15 Minute Break

OHSU

RESIDENT and FACULTY WELLNESS PROGRAM

Sydney Ey, Ph.D.Donald Girard, M.D.Mark Kinzie, M.D., Ph.D.Mary Moffit, Ph.D.

.

•Eligibility• All residents and fellows• All primary (0.5 FTE) SOM faculty • Resident/Fellow couples• Personal or Work Issues

•Providers• Mary Moffit, Ph.D., R.N.• Sydney Ey, Ph.D.• Mark Kinzie, M.D., Ph.D.• Outside Referral Sources

OHSU Faculty and Resident Wellness Programs

Services offered:• Brief evaluation/ consultation• Coaching/ Counseling• Psychiatric medical

consultation • Referrals to community

resources – counseling, psychiatric, primary care

OHSU Faculty and Resident Wellness Programs

Availability

• Over 100 visits a month • Over 400 residents and faculty physicians

seen since program started 6 years ago

• Appointments throughout the day, lunch times, early evening hours

• Same day appointments often possible

Confidentiality/privacy• No medical record• No insurance billing• Private location “on the hill”• No information shared with program w/o consent

(Unless there is a concern regarding safety—danger to self or others)

• No role in disciplinary or “fitness for duty evals”

OHSU Resident Wellness Program

Anonymous Resident Survey (Spring 2006 )n=133; 20% response rate

0%

10%

20%

30%

40%

50%

Unable to break Confidentiality Would it even help?

Other

What factors limit residents' ability to access services at RWP?

Anonymous Resident Survey (Spring 2006) n=133; 20% response rate

Can residents ask for an one hour break for self-care?

0%5%

10%15%20%25%30%35%40%45%

Yes No Don't Know

“You Can Do It, We Can Help”

• 58% of residents either did not know or thought they could not take an hour break for self-care to meet with counselor or PCP

• 89% of program directors (who responded to the April 2006 survey) said an hour break was allowed without explanation

Quality of RWP Services

• 80% rated services as “excellent”

• 9% rated as “good”

• 2% rated as “fair”

• 0 rated as “poor”

“Overall satisfaction with services”

• very satisfied 69%

• mostly satisfied 22%

• indifferent 10%

• quite dissatisfied 0%

(The RWP provider) “was extremely helpful to me. I am very grateful to her. Her flexibility in scheduling was essential to our success.”

“The RWP is a special program. It made a huge difference in my life and I am very thankful it exists. I don’t think I would have been able to be as successful (without it)”

“My intern year was especially difficult transition for me for a variety of reasons. I sought help through the residency wellness program and found the program very helpful”

Anonymous Resident Survey (Spring 2006) Feedback:

Scheduling an Appointment

• Contact Mary Moffit or any of the other providers • Email: moffitm@ohsu.edu • Pager 1-2047• Voice-mail: 4-1208• Urgent/ After Hours: (503) 330-7880

• Other Providers:• Mark Kinzie, M.D., Ph.D. • Email: kinziem@ohsu.edu ; pager 1-4559

• Sydney Ey, Ph.D.: • Email: eys@ohsu.edu ; pager 1-1291

TEN STEPS TO RESILIENCE

• Make connections• Avoid seeing crises as insurmountable problems• Accept that change is a part of living • Move toward your goals• Take decisive actions • Look for opportunities for self-discovery • Nurture a positive view of yourself • Keep things in perspective • Maintain a hopeful outlook • Take care of yourself

(American Psychological Association)

A

» a

Websites

http://www.ohsu/edu/resident-wellness/

/

http://www.ohsu.edu/faculty-wellness/

Clinical RiskAnd Patient Safety

16

1. Learn a bit about the Safety & Risk side of healthcare

2. Know who to call when you need someone right away

3. Understand how we (all of us) can make OHSU safer

What are we talking about, exactly?

• Safety of patients as relates to;– The National Patient Safety Goals– Safe Medical Practices– Ethical Practices

• Mitigation of Risk;– Risk Mitigation involves efforts taken to reduce either the

probability or consequences of a threat. – These may range from

• physical strategies (washing your hands), • to process strategies (the pre-procedural time out), • to resource strategies (alarms on ventilators).

Now Let’s Re-live the Events of 1999

• November 1999: Institute of Medicine published the results of their study, To Err is Human

• According to the report 98,000 – 120,000 people die each year from medical errors

• The costs for medical errors range from $17-$29 million annually

• Additional hospital days = 2.4 annually• Significant emotional impact for

patients, families and staff

20

The newest Stats indicate an Epidemic

• In American hospitals, healthcare-associated infections account for an estimated 1.7 million infections and 99,000 associated deaths each year.

