Welcome to St. David’s
South Austin Medical Center
New Physician Orientation
Topics
 WELCOME
 CMO OVERVIEW
 MEDICAL STAFF SERVICES
 HIM AND PHYSICIAN ACCESS
 INFECTION PREVENTION
 CASE MANAGEMENT
 PASTORAL CARE
 NURSING AND PATIENT SERVICES
 TOUR
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Medical Staff Leadership
Chief Medical Officer:
Al Gros, MD
Chief of Staff:
Robert Northway, MD
Chief of Staff-Elect:
Alex Esquivel, MD
Secretary:
David Savage, MD
Dr. Al Gros CMO, South Austin Medical
Center
Office: (512) 816-6112
Mobile: (512) 294-7064
Fax: (512) 816-7278
Email: Albert.Gros@stdavids.com
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Senior Leadership
Todd Steward
CEO
Sally Gillam
CNO
Brett Matens
COO/ECO
Wes Fountain
CFO
Nikki Sikes
Associate
Administrator
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Sally Gillam
 Chief Nursing Officer
 Worked at SAMC for 22
years; with HCA for 24
years
 From Temple, Texas
 Married to Andy; sons Kendall and Colby
 Departments include Emergency Services,
Women's Services, Surgical Services, Telemetry (3S
and 4C), Med/Surg (2C and 3C), Quality, Critical
Care, ISS, Endo, Outpatient Heart Center, Nursing
Administration
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Todd Steward
 Chief Executive
Officer
 CEO at SAMC
starting April 5,
2010; with HCA for 8
years.
 From Dallas, Texas
 Married to wife Toni; daughters Sophia
and Anna
 Departments include Human Resources,
Surgicare, Marketing, Medical Staff and all
Senior Managers
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Brett Matens
 Chief Operating
Officer
 Worked at SAMC for
8 years; with HCA for
12 years
 From Jackson, Mississippi
 Married to Christi; daughters Macy Caroline and
Sarah McClain and son McCord.
 Departments include Cardiovascular Services,
Plant Ops, Pharmacy, , Physician Relations,
Radiology, Pulmonary/ Neurodiagnostics,
Hyperbarics/ Wound Care
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Wes Fountain
 Chief Financial
Officer/Ethics and
Compliance Officer
 Worked at SAMC for
5 years; with HCA for
22 years
 From Atmore, Alabama
 Married to Melinda; son David and daughter Sarah
 Departments include Accounting, HIM, Materials
Management, Shared Services Group, Information
Systems, Ethics and Compliance
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Nikki Sikes
Picture
here
 Associate Administrator
 Worked at SDSAMC since
January 2010
 From Georgetown, Texas
 Departments include Rehab Services,
Laboratory, Environmental Services,
Nutrition Services, Spiritual Care,
Volunteers, Risk Management, Special Projects
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Physician Relations
The Physician Relations
Director is here for you!
