board. Term ended in 2007.
Albuquerque Area Indian Health Services. Area Representative, tribal
representative providing advocacy on IHS budget formulation and negotiation.
Appointed for two-year term.
New Mexico Board of Veterinary Examiners. Appointed by Governor Bruce King in
1993. Re-appointed by Governor Gary Johnson in 1998. Term ended October 2002.
Secretary of Agriculture’s Advisory Committee on Foreign Animal and Poultry
Diseases, U.S. Department of Agriculture. Initial appointment by the U. S.
Secretary of Agriculture in 1991; re-appointed for two-year term in July 1992. Term
ended in 1994.
Jemez Valley Credit Union Board. Initial appointment in 1989. Re-appointed in
March 1992, 1994, 1996, and 1998.
American Veterinary Medical Association, member.
COMMUNITY
ACTIVITIES:
Search Committee, Appointed by All Indian Pueblo Council to serve on Search
Committee selected to select the next President of New Mexico State University, 2004.
Seminars: Provide workshops on herd health management (parasite control,
vaccinations, fertility testing, West Nile Virus, etc.) for local livestock associations,
including Valles Caldera livestock program and the NM Indian Livestock Association
working jointly with the NM State Extension Agent at their annual seminar on effective
herd management and routine health maintenance programs.
MEMBERSHIP: Jemez Pueblo Land, Natural Resources, and Cultural Preservation Committee
Association of American Indian Physicians
Jemez Pueblo Cattlemen Association
American Indian Science and Engineering Society
HONORS:
1992 Hospital Design Merit Award, Veterinary Economics. My clinic was among 40
entries nationwide in the 1992 hospital design competition and was among six selected
for award.
1981 Outstanding Young Man in America
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Approval of Minutes
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UNM Hospital Board of Trustees
November 22, 2013 Meeting Minutes
Pavilion Conference Room 1500
Agenda Item
Subject/Discussion
Voting Members Present:
Michael Olguin, Michelle Coons, Jerry McDowell, Nick Estes, Debbie Johnson,
Dr. Warren Laskey
Ex-Officio Members Present:
Michael Richards, Stephen McKernan, Donna Sigl,
County Officials Present:
Maggie Hart-Stebbins, Emily Madrid
I.
Call to Order
A quorum being established, Michael Olguin, Chair, called the meeting to order at
9:12 a.m.
II.
Adoption of Agenda
The Chair, Mr. Michael Olguin, adopted the agenda, as submitted.
III.
Public Input
Doriane Mason, Staff Attorney at New Mexico Center on Law and Poverty,
expressed great concern about the restructuring of the UNM Care Program and
commented there will still be a large number of people left out of the programs’
protection, but include higher income bracket of people, who may not need the
assistance. While extending the reach of the program, it is also potentially
excluding a significant group of people that need the assistance. She stated they
believe the restructuring incentivizes people to select the Silver Plan, but states
the Silver Plan is unaffordable for most people. She requested the focus of the
program to be on the most vulnerable participants and to eliminate the
implementation of collection process in the restructuring. Letter submitted
Action/Responsible Person
Kim Zamorin, Ellevalle, thanked the board for the service and commitment to
Bernalillo County. She stated Ellevalle is in support of the letter submitted. They
believe the proposal to transition UNM Care to be a supplemental program will
UNM Hospital Board of Trustees
Minutes November 22, 2013
1
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Agenda Item
Subject/Discussion
leave tens of thousands of Bernalillo residents behind. Those residents are
uninsured and underinsured county residents, primarily, those under 200% of
poverty. They asked the board to consider keeping UNM Care, with a change of
determining eligibility solely on county residency and income. She further stated
they would like to see an end to collections for any county resident under 200% of
poverty.
Action/Responsible Person
Hadley Pope, Medical Debt Case Manager, Casa de Salud, asked that we not
send low income participants to collections, as these families are already
struggling. They requested to keep UNM Care, but change it to include all
residents who will be left out of the ACA plans.
IV.
Announcements
Steve McKernan responded to the public input that we do not have enough data
at this point to make a recommendation to the Board. The plan is to keep the
st
UNM Care program as is through March 31 , then review with the Board of
Trustees and make recommendations in the following months. He commented
that understanding the differences between the Silver and Bronze plans is still
technically difficult at this point.
V.
Approval of Minutes
UNM Hospitals Board of Trustees meeting minutes for October 25, 2013.
Ms. Michelle Coons made a motion to
approve the minutes of the October 25,
2013, Board meeting. Ms. Debbie Johnson
seconded the motion.
There being no
objections, the motion carried.
VI.
Consent Agenda
Following review of the consent items, the Chair, Mr. Michael Olguin requested a
motion to approve the consent items.
Ms. Debbie Johnson made a motion to
approve the consent agenda. Dr. Warren
Laskey seconded the motion. There being
no
objections,
the
motion
passed
unanimously.
Per recommendation by the Performance Oversight Community Engagement
Committee, the Clinical Privileging was presented for approval.
Dr. Warren Laskey made a motion to
approve the Clinical Privileging as
recommended by the POCEC. Ms. Debbie
Johnson seconded the motion. There being
no objections, the motion carried.
VII.
Board Initiatives
The Chair, Mr. Michael Olguin, welcomed Christine Glidden as the newest
member, to the Board of Trustees.
UNM Hospital Board of Trustees
Minutes November 22, 2013
2
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Agenda Item
VIII.
Administrative Reports
Subject/Discussion
Following a review of the updated Committee Assignments, the Chair, Mr.
Michael Olguin, requested a motion to approve the assignments.
Action/Responsible Person
Ms. Michelle Coons made a motion to
approve the Committee Assignments, as
presented. Ms. Debbie Johnson seconded
the motion. There being no objections, the
motion passed unanimously.
Briefing on the UNMH power system, by Rhonda Reynolds, certified electrical
engineer, who discussed alternate options in an emergency situation, and
reviewed the maintenance policies in place. Presentation presented is in the
packet.
Erin Doles / Rhonda Reynolds
Briefing on the ACA was presented by Rodney McNease. There are currently 37
Healthcare Guides and an additional 78 slated to become certified shortly. Call
centers specific to the ACA are in place. The State is supposed to automatically
enroll people from the SCI program to the current program, unless those people
do not qualify through Medicaid. We have an outreach which has identified 75%
of UNM Care participants are eligible for Medicaid. The SCI patients will default
to Molina.
Rodney McNease
An update on Milagro OB Clinic was presented by Sheena Ferguson, Michelle
Wafer, and Dr. Larry Lehman. The number of patients seen in this clinic is rising.
Patients may be seen in a number of clinics and the visits are grouped with
counseling. Patients may be referred in a number of ways: self-referral, word of
mouth, parole officers, and/or outlying community referrals.
Presentation
presented is in the packet.
Sheena Ferguson, Michelle Wafer, Dr. Larry
Lehman
An update on the Quality and Safety Program was presented by Dr. Richard
Crowell. A focus is how the institution is coaching the strategic goals identified
strictly on quality improvement. 1) Become the safest hospital/health system in
New Mexico, 2) Establish, monitor, report a select range of quality, safety
benchmarks. Presentation is in the packet.
Dr. Richard Crowell
HSC Chancellor Report – Dr. Roth noted he has been working with the
administration of the New Mexico HED to effectively increase the healthcare
workforce in New Mexico. Many of our legislative requests revolve around class
size for our nursing classes, BSN program.
Dr. Paul Roth
UNM Hospital Board of Trustees
Minutes November 22, 2013
3
Page 11/100
Agenda Item
Subject/Discussion
Action/Responsible Person
CEO Report – The CEO report is in the packet. Mr. McKernan noted that we
recently engaged in contract negotiations with Presbyterian and that we now have
a new contract for UNMH to provide services to Presbyterian. Presbyterian will
allow their patients to be seen at UNMH, though a more rigorous pre-authorization
system is now in place, which can create problems for existing patients related to
continuity of care.
Mr. Stephen McKernan
IX.
Updates
Financial Report Card – The financial dashboard was presented by Ms. Ella
Watt.
Ms. Ella Watt
X.
Committee Reports
Performance Oversight & Community Engagement Committee
The Performance Oversight & Community Engagement Committee met on
November 21, 2013 for credentialing purposes only.
Mr. William Lang
Finance and Audit Committee
The Finance and Audit Committee report is in the Board book.
XI.
Other Business
None
XII.
Closed Session
At 11:30AM, Mr. Michael Olguin, Chair, requested a motion to close the open
session of
the meeting to the public for purposes of discussion and
determination, where appropriate, of limited personnel matters per Section 10-151.H (2); and discussion and determination, where appropriate of matters subject
to the attorney-client privilege regarding pending or threatened litigation in which
UNMH is or may become a participant, pursuant to Section 10-15-1.H (7); and
discussion of matters involving strategic and long-range business plans or trade
secrets of UNMH pursuant to Section 10-15-1.H (9), NMSA.
XIII.
Certification
After discussion and determination where appropriate, of limited personnel
matters per Section 10-15-1.H (2); and discussion and determination, where
appropriate of matters subject to the attorney-client privilege regarding
pending or threatened litigation in which UNMH is or may become a
participant, pursuant to Section 10-15-1.H (7); and discussion of matters
involving strategic and long-range business plans or trade secrets of UNMH
pursuant to Section 10-15-1.H (9), NMSA, the Board certified that no other
items were discussed, nor were actions taken.
XIV.
Vote to Re-Open meeting
At 11:55AM, the Chair, Michael Olguin, requested a motion be made to return to
UNM Hospital Board of Trustees
Minutes November 22, 2013
Ms. Michelle Coons
Dr. Warren Laskey made a motion to move
to closed session. Ms. Debbie Johnson
seconded the motion. The motion passed
unanimously.
Mr. Jerry McDowell made a motion to move
4
Page 12/100
Agenda Item
XV.
Adjournment
Subject/Discussion
open session.
Action/Responsible Person
to closed session. Mr. Nick Estes seconded
the motion.
The motion passed
unanimously.
Mr. Michael Olguin requested a motion to be made that the Board accept the
Minutes of the meeting of those committees that were presented in Closed
Session to acknowledge for the record that those minutes were, in fact, presented
to, reviewed, and accepted by the Board and for the Board to accept and approve
the recommendations of those Committees as set forth in the Minutes of those
Committees meetings.
Mr. Nick Estes made a motion to accept the
minutes presented by the committees. Mr.
Jerry McDowell seconded the motion. The
motion passed unanimously.
The next scheduled Board meeting will be January 31, 2014 @ 9:00 am. There
being no further business, Mr. Michael Olguin adjourned the meeting at 11:57AM.
____________________________________
Michelle Coons, Secretary
UNM Hospital Board of Trustees
UNM Hospital Board of Trustees
Minutes November 22, 2013
5
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Architect &
Engineering
Approvals
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APPROVAL OF ARCHITECT SELECTION for
University of New Mexico Psychiatric Center (UNMPC) HVAC System
UNIVERSITY OF NEW MEXICO HOSPITAL
January 2014
REQUESTED ACTION:
As required by Section 7.11 of the Regents Policy Manual, it is recommended that the Board of Regents approve
the selection of the following Architect for design/planning of the University of New Mexico Adult Psychiatric
Center HVAC System. Project approval will be requested at a future meeting of the Board of Regents.
PROJECT DESCRIPTION:
1. This project will include program validation, planning and engineering design for a complete and
operational HVAC System.
2. The current location is 2600 Marble NW. The building is approximately 84,000 square feet and is in
need of an HVAC system upgrade. Due to the extent of the upgrade and having to function 24 hours a
day, there will be many phases to the project.
3. The HVAC system will be looked at in its entirety and the intent will be to completely upgrade and/or
replace mechanical systems.
PROJECT RATIONALE:
1. This recommendation is based on a qualification-based selection process in accordance with State of NM
Procurement Regulations. RFP Respondents were: Assurance Engineering; Beaudin- Ganze; Bridgers and
Paxton; and Coupland- Moran. All Firms are from Albuquerque, NM
2. The selection committee included: Lee Imhof, Manager Facilities Mechanical Engineer, UNM Hospitals;
John Blenk, Manager Facilities Planner, UNM Hospitals; Rudy Rael, Manager Facilities Planner, UNM
Hospitals. The committee evaluated the written proposals from the four firms in the areas of Competence
and Experience (25 pts), Past Performance (20 pts); Capacity and Capability (20 pts); Record of
Performance (20 pts); Scope of Service/Work Plan (5 pts); Familiarity with Area (5 pts); Volume of Work
(5 pts); and Fee Proposal (20 pts) in accordance with Procurement Regulations.
3. The committee recommended Bridges and Paxton based upon the highest total evaluation score
received.
PURCHASING PROCESS:
The Architect selection process was solicited through an RFP in accordance with the NM State Procurement
Code (UNMH RFP #1579-13). There were four respondents to the published RFP, listed below.
Recommended selection is:
Bridges and Paxton
4600 Montgomery Blvd.
Albuquerque, NM 87109
FUNDING:
The total design and construction administration fee will be determined upon completion of programming
requirements and is estimated to be $170,582 excluding NM Gross Receipts tax. The programming and
design for this project is funded from the UNM Hospital capital funds.
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REQUEST FOR CAPITAL PROJECT APPROVAL for
UNM Hospitals, North Fourth Street Clinic –Project Approval
UNIVERSITY OF NEW MEXICO
January 2014
REQUESTED ACTION:
In accordance with Section 7.12 of the Board of Regents Policy Manual and as required by the
New Mexico Higher Education Department and New Mexico State Board of Finance, project
approval is requested for UNM Hospital, North Fourth Street Clinic –Project Approval.
PROJECT DESCRIPTION:
The purchase of the land at 3401 4th Street NW was approved at the December NM State Board
of Finance meeting. The land purchase was closed on December 30, 2013. The clinic building
will be similar in design to the SW Mesa Clinic completed in November 2011. It is 17,000
square feet and has 22 exam rooms and one procedure room. In addition to increased exam room
capacity, the new clinic will also include pharmacy, laboratory, radiology and physical therapy
services as well as Behavioral Health and financial counseling.
UNMH worked closely with the Near North Valley Neighborhood Association to integrate the
site/building design into the Neighborhood. The site plan includes landscaped staff and visitor
parking which can be used after hours and on weekends for neighborhood events. The building
includes a conference room which can also be scheduled for use by the Neighborhood. The
project will be designed to meet LEED Silver requirements. This project is scheduled to be
completed in FY 15.
PROJECT RATIONALE:
UNMH has identified improved access to care as one of its top priorities as it responds to and
aligns itself with healthcare reform mandates, National Committee of Quality Assurance Patient
Centered Medical Home standards and patient and community feedback. We believe that
expanding Primary Care Services into the Albuquerque Community is an important step in
improving access. The North Valley of Albuquerque has a large patient population with the
highest visit rates to the hospital, income disparities, rates of asthma, hepatitis, HIV/AIDS, and
highest infant and adult death rates. It is expected that by developing a new location with adjacent
services such as pharmacy, lab, behavioral health, and financial services the result will be increased
access to health care in this community. It is estimated that the clinic visits will double within five
years. In addition, this location was chosen for its strong community support, proximity to a bus
line and easily accessible by foot traffic.
PURCHASING PROCESS:
FBT Architects, who were the Architects for both the SE Heights Clinic and the SW Mesa Clinic,
were selected by UNM RFP 1616-14 and approved by the UNMH Board, HSC Board and UNM
Regents in September 2013. The Maximum Allowable Construction Cost is estimated to be
$3,600,000 plus NMGRT. The schedule is to be completed in 2014.
FUNDING:
The Total Project Budget is $5,500,000 funded by UNM Hospital capital funds.
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REQUEST FOR CAPITAL PROJECT APPROVAL for
UNM – HOSPITAL LABORATORY - RENOVATION
January 2014
REQUESTED ACTION:
In accordance with Section 7.12 of the Board of Regents Policy Manual and as required by the
New Mexico Higher Education Department and New Mexico State Board of Finance, project
approval is requested for UNM Hospital Laboratory - Renovation.
PROJECT DESCRIPTION:
This is a 3,596 square foot project, located on the second floor of the Main Hospital at 2211
Lomas NE in Albuquerque. The project will reconstruct mechanical, electrical, plumbing and
Information Technology infrastructure. The existing laboratory is out of compliance with
current HVAC, electrical and data cabling requirements. Due to the need for this area to remain
fully operational 24/7, a phasing strategy will be used to renovate smaller areas for occupancy.
PROJECT RATIONALE:
This project is necessary to alleviate several code deficiencies identified by Joint Commission
and must be performed in a functioning laboratory, without impeding operations. The project
will improve patient safety by creating dependable air pressures and temperatures, improving
task lighting, increase data communications and adding work stations, while implementing
improved work flow and efficiencies.
PURCHASING PROCESS:
The Architectural firm selected through a RFP Process is Gregory T. Hicks and Associates, P.C.
and has been approved by the Board of Regents. The construction contract award will be
determined by RFP upon completion of Bid Documents anticipated in June 2014.
FUNDING:
The total estimated Project Budget is $2,720,000 and will be funded by UNM Hospital capital
funds.
Page 17/100
CAPITAL PROJECT APPROVAL
UNMH Main, Radiology Request, First Floor, Interventional Radiology CT Scanner Installation
January 2014
RECOMMENDED ACTION:
As required by Section 7.12 of the Board of Regents Policy Manual and the NM Commission on
Higher Education, capital project approval is requested for the UNMH Main, Radiology Request,
First Floor, Interventional Radiology CT Scanner Renovation.
PROJECT DESCRIPTION:
The scope of this project includes modifications to an existing Interventional Radiology Computed
Tomography (IR CT) room within the first floor Radiology Department. These modifications include
interior walls, mechanical, HVAC, and electrical systems to facilitate equipment installation, provide
reliable operations, as well as a safe environment for our staff and patients.
RATIONALE:
The project will include trading in two CT Scanners and replacing them with one new CT Scanner. One of
these existing scanners is at its end of life and the other existing scanner does not meet the needs of our
interventional radiologists. The IR CT equipment will be state-of-the-art, requiring modifications to the
control room, CT equipment room and other shielded walls to meet current clearances and codes. The
HVAC system will also be improved to meet Class A occupancy and to facilitate procedures to assess
patients with potentially infectious conditions.
PURCHASING PROCESS:
The Architectural firm selected through an RFP Process is KGA Architects (Kevin Georges). The
construction contract award will be determined by RFP upon completion of Bid Documents anticipated
in May 2014.
FUNDING:
The total project budget is estimated at $965,000, and will be funded by UNM Hospital capital funds.
Page 18/100
Construction
Approvals
Page 19/100
REQUEST FOR CAPITAL PROJECT ARCHITECT APPROVAL FOR
UNM Hospital, Fire Sprinkler All Floors
UNIVERSITY OF NEW MEXICO
January 2014
REQUESTED ACTION:
In accordance with Section 7.12 of the Board of Regents Policy Manual, project approval is requested for UNM
Hospital, Fire Sprinkler Construction Approval.
PROJECT DESCRIPTION:
The “Fire Sprinkler All Floors” project of UNM Hospitals, will include program validation, planning and
complete coverage of fire sprinklers at the Main Hospital. UNM Hospital is not fully sprinkled, and therefore
is not currently compliant with existing fire sprinkler codes.
The project is scheduled to be completed in FY 15.
PROJECT RATIONALE:
1. This recommendation is based on the analysis of the proposal received by a selection committee against the
following criteria: Management Plan and Technical Capability (20 pts); Past Performance by a General
Contractor (20 pts); Past Performance by Sub-Contractors (20 pts); and Price Proposal (40 pts).
2. The Committee determined that Sweep Construction met all requirements. Sweep Construction submitted a
price proposal of $382,729 (including NMGRT). The Price Proposal was determined to be fair and
reasonable.
UNM Hospital was constructed in the 1960s. At that time fire sprinklers were not mandated to cover all
areas of a hospital and therefore they were not installed in all areas of UNM Hospitals. At the end of this
project, it is UNM Hospitals intent to be compliant with current fire sprinkler code. Adding sprinklers to the
entire hospital will also provide for a safer environment for patients, visitors and staff.
PURCHASING PROCESS:
The Contractor was solicited through the RFP process in accordance with the NM State Procurement Code
(UNMH RFP #1570-13). The RFP was published for 30 days, with only one respondent:
Sweep Construction
3314 Vassar NE
Albuquerque, New Mexico, 87107
FUNDING:
The Construction fee for the Fire Sprinkler Main Hospital Project is $390,000. This will be funded by UNM
Hospital capital funds.
Page 20/100
Informational
Approval
Page 21/100
UNM Hospital Board of Trustees
Recommendation to HSC Board of Directors Finance and Audit Committee
January 2014
Informational
1) GE Healthcare
Ownership:
3135 Easton Turnpike
Fairfield, CT 06828
Officers Information:
Chairman and CEO: Jeffrey R. Immelt
Vice Chairman: Daniel C. Heintzelman
Source of Funds: UNM Hospital capital funds
Description: Request to purchase two Voluson E8 Expert 2013 Ultrasound Machines to be used
in Women’s Imaging. This equipment will:
 Allow for exploration of fetal images in the early stages;
 Introduce automation to facilitate efficient and reproducible exams;
 Improve the ultrasound examination data from a single sweep so that the focus can be on
early prevention rather than late diagnosis;
 Assist in early evaluation and classification of simple and complex masses.
Process: Novation Contract #XR0022
Total Cost: $444,912
Page 22/100
Clinical Privileging
Approvals
Page 23/100
UNMH Medical Staff Bylaws
Proposed Revisions Summary
Recommended by MEC 9/18/13
Preamble – change to “Professional Behavior”, remove term “Allied Health Professional Medical
Staff”
PREAMBLE
WHEREAS …..

