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ROBERT PACKER HOSPITAL

                                                                                                                 SAYRE, PA  18840
                                                                                                    MEDICAL EXECUTIVE COMMITTEE

                                                                                                                     MINUTES




                                                                                                                   January 2, 2019

                              Present:   David Bertsch, MD, Chair; Joseph Ronsivalle, DO; Hani Hojjati, MD, Theodore Them, MD, Jason Granet, MD, Brian Fillipo, MD, Jerry Terwilliger, MD, MD, Douglas

                              Trostle, MD, Donald Phykitt, DO, Dan Brown, MD     Absent:  Charles McGurk, MD James Scott, MD, Marc Harris, DO

                              Staff:     D. Luchaco, B. Gordon, J. Stenson, C. Mohr, E. Lampe, Counsel, B. Pennypacker

                              Meeting Started:  12:05 P.M.                                                                                                                         Meeting Adjourned 12:50 p.m.
                                          TOPIC                                             DISCUSSION/CONCLUSION                                            RECOMMENDATIONS/ ACTION/FOLLOW UP
                                                                                                                                                             /RESPONSIBLE PARTY


                                I.   Approval of Prior         The December meeting minutes were presented for approval.                                     On a motion made by Dr. Granet  seconded by Dr. Them,
                                Minutes                                                                                                                      the December minutes were approved as presented.
                                II.  Medical Records           Tamara Donaldson, Senior Director, Corporate HIM, was present for this portion of the         On a motion made by Dr. Granet seconded by Dr. Them,
                                Committee Charter (copy  committee to review a proposed committee charter outlining objectives, metrics,                     the charter was approved as presented.
                                attached to official copy of   performance improvement for the medical records committee.  Dr. VanderMeer has
                                minutes)                       agreed to co-chair this committee and regular reports will be forwarded to MEC.

                                III. Medical Staff Policy      Dr. Hojjati reviewed the critical value for pediatric patients that was approved in           On a motion made by Dr. Trostle and seconded by Dr.
                                (copy attached to official     December and the inclusion within the Critical Results Reporting Policy.                      Them, the policy was approved as presented.
                                copy of minutes)

                                IV.  Infection Control         Andrew Klee, Infection Control Preventionist, gave an overview of CAUTI infections            Additional data will be provided to the section chiefs in the
                                                               and reviewed changes for isolation precautions.   Patients with MRSA colonization will        form of a quarterly report.  Recommendation to precheck
                                                               no longer be placed on contract precautions.  Change in Epic infection flags are needed       the Epic orders to remove the Foley if criteria are not met.
                                                               to delineate active vs. colonized MRSA and patients with active MRSA will continued           On a motion made by Dr. Granet and seconded by Dr.
                                                               to be isolated under the current policy.                                                      Phykitt, this was approved.
                                V.  Clinical Quality           The Clinical Quality Committee minutes from December 11 and December 17, 2019                 Formulary actions approved on a motion made by Dr. Them
                                Committee                      were reviewed and accepted by consensus by the Committee.                                     and seconded by Dr. Trostle.

                                VI. Operations Report          Barb Pennypacker reviewed the Operations Report highlighting admissions year-to-date   Informational
                                (copy attached to official     and financial data as well as new services and performance improvement.
                                copy of minutes)

                                V.  Credentials                                                                                                              No Meeting this month
                                Committee
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