The physician or licensed practitioner with admitting privileges must CERTIFY each inpatient admission. Certification will consist of the following:

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1 VOLUME 5 ISSUE 10 OCTOBER 2013 ProgressNotes MONTHLY MEDICAL STAFF NEWSLETTER In this issue Medicare 2 Midnight Rule.....P 1-2 Torrance Memorial Awards/ Certifications.. P 2-3 Medical Executive Committee Approvals.... P 3 Influenza Vaccination...P 3 Smoke-Free Campus P 4 Medical Staff Calendar.P 5 Roster Updates.. P 6 New Medicare 2 Midnight Rule Effective October 1, 2013 Medicare has revised their requirement for each inpatient admission. INPATIENT STATUS should only be ordered if it is expected that the patient will be in the hospital AT LEAST two midnights. The physician or licensed practitioner with admitting privileges must CERTIFY each inpatient admission. Certification will consist of the following: 1. Order to Admit to Inpatient 2. Documentation of diagnosis (not symptoms) 3. Documentation of a reasonable and supportable expectation of care spanning more than 2 midnights. (Medical necessity criteria for Inpatient admission still applies) 4. All of the above must be completed and signed prior to the discharge of the patient If the above requirements are not met then OBSERVATION STATUS should be ordered. Frequently Asked Questions: Q. When does the clock for the 2 midnight rule start? Begins with initial outpatient service (i.e. Emergency Department or Observation status) Q. Are there any exceptions? CMS Inpatient Only Procedure List (supported by documentation of medical necessity) Death Transfer to another facility Leaving against medical advice Q. When does a patient in observation status become an inpatient? At the time that the expected stay becomes at least 2 midnights and inpatient criteria is met and documented by the physician Continued on next page... 1

2 New Medicare 2 Midnight Rule Effective October 1, 2013 Q. How does this rule affect the 3 day qualifying stay for SNF? It does not the 3 day qualifying stay for a SNF starts at the time of INPATIENT admission and there must be documentation of medical necessity. Q. What resources are we providing to help our Physicians? CPOE (coming soon) Physician Advisors Case Managers Reference: CMS FY2014 IPPS Final Rule 42 CFR Torrance Memorial Awards/Certifications Hunt Cancer Institute Receives National Outstanding Achievement Award Torrance Memorial Medical Center is one of 75 U.S. health care facilities with accredited cancer programs to receive the 2012 Outstanding Achievement Award by the American College of Surgeons (ACS) Commission on Cancer (CoC) for surveys performed last year. To be eligible, award recipients must have received commendation ratings in seven commendation standards, in addition to receiving a compliance rating for each of 29 other standards in four activity areas: cancer committee leadership, cancer data management, clinical services and quality improvement. Torrance Memorial Earns an A in Patient Safety by Hospital Safety Score Torrance Memorial Medical Center received an A Hospital Safety Score from The Leapfrog Group, an independent national nonprofit organization run by employers and other large purchasers of health benefits. The grades, A, B, C, D or F, are assigned to U.S. hospitals based on preventable medical errors, injuries, accidents, and infections. The Hospital Safety Score was compiled under the guidance of the nation s leading experts on patient safety. Transitional Care Unit Receives Five Star Rating By Federal Centers For Medicare And Medicaid Services Torrance Memorial Medical Center s Transitional Care Unit (TCU) has received an Overall Quality rating of five stars (the highest possible) from the Federal Centers for Medicare and Medicaid Services (CMS), putting it among the top 10 percent of nursing homes nationwide. The Overall Quality rating is based on performance measured in four categories: Health Inspections, Quality Measures, Staffing and Registered Nurse (RN) Staffing. The rating system was created to help customers, families, and caregivers make informed decisions when looking for a nursing home. Torrance Memorial Wins the Gold for Stroke and Heart Failure Treatment Torrance Memorial Medical Center has received the Get With The Guidelines - Stroke Gold Plus Quality Achievement Award from the American Heart Association. The American Heart Association and American Stroke Association recognize Torrance Memorial s commitment and success in implementing a higher standard of care by ensuring that stroke patients receive treatment according to nationally accepted guidelines. This marks the first year that Torrance Memorial has been recognized with a Gold Plus Award. It has made a steady climb toward this achievement, earning Bronze in 2010, Silver Plus in 2012 and now Gold Plus in Continued on next page... In addition, Torrance Memorial also received the Get With The Guidelines - Heart Failure Gold Quality Achievement Award from the American Heart Association. This recognition signifies that Torrance Memorial has reached an aggressive goal of treating heart failure patients according to the guidelines of care recommended by the American Heart Association/American College of Cardiology. This marks the second straight year that Torrance Memorial has been recognized with a quality achievement award. 2