Maintain a high degree of competence and professionalism behavior by each individual
practitioner
WHEREAS, it is recognized that these roles may be best accomplished by coordinated action of
the Organized Medical Staff and the Allied Health Professional Medical Staff;
NOW, THEREFORE, the clinicians authorized to practice hereby organize themselves into an
Organized Medical Staff and Allied Health Professional Medical Staff in conformity with the
Amended and Restated Bylaws of the Medical Staff, which supersede all previous Bylaws and
Rules and Regulations.
Section 1 – PURPOSES AND RESPONSIBILITIES
Section 1.002(n) Creating standards for the clinical documentation including History and Physical
Examination (H&P) and ensuring those standards are met throughout all UNM Hospitals, clinics,
and inpatient and outpatient programs.
Section 2 – Medical Staff Membership – add wording to include DDS/DMD
Section 2.001 ….. Membership on the Medical Staff of the UNMH is a privilege which shall be
extended only to professionally competent medical doctors (“MD”), doctors of osteopathy
(“DO”), and doctors of dentistry (“DDS/DMD”) and other non-physician health care providers
….
Section 2 – Multi-Department Privileges
Section 2.005 Multi Department Privileges. Physician Members privileged in multiple
Departments must be credentialed and privileged in the Department of their primary area of
practice. Additionally, Physician Members privileged in a Department other than the Department
of their primary area of practice must also be evaluated at time of initial appointment and at
reappointment by each Department Chair where he/she is privileged in collaboration with the
Department Chair of his/her primary area of practice. The responsibility for evaluation at
appointment and reappointment rests with the Department Chair at the Department to which they
are assigned.
1
Page 24/100
Section 2 - Criminal History Screening/Other Publicly available information
Section 2.007
(a) Criminal History Screening. UNMH may require fingerprints and other information
necessary for a state or national criminal records background check.
(b) Other publicly available information. UNMH may otherwise conduct searches of publicly
available information regarding applicants at appointment, reappointment, or such times as
deemed relevant.
Section 3 - Active Medical Staff with co-management Privilege – add Section (d)
Section 3.002 (d)
Active Medical Staff with co-management privileges (as defined in co-management clinical
privilege description) will only evaluate and treat patients in conjunction with a departmentally
assigned co-managing physician-of-the-day with privileges in the same primary area of practice.
Section 4 - Allied Health Professionals – add/delete according to current license types
Section 4.001 Allied Health Professionals. “Allied Health Professionals” (AHP) consists of
clinicians whose primary license, certification, or professional degree is as an Advanced Practice Nurses
(APN), an Anesthesiology Assistant-Certified (AAC), Clinical Nurse Specialists (CNS), Certified Nurse
Practitioners (CNP), Certified Nurse Midwives (CNM), Certified Registered Nurse Anesthetists (CRNA),
Physician Assistants-Certified (PA-C), Pharmacist Clinician (PhC), or Doctors of Oriental Medicine
(DOM), Doctors of Chiropractic (DC) licensed optometrists (OD), and such other allied health
professions as may be recognized by the Medical Staff from time to time as required by law, accreditation
standards, or the discretion of the Medical Executive Committee.
Section 5 - Removal of requirement for paper copies of licenses/certificates/diplomas
5.006(g) Verification of Ccurrent valid license to practice his/her profession within the State of
New Mexico;
5.006 (h) “A current copy Verification of his/her Federal and State of New Mexico Controlled
Substance Registration Certificates, if applicable or if otherwise required by the applicant’s
Clinical or Associate Department Chair or UNMH;”
5.009 (d) “copies of the Medical Staff member’s current licenses (including his/her current
license to practice medicine, issued by the New Mexico Medical Board of [sic] New Mexico
Board of Osteopathy or an AHP license) in the State of New Mexico and certificates;”
Verification of current valid license to practice his/her profession within the State of New
Mexico;
2
Page 25/100
Section 6 - Ratify Temporary Amendment under Section 15.003, Urgent Amendment to Medical
Staff Bylaws
Section 6.018 History and Physical Examination (H&P) The History and Physical
Examination (H&P) shall be performed and recorded by a doctor of medicine or osteopathy, or,
for patients admitted only for oromaxillofacial surgery, by an oromaxillofacial surgeon. All or
part of the H&P may be delegated to other practitioners in accordance with New Mexico law and
UNMH policy. The H&P must be completed no more than 30 days before or 24 hours after an
admission or registration, but prior to surgery or a procedure requiring anesthesia services. An
updated examination must be completed and documented within 24 hours after admission or
registration, but prior to surgery or a procedure requiring anesthesia services, when the medical
history and physical examination are completed within 30 days before admission or registration.
The applicable Medical Staff policy is Documentation of Clinical Activities by UNMH Medical
Staff and House Staff.
Section 8 – MEC Voting Membership changes
8.007(a) insert – “Clinical Operations Director of UNM Cancer Center” (between “the Chairs of
all Clinical Departments” and Associate Dean for Graduate Medical Education”
8.007(a) revise “up to four five Executive Medical Directors, as appointed by the Chief Medical
Officer”
Section 8 – Medical Executive Committee Replacement of Members at Large
8.007 (e) insert new – Replacement of Members-at-Large. In the event of resignation from the
MEC or other reason for extended absence from the Medical Executive Committee, the Memberat-Large vacancy will be filled at the discretion of the Chief of Staff to complete the ongoing twoyear term.
Section 8 - Quality Committee to Quality Oversight Committee
 Change in name of Quality Committee to Quality Oversight Committee
 Page iv, 42,43 and any other necessary places (pgs 35, 36, 41)
Section 15.004 - Petitions and Motions for Bylaws Changes and Amendments
15.004 Petitions and Motions for Bylaws Changes and Amendments. A petition for changes
or amendments to these bylaws may be made by members of the Medical Staff when twelvepoint-five twenty-five percent (12.525%) twelve and one half percent (12.5%)of the voting
eligible Medical staff have indicated their assent to the change or amendment…
3
Page 26/100
UNMH Nurse Practitioner (CNP) Clinical Privileges
Name:
Effective Dates:
To:
o Initial privileges (initial appointment)
o Renewal of privileges (reappointment)
o Expansion of privileges (modification)
All new applicants must meet the following requirements as approved by the UNMH Board of
Trustees effective: 01/31/2014
INSTRUCTIONS
Applicant: Check off the "Requested" box for each privilege requested. Applicants have the
burden of producing information deemed adequate by the Hospital for a proper evaluation of
current competence, current clinical activity, and other qualifications and for resolving any doubts
related to qualifications for requested privileges.
Department Chair: Check the appropriate box for recommendation on the last page of this
form. If recommended with conditions or not recommended, provide condition or explanation on
the last page of this form.
OTHER REQUIREMENTS
1. Note that privileges granted may only be exercised at UNM Hospitals and clinics that have the
appropriate equipment, license, beds, staff, and other support required to provide the services
defined in this document. Site-specific services may be defined in hospital or department policy.
2. This document defines qualifications to exercise clinical privileges. The applicant must also
adhere to any additional organizational, regulatory, or accreditation requirements that the
organization is obligated to meet.
Practice Area Code: CNP-core
Page 27/100
Version Code: 12-2013a
Page: 1
UNMH Nurse Practitioner (CNP) Clinical Privileges
Name:
Effective Dates:
To:
Qualifications for Nurse Practitioner Core
Initial privileges - To be eligible to apply for privileges as a nurse practitioner (CNP), the
applicant must meet the following criteria:
Completion of a master's/post-master's degree or certification in an accredited nursing program
within the NP's specialty area that included 500 hours of supervised clinical practicum
AND
Current certification by the American Nurses Credentialing Center (ANCC), American Academy
of Nurse Practitioners (AANP), Pediatric Nursing Certification Board (PNCB), or the National
Certification Corporation for the Obstetric, Gynecologic, & Neonatal Nursing Specialties (NCC)
AND
Current active licensure to practice professional nursing in the state of New Mexico, and current
active certification by the Board of Nursing as an advanced nurse practitioner in the nurse
practitioner category
AND
Maintain current area specific advance life support (i.e. ACLS, PALS, NRP, etc.) and BLS.
Required current experience: Provision of care, reflective of the scope of privileges requested, for an
adequate number of patients during the past 12 months, or successful completion of an accredited
training program within the past 12 months. Experience must correlate to the privileges requested.
Reappointment Requirements - To be eligible to renew privileges as a nurse practitioner (CNP),
the reapplicant must meet the following criteria:
Current demonstrated competence and an adequate volume of experience with acceptable
results, reflective of the scope of privileges requested, for the past 24 months based on results of
ongoing professional practice evaluation and outcomes. Evidence of current ability to perform
privileges requested is required of all applicants for renewal of privileges.
CORE PRIVILEGES: Nurse Practitioner (CNP) - Adolescent/Adult/Geriatric
Assess, diagnose, monitor, treat, refer, and manage acutely, critically, and chronically ill adolescents,
young adults, adults, and geriatric patients in the inpatient and/or outpatient settings. This includes the
development of treatment plans, health counseling, and appropriate patient and family education.
Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical
staff policy regarding emergency and consultative call services. The core privileges in this specialty
include the procedures on the attached procedure list and such other procedures that are extensions of
the same techniques and skills.
¨ Requested
Practice Area Code: CNP-core
Page 28/100
Version Code: 12-2013a
Page: 2
UNMH Nurse Practitioner (CNP) Clinical Privileges
Name:
Effective Dates:
To:
CORE PRIVILEGES: Nurse Practitioner (CNP) - Pediatrics
Assess, diagnose, monitor, treat, refer, and manage acutely, critically, and chronically ill newborn
patients through young adulthood in the inpatient and/or outpatient settings. This includes the
development of treatment plans, health counseling, and appropriate child and family education. Assess,
stabilize, and determine disposition of patients with emergent conditions consistent with medical staff
policy regarding emergency and consultative call services. The core privileges in this specialty include
the procedures on the attached procedure list and such other procedures that are extensions of the same
techniques and skills.
¨ Requested
Nurse Practitioner (CNP) Core Procedures List
This list is a sampling of procedures included in the core. This is not intended to be an all-encompassing
list but rather reflective of the categories/types of procedures included in the core.
To the applicant: If you wish to exclude any procedures, please strike through those procedures
which you do not wish to request, then initial and date.
1. Advanced Life Support (ALS)
2. Full prescriptive authority as determined by NM Boards of Nursing and Pharmacy
3. Make daily rounds on hospitalized patients including admission and discharge documentation
4. Initiate therapeutic modalities such as medications, treatments, IV fluids and electrolytes.
5. Ordering of and preliminary interpretation of laboratory, diagnostic imaging and electrocardiographic
examinations
6. Use of local/topical anesthesia for minor procedures.
7. Incision, drainage and packing of superficial abscesses
8. Perform debridement, suturing, and general care for minor wounds/non facial lacerations/burns
9. Perform minor superficial surgical procedures including foreign body removal
10. Intrauterine device removal
11. Brace, cast and splint application of extremity fractures, removal, and management.
Practice Area Code: CNP-core
Page 29/100
Version Code: 12-2013a
Page: 3
UNMH Nurse Practitioner (CNP) Clinical Privileges
Name:
Effective Dates:
To:
Acknowledgment of practitioner
I have requested only those privileges for which by education, training, current experience, and
demonstrated performance I am qualified to perform and for which I wish to exercise at UNM
Hospitals and clinics, and I understand that:
a. In exercising any clinical privileges granted, I am constrained by hospital and medical staff policies
and rules applicable generally and any applicable to the particular situation.
b. Any restriction on the clinical privileges granted to me is waived in an emergency situation, and in
such situation my actions are governed by the applicable section of the medical staff bylaws or related
documents.
Signed ______________________________________________ Date _____________________
Clinical Director/Division Chief recommendation(s) (if applicable)
I have reviewed the requested clinical privileges and supporting documentation for the above-named
applicant and recommend action as presently requested above:
Name______________________ Signed _____________________ Date __________________
Name______________________ Signed _____________________ Date __________________
Department Chair recommendation
I have reviewed the requested clinical privileges and supporting documentation for the above-named
applicant and:
o Recommend all requested privileges with the standard professional practice plan
o Recommend privileges with the standard professional practice plan and the following
conditions/modifications:
o Do not recommend the following requested privileges:
Privilege Condition/Modification/Explanation
Notes:
______________________________________________________________________________
______________________________________________________________________________
Department Chair Signature ______________________________ Date _____________________
Criteria approved by UNMH Board of Trustees on 01/31/2014
Practice Area Code: CNP-core
Page 30/100
Version Code: 12-2013a
Page: 4
UNMH Nurse Practitioner & Physician Assistant (CNP & PA)
Cardiology Special Procedures (Appendix A)
Name:
Effective Dates:
To:
o Initial privileges (initial appointment)
o Renewal of privileges (reappointment)
o Expansion of privileges (modification)
All new applicants must meet the following requirements as approved by the UNMH Board of
Trustees effective: DATE
INSTRUCTIONS
Applicant: Check off the "Requested" box for each privilege requested. Applicants have the
burden of producing information deemed adequate by the Hospital for a proper evaluation of
current competence, current clinical activity, and other qualifications and for resolving any doubts
related to qualifications for requested privileges.
Department Chair: Check the appropriate box for recommendation on the last page of this
form. If recommended with conditions or not recommended, provide condition or explanation on
the last page of this form.
OTHER REQUIREMENTS
1. Note that privileges granted may only be exercised at UNM Hospitals and clinics that have the
appropriate equipment, license, beds, staff, and other support required to provide the services
defined in this document. Site-specific services may be defined in hospital or department policy.
2. This document defines qualifications to exercise clinical privileges. The applicant must also
adhere to any additional organizational, regulatory, or accreditation requirements that the
organization is obligated to meet.
Practice Area Code: CNP.PA-A
Page 31/100
Version Code: DRAFT
Page: 1
UNMH Nurse Practitioner & Physician Assistant (CNP & PA)
Cardiology Special Procedures (Appendix A)
Name:
Effective Dates:
To:
Qualifications for Special Procedures in Cardiology
Criteria: Currently privileged with core privileges as a CNP or PA at UNM Hospitals and clinics.
Successful completion of training in requested procedure(s), or documentation of a special course for
requested procedure(s) accompanied with demonstrated proctoring for requested procedures with
acceptable outcomes.
Required Current Experience: Demonstrated current competence and evidence of performance of
an acceptable volume of requested procedure(s) with acceptable results in the past 12 months.
Renewal of Privilege: Demonstrated current competence and evidence of performance of an
acceptable volume of requested procedure(s) with acceptable results in the past 24 months based on
results of ongoing professional practice evaluation and outcomes.
NON-CORE PRIVILEGE: Interrogation of pacemaker & implantable defibrilator
¨ Requested
Practice Area Code: CNP.PA-A
Page 32/100
Version Code: DRAFT
Page: 2
UNMH Nurse Practitioner & Physician Assistant (CNP & PA)
Cardiology Special Procedures (Appendix A)
Name:
Effective Dates:
To:
Acknowledgment of practitioner
I have requested only those privileges for which by education, training, current experience, and
demonstrated performance I am qualified to perform and for which I wish to exercise at UNM
Hospitals and clinics, and I understand that:
a. In exercising any clinical privileges granted, I am constrained by hospital and medical staff policies
and rules applicable generally and any applicable to the particular situation.
b. Any restriction on the clinical privileges granted to me is waived in an emergency situation, and in
such situation my actions are governed by the applicable section of the medical staff bylaws or related
documents.
Signed ______________________________________________ Date _____________________
Clinical Director/Division Chief recommendation(s) (if applicable)
I have reviewed the requested clinical privileges and supporting documentation for the above-named
applicant and recommend action as presently requested above:
Name______________________ Signed _____________________ Date __________________
Name______________________ Signed _____________________ Date __________________
Department Chair recommendation
I have reviewed the requested clinical privileges and supporting documentation for the above-named
applicant and:
o Recommend all requested privileges with the standard professional practice plan
o Recommend privileges with the standard professional practice plan and the following
conditions/modifications:
o Do not recommend the following requested privileges:
Privilege Condition/Modification/Explanation
Notes:
______________________________________________________________________________
______________________________________________________________________________
Department Chair Signature ______________________________ Date _____________________
Criteria approved by UNMH Board of Trustees on Date
Practice Area Code: CNP.PA-A
Page 33/100
Version Code: DRAFT
Page: 3
UNMH Endocrinology, Diabetes, & Metabolism Clinical Privileges
Name:
Effective Dates:
To:
o Initial privileges (initial appointment)
o Renewal of privileges (reappointment)
o Expansion of privileges (modification)
All new applicants must meet the following requirements as approved by the UNMH Board of
Trustees effective: 01/31/2014
INSTRUCTIONS
Applicant: Check off the "Requested" box for each privilege requested. Applicants have the
burden of producing information deemed adequate by the Hospital for a proper evaluation of
current competence, current clinical activity, and other qualifications and for resolving any doubts
related to qualifications for requested privileges.
Department Chair: Check the appropriate box for recommendation on the last page of this
form. If recommended with conditions or not recommended, provide condition or explanation on
the last page of this form.
OTHER REQUIREMENTS
1. Note that privileges granted may only be exercised at UNM Hospitals and clinics that have the
appropriate equipment, license, beds, staff, and other support required to provide the services
defined in this document. Site-specific services may be defined in hospital or department policy.
2. This document defines qualifications to exercise clinical privileges. The applicant must also
adhere to any additional organizational, regulatory, or accreditation requirements that the
organization is obligated to meet.
Practice Area Code: 16
Page 34/100
Version Code: 12-2013a
Page: 1
UNMH Endocrinology, Diabetes, & Metabolism Clinical Privileges
Name:
Effective Dates:
To:
Qualifications for Endocrinology, Diabetes, and Metabolism
Initial applicants: To be eligible to apply for privileges in endocrinology, diabetes, and metabolism, the
applicant must meet the following criteria:
Successful completion of an Accreditation Council for Graduate Medical Education (ACGME)–
or American Osteopathic Association (AOA)–accredited residency in internal medicine, followed
by successful completion of a fellowship in endocrinology, diabetes, and metabolism.
AND/OR
Current subspecialty certification or active participation in the examination process leading to
subspecialty certification in endocrinology, diabetes, and metabolism by the American Board of
Internal Medicine or Certificate of Special Qualifications in endocrinology by the American
Osteopathic Board of Internal Medicine.
AND
Required current experience: Inpatient or consultative services, reflective of the scope of privileges
requested, for at least 24 patients during the past 12 months, to include 5 thyroid biopsies, or successful
completion of an ACGME- or AOA-accredited residency or clinical fellowship within the past 12
months.
Renewal of privileges: To be eligible to renew privileges in endocrinology, diabetes, and metabolism,
the applicant must meet the following criteria:
Current demonstrated competence and an adequate volume of experience with acceptable
results, reflective of the scope of privileges requested, for the past 24 months based on results of
ongoing professional practice evaluation and outcomes. Evidence of current physical and mental
ability to perform privileges requested is required of all applicants for renewal of privileges.
Practice Area Code: 16
Page 35/100
Version Code: 12-2013a
Page: 2
UNMH Endocrinology, Diabetes, & Metabolism Clinical Privileges
Name:
Effective Dates:
To:
CORE PRIVILEGES: Endocrinology, diabetes, and metabolism
Admit, evaluate, diagnose, treat, and provide consultation to patients of all ages with injuries or
disorders of the internal (endocrine) glands, such as the thyroid and adrenal glands. Includes
management of disorders such as diabetes, metabolic, and nutritional disorders, obesity, pituitary
diseases, and menstrual and sexual problems. Assess, stabilize, and determine disposition of
patients with emergent conditions consistent with medical staff policy regarding emergency and
consultative call services. The core privileges in this specialty include the procedures on the
attached procedures list and such other procedures that are extensions of the same techniques
and skills.
¨ Requested
Endocrinology, diabetes & metabolism core procedures list
This is not intended to be an all-encompassing procedures list. It defines the types of
activities/procedures/privileges that the majority of practitioners in this specialty perform at this
organization and inherent activities/procedures/privileges requiring similar skill sets and techniques.
To the applicant: If you wish to exclude any procedures, please strike through the procedures that you
do not wish to request, and then initial and date.
1. Performance of history and physical exam
2. Interpretation of laboratory studies, including the effects of non-endocrine disorders
3. Interpretation of hormone assays
4. Performance of and interpret stimulation and suppression tests
5. Performance of fine-needle aspiration of the thyroid
6. Radiologic measurement of bone density and perform other tests used in the management of
osteoporosis and other metabolic bone diseases
7. Interpret radiologic and other imaging studies for diagnosis and treatment of endocrine and
metabolic diseases
8. Radionuclide localization of endocrine tissue
9. Ultrasonography of the soft tissues of the neck
Practice Area Code: 16
Page 36/100
Version Code: 12-2013a
Page: 3
UNMH Endocrinology, Diabetes, & Metabolism Clinical Privileges
Name:
Effective Dates:
To:
Acknowledgment of practitioner
I have requested only those privileges for which by education, training, current experience, and demonstrated
performance I am qualified to perform and for which I wish to exercise at UNM Hospitals and clinics, and I
understand that:
a. In exercising any clinical privileges granted, I am constrained by hospital and medical staff policies and
rules applicable generally and any applicable to the particular situation.
b. Any restriction on the clinical privileges granted to me is waived in an emergency situation, and in such
situation my actions are governed by the applicable section of the medical staff bylaws or related documents.
Signed ________________________________________ Date _____________________
Division Chief recommendation
I have reviewed the requested clinical privileges and supporting documentation for the above-named
applicant and recommend action on the privileges as presently requested above.
Signed ________________________________________ Date _____________________
Patient Safety Officer recommendation
I have reviewed the requested clinical privileges and supporting documentation for the above-named
applicant and recommend action on the privileges as presently requested above.
Signed ________________________________________ Date _____________________
Department Chair recommendation
I have reviewed the requested clinical privileges and supporting documentation for the above-named
applicant and:
□ Recommend all requested privileges
□ Recommend privileges with the following conditions/modifications:
□ Do not recommend the following requested privileges:
Privilege Condition/Modification/Explanation
Notes:
______________________________________________________________________________
______________________________________________________________________________
Department Chair Signature ________________________ Date _____________________
Criteria approved by UNMH Board of Trustees on 01/31/2014
Practice Area Code: 16
Page 37/100
Version Code: 12-2013a
Page: 4
UNMH Infectious Disease Clinical Privileges
Name:
Effective Dates:
To:
o Initial privileges (initial appointment)
o Renewal of privileges (reappointment)
o Expansion of privileges (modification)
All new applicants must meet the following requirements as approved by the UNMH Board of
Trustees effective: 01/31/2014
INSTRUCTIONS
Applicant: Check off the "Requested" box for each privilege requested. Applicants have the
burden of producing information deemed adequate by the Hospital for a proper evaluation of
current competence, current clinical activity, and other qualifications and for resolving any doubts
related to qualifications for requested privileges.
Department Chair: Check the appropriate box for recommendation on the last page of this
form. If recommended with conditions or not recommended, provide condition or explanation on
the last page of this form.
OTHER REQUIREMENTS
1. Note that privileges granted may only be exercised at UNM Hospitals and clinics that have the
appropriate equipment, license, beds, staff, and other support required to provide the services
defined in this document. Site-specific services may be defined in hospital or department policy.
2. This document defines qualifications to exercise clinical privileges. The applicant must also
adhere to any additional organizational, regulatory, or accreditation requirements that the
organization is obligated to meet.
Practice Area Code: 25
Page 38/100
Version Code: 12-2013a
Page: 1
UNMH Infectious Disease Clinical Privileges
Name:
Effective Dates:
To:
Qualifications for Infectious Disease
Initail applicant: - To be eligible to apply for privileges in infectious disease, the initial applicant
must meet the following criteria:
Successful completion of an Accreditation Council for Graduate Medical Education (ACGME)–
or American Osteopathic Association (AOA)–accredited residency in internal medicine and
successful completion of a fellowship in infectious disease.
AND/OR
Current subspecialty certification or active participation in the examination process leading to
subspecialty certification in infectious disease by the American Board of Internal Medicine or the
American Osteopathic Board of Internal Medicine.
AND
Required Current Experience: Inpatient or consultative services for an acceptable number of
patients, reflective of the scope of privileges requested, for at least 24 patients during the past 12
months or successful completion of an ACGME- or AOA-accredited residency or clinical
fellowship within the past 12 months.
Renewal of Privileges - To be eligible to renew privileges in infectious disease, the reapplicant
must meet the following maintenance of privilege criteria:
Current demonstrated competence and an adequate volume of experience (inpatients or
consultative services) with acceptable results, reflective of the scope of privileges requested, for
the past 24 months based on results of ongoing professional practice evaluation and outcomes.
Evidence of current physical and mental ability to perform privileges requested is required of all
applicants for renewal of privileges.
Practice Area Code: 25
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UNMH Infectious Disease Clinical Privileges
Name:
Effective Dates:
To:
CORE PRIVILEGES: Infectious Disease
Admit, evaluate, diagnose, consult and provide care to patients of all ages, with infectious