To help you get to know the
facility, where things are and
how processes work
Help you with special requests,
issue resolution, answer
questions
Kathryn Scoblick,
Physician Relations
Director
512-816-6113
512-897-0661 (cell)
Help you meet other physicians
in the area
Physician Referral Line
CME/Grand Rounds
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Overview of Medical Center
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Core Measures
 AMI (Acute Myocardial Infarction)
 HF (Heart Failure)
 PN (Pneumonia)
 SCIP (Surgical Care Improvement Project)
SCIP Core Measures
SCIP INFECTION QUALITY INDICATORS
 Prophylactic Antibiotic Received within 1 Hour of Incision (2 hrs for
Vancomycin or fluoroquinolones)
 Recommended Prophylactic Antibiotic Selection for Surgical Patients
 Prophylactic Antibiotics Discontinued within 24 Hours After Surgery End
Time (48 hrs for Cardiac Surgery)
 Cardiac Surgery Patients with Controlled 6 A.M. Post-op Serum Glucose
(<200 mg/dL) post-op day 1 & 2
 Surgery Patients with Appropriate Hair Removal (no razors)
 Urinary Catheter Removed on Post-op Day 1 or 2
 Surgery Patients with Perioperative Temperature Management (active
warming intraoperatively or one body temp. > 96.8o within 30 min. prior
to 15 min. after Anesthesia End Time)
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SCIP Core Measures
SCIP VTE QUALITY INDICATORS
 Recommended Venous Thromboembolism Prophylaxis
Ordered anytime from hospital arrival to 24 hrs after
Anesthesia End Time
 Recommended Venous Thromboembolism Prophylaxis
within 24 Hours Prior to Anesthesia Start Time to 24 Hours
After Anesthesia End Time
SCIP CARDIAC QUALITY INDICATOR
 Surgery Patients on Beta Blocker Therapy Prior to
Admission Who Received a Beta Blocker During the
Perioperative Period
SCIP HEART FAILURE QUALITY INDICATOR
 ACEI or ARB Prescribed at Discharge for Patients with <40%
LVEF
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Governance & Peer Review
Board of Trustees
Medical Executive Committee
(MEC)
Credentialing Function
Medical Care Evaluation Committee
(MCEC)
Your Department
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BOT
MEC
(Chief of Staff)
Peer
Review
Process
Action
MCEC
(Chief Medical Officer)
Rapid Review Team
Egregious Event:
(incl. Sentinel Events,
In-House Physician Quality Issues)
Medical Director /
Vice Chief of Staff
Department
Clinical Issue: Competence,
Core Measures, Outcomes
Indicator
'Fall-outs'
Triage
(Med Dir
& PIC)
Variance Reports
Patient Complaints
Approved by MEC 2/08
Compliance / Social Issue:
(i.e., Complaints,
Non-compliance,
Behavior)
Prof. Liability Actions
Physician
PI Coordinator
Sentinel Events
Failed Measures
Employee Complaints
Fall-out from Screens
Compliance Issues
www.sahmedweb.com
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Educational Programs
 Medical Grand Rounds
 Ethics Credit
 CPR/ACLS Education
 Tumor Board Conferences
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Medical Staff Meetings
 Monthly meeting calendars are posted on the
MedWeb site, faxed, and e-mailed to
members.
 There is a 50% meeting attendance
requirement for Active members in the
departments of Medicine, Surgery, and
Cardiology.
 There is a 25% meeting attendance
requirement at the quarterly General Medical
Staff meetings for all Active members.
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Credentialing and Medical Staff Services
 St. David’s and HCA structure regarding
credentialing
 Standardized market forms
 Individual facility approvals
 Qualification: Board certification or obtained
within 5 years of initial appointment.
Certification must be maintained.
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Physician Health
 Forms of Impairment
 Alcoholism and other drug use
 Other psychiatric disorders
 Addressed by the TCMS Physician Health
and Rehabilitation committee
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Health Information Management
 Hours of Operation
 Monday-Friday 8:00 am
to 4:30 pm.
 Dictation
 Timeliness
 Requirements
Electronic Health Record and
Chart Completion for
Physicians
Select Dictation
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Health Information Management
•
Notification Process
•
•
Deficiencies color coordinated in portal
for your convenience
•
BLUE: Incomplete 0-15 days
•
RED: Warning 16-29 days
•
YELLOW: Delinquent 30+ days
•
Notification and Suspension
letters are faxed to physician
offices every Wednesday, as a
courtesy only.
Process Incompletes
by selecting Process or
Process All
Coding Query Process
Queries are
presented as Missing
Text deficiencies
Press the PgUp key
or click Page 1 to
reference the
coding question
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For questions about Incomplete Deficiencies- please contact Health Information Management at 816-6308
For questions about Portal or access- contact the help desk at 901-HELP or Ryder Bodoin at 632-1618
Electronic Medical Record (EMR)
 What is the Clinician Portal?