• Of these infections: – 32 percent → UTIs– 22 percent → surgical site infections – 15 percent → pneumonia– 14 percent → bloodstream infections

21

The Joint Commission’s NPSGs

There are 18 NPS Goals and 3 Standards of the Universal Protocol we are measured against

What is the focus of the goals?

Patient IdentificationCommunicationMedication Safety and ReconciliationInfectionFallsPopulation RisksResponse to Patient Condition

22

The National Patient Safety Goals

• They are national so they don’t vary in concept from location to location

• HOWEVER, they may vary in details• At OHSU you need to know some specifics…

– 2-patient identifiers always name and birth date (medical record number if a conflict)

– Expect, request read back of telephone orders. Keep verbal orders to absolute emergencies only!

– At OHSU our providers use their initials to mark the site.– We have different abbreviations that are not allowed;

check the Pharmacy website

23

Critical Tests and Critical Results

Policy: Critical Test Results (Clin 01.08) Critical Tests: those tests that will always require

rapid communication, even if the results are normal.– Radiology; all EE(extreme emergent) tests– Laboratory; frozen sections

• Critical Results (values):Sometimes called panic values, are results that fall significantly outside the normal range and may represent life-threatening values even if from routine tests (non-critical tests).– If on the hospitals’ list of critical values, they

require rapid communication

24

And …

• There is a Resident hand off communication tool• Hand washing is not optional• Other Infection Control Practices;

– No fleece in the O.R.– No hair showing in the O.R.– Wash your white coats (thus the word ‘white’), clothing,

and stethoscopes, and have your ties cleaned!• Medication Reconciliation is a PHYSICIAN’S responsibility; if

you use Epic correctly it is a piece of cake. – *most frequent error is forgetting to hit the ‘reviewed’ button

25

Finally …

• We have an amazing Rapid Response Team (RRT); use them!

• The Universal Protocol applies to all high risk and/or invasive procedures in any location of OHSU– Even if you are doing it alone, you need to

• Complete the ‘pre-procedural checklist’ in EPIC• Mark the site using your INITIALS with a permanent

marker (and visible when draped)• And do the ‘team pause’ AND DOCUMENT IT (with dot

phrase or Epic record), verifying the following:

CONTENT OF THE TEAM PAUSEPatient identification; use the two identifiersProcedure(s) as listed on the consentSite/side marked … which is ALWAYS done by the Provider or Resident

involved in the caseCorrect position of the patientRelevant images and test results labeled and displayed?Need to administer antibiotics or fluids for irrigation?Have we taken all safety precautions based on patient’s history and

medication use?ADDITIONAL QUESTIONS OR CONCERNS?

26

What to do when an event occurs

• Care for the patient• Contact your attending• Fill out a Patient Safety Net (PSN) report (on-

line)• Access via EPIC• Page the Clinical Risk pager, day or night, at

17049.• Or Call Risk Management• Care for yourself!

27

1. Electronic Reporting system used since 2006

2. Know how to access it3. And then ACCESS it!

28

29

Monthly – Total Number of Patient Event ReportsJune 2009 – May 2010

Confidential document for the improvement of patient care protected pursuant to ORS 41.675

Jun-09

Jul-0

9

Aug-09

Sep-09

Oct-09

Nov-09

Dec-09

Jan-10

Feb-10

Mar-10

Apr-10

May-10

050

100150200250300350400450500

325

340 41

7

361

350

339 37

5

331

329 37

3 437

425

Month Monthly Average (366.8)

# of

repo

rted

even

ts

31

PSN Reports Submitted by Physicians

Jan-10 Feb-10 Mar-10 Apr-10 May-100.0%1.0%2.0%3.0%4.0%5.0%6.0%7.0%8.0%9.0%10.0%

0

5

10

15

20

25

30

35

40

45

7.4% 5.8% 5.0% 8.9% 3.3%

24

19 19

39

14

2

9 85

2

Percent total events by resident/intern/fellowGoal (6.0%)Physician – resident/intern/fellowPhysician – attending/staff

32

Human Error• Root Cause Analysis

• A problem solving method to systematically answer why the event happened, how it occurred and how to prevent it from recurring in the future.

• By directing corrective measures at root causes the likelihood of problem recurrence will be minimized.