diseases of all types and in all organ systems. This includes but is not limited to infections of the
reproductive organs; infections in solid organ transplant patients; infections in bone marrow
transplant recipients; sexually transmitted diseases; viral hepatitis, including hepatitis B and C; and
infections in travelers. Assess, stabilize, and determine disposition of patients with emergent
conditions consistent with medical staff policy regarding emergency and consultative call services.
The core privileges in this specialty include the procedures on the attached procedure list and
such other procedures that are extensions of the same techniques and skills.
¨ Requested
Infectious Disease Core procedures list
This list is a sampling of procedures included in the core. This is not intended to be an allencompassing list but rather reflective of the categories/types of procedures included in the core.
To the applicant: If you wish to exclude any procedures, please strike through those procedures that
you do not wish to request, initial, and date.
1.
2.
3.
4.
5.
6.
7.
Perform history and physical exam
Administration of antimicrobial and biological products via all routes
Application and interpretation of diagnostic tests
Aspiration of superficial abscess
Interpretation of Gram’s stain
Lumbar puncture
Management, maintenance, and removal of indwelling venous access catheters
Practice Area Code: 25
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UNMH Infectious Disease Clinical Privileges
Name:
Effective Dates:
To:
Qualifications for HIV/AIDS Specialist
Initial Applicants - To be eligible to apply for privileges as a HIV/AIDS specialist, the initial
applicant must meet the following criteria:
Successful completion of an Accreditation Council for Graduate Medical Education (ACGME)–
or American Osteopathic Association (AOA)–accredited postgraduate training program in
internal medicine and successful completion of a training program in infectious disease.
AND/OR
Current certification or active participation in the examination process leading to subspecialty
certification in infectious disease by the American Board of Internal Medicine or the American
Osteopathic Board of Internal Medicine.
AND
Successful completion of documented fellowship training or at least 30 Category I CME credits
in HIV/AIDS related medicine.
AND
Required Current Experience: Inpatient or consultative services for an acceptable number of
patients, reflective of the scope of privileges requested, during the past 12 months or successful
completion of an ACGME- or AOA-accredited residency, clinical fellowship within the past 12
months.
Renewal of Privileges: - To be eligible to renew core privileges in infectious disease, the
applicant must meet the following maintenance of privilege criteria:
Current demonstrated competence and an adequate volume of experience (inpatients or
consultative services) with acceptable results, reflective of the scope of privileges requested, for
the past 24 months based on results of ongoing professional practice evaluation and outcomes.
Evidence of current physical and mental ability to perform privileges requested is required of all
applicants for renewal of privileges.
Practice Area Code: 25
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UNMH Infectious Disease Clinical Privileges
Name:
Effective Dates:
To:
CORE PRIVILEGES: HIV/AIDS Specialist
Admit, evaluate, diagnose, consult, and provide care to patients of all ages with AIDS and
secondary infections and other related medical conditions. Assess, stabilize, and determine
disposition of patients with emergent conditions consistent with medical staff policy regarding
emergency and consultative call services. The core privileges in this specialty include the
procedures on the attached procedure list and such other procedures that are extensions of the
same techniques and skills.
¨ Requested
HIV/AIDS Core procedures list
This list is a sampling of procedures included in the core. This is not intended to be an allencompassing list but rather reflective of the categories/types of procedures included in the core.
To the applicant: If you wish to exclude any procedures, please strike through those procedures that
you do not wish to request, initial, and date.
1. Perform history and physical exam
2. Coordinate interdisciplinary care by a range of specialists, including all of the medical specialties
as well as social services, physical therapy, and psychological support
3. Manage antiretroviral therapy
4. Manage opportunistic infections and diseases
5. Monitor patient immune system
6. Provide expertise in the use of new drugs and possible side effects, including treatment-related
lipid disorders and interactions with other drugs
7. Provide patient education, including risk reduction and harm reduction counseling
8. Recommend post exposure prophylaxis protocols and infection control measures
9. Test for and diagnose HIV/AIDS, using state of the art diagnostic techniques, including
quantitative viral measures and resistance testing
10. Treat commonly associated comorbid conditions, including tuberculosis, hepatitis B and C, and
syphilis
Practice Area Code: 25
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UNMH Infectious Disease Clinical Privileges
Name:
Effective Dates:
To:
Acknowledgment of practitioner
I have requested only those privileges for which by education, training, current experience, and demonstrated
performance I am qualified to perform and for which I wish to exercise at UNM Hospitals and clinics, and I
understand that:
a. In exercising any clinical privileges granted, I am constrained by hospital and medical staff policies and
rules applicable generally and any applicable to the particular situation.
b. Any restriction on the clinical privileges granted to me is waived in an emergency situation, and in such
situation my actions are governed by the applicable section of the medical staff bylaws or related documents.
Signed ________________________________________ Date _____________________
Division Chief recommendation
I have reviewed the requested clinical privileges and supporting documentation for the above-named
applicant and recommend action on the privileges as presently requested above.
Signed ________________________________________ Date _____________________
Patient Safety Officer recommendation
I have reviewed the requested clinical privileges and supporting documentation for the above-named
applicant and recommend action on the privileges as presently requested above.
Signed ________________________________________ Date _____________________
Department Chair recommendation
I have reviewed the requested clinical privileges and supporting documentation for the above-named
applicant and:
□ Recommend all requested privileges
□ Recommend privileges with the following conditions/modifications:
□ Do not recommend the following requested privileges:
Privilege Condition/Modification/Explanation
Notes:
______________________________________________________________________________
______________________________________________________________________________
Department Chair Signature ________________________ Date _____________________
Criteria approved by UNMH Board of Trustees on 01/31/2014
Practice Area Code: 25
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UNMH Physician Assistant (PA) Emergency Medicine Core Privileges
Name:
Effective Dates:
To:
o Initial privileges (initial appointment)
o Renewal of privileges (reappointment)
o Expansion of privileges (modification)
All new applicants must meet the following requirements as approved by the UNMH Board of
Trustees effective: DATE
INSTRUCTIONS
Applicant: Check off the "Requested" box for each privilege requested. Applicants have the
burden of producing information deemed adequate by the Hospital for a proper evaluation of
current competence, current clinical activity, and other qualifications and for resolving any doubts
related to qualifications for requested privileges.
Department Chair: Check the appropriate box for recommendation on the last page of this
form. If recommended with conditions or not recommended, provide condition or explanation on
the last page of this form.
OTHER REQUIREMENTS
1. Note that privileges granted may only be exercised at UNM Hospitals and clinics that have the
appropriate equipment, license, beds, staff, and other support required to provide the services
defined in this document. Site-specific services may be defined in hospital or department policy.
2. This document defines qualifications to exercise clinical privileges. The applicant must also
adhere to any additional organizational, regulatory, or accreditation requirements that the
organization is obligated to meet.
Practice Area Code: PA-02
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UNMH Physician Assistant (PA) Emergency Medicine Core Privileges
Name:
Effective Dates:
To:
Qualifications for Physician Assistant (PA) Emergency Medicine
Initial privileges - To be eligible to apply for privileges as a physician assistant (PA) in
emergency medicine/urgent care, the applicant must meet the following criteria:
Completion of an Accreditation Review Commission on Education for the Physician Assistant
(ARC-PA)-approved program (prior to January 2001, completion of a Commission on
Accreditation of Allied Health Education Programs-approved program) that included training in
the emergency department (ED) procedures for which privileges are sought, or demonstrate
completion of an accredited emergency medicine PA residency program
AND
Current certification by the National Commission on Certification of Physician Assistants
(NCCPA)
AND
Current licensure to practice as a physician assistant issued by the NM State Medical Board
AND
Documentation of current medical staff supervising physician in area of clinical practice
AND
Maintainence of age-appropriate advance life support training (ACLSand/or PALS) based on
patient population
Required current experience: Provision of care, reflective of the scope of privileges
requested, for an adequate number of patients during the past 12 months, or successful
completion of an accredited training program within the past 12 months.
Reappointment (Renewal of Privileges) Requirements - To be eligible to renew privileges as a
physician assistant (PA) in emergency medicine/urgent care, the reapplicant must meet the
following maintenance of privilege criteria:
Current demonstrated competence and an adequate volume of experience with acceptable
results, reflective of the scope of privileges requested, for the past 24 months based on results of
ongoing professional practice evaluation and outcomes. Evidence of current ability to perform
privileges requested is required of all applicants for renewal of privileges. Maintenance of age
appropriate ALS certification.
CORE PRIVILEGES: Physician Assistant (PA) - Emergency Medicine
Assess, evaluate, diagnose, promote health and protection from disease, stabilize, manage, and treat
acute and chronically ill and injured patients of all ages, who present in the ED with any symptom,
illness, injury or condition. Privileges do not include long-term care of patients on an in-patient basis.
The core privileges in this specialty include the procedures on the attached procedure list and such other
Practice Area Code: PA-02
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UNMH Physician Assistant (PA) Emergency Medicine Core Privileges
Name:
Effective Dates:
To:
procedures that are extensions of the same techniques and skills.
¨ Requested
Physician Assistant (PA) Emergency Medicine Core Procedures List
This list is a sampling of procedures included in the core. This is not intended to be an all-encompassing
list but rather reflective of the categories/types of procedures included in the core.
To the applicant: If you wish to exclude any procedures, please strike through those procedures which
you do not wish to request, then initial and date.
Abscess incision and drainage
Administer medications
Advanced Cardiac Life Support and/or Pediatric Advanced Life Support
Anoscopy
Cast and splint application, removal, and management
Counsel and instruct patients and significant others as appropriate on medications, disease, and
preventive healthcare
7. Ears, nose, rectum, soft tissue, throat, vaginal, and gastric lavage
8. Epistaxis management including cautery, anterior and posterior nasal packing
9. Immobilization (spine, long bone, soft tissue)
10. Local anesthesia
11. Nail trephination and removal
12. Ocular tonometry
13. Ophthalmologic evaluation (including Slit lamp exam, flouroscein stain, tonometry and superficial
corneal foreign body removal)
14. Order, prescribe, and dispense orthosis, orthotics, braces, and other orthopedic devices
15. Ordering and preliminary interpretation of laboratory, diagnostic imaging and
electrocardiographic examinations
16. Perform history and physical
17. Perform minor outpatient surgical procedures such as, but not limited to, laceration repair, wound
management, wound debridement, irrigation and debridement
18. Perform vaginal speculum exam (includes wet preps)
19. Peripheral nerve blocks of the following sites: facial, oral, digital, and ulnar at the wrist
20. Closed reductions of simple fractures and joint dislocations
1.
2.
3.
4.
5.
6.
Practice Area Code: PA-02
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UNMH Physician Assistant (PA) Emergency Medicine Core Privileges
Name:
Effective Dates:
To:
Acknowledgment of practitioner
I have requested only those privileges for which by education, training, current experience, and
demonstrated performance I am qualified to perform and for which I wish to exercise at UNM
Hospitals and clinics, and I understand that:
a. In exercising any clinical privileges granted, I am constrained by hospital and medical staff policies
and rules applicable generally and any applicable to the particular situation.
b. Any restriction on the clinical privileges granted to me is waived in an emergency situation, and in
such situation my actions are governed by the applicable section of the medical staff bylaws or related
documents.
c. The UNMH Supervising Physician is: _____________________________________________
Signed __________________________________________ Date _________________________
Department recommendation(s)
I have reviewed the requested clinical privileges with the applicant and the supporting documentation for
the above-named applicant and:
o Recommend all requested privileges with the standard professional practice plan
o Recommend privileges with the standard professional practice plan and the following
conditions/modifications:
o Do not recommend the following requested privileges:
Privilege Condition/Modification/Explanation
Notes:
____________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
UNMH Supervising Physician Signature _________________________ Date _________________
Department Signature ________________________________ Date ________________________
Print Name________________________________________ Title ________________________
Department Chair Signature ___________________________ Date ________________________
Print Name________________________________________
Criteria approved by UNMH Board of Trustees on
Practice Area Code: PA-02
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UNMH Pediatric General Surgery Clinical Privileges
Name:
Effective Dates:
To:
o Initial privileges (initial appointment)
o Renewal of privileges (reappointment)
o Expansion of privileges (modification)
All new applicants must meet the following requirements as approved by the UNMH Board of
Trustees effective: 01/31/2014
INSTRUCTIONS
Applicant: Check off the "Requested" box for each privilege requested. Applicants have the
burden of producing information deemed adequate by the Hospital for a proper evaluation of
current competence, current clinical activity, and other qualifications and for resolving any doubts
related to qualifications for requested privileges.
Department Chair: Check the appropriate box for recommendation on the last page of this
form. If recommended with conditions or not recommended, provide condition or explanation on
the last page of this form.
OTHER REQUIREMENTS
1. Note that privileges granted may only be exercised at UNM Hospitals and clinics that have the
appropriate equipment, license, beds, staff, and other support required to provide the services
defined in this document. Site-specific services may be defined in hospital or department policy.
2. This document defines qualifications to exercise clinical privileges. The applicant must also
adhere to any additional organizational, regulatory, or accreditation requirements that the
organization is obligated to meet.
Practice Area Code: 81
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UNMH Pediatric General Surgery Clinical Privileges
Name:
Effective Dates:
To:
Qualifications for Pediatric General Surgery
Initial Applicant - To be eligible to apply for privileges in pediatric general surgery, the initial
applicant must meet the following criteria:
Successful completion of Accreditation Council for Graduate Medical Education (ACGME) or
American Osteopathic Association (AOA) accredited residency in general surgery followed by
successful completion of an accredited fellowship in pediatric surgery.
AND/OR
Current subspecialty certification or active participation in the examination process leading to
subspecialty certification in pediatric surgery by the American Board of Surgery.
AND
Required Current Experience: An adequate volume of pediatric general surgical procedures
with acceptable results, reflective of the scope of privileges requested, during the past 12 months
or successful completion of an ACGME or AOA accredited residency or clinical fellowship
within the past 12 months..
Reappointment (Renewal of Privileges) Requirements - To be eligible to renew privileges in
pediatric general surgery, the reapplicant must meet the following criteria:
Current demonstrated competence and an adequate volume of pediatric surgical procedures with
acceptable results, reflective of the scope of privileges requested, for the past 24 months based
on results of ongoing professional practice evaluation and outcomes.
Evidence of current physical and mental ability to perform privileges requested is required of all
applicants for renewal of privileges.
Practice Area Code: 81
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UNMH Pediatric General Surgery Clinical Privileges
Name:
Effective Dates:
To:
CORE PRIVILEGES: Pediatric General Surgery
Admit, evaluate, diagnose, consult and provide surgical (including pre- and post-operative)
management to neonatal and pediatric age groups through young adulthood with congenital and
acquired abnormalities and diseases, whether developmental, inflammatory, neoplastic, or
traumatic. Assess, stabilize, and determine disposition of patients with emergent conditions
consistent with medical staff policy regarding emergency and consultative call services. The core
privileges in this specialty include the procedures on the attached procedure list and such other
procedures that are extensions of the same techniques and skills.
¨ Requested
Pediatric General Surgery Core Procedures List
This list is a sampling of procedures included in the core. This is not intended to be an all-encompassing
list but rather reflective of the categories/types of procedures included in the core.
To the applicant: If you wish to exclude any procedures, please strike through those procedures which
you do not wish to request, then initial and date.
1. Perform history and physical exam
2. Anoscopy
3. Appendectomy
4. Bronchoscopy
5. IV access procedures, central venous catheter, and ports
6. Catheterization of bladder
7. Circumcision
8. Correction of intussusception
9. Correction of malrotation of intestine, congenital megacolon, intestinal obstructions
(including newborn)
10. Diagnostic Laparoscopy
11. Esophagoscopy
12. Excision of Meckel’s diverticulum
13. Excision of neck masses
14. Excision of thyroid tumors
15. Excision of thyroglossal duct cyst
16. Gastrostomy
17. Gastrointestinal esophageal dilatation, gastroscopy, G-tube placement, gastroduodenoscopy
18. Incision and drainage of abscesses and cysts
Practice Area Code: 81
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UNMH Pediatric General Surgery Clinical Privileges
Name:
Effective Dates:
To:
19. Excision of subcutaneous cysts or tumors; subcutaneous foreign body removal
20. Insertion and management of pulmonary artery catheter
21. Jejunostomy
22. Laparotomy for diagnostic or exploratory purposes or for management of intra abdominal
sepsis and trauma
23. LADDS procedure for malrotation
24. Laparoscopy, appendectomy, cholecystectomy, lap splenectomy
25. Limited assisted laparoscopy for small bowel resections
26. Laryngoscopy
27. Lower intestinal endoscopy
28. Management of burns
29. Management of soft tissue tumors, inflammations, infection
30. Management of congenital defects of the abdominal wall and diaphragm excluding groin and
umbilical hernia
31. Management of intra abdominal trauma, including injury, observation, paracentesis, lavage
32. Management of multiple trauma
33. Management of tracheoesophageal fistulas or other congenital anomalies of the upper
respiratory tract or the upper intestinal tract
34. Operations on gallbladder, biliary tract, bile ducts, hepatic ducts, including biliary tract
reconstruction
35. Parathyroidectomy / thyroidectomy
36. Peripheral arterial/venous access, percutaneous or cutdown
37. Pyloromyotomy
38. Simple excision, biopsy (skin)
39. Small bowel surgery for benign or malignant disease
40. Suprapubic cystostomy tubes for neurogenic bladder
41. Surgery of the abdominal wall, including management of all forms of hernias, including
diaphragmatic hernias, inguinal hernias, and orchiectomy in association with hernia repair
42. Splenectomy (trauma, staging, therapeutic)
43. Thoracentesis
44. Thoracotomy with drainage
45. Tissue laceration repair
46. Thorascopy for lung biopsy and decortication
47. Tracheostomy
48. Tube thoracostomy
Practice Area Code: 81
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UNMH Pediatric General Surgery Clinical Privileges
Name:
Effective Dates:
To:
Special Non-Core Privileges (See Specific Criteria)
If desired, non-core privileges are requested individually in addition to requesting the core. Each
individual requesting non-core privileges must meet the specific threshold criteria governing
the exercise of the privilege requested including training, required experience, and maintenance of
clinical competence.
Qualifications for Advanced Laproscopic Procedures
Criteria: Successful completion of an accredited residency in general surgery or pediatric general
surgery that included advanced laparoscopic training or completion of a hands on CME.
Required Current Experience: Demonstrated current competence and evidence of the performance
of an adequate volume of laparoscopic advanced laparoscopic procedures with acceptable results,
reflective of the scope of privileges requested in the past 12 months or completion of training in the past
12 months.
Renewal of Privilege: Demonstrated current competence and evidence of the performance of an
adequate volume of laparoscopic advanced laparoscopic procedures with acceptable results, reflective
of the scope of privileges requested in the past 24 months based on results of ongoing professional
practice evaluation and outcomes.
NON-CORE PRIVILEGES: Laproscopic Procedures (as listed below)
¨ Requested
This list is a sampling of procedures included in the special non-core privilege. This is not intended to be
an all-encompassing list but rather reflective of the categories/types of procedures.
To the applicant: If you wish to exclude any procedures, please strike through those procedures which
you do not wish to request, then initial and date.
1. Adrenalectomy
2. Colectomy
3. Common Duct Exploration/Stone Extraction,
4. Donor Nephrectomy
Practice Area Code: 81
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UNMH Pediatric General Surgery Clinical Privileges
Name:
Effective Dates:
To:
Qualifications for Endoscopy Procedures
Criteria: Successful completion of an accredited residency in general surgery or pediatric general
surgery that included training in upper endoscopy procedures with a minimum of 35 performed during
training or equivalent training and/or experience obtained outside a formal program that is at least equal
to that obtained within the formal residency program.
Required Current Experience: Demonstrated current competence and evidence of the performance
of an adequate volume of EGD procedures with acceptable results, reflective of the scope of privileges
requested in the past 12 months or completion of training in the past 12 months.
Renewal of Privileges: Demonstrated current competence and evidence of the performance of an
adequate volume of procedures with acceptable results, reflective of the scope of privileges requested in
the past 24 months based on results of ongoing professional practice evaluation and outcomes.
NON-CORE PRIVILEGES: EGD with and without Biopsy
¨ Requested
Qualifications for Insertion and Management of Pulmonary Artery Catheters (PAC)
Criteria: Successful completion of an ACGME or AOA post graduate training program that included
training in the insertion and management of PACs with the performance of at least of an acceptable
number of PACs as primary operator, or completion of a Category 1 CME and successful insertion and
subsequent management of pulmonary artery catheters for an acceptable number of patients during the
past 36 months.
Required Current Experience: Demonstrated current competence and evidence of the performance
(as the primary operator) of an adequate volume of PACs with acceptable results, reflective of the
scope of privileges requested during the past 12 months or completion of training in the past 12 months.
Renewal of Privilege: Demonstrated current competence and evidence of the performance of an
adequate volume of PACs with acceptable results, reflective of the scope of privileges requested in the
past 24 months as the primary operator.
NON-CORE PRIVILEGES: Insertion and Management of Pulmonary
Artery Catheters (PAC)
¨ Requested
Practice Area Code: 81
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UNMH Pediatric General Surgery Clinical Privileges
Name:
Effective Dates:
To:
Qualifications for Colonoscopy Procedures
Criteria: Successful completion of an accredited residency in general surgery or pediatric general
surgery that included training in lower endoscopy procedures with a minimum of 50 performed during
training or equivalent training and/or experience obtained outside a formal program that is at least equal
to that obtained within the formal residency program.
Required Current Experience: Demonstrated current competence and evidence of the performance
of an adequate volume of colonoscopy procedures with acceptable results, reflective of the scope of
privileges requested, in the past 12 months or completion of training in the past 12 months.
Renewal of Privileges: Demonstrated current competence and evidence of the performance of an
adequate volume of procedures with acceptable results, reflective of the scope of privileges requested in
the past 24 months based on results of ongoing professional practice evaluation and outcomes.
NON-CORE PRIVILEGES: Colonoscopy with Polypectomy
¨ Requested
Qualifications for Laproscopic Nissen Fundoplication (Antireflux Surgery)
Criteria: Successful completion of an accredited ACGME or AOA residency in general surgery or
pediatric general surgery that included advanced laparoscopic training or completion of a hands on
CME in laparoscopic Nissen fundoplication that included preceptorship by a surgeon experience in the
procedure.
Required Current Experience: Demonstrated current competence and evidence of the performance
of an adequate volume of laparoscopic Nissen fundoplication procedures with acceptable results,
reflective of the scope of privileges requested in the past 12 months or completion of training in the past
12 months.
Renewal of Privilege: Demonstrated current competence and evidence of the performance of an
adequate volume of laparoscopic Nissen fundoplication procedures with acceptable results, reflective of
the scope of privileges requested in the past 24 months based on results of ongoing professional
practice evaluation and outcomes.
NON-CORE PRIVILEGES: Laproscopic Nissen Fundoplication
(Antireflux Surgery)
¨ Requested
Practice Area Code: 81
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UNMH Pediatric General Surgery Clinical Privileges
Name:
Effective Dates:
To:
Qualifications for PDA Ligation
Criteria: Successful completion of an ACGME- or AOA-accredited fellowship that included training
in PDA ligation or documentation of successful completion of at least 6 procedures performed under
the supervision of a qualified physician preceptor.
AND
Required current experience: Demonstrated current competence and evidence of performance for
an acceptable number of procedures with acceptable results, in the past 12 months or completion of
training in the past 12 months.
Renewal of privileges: Demonstrated current competence and evidence of the performance of an
adequate volume of procedures with acceptable results in the past 24 months based on results of
ongoing professional practice evaluation and outcomes.
NON-CORE PRIVILEGES: PDA Ligation
¨ Requested
Qualifications for Thoracoscopy
Criteria: Successful completion of an ACGME- or AOA- accredited fellowship in thoracoscopy that
included training in specific procedures requested or documentation equivalent experience with
acceptable outcomes.
AND
Required current experience: Demonstrated current competence and evidence of performance for
an acceptable number of procedures with acceptable results, in the past 12 months or completion of
training in the past 12 months.
Renewal of privileges: Demonstrated current competence and evidence of the performance of an
adequate volume of procedures with acceptable results in the past 24 months based on results of