3 Torrance Memorial Awards/Certifications Burn Center Receives Verification Torrance Memorial Medical Center s Burn Center has been verified as a burn center by the American Burn Association and the Committee on Trauma of the American College of Surgeons. It is one of two burn centers to earn this distinction in Los Angeles County. This achievement recognizes its dedication to providing optimal care for its patients. For nearly four decades, the Burn Center has been caring of burn patients of all ages. It provides specialized care for hundreds of survivors of residential and industrial fires and accidents each year. Torrance Memorial Medical Center is Named Among the Best Hospitals in California and the Los Angeles Metro Area for 2013 Torrance Memorial Medical Center has been ranked as one of the best hospitals for in California and the Los Angeles metro area for the second year in a row by U.S. News & World Report, placing the hospital in the top 6 percent in the state. The report recognizes Torrance Memorial for providing high performing and quality care in six specialty areas: geriatrics, nephrology, urology, gynecology, orthopedics and endocrinology/diabetes. Medical Executive Committee Approvals At its September 10, 2013 meeting the Medical Executive Committee approved revisions to the Medical Staff General Rules and Regulations. For details contact the Medical Staff Services Department at (310) or visit the following website: Influenza Vaccination The Medical Executive Committee has agreed that all Medical Staff members (physicians and non-physicians) shall either receive the influenza vaccine this year or complete the declination form and wear a mask. Vaccinations are being offered at various Medical Staff meetings, the General Staff Luncheon Meeting on October 23rd, or in the Employee Health Services Department from 6:00 a.m. 12:00 p.m. and 1:00 p.m. 4:00 p.m. (please bring your ID badge to receive the vaccine). Vaccinated physicians will receive stickers that are to be displayed on their ID badges. Please forward confirmation of vaccination to the Medical Staff Services Department either by fax to (310) or by to medicalstaff@tmmc.com. If you do not wish to be vaccinated, please advise the Medical Staff Services Department by and request a declination form. Medical staff members who do not have a proof of vaccination by November 1, 2013 will be required to wear a mask from November 1, 2013 through March 31, If you have questions please contact the Medical Staff Services Department at (310) Save the Date October 23, :00 pm General Staff Meeting West Tower Auditorium 3

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5 Medical Staff Calendar Monday Tuesday Wednesday Thursday Friday October 8:00a TCU..WT-C 12:30p Infection Control/P&T...WT-C 7:45a Lung/Thoracic Tumor Board......WT-Aud 12:30p Medical Staff PI...WT-D 7:30a IRB..WT-D :00a Quality & Patient Safety Committee...WT-D 12:30p Cardiology...WT-D 12:30p Credentials......WT-C 5:00p Professional Relations...WT-C 6:00p Medical Executive..WT-D 7:00a Anesthesia PI...WT-Aud 7:30a Endocrinology Subc...WT-B 12:30p CME Conference.HCC-1&2 7:45a GI Tumor Board...WT-Aud :00a New Main Tower Planning Committee...WT-D 12:00p Radiology Dept...WT-Aud 12:30p CME Conference.HCC-1&2 12:30p Gastroenterology Subc..WT-B 7:45a Lung/Thoracic Tumor Board......WT-Aud 9:00a Emergency Dept.WT-D 12:30p Pediatric Dept.WT-Aud :00a Quality & Patient Safety Committee...WT-D 8:00a Vascular Surg Subc...WT-C 12:00p Burn & Wound Surg...WT-C 7:00a Breast Program Subc...WT-B 7:00a Surgery Dept..WT-Aud 8:00a Medicine PI...WT-E 12:30p OB/GYN Dept.WT-Aud 12:00p General Staff Mtg... WT-Aud 7:30a Family Practice Dept..WT-B 7:45a Gen Tumor Board..WT-Aud 12:30p Credentials....WT-C :30p Stroke Ad-Hoc...WT-D 4:00p Bariatric Surgery...WT-C 12:30p Medicine Dept.WT-B 3:30p Cardiac PI WT-D 4:30p Ortho COE...WT-D 7:45a Gen Tumor Board..WT-Aud 12:00p Surgery Advisory....WT-D CME CONFERENCES Wednesdays, 12:30 p.m. Health Conference Center Torrance Memorial Medical Center is accredited by the Institute for Medical Quality/California Medical Association (IMQ/CMA) to provide continuing medical education for physicians. Torrance Memorial Medical Center designates this live activity for a maximum of 1 AMA PRA Category I credit TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This credit may also be applied to the CMA Certification in Continuing Medical Education. For up-to-the-minute conference information call (310) October 2, 2013 October 9, 2013 DVT Prophylaxis & Treatment Thomas Hirose, M.D. UCLA School of Medicine Commercial Support: Janssen October 16, 2013 Dementia Mario Mendez, M.D. UCLA School of Medicine Commercial Support: Lilly October 23, 2013 October 30, 2013 November 6, 2013 The Hospitalist Movement Michael Lazarus, M.D. UCLA School of Medicine Commercial Support: None November 13,

6 Physician Roster Updates Kartik Ananth, M.D. Anesthesiology Pacific Pain & Wellness Group Crenshaw Blvd., Ste. 100 Torrance, CA Phone: (310) Fax: (310) The Medical Staff Newsletter Progress Notes is published monthly for the Medical Staff of Torrance Memorial Medical Center. Thomas G. Simko, M.D. Chief of Staff Robin S. Camrin, CPMSM, CPCS Vice President, Medical Staff Services & Performance Improvement ANK-10/2013 6

7 Medical Staff Services 3330 Lomita Boulevard Torrance, CA Phone: (310) Fax: (310) Mailing Label ProgressNotes Vol. 5 Issue 10 October 2013 MONTHLY MEDICAL STAFF NEWSLETTER ProgressNotes