33

Human Error

• Not the cause of the failure,but a symptom of the failure

• Should be the starting point of the investigation, not the end-point

• Influencing behaviors: Policies, Culture, Work- Flows, Technology & Environment

Swiss Cheese Effect

Categories 2008 2009 2010

Wrong Side/Site Procedures

3 1 0

Retained Foreign Object 1 4 0

Equipment 3 0 0

Medication Errors 3 1 0

Falls 1 0 0

Skin Integrity (burn/pressure ulcer)

3 1 0

Delay in Care/Treatment 1 1 0

Other 3 6 1*

34

2008-2010 Compare

* Behavioral: Patient self-harm in psychiatric unit

Case Study

Sept. 2008 Root Cause Analysis conductedThree-month delay in read of an MRI Issues:

• On-going issue of delay in radiology reads.• Delay of this read in patient with a spinal tumor.• Change over from one technical support to a different system

→ eliminated back-up system for tech verification errors.Changes:

• Assigned a radiologist from each section to ensure all exams are read within 5 days of exam.

• Policy developed to resolve unread exams. • On-going tracking and trending of reads and reporting to

department.

Results Recent tracking for March 2009 = 15 unread exams

Jan-08

Feb-08

Mar-08

Apr-08

May-08

Jun-08

Jul-0

8

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

0

20

40

60

80

100

120

140

160

67

55

70

90 86

119

141

117

2318 15 13

Average Number of Unread Exams 2 Weeks Post Completion

37

“The strength of the teamis in each individual member…the strength of each member

is the team.”Phil Jackson as coach of the Chicago Bulls

I am from Massachusetts and NOT a Lakers fan… that is why the print is so very small

• You all know the story

• Jan. 2009, New York, Hudson River 36°

• US Airways to Charlotte NC w/ 155 passengers and crew

• Sully the captain of US Airways plane

• Another hero….38

One more story

Learnings from the Story

• Sully was not alone….• Air traffic controller told him to turn back and had

the runway cleared while communicating with him• Air traffic controller told him to go to NJ, and while

on the phone with Sully had their runway cleared.• When told by Sully he could only land in the H2O,

Air traffic controller alerted Coast Guard and rescuers telling them to go to scene for rescue.

• Without team work, hypothermia would have set in quickly and deaths may have resulted.

• You are not alone…. 39

40

The OHSU Culture of Patient Safety

• Proactive approach to patient safety & clinical errors– Goal is to identify potential risk issues via

early reporting before there is an adverse event

• Non-punitive approach– Focus on identifying system issues that

contribute to adverse events

41

Patient Safety Philosophy

• Honesty – Expected when there is an adverse event– Patients expect you to tell them– It is the right thing to do!!!!

• Supportive philosophy – You are not alone; we will support you through

the process from start to finish

42

Professional Liability Claims Team

Jilma Meneses Risk Management Director

Extension 4-8819

Renee Wenger Professional Liability

Claims Manager Extension 4-8314

Lori Davis Professional Liability

Claims Manager Extension 4-7911

Chas Lopez Professional Liability

Claims Manager Extension 8-3365

Monique Parker Professional Liability

Claims ExaminerExtension 4-4257

Risk Management Main Line 4-7189

Risk Management Pager 12273

What should you report?

Unexpected patient deathMajor permanent loss of functionUnexpected outcome/complicationSerious adverse eventAnytime you have a concernCharting a patient’s dissatisfaction If you are contacted by an attorneyIf patient threatens a lawsuit

43

44

Reporting

Patient Advocate Office

Risk Management Office

Quality Management Office

Reducing Risk Through Reporting

45

QUESTIONS?

Medication Use System& Pharmacy Services

Joseph Bubalo, PharmD, BCPS, BCOPJune 2010

Medication Errors

• 1.3 million injuries annually from medication errors

• 44-98,000 patient in-hospital deaths/yr from medical errors

• Total national costs of preventable errors $17-28 billion/yr

• Medication errors cause approx 7,000 deaths/yr• “More people die in a given year as a result of

medical errors then from MVA, breast cancer, and AIDS combined.”

Medication Use System

• Average admission has about 120 handoffs

• ~4,000 orders/day = 1,460,000/yr• ~9,000 doses/day = 3.2 million doses/yr

Can You Read This?

The pweor of the hmuan mnid.Aoccdrnig to rcesaerh at Cmabrigde Uinervtisy, it

deosn’t mttaer in what oredr the ltteers in a wrod are, the olny iprmoatnt tihng is taht the frist and lsat ltteer be at the rghit pclae. The rset can be a

total mses and you can still raed it wouthit porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a

wlohe.Amzanig huh?