 Physician electronic access point for clinical information
• Integrated systems
• Simplified sign-on—one username, one password
• Simplified Remote Access – no more tokens
• User-friendly, intuitive interface
 Access to complete patient list

Resources section
• Clinical references
• Training modules
• Facility-specific information

Accessible from hospital, home, office, or while traveling
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Clinical Portal-Enhancements
 Electronic signature and record
 Post-discharge records available electronically
 These new features are available via Horizon Patient Folder
(HPF)—a new enabling technology supported by the Health
Information Management Shared Services Initiative—and will
be available from within the clinician portal.
 What you need to know
 Decide which type of training will work for you
 Web-based training (WBT)
 One-on-one sessions
 Or a combination of training methods
 Collect all of your clinical system passwords
 Plan to attend a training session to set up your account
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Unacceptable
Abbreviations
Intended
Meaning
Misinterpretation
Expected Action
U
Units
O, “4”
Write out entire
word “Units”
IU
International units
Misread as IV
(intravenous) or the
number 10
Use the word
“units”
Trailing Zero (i.e. 1.0
mg)
1 mg
Misread as 10
Do NOT use trailing
zeros after a
decimal point
Lack of a leading
zero
0.1 mg
Misread as 1 or 11
mg
ALWAYS use a zero
before a decimal
point
MS
MSO4
MgSO4
Morphine sulfate or
magnesium sulfate
Confused for one
another. Can mean
morphine sulfate or
magnesium sulfate
Write “morphine
sulfate” or
“magnesium
sulfate”
Q.D., q.d., qd
Q.O.D, q.o.d, qod
“Daily” and “every
other day”
Mistaken for each
other. The period
after Q can be
mistaken for an “I”
or the “O” can be
mistaken for an “I”
Write “daily” and
“every other day”
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Meditech
(Clinical Patient Care System)
√ PCI (Patient Care Inquiry)
LAB, RAD, PATH and HIM reports
√ Demographic/Insurance Info.
√ Access from hospital, office or home
√ Physicians MUST write Consult Orders so consulting physician
will have access to the patient
√ Electronically sign dictated reports remotely
√ Software provided by the hospital for remote installation
 Physician Help Desk #: 901-4357 (HELP)
 Obtain Access, Schedule Training, & Report Problems
 24/7 service
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Cancer Registry
 Cancer Registry
 Cancer Committee
 Tumor Boards
 Patient Care Evaluation Studies
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Case Management Department
 In existence at SAMC since early 1996
 Drives the discharge process
 Coordinate the care across the continuum,
services and resources for patients/families
 Education of patient/family regarding continuum of
care
 Conduct concurrent insurance reviews
 Plans and implements discharges with the
interdisciplinary team
 Consists of both RNs & Social Workers
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Your Role in Case Management
 Interqual Criteria
 Code 44
 “Admit to Case Management”
 Keeping the case manager informed of plans for the
patient
 Communication with case manager is key to timely
discharge/movement to next level of care
 Daily discharge of patients by 11:00 a.m.
Case Management
Office. 816-6260
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Spiritual Care – Chaplain Services
 SDSAMC employs professional chaplains
 Available 24/7
 Provide information and assistance with Advance
Directives
 Bioethics Committee is co-chaired by a physician
and chaplain. Meets quarterly.
 Responsible for bioethical consults, edcuation, and
policy recommendation.
 Texas Organ Sharing Alliance
Digital Pager #512-205-1881, Office #512-816-7198
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Admissions & Central Scheduling
Hospital‘s Main Number 447-2211
Central Scheduling Main 816-7340
Central Scheduling Physician's Line 816-7464
Hours: 7:30 to 5:30 pm
(After hours, contact the Operating Room or House Supervisor)
Registration/Admissions 24hrs/7day #816-7116
Director of Patient Access: Dan Wiens 816-7112
House/Nurse Supervisor 816-7109
Physician's Direct Line to PBX operators 816-7497
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One Call Patient Transfer Center
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Thank you for taking the time to view this
orientation program. We want your experience at
South Austin Medical Center to be the best in the city
and we want to be your #1 facility of choice for your
patients.
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