ongoing professional practice evaluation and outcomes.
NON-CORE PRIVILEGES: Thoracoscopy [for below listed procedures]
¨ Requested
This list is a sampling of procedures included in the special non-core privilege. This is not intended to be
an all-encompassing list but rather reflective of the categories/types of procedures.
Practice Area Code: 81
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UNMH Pediatric General Surgery Clinical Privileges
Name:
Effective Dates:
To:
To the applicant: If you wish to exclude any procedures, please strike through those procedures which
you do not wish to request, then initial and date.
1. Bronchogenic cysts
2. Congenital diaphramatic hernia repair
3. EATEF (Esophageal atresia with tracheoesophageal fistula repair)
4. Lung Resection
Qualifications for Use of laser
Criteria: Successful completion of an approved residency in a specialty or subspecialty that included
training in laser principles or completion of an approved 8- to 10-hour continuing medical education
course that included training in laser principles. In addition, an applicant for privileges should spend time
after the basic training course in a clinical setting with an experienced operator who has been granted
laser privileges acting as a preceptor. Practitioner agrees to limit practice to only the specific laser types
for which he or she has provided documentation of training and experience. The applicant must supply a
certificate documenting that he or she attended a wavelength and specialty-specific laser course and also
present documentation as to the content of that course.
AND
Required current experience: Demonstrated current competence and evidence of the performance
of an adequate volume of procedures with acceptable results, in the past 12 months or completion of
training in the past 12 months.
Renewal of privileges: Demonstrated current competence and evidence of the performance of an
adequate volume of procedures with acceptable results in the past 24 months based on results of
ongoing professional practice evaluation and outcomes.
NON-CORE PRIVILEGES: Use of Laser
¨ Requested
Qualifications for Use of Robotic Assisted System for Pediatric Surgery
Initial Criteria - To be eligible to apply for privileges in robotic assistance in surgical
procedures, the applicant must meet the following criteria:
Successful completion of ACGME or AOA postgraduate training program that included training
in minimal access (laparoscopic) procedures and therapeutic robotic devices and their use
OR
Practice Area Code: 81
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UNMH Pediatric General Surgery Clinical Privileges
Name:
Effective Dates:
To:
Completion of approved structured training program that included didactic education on the
specific technology, animal laboratory training, and the specialty specific approach to organ
systems.
AND
Must hold open/laparoscopic privileges to perform the procedures being requested for use with
robotic system
AND
Must hold privileges in, or demonstrate training and experience in, general laparoscopic
procedures.
Required Current Experience: Demonstrated current competence and evidence of the performance
of an adequate volume of experience with acceptable results, or completion of training program within
the last 12 months. First three (3) cases must be proctored in the OR by a physician holding robotic
privileges at UNMH for applicants meeting criteria #1 (above) or applicants with verified current
competency after #2. First ten (10) cases must be proctored in the OR by a physician holding robotic
privileges at UNMH for applicants meeting criteria #2 and without verified current competency.
Additional proctoring may be required as deemed appropriate by the proctor.
Renewal of privileges: Current demonstrated competence and an adequate volume of experience
with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on
results of ongoing professional practice evaluation and outcomes.
NON-CORE PRIVILEGES: Use of Robotic Assisted System for Pediatric
Surgical Procedures
¨ Requested
This list is a sampling of procedures included in the special non-core privilege. This is not intended to be
an all-encompassing list but rather reflective of the categories/types of procedures.
To the applicant: If you wish to exclude any procedures, please strike through those procedures which
you do not wish to request, then initial and date.
1. Ureteropelvic Junction Obstruction
2. Antireflex procedures for Gastroesophageal Reflux Disease
3. Pediatric Congenital Heart Disease such as Ligation of Patent Ductus Arte
Practice Area Code: 81
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Version Code: 12-2013a
Page: 10
UNMH Pediatric General Surgery Clinical Privileges
Name:
Effective Dates:
To:
Acknowledgment of practitioner
I have requested only those privileges for which by education, training, current experience, and
demonstrated performance I am qualified to perform and for which I wish to exercise at UNM
Hospitals and clinics, and I understand that:
a. In exercising any clinical privileges granted, I am constrained by hospital and medical staff policies
and rules applicable generally and any applicable to the particular situation.
b. Any restriction on the clinical privileges granted to me is waived in an emergency situation, and in
such situation my actions are governed by the applicable section of the medical staff bylaws or related
documents.
Signed ________________________________________ Date _____________________
Department Chair recommendation
I have reviewed the requested clinical privileges with the applicant and the supporting documentation for
the above-named applicant and:
□ Recommend all requested privileges with the standard professional practice plan
□ Recommend privileges with the standard professional practice plan and the following
conditions/modifications:
□ Do not recommend the following requested privileges:
Privilege Condition/Modification/Explanation
Notes:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Department Chair Signature ________________________ Date _____________________
Criteria approved by UNMH Board of Trustees on 01/31/2014
Practice Area Code: 81
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Version Code: 12-2013a
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UNMH Radiation Oncology Clinical Privileges
Name:
Effective Dates:
To:
o Initial privileges (initial appointment)
o Renewal of privileges (reappointment)
o Expansion of privileges (modification)
All new applicants must meet the following requirements as approved by the UNMH Board of
Trustees effective: DATE
INSTRUCTIONS
Applicant: Check off the "Requested" box for each privilege requested. Applicants have the
burden of producing information deemed adequate by the Hospital for a proper evaluation of
current competence, current clinical activity, and other qualifications and for resolving any doubts
related to qualifications for requested privileges.
Department Chair: Check the appropriate box for recommendation on the last page of this
form. If recommended with conditions or not recommended, provide condition or explanation on
the last page of this form.
OTHER REQUIREMENTS
1. Note that privileges granted may only be exercised at UNM Hospitals and clinics that have the
appropriate equipment, license, beds, staff, and other support required to provide the services
defined in this document. Site-specific services may be defined in hospital or department policy.
2. This document defines qualifications to exercise clinical privileges. The applicant must also
adhere to any additional organizational, regulatory, or accreditation requirements that the
organization is obligated to meet.last page of this form.
Practice Area Code: 61
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UNMH Radiation Oncology Clinical Privileges
Name:
Effective Dates:
To:
Qualifications for Radiation Oncology
To be eligible to apply for core privileges in radiation oncology, the initial applicant must
meet the following criteria:
Successful completion of an Accreditation Council for Graduate Medical Education (ACGME)– or
American Osteopathic Association (AOA)–accredited residency in radiation oncology
AND/OR
Current certification or active participation in the examination process [with achievement of certification
within 3 years of eligibility] leading to certification in therapeutic radiology or radiation oncology by the
American Board of Radiology or the American Osteopathic Board of Radiology.
Required previous experience: Applicants for initial appointment must be able to demonstrate the
performance of at least 50 irradiation procedures, reflective of the scope of privileges requested, during
the past 12 months or demonstrate successful completion of an ACGME- or AOA-accredited
residency, clinical fellowship, or research in a clinical setting within the past 12 months.
Reappointment requirements: To be eligible to renew core privileges in radiation oncology, the
applicant must meet the following maintenance of privilege criteria:
Current demonstrated competence and an adequate volume of experience (50 irradiation procedures)
with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on
the results of ongoing professional practice evaluation and outcomes. Evidence of current ability to
perform the privileges requested is required of all applicants for renewal of privileges.
Core Privileges: RADIATION ONCOLOGY
Admit and provide comprehensive (multidisciplinary) evaluation and treatment planning for patients with
cancer, related disorders, and therapeutic radiation for benign diseases, and consult on patients of all
ages. [May provide care to patients in the intensive care setting in conformance with unit policies.]
Assess, stabilize, and determine the disposition of patients with emergent conditions consistent with
medical staff policy regarding emergency and consultative call services. The core privileges in this
specialty include the procedures on the attached procedure list and such other procedures that are
extensions of the same techniques and skills.
¨ Requested
Practice Area Code: 61
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UNMH Radiation Oncology Clinical Privileges
Name:
Effective Dates:
To:
Core Procedures List
This list is a sampling of procedures included in the core. It is not intended to be an allencompassing list, but rather is reflective of the categories/types of procedures included in the
core.
To the applicant: If you wish to exclude any procedures, please strike through those you do not wish
to request, then initial and date.
Radiation Oncology Core Procedures
1. Administration of drugs and medicines related to radiation oncology and cancer supportive care
2. Administration of radiosensitizers, radioprotectors under appropriate circumstances
3. Brachytherapy both interstitial and intracavitary and unsealed radionuclide therapy, provided the
physician is an Authorized User as documented by the State of New Mexico and UNM Radiation
Safety.
4. Combined modality therapy (e.g., surgery, radiation therapy, chemotherapy, or immunotherapy used
concurrently or in a timed sequence)
5. Computer assisted treatment simulation and planning (external beam therapy and radioactive
implants)
6. Fractionated stereotactic radiotherapy
7. Immunotherapy
8. Intraoperative radiation therapy
9. Interpretation of studies as they pertain to neoplastic or benign conditions
10. Perform history and physical exams
11. Placement of catheters, IV’s, IV contrast dye and radiopaque devices that pertain to treatment
planning
12. Radiation prescription of doses, treatment volumes, field blocks, molds and other special devices
for external beam therapy
13. Radiation therapy by external beam (photon and electron irradiation)
14. Radiation therapy contact therapy (SR, molds, etc.)
15. Radioactive isotope therapy: intraperitoneal, intracavitary, interstitial, intraluminal implantation,
regional and systemic, and intravenous, radioactive antibody therapy, provided the physician is an
Authorized User as documented by the State of New Mexico and UNM Radiation Safety
16. Total body irradiation
17. X-ray, ultrasound, CT, MRI and PET, assisted treatment planning
Practice Area Code: 61
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UNMH Radiation Oncology Clinical Privileges
Name:
Effective Dates:
To:
Special Non-Core Privileges (See Specific Criteria)
If desired, non-core privileges are requested individually in addition to requesting the core. Each
individual requesting non-core privileges must meet the specific threshold criteria governing
the exercise of the privilege requested including training, required experience, and maintenance of
clinical competence.
Qualifications for HDR Brachytherapy
Criteria: In addition to the requirements for core privileges in radiation oncology, successful
documented completion of an accredited ACGME or AOA postgraduate training program in radiation
oncology with that included training in high dose rate (HDR) brachytherapy and/or completion of a
formal course in HDR brachytherapy. Experience and training must be in the particular radiation therapy
system to be used. The applicant may receive training at UNM, which requires 5 proctored cases prior
to privileging. Furthermore, in order to be privileged in HDR brachytherapy, the physician must be an
authorized user with specific documentation for the modality/isotope utilized as documented by the State
of New Mexico (contact Radiation Safety for details)
Required previous experience: Demonstrated current competence and evidence of the performance
of at least 3 regular HDR brachytherapy procedures in the past 12 months.
Reappointment requirements: Demonstrated current competence and evidence of the performance
of at least 3 regular HDR brachytherapy procedures in the past 24 months based on the results of
ongoing professional practice evaluation and outcomes. Applicant must demonstrate training and
experience with the specific radiation therapy system to be used.
Basis: Partially adapted ACR-ASTRO Practice Guideline for High Dose Rate Brachytherapy, 2010.
Non-Core Privileges: HDR BRACHYTHERAPY
¨ Requested
Qualifications for Stereotactic Radiosurgery
Criteria: In addition to the requirements for core privileges in radiation oncology, successful completion
of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic
Association (AOA) accredited residency in radiation oncology that included documented training in
stereotactic radiosurgery (SRS) or completion of an approved training program in radiosurgery. If
Practice Area Code: 61
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UNMH Radiation Oncology Clinical Privileges
Name:
Effective Dates:
To:
training in SRS was not obtained during residency, the applicant must present evidence of equivalent
training. The applicant may receive training at UNM, which requires 5 proctored cases prior to
privileging. Applicant must demonstrate training and experience with the specific delivery system to be
used. If the applicant has experience with a different delivery system, then they may receive credentialing
here after supervision of 3 cases. (UNM uses Linac-based SRS)
Required previous experience: Demonstrated current competence and evidence of the performance
of at least 3 radiosurgery procedures in the past 12 months. In addition, proctoring by an experienced
radiosurgery physician is required for at least the first 3 cases.
Reappointment requirements: Demonstrated current competence and evidence of the performance
of at least 3 radiosurgery procedures in the past 24 months based on results of ongoing professional
practice evaluation and outcomes.
Source: Partially adapted from ACR-ASTRO Guideline for Performance of Stereotactic Radiosurgery,
2011 (CSC/BOC).
Non-Core Privileges: STEREOTACTIC RADIOSURGERY
¨ Requested
Qualifications for Stereotactic Body Radiotherapy
Criteria: In addition to the requirements for core privileges in radiation oncology, successful completion
of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic
Association (AOA) accredited residency in radiation oncology that included training in stereotactic body
radiotherapy (SBRT) or completion of an approved training program in SBRT. If training in SBRT was
not obtained during residency, the applicant must present evidence of equivalent training. The applicant
may receive training at UNM, which requires 5 proctored cases prior to privileging.
Required previous experience: Demonstrated current competence and evidence of the performance
of at least 3 SBRT procedures in the past 12 months. In addition, proctoring by an experienced
radiosurgery physician is required for at least the first 3 cases.
Reappointment requirements: Demonstrated current competence and evidence of the performance
of at least 3 SBRT procedures in the past 24 months based on results of ongoing professional practice
evaluation and outcomes.
Source: Partially adapted from ACR-ASTRO Guideline for Performance of Stereotactic Body
Practice Area Code: 61
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UNMH Radiation Oncology Clinical Privileges
Name:
Effective Dates:
To:
Radiation Therapy, 2009 (Resolution 4).
Non-Core Privileges: STEREOTACTIC BODY RADIOTHERAPY
¨ Requested
Qualifications for Transperineal Permanent Prostate Brachytherapy
Criteria: In addition to the requirements for core privileges in radiation oncology, successful completion
of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic
Association (AOA) accredited residency in radiation oncology that included training in transperineal
permanent prostate brachytherapy (TPPB) or completion of an approved training program in TPPB. If
training in TPPB was not obtained during residency, the applicant must present evidence of equivalent
training. The applicant may receive training at UNM, which requires 5 proctored cases prior to
privileging.
Required previous experience: Demonstrated current competence and evidence of the performance
of at least 3 TPPB procedures in the past 12 months. In addition, proctoring by an experienced
radiosurgery physician is required for at least the first 3 cases.
Reappointment requirements: Demonstrated current competence and evidence of the performance
of at least 3 TPPB procedures in the past 24 months based on results of ongoing professional practice
evaluation and outcomes.
Source: Partially adapted from ACR-ASTRO Guideline for Performance of Transperineal Permanent
Brachytherapy of Prostate Cancer, 2010 (Resolution 2).
Non-Core Privileges: TRANSPERINEAL PERMANENT PROSTATE
BRACHYTHERAPY
¨ Requested
Practice Area Code: 61
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UNMH Radiation Oncology Clinical Privileges
Name:
Effective Dates:
To:
Acknowledgment of practitioner
I have requested only those privileges for which by education, training, current experience, and
demonstrated performance I am qualified to perform and for which I wish to exercise at UNM
Hospitals and clinics, and I understand that:
a. In exercising any clinical privileges granted, I am constrained by hospital and medical staff policies
and rules applicable generally and any applicable to the particular situation.
b. Any restriction on the clinical privileges granted to me is waived in an emergency situation, and in
such situation my actions are governed by the applicable section of the medical staff bylaws or related
documents.
Signed ________________________________________ Date _____________________
Clinical directors' recommendations
I have reviewed the requested clinical privileges and supporting documentation for the above-named
applicant and recommend action as presently requested above:
Signed ________________________________________ Date _____________________
Signed ________________________________________ Date _____________________
Signed ________________________________________ Date _____________________
Department Chair recommendation
I have reviewed the requested clinical privileges and supporting documentation for the above-named
applicant and:
o Recommend all requested privileges
o Recommend privileges with the following conditions/modifications:
o Do not recommend the following requested privileges:
Privilege Condition/Modification/Explanation
Notes:
______________________________________________________________________________
______________________________________________________________________________
Department Chair Signature ________________________ Date _____________________
Criteria approved by UNMH Board of Trustees on [Date]
Practice Area Code: 61
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Board Initiatives
Section A
Page 66/100
Applies To: UNMH
Responsible Department: Administration
Revised: January 2014
Title: UNM Hospital
Patient Age Group:
Board of Trustees Finance Committee
(X) N/A
() All Ages
() Newborns
Policy
() Pediatric
() Adult
POLICY PURPOSE
It is the policy of the UNM Hospital Board of Trustees Finance Committee to provide financial,
audit, and human resource oversight of the UNM Hospitals while advancing the mission and
community responsibility as delegated by the UNM Hospital Board of Trustees (BOT).
REFERENCES
University of New Mexico Regents’ Policy Manual Section 3.6: UNM Hospital Board of Trustees
GENERAL INFORMATION AND DESIRED OUTCOME
The UNM Hospitals Finance Committee shall be authorized and expected to provide oversight as
follows:
Financial
 Review financial performance of UNM Hospitals.
 Review and recommend for approval to UNM Hospital Board of Trustees:
o UNM Hospitals operating budgets
o UNM Hospitals capital budget
o UNM Hospitals budget revisions
o UNM Hospitals annual external audits
o UNM Hospitals disposal of property
o UNM Hospitals consent for procurement items
o Other UNM Hospitals financial issues and documents as needed
o Review performance of investment management
o Review proposals for union negotiations and contracts
o Review financial priorities and strategies
o Other duties or responsibilities as delegated by the UNMH BOT.
Human Resources
 Review compensation philosophy
 Review labor and salary negotiations and program goals
 Provide oversight for significant employee and labor policy changes
 Review benefits program goals
 Comment on CEO Annual Evaluation
 Review human resources issues and activities as necessary
 Review all required human resources reporting
 Other duties or responsibilities as delegated by the UNMH BOT
PROCEDURE
1. Finance Committee Structure and Membership
The UNM Hospitals Finance Committee Chair is a UNM Hospital Board of Trustees member and is
nominated by the UNM Hospital Board of Trustees Chair. The UNM Hospitals Finance Committee
Chair shall be nominated for one year and may continue to serve as Chair at the request of the UNM
Hospital Board of Trustees Chair or until a replacement is named.
_________________________________________________________________________________________________________________
Title: UNM Hospital Board of Trustees Finance Committee
Owner: Administration & Board of Trustees
Effective Date:
Doc. #
Page 1 of 3
Page 67/100
1.1 The UNM Hospitals Finance Committee Chair shall:
 Conduct the Finance Committee meetings
 Establish the Finance Committee calendar
 Direct the Finance Committee agenda
 Make recommendations to the UNM Hospital Board of Trustees regarding financial
performance, plans, and any other appropriate informational or approval items
 Advise the UNM Hospitals Chief Executive Officer (CEO) and Chief Financial Officer
on hospital financial, or human resources issues
 Ensure adequate financial knowledge and expertise of Finance Committee Board
members
 Report risk or financial concerns to the UNM Hospital Board of Trustees
 Ensure financial integrity and performance while advancing the mission of UNM
Hospitals.
1.2. Membership:
 The UNM Hospitals Finance Committee is comprised of the Finance Committee Chair
plus two UNM Hospital Board of Trustees members and one or two physicians as
designated by Finance Committee Chair
 The UNM Hospitals Finance Committee is supported by the UNM Hospital CEO and
CFO
 The UNM Hospitals CFO serves as primary staff and advisor to the UNM Hospitals
Finance Committee Chair
 Ad hoc staff include:
o Administrator of Human Resources
o Executive Director of Compliance and Audit
o Other executives as needed
2. Finance Committee Duties
The UNM Hospitals are part of UNM Health Sciences Center, a division of the University of New
Mexico and are instrumentalities of a political subdivision of the State of New Mexico. The UNM
Hospitals Finance Committee, as delegated by the UNM Hospital Board of Trustees, has the
fiduciary responsibility to ensure that the use of public funds of the UNM Hospitals is reported
appropriately. The public’s confidence in the UNM Hospitals financial integrity is dependent upon
the foundation of trust placed in the UNM Hospital Board of Trustees and its Committees. The
Chair of the UNM Hospitals Finance Committee must accept this role as the ultimate responsibility
of his/her position.
DEFINITIONS
The UNM Hospitals Finance Committee: formed to provide financial and human resources
oversight of the UNM Hospitals while advancing the mission and community responsibility as
delegated by the UNM Hospital BOT.
SUMMARY OF CHANGES
Replaces document of same name, last revision 2/2009.
DOCUMENT APPROVAL & TRACKING
Item
Owner
Consultant(s)
Human Resources
Official Approver
Contact
Administration and UNMH Board of Trustees
Jim Pendergast, Administrator, Human Resources
xxx, Board of Trustees Representative
Date
Approval
Y
Y
_________________________________________________________________________________________________________________
Title: UNM Hospital Board of Trustees Finance Committee
Owner: Administration & Board of Trustees
Effective Date:
Doc. #
Page 2 of 3
Page 68/100
Official Signature
Date:
Effective Date
Origination Date
Issue Date
1/2014
2/2009
ATTACHMENTS
None
_________________________________________________________________________________________________________________
Title: UNM Hospital Board of Trustees Finance Committee
Owner: Administration & Board of Trustees
Effective Date:
Doc. #
Page 3 of 3
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UNM Hospital Board of Trustees Finance Committee Policy
Summary of changes
REFERENCES:
1. Changed from “University of New Mexico Board of Regents’ Policy 2.13 Delegation of Authority”
to “University of New Mexico Board of Regents’ Policy Manual Section 3.6: UNM Hospital Board
of Trustees.”
GENERAL INFORMATION AND DESIRED OUTCOME
1. Financial
a. Removed the following bullet points:
i. “Review UNM Care Committee and Care One activities”
ii. “Review internal audit calendar and reports”
b. Added the following bullet point:
i. “UNM Hospitals consent for procurement items”
2. Audit – Removed the entire “Audit” section of this document shown below:
“Serve the UNM Hospitals audit review committee for:
 External Audits
 Internal Audits
 Compliance Audits
 Ambulatory Payment Classification (APC) audits
 Billing audits
 Other duties or responsibilities as delegated by the UNMH BOT”
PROCEDURE
1. Finance Committee Structure and Membership
a. 1.1.The UNM Hospitals Finance Committee Chair shall:
i. Changed the last bullet from “Advance the mission of UNM Hospitals while
reviewing to ensure financial integrity and performance” to “Ensure financial
integrity and performance while advancing the mission of UNM Hospitals.”
b. 1.2. Membership:
i. On the first bullet changed “two or more physicians” to “one or two physicians”.
3. Finance Committee Duties
a. Removed the following quote:
“We are here to provide quality care. Strong finances are a means of ensuring we are in
the position to do so.”
Gordon R. Clark,
President and CEO of the Governance Institute
DEFINITIONS
1. Removed “audit” from “formed to provide financial and human resources oversight”.
Page 70/100
Board Initiatives
Section B
Page 71/100
Applies To: UNMH
Responsible Department: Administration
Revised: January 2014
Title: UNM Hospital
Patient Age Group:
Board of Trustees Audit Committee
(X) N/A
() All Ages
() Newborns
Policy
() Pediatric
() Adult
POLICY STATEMENT
It is the policy of the UNM Hospital Board of Trustees Audit Committee to provide
coordination and oversight for internal and external audits of the UNM Hospitals while
advancing the mission and community responsibility as delegated by the UNM Hospital
Board of Trustees (BOT).
CROSS REFERENCES
University of New Mexico Regents’ Policy Manual Section 3.6: UNM Hospital Board of
Trustees.
GENERAL INFORMATION AND DESIRED OUTCOME
The UNM Hospitals Audit Committee shall be authorized and expected to provide
coordination and oversight as follows:
1. Internal Audit
 Review the risk analysis for the Hospital.
 Review and approve the internal audit plan for UNM Hospitals.
 Review and recommend approval for internal audit reports.
 Follow up with management on corrective action implemented as recommended in
internal audit reports.
2. External Audit
 Review and approve the external audit plan.
 Review and recommend approval of external audit report to BOT.
 Follow up with management in regards to any audit findings or other matters
identified in external audit report.
3. Reporting
The professional outside auditors shall be hired in accordance with State of New Mexico
Purchasing regulations. However, from a practical and operating standpoint, the auditors
will have direct access to the audit committee.
4. Access
Any member of management or UNM Hospitals employee may bring issues of concern
directly to the audit committee or any audit committee member.
5. Audit Committee Structure and Membership
The UNM Hospitals Audit Committee Chair is a UNM Hospital Board of Trustees member
and is nominated by the UNM Hospital Board of Trustees Chair. The UNM Hospitals
Audit Committee Chair shall be nominated for one year and may continue to serve as Chair
at the request of the UNM Hospital Board of Trustees Chair or until a replacement is
named.
5.1 The UNM Hospitals Audit Committee Chair shall:
 Conduct the Audit Committee meetings
 Establish the Audit Committee calendar
 Direct the Audit agenda
Title: UNM Hospital Board of Trustees Audit Committee
Owner: Administration
Effective Date:
Doc. #
Page 1 of 2
Page 72/100