Paper Orders

• Adults and Pediatrics Inpatient:– TPN – CRRT/Dialysis– Antineoplastics – Beacon module this fall

• All other are CPOE

CPOE – Computerized Provider Order Entry

Order Writing: Avoiding Medication Errors

• Each electronic or written order must be legible and complete– Drug name-strength-dose-route-frequency

• Docusate 100mg PO TID– PRN orders also require an indication

• Acetaminophen 650mg PO q6h PRN pain

Order Writing: Avoiding Medication Errors

• Each electronic or written order must be legible and complete– IV orders:

• Route - Fluid-additives/liter-rate– IV LR + 20 mEq KCl/liter to run at 100 mL/hr

• Titrate orders require parameters– Midazolam IV to run at 1-4mg/hr,

titrate to sedation level 3

Order Writing: Avoiding Medication Errors

• Each order must be legible and complete– “Hold” orders require parameter(s)

• Hold metoprolol for HR less than 50 bpm– If no parameter(s), the “hold” order is interpreted

as “discontinue”• Hold metoprolol = discontinue metoprolol

Medication Reconciliation

• 50% of all medication errors and 20% of adverse drug events occur at transitions of care1

• 63% of medication errors resulting in death or serious injury are due to communication breakdowns; half could be prevented by reconciliation2

1Institute for Healthcare Improvement 2Joint Commission Sentinel Event Database

Medication Reconciliation

• On Admission– Obtain (with the involvement of the patient) a complete list

of the patient’s current medications and review it in Epic per the Medication Reconciliation admission process

• include name, dosage, frequency, and route• Review and document in Epic within 24 hours of admission

– Med list may be obtained and documented during the clinic visit prior to scheduled admission and then just reviewed.

• Medications not given during the admission can be resumed post discharge in Epic

Transferring Patients

• Review all orders at transitions– Post-op– Transfer into or out of ICU or L&D– Change of service

• Review transfer orders if transfer is delayed greater than 24 hours

Safe Prescribing Tips (reflect in note documentation as well)

• Write medications by full generic name• No trailing zeros (1.0 can be read as 10)• Always lead the decimal point with a zero

(0.1mg not .1 mg)• Write out units if not mg (“u” can be read as

a 0 or IU as IV… use mcg)• Write hr instead of ° (misread as 0)• Write mL for all volumes instead of cc• Write daily instead of QD• Write every other day instead of QOD

Standard Administration Times

• Pharmacists and nurses interpret new orders to start at next standard administration time

• If order should be administered PRIOR to the next standard administration time, do “first dose now” in Epic– Atenolol 50mg PO daily, select “first dose now” if

ordered at 1500 and want before 0900 the next day• TPN (paper) order deadline: 1400 daily• Chemotherapy (paper) order deadline: 1500

daily

Dietary Supplements/Herbal Products

• Not regulated by FDA– No quality controls– No standardized manufacturing process

• Cannot be used at OHSU– Even if patient has own med– Explanatory handout available to give to patient

Patient’s Own Meds

• Send meds home with patient’s family whenever possible

• Can only be used if pharmacy can positively identify drug – not possible for liquids (IV, ophthalmic, otic, or PO)

• Only Non-Formulary drugs may be used• Controlled substances may not be used

Non-Formulary Medications

• Epic will flag non-formulary medications– Reason for use is chosen if you proceed

• Most agents have a formulary alternative• Interchange guidance in Epic for some

types• Indicate in if it is acceptable for pharmacist

to substitute a formulary alternative or select with Epic guidance if presented

Help Meds

• If unsure of medication and cannot find it in Epic– Type “Help” in order entry search field

• Then a complete order must be written• Drug name, strength, dose, frequency

• Alternatively, page/call your pharmacist

Discharge Prescriptions

• OHSU discharge time: 1100• Prescriptions can be done in Epic the day

before for stable medications• Ask patient if they want prescriptions filled at

an OHSU Ambulatory Pharmacy– Pharmacy choice can be selected electronically– The patient then must pick them up at pharmacy

• Any prescriptions printed on the patient care unit must be manually signed (e.g., controlled substances)

Paper Order Guidelines

• Sign (add pager #), date, and time all orders• Patients < 40 kg indicate dose in mg/kg –

need total dose on order• Order style• Legible and complete (please don’t write

“add 20 mEq KCL to IVF”)– Minimize abbreviations, standard ones only if

used

General Order Writing

• Medication Reconciliation/review of orders at all transitions of care– Unit or team transfers, admits, discharges,

in/out ICU or L & D, post-ops• Standard administration times are used –

write first dose now if you want a dose prior to then

• Antineoplastics – Attending MD only may write (regardless of use)

