Minutes
The University of Toledo Board of Trustees
Clinical Affairs Committee Meeting
July 10, 2012
Committee Chair Mr. Gary P. Thieman was present, as well as members Dr. S.
Amjad Hussain and Ms. Sharon Speyer; Ms. Susan E. Gilmore was absent.
Faculty representative Dr. Sanford Kimmel was in attendance. Trustee Mr.
William C. Koester also attended the meeting. Administrative Liaisons Dr.
Jeffrey Gold and Dr. Scott Scarborough were present. Additional attendees
included Mr. Dan Barbee, Ms. Lauri Cooper, Dr. Lloyd Jacobs, Mr. Chuck
Lehnert, Dr. Carl Sirio and Ms. Joan Stasa. Special Guest, Ms. Britney Ward,
also was at the meeting.
ATTENDANCE
The meeting was called to order at 7:30 a.m. by Committee Chair Thieman in the CALL TO ORDER
Faculty Club Room at the Toledo Hilton Hotel.
Committee Chair Thieman requested a motion to waive the reading of the
minutes of the June 5, 2012 Committee meeting and accept them as written. A
motion for approval was received by Trustee Speyer and seconded by Trustee
Hussain. The minutes were approved by the Committee.
APPROVAL OF
MINUTES
Dr. Jeffrey Gold, Chancellor and Executive VP Biosciences and Health
Affairs/Dean of the College of Medicine and Life Sciences, introduced Ms.
Britney Ward, MPH, Assistant Director Health Planning at The Hospital Council
of Northwest Ohio. Dr. Gold reported that he recently attended one of the
Council’s meetings regarding an assessment of Northwest Ohio community
health needs; he commented that the assessment provided good quality statistical
information. Ms. Ward reported that the Council represents member hospitals
and health systems in the Northwest Ohio area and provides opportunities to
improve the health status of Northwest Ohio citizens. She shared with the
Committee the names of those from the Council involved with project
management, secondary data, data collection, and report development, as well as
the physicians from UTMC involved with data collection and analysis. A
timeline of the planned health assessments by county was reviewed from 2003
through 2013 and a map showing assessments completed and those yet to
complete. Ms. Ward presented an overview of the areas assessed in the 165 page
report and county rankings based on the Robert Wood Johnson Foundation. The
Lucas County strategic planning process was discussed with the Committee and
leading causes of death for each county. Ms. Ward compared adult health care
coverage and access, adult chronic disease, adult risky behaviors, and adult
weight control with several Northwest Ohio counties, the State of Ohio, and the
nation, with data from 2009 through 2011. She also discussed obesity trends
among U.S. adults for a 25 year period from 1985 through 2010. Lucas County
adult priorities include economic stability and related health disparities, healthy
HEALTH STATUS
INDEX FOR
NORTHWEST OHIO
living, and tobacco use. Youth weight control, injury-related behaviors, and
risky behaviors were also compared by county, the State of Ohio, and the nation
with data from 2009-2011. Ms. Ward reviewed the Lucas County youth
priorities focus areas chosen. Children’s health insurance, access, utilization,
and medical home were also compared for Lucas County with the State and
nation for 2007 and 2011. Focus areas chosen for children’s priorities were also
reviewed with the Committee. Dr. Gold thanked Ms. Ward for her presentation
and stated that there is a very long list of items that UT is doing to assist with
this program.
Dr. Scott Scarborough, Sr. VP and UTMC Executive Director, gave the
Committee a brief update on the UTMC Emergency Department patient
experience. He reported that 57% of the hospital’s admissions come through the
ED, which has increased tremendously in the last three years. A pie chart was
reviewed of the ED payor mix where Dr. Scarborough indicated that charity
patient care continues to be a challenge. He discussed changes in the ED –
facilities renovation, management change, process changes, and facilities
expansion. Graphs showing UTMC ED visits were also reviewed with the
Committee comparing data from 2010 through 2012.
EMERGENCY
MEDICINE
SERVICES
UPDATE/PATIENT
EXPERIENCE
Dr. Gold provided the Committee with information about UT and The Patient
STATUS
Protection and Affordable Care Act. He reviewed with the Committee that
REPORTS AND
Academic Medical Centers consist of the teaching hospital, the medical school
UPDATES
and sound physicians focusing on access to care, cost of care, quality of care, and
workforce for care. Discussion involved how The Patient Protection and
Affordable Care Act connects to the Academic Medical Center and the many
different areas of interactive and moving parts related to the Act. Dr. Gold talked
about health care reform and feedback of reform impact. He commented that all
strategic initiatives are extremely important to health care delivery across the
country. He also reported that on June 28 of this year, in a 5 to 4 decision, the
U.S. Supreme Court declared the individual mandate of the Act constitutional.