Make recommendations to the UNM Hospital Board of Trustees regarding internal
and external audit report findings, risk analysis, plans, and any other appropriate
informational or approval items
 Advise the UNM Hospitals Chief Executive Officer (CEO) and Chief Financial
Officer (CFO) on hospital audit issues
 Ensure adequate financial knowledge and expertise of Audit Committee Board
members
 Report risk or audit concerns to the UNM Hospital Board of Trustees
 Ensure financial integrity and performance while advancing the mission of UNM
Hospitals.
 Provide support to the UNM Regents Audit Committee
5.2. Membership:
 The UNM Hospitals Audit Committee is comprised of the Audit Committee Chair
plus two UNM Hospital Board of Trustees members and one or two physicians as
designated by Audit Committee Chair.
 The UNM Hospitals Audit Committee is supported by the UNM Hospitals’ CEO,
CFO and Executive Director Compliance and Audit .
 The UNM Hospitals Executive Director Compliance and Audit serves as primary
staff and advisor to the UNM Hospitals Audit Committee Chair.
6. Audit Committee Duties
The UNM Hospitals are part of UNM Health Sciences Center, a division of the University
of New Mexico and are instrumentalities of a political subdivision of the State of New
Mexico. The UNM Hospitals Audit Committee, as delegated by the UNM Hospital Board
of Trustees, has the fiduciary responsibility to ensure that the use of public funds of the
UNM Hospitals is reported appropriately. The public’s confidence in the UNM Hospitals
financial integrity is dependent upon the foundation of trust placed in the UNM Hospital
Board of Trustees and its Committees. The Chair of the UNM Hospitals Audit Committee
must accept this role as the ultimate responsibility of his/her position.
DEFINITIONS
The UNM Hospitals Audit Committee: formed to provide coordination and oversight for
internal and external audits of the UNM Hospitals while advancing the mission and
community responsibility as delegated by the UNMH BOT.
SUMMARY OF CHANGES
Replaces document of same name, last revision, 2/2009.
DOCUMENT APPROVAL & TRACKING
Item
Owner
Consultant(s)
Human Resources
Official Approver
Contact
Administration and UNMH Board of Trustees
Date
Jim Pendergast, Administrator, Human Resources
xxxxx, Board of Trustees Representative
Y
Y
Official Signature
Date:
Effective Date
Origination Date
Issue Date
1/2014
2/2009
Title: UNM Hospital Board of Trustees Audit Committee
Owner: Administration
Effective Date:
Doc. #
Page 2 of 2
Page 73/100
Approval
UNM Hospital Board of Trustees Audit Committee Policy
Summary of changes
CROSS REFERENCES
1. Changed from “University of New Mexico Board of Regents’ Policy 2.13 Delegation of Authority”
to “University of New Mexico Board of Regents’ Policy Manual Section 3.6: UNM Hospital Board
of Trustees.”
GENERAL INFORMATION AND DESIRED OUTCOME
1. Internal Audit
a. Removed “to BOT” from “Review and recommend approval for internal audit reports.”
b. Changed from “Follow up with management on changes recommended in internal audit
reports” to “Follow up with management on corrective action implemented as
recommended in internal audit reports.”
2. External Audit
a. Changed from “Review and recommend approval to BOT of external audit reports” to
“Review and recommend approval of external audit report to BOT.”
b. Changed from“Follow up with management on management report in the external
audit” to “Follow up with management in regards to any audit findings or other matters
identified in external audit report.”
3. Audit Committee Structure and Membership
a. 5.1 The UNM Hospitals Audit Committee Chair Shall:
i. Added “(CFO)” to the fifth bullet behind “Advise the UNM Hospitals Chief
Executive Officer (CEO) and Chief Financial Officer”.
ii. Changed the second to last bullet from “Advance the mission of UNM Hospitals
while reviewing to ensure financial integrity and performance” to “Ensure
financial integrity and performance while advancing the mission of UNM
Hospitals.”
b. 5.2 Membership
i. On the first bullet changed “two or more physicians” to “one or two physicians”.
ii. On the second bullet changed “Internal Auditor” to “Executive Director
Compliance and Audit.”
iii. On the third bullet changed “Internal Auditor and Compliance Director” to
“Executive Director Compliance and Audit”.
Page 74/100
Board Initiatives
Section C
Page 75/100
Infection Prevention and Control Plan
2014
INTRODUCTION
The Department of Infection Prevention and Control is part of University of New Mexico Hospitals within
the University Health System and within the Department of Quality and Patient Safety.
PURPOSE and SCOPE
The overall purpose of the Infection Prevention and Control Program is to reduce and prevent healthcareacquired infections (HAIs) among patients and to prevent transmission of epidemiologically significant
organisms and other infectious diseases within hospital and clinic settings. The scope of this plan extends to
anyone who accesses University of New Mexico Hospital (UNMH) or its clinics (which includes all
employees, contract personnel, medical personnel including faculty, students, volunteers, patients or
visitors).
The Joint Operating Goals of the University Health System include achieving the goal of the safest hospital in
New Mexico by delivering safe, high quality patient care. To achieve these goals, critical parts of the
Infection Prevention and Control Program include:
 Involvement and integration of key stakeholders for Infection Control Committee Meetings and
Work Groups.
 Reporting infection surveillance, prevention and control information to appropriate hospital staff;
federal, state and local public health authorities in accordance with law and regulation; accrediting
bodies; and the referring or receiving organization when a patient has been transferred or referred
and the presence of an infection was not known at the time of the transfer or referral.
 Systems to communicate with licensed independent practitioners, staff, students, volunteers, and,
as appropriate, visitors, patients, and families about infection prevention and control issues,
including their responsibilities in preventing the spread of infection within the hospital.
 Applicable policies and procedures throughout UNMH to support the infection control program.
 A written Annual Report to the Quality Oversight Committee and UNM Hospitals Board of Trustees.
 A risk assessment of relevant and prioritized issues related to infection prevention and control
performed annually.
 A written Infection Prevention and Control Plan completed annually.
Risk Factors Involved in the Acquisition and Transmission of Infectious Agents. (IC.01.03.01)
Risk analysis involves consideration of geographic location and community environment; characteristics of
the population served; results of the analysis of the organization’s infection prevention and control data;
and care, treatment and services provided by the hospital(s). The risk analysis is formally reviewed annually
or if factors mentioned above change significantly.
Services Provided and Geographic Location
University of New Mexico Hospitals are located in Albuquerque, New Mexico and includes UNMH, New
Mexico Children’s Hospital, and affiliated clinics. UNMH is currently a 567-bed hospital and serves a
diverse population within New Mexico. There are 18 inpatient units and 53 affiliated clinics. University
Health System also includes Sandoval Regional Medical Center and Clinics run by UNM Medical Group.
UNMH provides emergency, medical, surgical, obstetric, pediatric, and neonatal services. It is the only
Level 1 Trauma Center in New Mexico and is a tertiary care hospital serving patients with severe illness
or requiring more specialized care. UNMH serves all of New Mexico and other areas in surrounding
2014 Infection Prevention and Control Plan
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P a g e |1
southern Colorado, western Texas and eastern Arizona. Risk factors for infection based on provided
services include central line use, indwelling urinary catheters, and mechanical ventilation.
Patient Population
Chronic conditions in New Mexico are prevalent (ref – State of Health, NM Dept of Health 2013); these
conditions (cancer, heart disease, emphysema, stroke, and diabetes) account for five of the leading six
causes of death in New Mexico. Unintentional injuries accounted for 10% of the deaths in New Mexico
in 2012 (3rd ranked cause of death in 2012). More than 25% of New Mexicans live in poverty and over
33% of the state’s children live in low-income families. Other issues affecting New Mexico include high
rates of substance abuse which lead to greater number of deaths due to drug and alcohol use
(substance abuse-related deaths) and higher rates of violence (second highest violent death rate in the
nation with 28.5 deaths per 100,000 population). Regarding infectious disease risk, New Mexico is
experiencing a pertussis outbreak (higher rates than seen since the 1980s) and has a high rate of
invasive pneumococcal disease.
Surveillance Results
Surveillance activities, including data collection and analysis, are used to identify infection prevention and
control risks pertaining to patients with a focus on healthcare-acquired infections (HAIs). Additionally,
surveillance activities also track risks among UNMH employees; HSC faculty, students and trainees; and
visitors and families as warranted.
Healthcare workers face the possibility of exposure to the following:
 Blood Borne Pathogen disease by means of mucous membrane, cutaneous and parenteral
exposure
 Active pulmonary/extrapulmonary tuberculosis
 Other communicable diseases such as varicella zoster virus or pertussis
 Exposure to multi-drug resistant organisms, such as methicillin-resistant Staphylococcus aureus
(MRSA), vancomycin-resistant enterococci (VRE), carbapenem-resistant Enterobacteriaceae (CRE),
extended spectrum beta-lactamase-producing gram negative rods (ESBLs), multi-drug resistant
Gram-negative organisms (MDROs), and Clostridium difficile infection (CDI).
INFECTION CONTROL PRIORITIES AND GOALS
Priorities are established following a review of risk factors, with a focus upon high risk, high volume, and
problem-prone services and activities. Priorities and goals may be modified based upon emerging need
and regulatory requirements.
1. Central Line Associated Blood Stream Infections (CLABSI)s
Goals for 2014
 Reduce number of CLABSIs relative to 2013. Interim goal is to reduce CLABSIs to <5 per quarter.
 Decrease quarterly hospital-wide NHSN CLABSI Standardized Infection Ratio (SIR) to less than
national average of 0.5.
 Long-term goal is to eliminate throughout the facility.
 Decrease rate of potential blood culture contaminant in blood cultures throughout the facility.
Strategies
 Continued review of CLABSIs by nursing staff for continued quality improvement in maintenance
practices including continued use of alcohol-impregnated caps on all lines.
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





Development of insertion-related CLABSI review for CLABSIs that occur within 7 days of insertion
to assess practices.
Implementation of routine audits for NPSG targets related to CLABSIs.
In CLABSI Maintenance Work Group, determine best practices, evaluate current documentation,
create education plan regarding best practices, and update central line policies accordingly.
In CLABSI Insertion Work Group, develop consensus about insertion bundle, evaluate current
documentation with move toward standardization, evaluate resident education related to
insertion practices, and update central line policy accordingly.
Evaluate the possibility of automated data collection for central line days.
Improve blood culture draws and standardize blood culture draw process throughout facility to
decrease risk for false-positive blood cultures. Create policy for blood culture draws for nursing.
Evaluation
 Infection Prevention and Control Department (IPCD) HAI surveillance – CLABSI numbers and
rates generated through NHSN
 Curos Cap Audits
 Central line audits of maintenance and insertion practices
 Monthly tracking of blood cultures with possible contaminants
2. Catheter Associated Urinary Tract Infections (CAUTI)s
Goals for 2014
 For adult ICUs, decrease NHSN CAUTI SIR in Adult ICUs with a goal of less than 25th percentile
based on unit type.
 For all inpatient units, decrease urinary catheter device utilization ratio to less than NHSN 10th
percentile based on unit type.
Strategies
 Develop the following nurse-driven protocols:
o Collection of urine samples from Foley catheters to distinguish between actual catheterassociated infections and colonization.
o Criteria for replacing urinary catheters.
 Routinely report device utilization rates for urinary catheters to each unit accompanied by
national medians or means for unit type and explanation of device utilization ratio.
 Create list of standardized indications for insertion and continued use of urinary catheters.
Perform ongoing evaluations of appropriateness as documented in notes and as explained by
nursing staff to target and minimize inappropriate use.
 Standardize competency assessment for insertion practices.
 Evaluate the possibility of automated data collection for Foley catheter days.
 Continue coordination of CAUTI Super-User liaisons for departments to facilitate education and
create a resource for staff members. Improve urinary catheter care.
 Explore feasibility of expanding CAUTI surveillance to facility-wide.
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Evaluation
 IPCD HAI surveillance – CAUTI numbers and rates generated through NHSN
 Quarterly audits for evaluation catheter maintenance practices
 Device utilization ratios for Foley catheters
 Audits of catheter appropriateness (at time of insertion or through daily assessment of need)
3. C. difficile Infections (CDI)s
Goals for 2014
 Decrease hospital-onset CDI by 10% relative to 2013.
 Improve communication and transfer of data between IPCD and Environmental Services.
 Improve communication between Environmental Services and Unit nursing staff regarding
terminal cleaning for CDI.
Strategies
 Encourage implementation microfiber cleaning techniques hospital wide by EVS.
 Create a standardized assessment of CDI-affected rooms in conjunction with EVS after terminal
cleans. Correlate data from EVS with IPCD data to evaluate impact.
 Evaluate clustering of CDI cases within UNMH. Develop further strategies to impact rates
working with nursing, EVS, Antimicrobial Stewardship, and practitioners.
 Improve communication regarding previous history of CDI with nursing and physicians.
 Enhance communication between nursing and environmental services to ensure timely and
appropriate cleaning of rooms previously occupied by patients with CDI through education and
improvements within the system.
 Develop education plan for nursing and EVS regarding daily cleaning of rooms with patients with
CDI.
 Create separate policy for CDI isolation precautions.
 Work with Tricore to improve communication regarding CDI and laboratory turnaround times
for test results.
Evaluation
 Reports in Infection Control Committee Meeting
 Add CDI to monthly HAI report
 Reports in Environmental IC Work Group
 ATP testing of units and rooms
 Audits of personal protective equipment (PPE) use and equipment cleaning
4. Ventilator Associated Pneumonia/Events (VAP/VAE)s
Goals for 2014
 Determine benchmarks for new measures within VAE definition.
 Automate data collection including obtaining Infection Control Surveillance Software.
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Strategies
 Work with respiratory therapy to improve surveillance methods for VAEs/VAPs.
 Seek out further information regarding current prevention bundles for VAE prevention within
adult ICUs. Determine frequency of use and the possibilities of creating audits. Pursue further
discussion with ICUs regarding further advances in evidence for VAE/VAP prevention.
 Evaluate current transport practices for ventilated patients.
 Compare prior VAP data (prior to 2013) with current VAE data (2013 onward).
Evaluation
 IPCD HAI surveillance – VAE numbers and rates generated through NHSN
 Audits for VAP prevention
5. Surgical Site Infections (SSI)s
Goals for 2014
 Automate monthly collection of NHSN denominator data for colon and abdominal hysterectomy
procedures to report required procedures to CMS.
 Expand surgical site infection surveillance to include many surgeries previously trended by
Infection Prevention and Control.
 Improve communication and feedback regarding SSIs to appropriate surgical services.
Strategies
 As available, determine future plans for NHSN with transition from ICD-9 to ICD-10 codes. Make
appropriate changes within surveillance system.
 Work with surgical clinics to track SSIs for commonly performed surgeries and develop
surveillance system to track.
 Develop plan for expansion of SSI surveillance and obtain data needed for surveillance (e.g.,
wound culture data and SurgiNet data for denominator).
 Explore Staphylococcus aureus surveillance and decolonization and consider standardization for
various surgical services including Orthopedics and Cardiology EP.
Evaluation
 NHSN SSI data
 Review of SCIP adherence in conjunction with Quality
6. Healthcare Personnel (HCP) Influenza Vaccination
Goals for 2014
 Implement mandatory influenza for UNMH HCP.
 Improve documentation for licensed providers. Report this information regularly during the
influenza season.
 Develop a Flu Committee to address issues related to HCP influenza vaccination.
 Obtain more comprehensive data for trainees, students, and volunteers at UNMH.
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P a g e |5
Strategies
 Finalize University Health System Immunization Policy and include key stakeholders.
 Create checklist for next year’s influenza season including marketing, tracking, and
implementation.
Evaluation
 NHSN HCP influenza vaccination
 Occupational Health Database and accompanying reports
7. Hand Hygiene
Goals for 2014
 Target hand hygiene rates with goal of > 90% for UNMH overall at least quarterly.
Strategy
 Consideration of automated data collection systems for tracking hand hygiene.
 Pilot new alcohol hand gel and new dispensers in 3 areas to determine if 70% alcohol can be
implemented and if dispensing system can be improved upon.
 Education and facilitation of hand hygiene for patients and visitors.
 Participate in AEH Hand Hygiene Learning Network and learn key areas to expand to other units.
Evaluation
 Hand hygiene rates per unit.
 Hand hygiene audits for quality of hand hygiene.
8. Isolation Precautions and Infection Control Practices
Goals for 2014
 Implement team-driven isolation orders to improve efficiency and efficacy of isolation
precautions.
 Update Infection Control Manual.
 Improve guidance for infection control practices in ambulatory settings.
 Improve communication regarding infection control practices.
Strategies
 Develop policies and procedures for infection control in ambulatory settings.
 Continue to expand role of infection prevention consult note.
 Add team-driven isolation practices into current policies and expand information on website to
assist with correct isolation.
 Create separate carbapenem-resistant Enterobacteriaceae policy.
 Create CDI contact isolation policy.
 Assess need for other policies within the Infection Control Manual.
Evaluation
 Audits to assess current practice for isolation and PPE use.
9. Epidemiologically Significant Organisms (ESO)s
Goals for 2014
 Characterize patterns with ESOs and present at Infection Control Committee Meeting quarterly.
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P a g e |6
 Create more useful reports and presentations related to ESOs.
Strategies
 Develop maps for each unit with specific ESOs to evaluate clustering or other patterns.
 Perform more frequent data analyses with ESOs with historical comparisons.
Evaluation
 Data presented including inpatient unit maps at ICC meetings.
10. Reportable Diseases
Goals for 2014
 Continue communication and reporting with NM Dept of Health.
Strategies
 Continue communication with the NM Department of Health and provide required information
for reportable diseases.
 Update NM Department of Health tracking form to minimize data collection.
 Create notifications regarding ordering of specific notifiable diseases as a back up to physician
reporting.
Evaluation
 Quarterly evaluation of reporting based on tracking form.
11. Intersection of Environment and Infection Control
Goals for 2014
 Create a forum for reporting, communication, and collaboration between infection prevention
and control and environmental services, food & nutrition, facilities, and clinical engineering.
Strategies
 Develop a regular schedule for meetings.
 Create a report for the Safety Committee regarding findings, recommendations, and action
plans.
 Communicate infection prevention and control surveillance data regarding legionella, mold, CDI,
and risk assessments.
 Routinely obtain air balance reports, water testing reports including dialysis, construction, and
water damage reports.
 Continue Infection Control Risk Assessments for all construction/renovation projects.
 Create a more standardized risk assessment log.
Evaluation
 Track issues addressed and plans with improvements or resolution
 Risk Assessment Log
12. Disinfection
Goals for 2014
 Complete reusable medical equipment policy with concurrent education.
 Complete equipment cleaning reference chart with education.
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P a g e |7