He then reviewed the status of many areas of UT and UTMC as it relates to
compliance with The Patient Protection and Affordable Care Act.
Dr. Gold briefed the Committee on the Accountable Care Organization of
Toledo. He discussed the Centers for Medicare & Medicaid Services (CMS) and
how they strive to lower insurance premiums and give consumers better
information to make informed health care decisions, coordinate care and spread
innovation. CMS provides health coverage for 100 million people. Dr. Gold
reported that CMS is currently:
 Caring for our Community through Coordination
 Keeping as Many People Healthy as Possible
 Making Health Care More Affordable
CMS has also established a Medicare Shared Savings Program (MSSP) to
facilitate coordination and cooperation among providers to improve the quality
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of care for Medicare Fee-For-Services (FFS) beneficiaries and reduce
unnecessary costs. Eligible providers, hospitals, and suppliers may participate in
this program by creating or participating in an Accountable Care Organization
(ACO), participation is voluntary. The Program is designed to improve
beneficiary outcomes and increase value. The Program will reward ACOs that
lower their growth in health care costs while meeting performance standards on
quality of care and putting patients first. Dr. Gold also explained goals and
measures of an ACO. He reported that approximately five months ago, UTMC
entered into a partnership agreement with The Toledo Clinic regarding this
Program. He then reviewed the June 21, 2012 letter to ACO of Toledo, Inc.
from the Medicare Shared Saving Program indicating approval of their
application to participate in the MSSP.
Dr. Gold reported that the August 2012 issue of the magazine Consumer Reports CONSUMER
REPORTS
contained the article, “How Safe is Your Hospital?” This report rated the safety
of approximately 18% of hospitals across the nation according to data published ARTICLE
from a variety of state and federal agencies in 2010. UTMC did not score well in
the report and Dr. Gold indicated that it was disappointing as employees at
UTMC have been working hard over the last several years to change the culture
of the institution and to focus efforts on what is best for the patients. In July of
2011, U.S. News and World Report recognized UTMC as the best hospital in the
region. In November 2011, the Joint Commission gave UTMC a glowing
accreditation report and just last month UTMC received the 2012 National
Success Story of the Year Award from Press Ganey. Dr. Gold commented that
UTMC is very proud of the progress they have made and a lot has been
accomplished, but more still needs to be done. He, Dr. Scarborough and Dr.
Jacobs have sent a letter to the University community today saying what he just
reported. As UTMC has not yet been able to precisely define the data set
included and the methodology used in the report, they hope to learn something
from it. Much discussion ensued among the Trustees about the article.
Trustee Thieman requested a motion to enter Executive Session to discuss
privileged information related to the evaluation of medical staff personnel
appointments and quality reporting. The motion was received by Trustee
Speyer, seconded by Trustee Hussain, and a roll call of the Committee was
conducted: Dr. Hussain, yes; Ms. Speyer, yes; and, Mr. Thieman, yes. After
discussion, the Committee voted to exit Executive Session.
EXECUTIVE
SESSION
Mr. Thieman requested a motion to approve the Chief of Staff Report –
Attachment 1. A motion was made by Trustee Hussain and seconded by Trustee
Speyer. The report was approved by the Committee.
CHIEF OF STAFF
REPORT
With no further business before the Committee, Trustee Thieman adjourned the
meeting at 9:17 a.m.
ADJOURNMENT
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Attachment 1
CHIEF OF STAFF REPORT
July 10, 2012
New Medical Staff Applicants
Yousef A. Al Ahwel, M.D.
Internal Medicine Service
Provisional Staff Status
Privileges in Internal Medicine & Moderate Sedation
Anjali Ambekar, M.D.
Radiation Oncology Service
Provisional Staff Status
Privileges in Radiation Oncology
David A. Banas, M.D.
Family Medicine Service
Provisional Staff Status
Privileges in Family Medicine & Moderate Sedation
Jason F. Bombard, D.O.
Psychiatry Service
Provisional Staff Status
Privileges in Psychiatry
Mouhammad Jumaa, M.D.