Improve availability and location of wipes on units for easier access.
Strategies
 Post equipment cleaning reference chart on website; determine other potential mechanisms for
education of appropriate staff.
 Audit disinfectant wipe availability.
Measure
Prioritization
Outline
CLABSI rates and
processes
SSI rates and
processes
CAUTI rates and
processes
C. diff, MRSA and
MDR-GNR reporting
Employee influenza
vaccination rates
CMS-required
reporting via
NHSN/Hospital
Compare
NPSG 2013
All ICUs since Jan 1, 2011
Colon and Abd. Hyst
started Jan 1, 2012
All ICUs since Jan 1, 2012
(except NBICU)
MRSA bacteremia and
CDI Lab ID started Jan 1,
2013
Facility
goal
New
Mexico
public
reporting
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Aggregate rate reporting
started Jan 1, 2013
Hand Hygiene
Environmental
cleaning
Reusable medical
equipment
reprocessing at all
levels
Other environmental
monitoringconstruction, airflow
etc.
VAE (Adults) VAPs
(Pediatrics)
Infection control in
outpatient settingsreview of the basic
CDC requirements for
ambulatory care and
oncology
Inter-facility
communication on
MDRO.
2014 Infection Prevention and Control Plan
TJC IC
standard
Yes
Yes
Yes
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Yes
Yes
Yes
Yes
P a g e |8
Board Initiatives
Section E
Page 84/100
UNM Hospitals Board of Trustees
Health Reform Activities Update
January 31, 2014
1
Page 85/100
UNMH Activities
 Forty Two Certified Healthcare Guides to assist with
Marketplace Applications
 Expanded evening and weekend hours to assist
patients with enrollment in the Marketplace or
Centennial Care
 Call Center Established for ACA and Centennial Care
Related Activities
 Currently receiving over 4,500 calls each month
 Provides Centralized Scheduling for Financial Assistance
Appointments
 Currently scheduling in April 2014
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2
Marketplace Activity
 The Federal Marketplace in New Mexico is experiencing limited
enrollment through Healthcare Guides according to New Mexico
Health Exchange Reporting
 For the Month of December 2013 less thank 200 completed
enrollments statewide through a guide
 Total enrollment statewide is around 7,600
 Cost of plans and cost sharing are resulting in a small
percentage of people who see a healthcare guide actually
enrolling in a plan
 Continued technical issues related to enrollment and payment
 UNMH 66 enrollments for the month of December
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3
Medicaid Centennial Care
 The Yes New Mexico enrollment portal is
functioning, but is time and resource intensive
 To date UNMH has enrolled approximately 4,500
patients in Centennial Care
 Current enrollment of around 400 patients each
week
 UNM SCI patient transitioned to Molina Centennial
Care 5,400 patients
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4
Centennial Care Transition
Issues
 Data backlog with getting MCO systems populated
with enrollment information from Medicaid
 Data consistency issues with State Verification
system and MCO data
 Creates issues with eligibility verification
 Authorization and Utilization Management issues
 A large number of SCI members appear to have
been moved to Family Planning Services only
 For UNM SCI this impacts around 3,500 patients
 Working with Medicaid and Molina to resolve
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5
UNM Care and Financial Assistance
 Patients are continuing to be qualified for UNM care,
Limited Financial Assistance and the Self Pay Discount
Program as appropriate
 UNM Care and other patients without insurance or third
party coverage are offered enrollment assistance with
Medicaid or the Marketplace.
 Over 4,000 Financial Assistance Appointments each
month
6
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QUESTIONS?
7
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Administrative
Reports
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MEMORANDUM
To:
From:
Date:
Subject:
Board of Trustees
Stephen McKernan
Chief Executive Officer
January 31, 2014
Monthly Hospital Activity Update
The Hospital has been involved in a variety of activities.
Activities Levels: Activity at UNMH remains strong. Adult patient days are 1% greater than last year. Adult
discharges have increased 4% and pediatric discharges have increased 5% over the prior year. This has
been offset by a 5% drop in obstetric and newborn discharges. Surgeries are 2% greater than the prior year
but deliveries have decreased 3% from the prior year. Clinic visits have increased 2% and Emergency room
visits have increased 12% from the prior year. The overall measure of activity levels, the case mix adjusted
all patient days has increased 5% and the case mix adjusted all patient discharges has increased 9% over the
prior year.
Finances: The finances of UNMH remain stable. Net margin through the first six months is slightly over $1
million or about .25% of revenues – very tight. Billings have increased this year about 11% over the prior year
without any price increase, which is the first time in a couple of years the hospital has shown billings growth.
Net revenues have increased 9% which is consistent with the overall activity growth. Expenses have similarly
grown about 9%, with most of the growth in the outsourcing that UNMH is doing to support post-acute care
programs with other organizations, and in supplies which is related to some high risk patients.
The balance sheet is stable with all line items consistent with their June benchmarks. Accounts payable and
the County receivable have both increased, but will both be reduced when the mil levy payments are received
in January.
Strategic Planning: The hospital was very involved with operational planning in coordination with the Health
System during December and January. The result in an Operating Plan briefing that will be brought to the
Board at the February meeting. The objectives of the Operating Plan will be in each administrator, director
and manager’s goals for the next year. The main focus is for greater efficiency and improvement in the
quality of care as we sort out the changes related to the Affordable Care Act.
Human Resources: Turnover rates have stabilized in the past few months around the 12 to 13% range. The
preferred rate is in single digits. Management believes that compensation is a key issue for hospital and
medical staff and should be a key objective of the next budget cycle.
Information System: The Hospital is embarking on a major initiative to improve the documentation that goes
to the Electronic Medical Record. In the past the EMR has been mostly a repository of information from the
doctors, nurses and other professionals and information from the other systems such as lab, radiology and
pharmacy. The new documentation system will make the process more interactive and help the providers
add new information without having to constantly re input information that is already in the system. The plan
is to do this in a logical manner and improve efficiency.
The other significant issue for this year in the EMR area is ICD 10 coding. This is a major change for
providers. The new system has about 10 times more codes than the current system. The manner in which
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Page 2
the providers need to document will change. The education and training of providers for ICD 10 and the
upgrade of the information systems to accommodate the changes will be a major part of the work plan for the
next 9 months.
Quality Initiatives: Under Dr Crowell’s leadership, there are a number of new task forces that are working
on the hard wiring of safety initiatives to reduce infections and to meet the requirements of the core measures
and national safety metrics.
Affordable Care Act: Most of the activity is related to the enrollment of UNM uninsured patients in the
Medicaid program. There have been some delays because of technical issues related to the State’s new
eligibility system, unrelated to the exchanges. UNM is enrolling more than 400 people a week into
Medicaid. UNM will be enrolling any new patients that access the system to Medicaid, because its
enrollment is open and rolling. It is expected that about 80% of our UNM Care will be eligible for
Medicaid.
It would appear that in New Mexico, very few patients used the exchange to enroll for health insurance.
This, we believe, in principally due to the high cost of the premiums and out of pocket expenses. We will
bring a proposal to the Board on how to fashion the UNM Care program to respond to the current status
of the exchanges.
If there are any questions on this or other matters, please feel free to contact me.
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Updates
Page 95/100
Finance and Audit Committee Dashboard Report
Year To Date as of December 2013
3 Mo. Trend
Desired
Actual
Patient Days (includes newborn) for UNMH