Neurology Service
Provisional Staff Status
Privileges in Neurology
Ankush Moza, M.D.
Internal Medicine Service
Provisional Staff Status
Privileges in Internal Medicine and Moderate Sedation
Nicole M. Payne, M.D.
Emergency Medicine Service
Provisional Staff Status
Privileges in Emergency Medicine and Moderate Sedation
Ehsan Rafiq, M.D.
Internal Medicine Service
Provisional Staff Status
Privileges in Internal Medicine and Moderate Sedation
Mohammad Taleb, M.D.
Internal Medicine Service
Provisional Staff Status
Privileges in Internal Medicine and Moderate Sedation
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Cherian Verghese, M.D.
Internal Medicine Service
Provisional Staff Status
Privileges in Internal Medicine, Hematology-Oncology, and Moderate Sedation
Dingding Xiong, M.D., Ph.D.
Pediatrics Service
Provisional Staff Status
Privileges in Pediatrics
Syed F.A. Zaidi, M.D.
Neurology Service
Provisional Staff Status
Privileges Neurology
Medical Staff Request for Leave of Absence
Nael Bahhur, M.D.
Family Medicine Service
Effective June 16, 2012
Revised Delineation of Privileges Forms
Urology
Added: Pelvic/Sacral Nerve Stimulation
Pathology
Added: Ultrasound-Assisted Fine Needle Aspiration of Superficial Lesions
New Delineation of Privileges Form
Endovascular Surgical Neuroradiology
Medical Staff Requests for Additional Privileges
Luis E. De Las Casas, M.D.
Pathology Service
Additional Privileges in Pathology – Ultrasound-Assisted Fine Needle Aspiration of Superficial
Lesions
Mouhammad Jumaa, M.D.
Neurology Service
Additional Privileges in Endovascular Surgical Neuroradiology
Syed F.A. Zaidi, M.D.
Neurology Service
Additional Privileges in Endovascular Surgical Neuroradiology
Medical Staff Resignations
Faheem Ahmad, M.D.
Radiation Oncology Service
Effective June 29, 2012
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Rajender K. Ahuja, M.D.
Radiation Oncology Service
Effective June 29, 2012
Wayne S. Court, M.D.
Radiation Oncology Service
Effective June 29, 2012
Qais A. Farjo, M.D.
Surgery Service
Effective June 1, 2012
Shaneli A. Fernando, M.D.
Radiation Oncology Service
Effective June 29, 2012
Jeffrey A. Forquer, M.D.
Radiation Oncology Service
Effective June 29, 2012
James A. Fugazzi, M.D.
Radiation Oncology Service
Effective June 29, 2012
Kara E. Hertzfeld, M.D.
Radiation Oncology Service
Effective June 29, 2012
Wainwright A. Jaggernauth, M.D.
Radiation Oncology Service
Effective June 29, 2012
Ryan Y. Jin, M.D.
Radiation Oncology Service
Effective June 29, 2012
Ronald M. Kendrick, D.O.
Surgery Service
Effective March 30, 2012
Eric P. Kielhorn, M.D.
Radiation Oncology Service
Effective June 29, 2012
Roger Kucway, M.D.
Radiation Oncology Service
Effective June 29, 2012
Dhaval Parikh, M.D.
Radiation Oncology Service
Effective June 29, 2012
Steven J. Rubin, M.D.
Radiation Oncology Service
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Effective June 29, 2012
Steven R. Zeidner, M.D.
Radiation Oncology Service
Effective June 29, 2012
Reason: End of contract between UTMC and Toledo Radiation Oncology
Kamal Yoakim, M.D.
Family Medicine Service
Effective May 14, 2012
Reason: No longer has UT COM faculty appointment
New Clinical Associate Staff Applicants
Theresa Cluse-Tolar, LISW-S, PhD
Pediatrics Service
Privileges as Licensed Independent Social Worker
Sponsoring Physician: Jeffrey Blumer, M.D.
Robert David Denyer, AA-C
Anesthesiology Service
Privileges as Anesthesiologist Assistant
Sponsoring Physician: Alan Marco, M.D.
Clinical Associate Staff Changes in Sponsoring Physician
Erica Krause, MSN, CNM
Obstetrics and Gynecology Service
From Nauman Khurshid, M.D. to Albert Payne, M.D.
Judith M. Malhotra, MSN, CNP
Internal Medicine Service
From Joseph Shapiro, M.D. to Shobha Ratnam, M.D.
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