78,116
79,963
78,854 ICU, Peds, OB and NB days decreased from PYTD and budget
Discharges for UNMH


13,721
14,782
13,420
< 5.41
5.69
5.41
5.88
< 5.7
5.86
5.71
6.17 Current YTD is thru Nov 2013, PYTD is thru Nov 2012
244,740
227,260
248,346
40,620
37,794
Average Length of Stay for UNMH
UHC Risk Based Adjusted LOS for UNMH
YTD
YTD Budget
Prior YTD
Comment
as reported by UHC.
Outpatient Clinic Visits for UNMH


Emergency Department Visits for UNMH
240,932 Includes 17,480 Flu Shots YTD and 18,605 PYTD, core
222,327 clinic visits increased compared to PYTD
36,343
Urgent Care


10,473
8,956
7,872 Improved from PYTD and budget. Hours expanded to Saturday
Operations


9,484
9,470
9,312 Improved from PYTD and budget
Births

-
1,672
1,680
1,718 In line with budget
Days for all Behavioral Operations


10,448
10,557
10,472
Visits for all Behavioral Operations


71,099
64,940
70,082
UNM Care Enrollment


26,486
36,000
28,997 Target of 36,000 is the benchmark for enrollment in
UNMCI Enrollment


9,519
beginning June 2013
UNM Care and UNMCI
Net Income (Loss) for all Operations
$1,372
> $0
10,332 HSD's current SCI waiting list has been exhausted
$7
($3,481)
(in thousands)
Case Mix Index (CMI) - w/o newborn


1.652
1.640
Re-Admission Rates


9.27%
9.50%
Days Cash on Hand for UNMH


49.93
38.18
49.58
5.52
5.77
5.77
18.83
18.23
19.11
5,433
5,558
5,462
80
148
58
1.630
8.04% Patients re-admitted within 30 days of discharge,
thru Oct 2013 as reported by UHC
Human Resources:
FTEs (Worked) per adj patient day for all Operations
Hours of Care - UNMH Nursing
Paid FTE's for UNMH and BHOs
Paid FTE's for AIC and CC
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Committee Reports
Page 97/100
Performance Oversight & Community Engagement Committee
Report Summary – January 17, 2014
Community Benefits Reports
1. 2014 Community Engagement Reporting Calendar – Rodney McNease, Executive
Director, Behavioral Health Finances
Mr. McNease presented the 2014 Community Engagement Reporting Calendar for the
Committee’s approval.
2. Patient Satisfaction Report (Information Item) – Darlyne Hawkins, QA Customer
Service Manager
Ms. Hawkins reported that the overall goal of the Customer Service Department is to work with
areas within the organization improve the overall patient experience and increase satisfaction
scores. Overall, patient satisfaction score trending continues to be positive. The most recent
HCAHPS reports show consistent positive trending in almost every category. For the inpatient
service line, the focus is on effective rounding as a means of continuing that positive trending.
The primary goal throughout, as it relates to patient satisfaction, is to increase awareness of the
impact of an overall positive patient experience on the organization as a whole. This impact
includes, but is not limited to, the financial implications of value based purchasing. Patients, as
well as the general public, are able to view HCAHPS (Hospital Consumer Assessment of
Healthcare Providers and Systems) scores in order to evaluate UNMH services as compared to
other institutions.
3. Patient Financial Services Advisory Committee - Rodney McNease, Executive Director,
Behavioral Health Services
Patient Financial Services Staff has been working on anticipated changes that will occur under
Centennial Care and the implementation of the Federal Healthcare Marketplace. This topic has
seen extensive discussion during the Patient Financial Services Advisory Committee Meetings,
along with the status of the current UNMH financial assistance programs. The group has also
discussed verification and documents required for Medicaid, and UNMH Financial Assistance
programs.
The new Medicaid Portal, (Yes New Mexico) went online in October 2013. Over the last
quarter UNMH Financial Assistance staff has been focused on the transition of UNM Care and
UNM SCI patients onto the new expanded Centennial Care Medicaid Programs. For the
months of November and December we completed and submitted to Medicaid approximately
1,200 applications each month. In addition around 5,300 UNM SCI patients were transitioned
onto Medicaid Coverage with Molina Healthcare. UNM SCI patients are still in the process of
transition with Molina Healthcare not having received eligibility data on around 3,000 UNM SCI
members.
The Federal Marketplace has proved to be more of a challenge, with numerous systems issues
occurring over the last three months. UNMH has processed in total less than one hundred
exchange applications. The total number of applications completed with assistance from
Healthcare Navigators statewide, is estimated at being less than two hundred in the month of
December by the New Mexico Health Exchange.
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4. American Essential Hospital (AEH) Fellowship Presentation on HLQAT - Gloria
Doherty, Executive Director, Inpatient Providers, Respiratory Services & Pulmonary
Diagnostics
Due to time constraints the AEH presentation was deferred until the February POCEC meeting.
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UNM HOSPITALS BOARD OF TRUSTEES
Finance and Audit Committee Meeting
Monday, January 27, 2014 at 11:30 AM
UNM Hospitals Administration, CEO Conference Room
Objectives


Provide audit oversight of UNM Hospitals.
Provide financial and human resources oversight of UNM Hospitals.
Audit Committee Meeting, the following was discussed:
I.
Approval of meeting minutes from December 18, 2013.
II.
UNM Hospital Board of Trustees Audit Committee Policy by Ella Watt. The Audit Committee
Chairperson or her designee will recommend the policy for approval at the UNM Hospitals Board
of Trustees meeting on January 31, 2014.
Finance Committee Meeting, the following was discussed:
I.
Approval of meeting minutes from December 18, 2013.
II.
UNM Hospital Board of Trustees Finance Committee Policy by Ella Watt. The Finance
Committee Chairperson or her designee will recommend the policy for approval at the UNM
Hospitals Board of Trustees meeting on January 31, 2014.
III.
Consent Items:
1. UNM Psychiatric Center (UNMPC) HVAC System (Architect and Engineering Approval)
2. UNM Hospital North Fourth Street Clinic (Construction Approval)
3. UNM Hospital Laboratory Renovation (Construction Approval)
4. UNM Hospital Interventional Radiology CT Scanner (Construction Approval)
5. UNM Hospital Fire Sprinkler Project (Construction Approval)
6. GE Healthcare (Informational)
The Finance Committee Chairperson or her designee will recommend items one through five for
approval at the UNM Hospitals Board of Trustees meeting on January 31, 2014.
IV.
Series 2004 Bond Optional Redemption Resolution by Ella Watt. The Finance Committee
Chairperson or her designee will recommend the resolution for approval at the UNM Hospitals
Board of Trustees meeting on January 31, 2014.
V. Presentation of FY 2013 UNM Hospitals’ financials through December 31, 2013 by Ella Watt.
VI.
Collective Bargaining Presentation by Ryan Randall.
VII.
Human Resources Update by Jim Pendergast
1. Development Officer Update
2. Chief Operating Officer Update
3. Flu Compliance Update
4. Union Negotiations Update
VIII.
UNM Hospitals Update by Ella Watt
1. Triwest Update
2. Presbyterian Contract Negotiation Update
3. Financial Assistance Update
IX.
The next UNMH Board of Trustees Finance and Audit Committee meeting is scheduled for
February 26, 2014.
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