General Order Writing

• High Alert medications– Heparin, opioids, antineoplastics, insulin, hypertonic

saline– LIP to order; no verbal/telephone orders for these

medications• Patient’s own pump

– Complete order required, pharmacy provides drug– Allowed for insulin (requires Endocrinology consult),

Flolan, Remodulin, iloprost– Implanted pumps need orders written

• No self-administered meds left at bedside

Drug Information

• Pharmacists– In the pharmacies

• Central 24/7– On the units- 0700-

2100– Drug Information

Center• x 4-7530 • Monday-Friday 8:30

am – 4:00 pm

• Micromedex– Online at all clinical

workstations• Type “micromedex” in

address line of web browser

Hospital Formulary

• Pharmacy & Therapeutics Committee of the Medical Staff

• Information available:– Black box warnings– Restrictions– Safety recommendations– Drugs in short supply

• Can be downloaded to PDA

• Available on Ozone– Physician’s page– Pharmacy page– Icon on all clinical

workstations

OHSU Formulary.URL

Pharmacy Services

• Consultations– Anticoagulation, pharmacokinetics, renal

dosing, unusual medications, profile reviews/drug interactions, delirium, targeted issues.

• Adverse drug reactions and management• Patient Safety Net (PSN)• Parenteral nutrition consults• Medication therapy management

LIP orders anticoagulation and designates therapy management process

Pharmacist to manage Treatment team to manage

Pharmacist orders medication and monitoring and coordinates process*

Pharmacist monitors and interacts with team per normal procedures

Pharmacist writes notes and interacts with team to communicate recommendations and changes

Team doses and monitors per standard of care. Team responsible for meeting NPSG standards

Department of Pharmacy Services

* Note: RN communicates with pharmacy as LIP managing dosing and critical values

Questions??????

• Avoid guessing and incomplete orders• Call a pharmacist

– Central Pharmacy: 4-0699– OR Pharmacy: 4-7375– Drug Information: 4-7530– Clinical Pharmacists:

• Pediatrics, Oncology, Transplant, Nutrition Support, Internal Medicine, Critical Care, Surgery, Cardiology, Gynecology, Antimicrobial Management

Pain in the house: Managing pain in the

hospital

Grace Chen, MDPamela Kirwin , MD

Pain DivisionDepartment of Anesthesiology and Preoperative Medicine

Oregon Health and Science University

Pain • “An unpleasant sensory and emotional

experience associated with actual or potential tissue damage, or described in terms of such damage.”

Types of pain

• Acute: immediate, directly related to injury• Chronic: continues after expected healing• Cancer: related to cancer or its treatment

Why care about pain?

• Common in hospitalized patients• Pain interferes with healing• We can treat pain• These treatments can be dangerous• Assessment, documentation, and

management mandated by accrediting agencies

• We are privileged to serve the suffering

Physician barriers to pain treatment

• Poor assessment• Poor recognition of individual variability• Underestimating painful aspects of

hospitalization• Fears/misconceptions about medications• Preconceptions about “pain patients”• Real experiences with pain treatment (i.e.,

anecdotal decision making

Some patients with special needs

Chronic PainHigher pain levels & treatment requirementsEspecially NPO/withdrawal

Substance abuse Neuropathic Pain

May resist treatmentSleep Apnea

Vulnerable to respiratory depressionDepression/Anxiety/Background Stress

Multimodal Treatment

• Non-opioid analgesics on schedule• Opioids: oral – parenteral – neuraxial• Local Anesthetic: wound – regional – neuraxial• Physical measures: PT – surgery – splint – ice• Psychological therapy• Plan for transitions:

– How long will patient have pain?– Risk factors for increased pain– Bridge to next step and/or appointment

Non-opioid analgesics

• Anti-inflammatories & Acetaminophen– On schedule or as needed?– Adverse effects

• Gastrointestinal• Renal• Hematological

• Anticonvulsants– Especially gabapentin and pregabalin

• Antidepressants (not SSRI’s

Opioid analgesics

• Big question is not which drug, but how to use it.– Continuous phase– Intermittent demand phase

• Common choices– Parenteral

• Morphine• Hydromorphone (Dilaudid)• Fentanyl

– Oral • Oxycodone (± acetaminophen)• Hydrocodone + acetaminophen• Morphine• Hydromorphone

Relationship between serum opioid concentration and method of administration

PCA management

• Use EPIC order set• Provide a loading dose• Note daily consumption• Who likes PCA: informed, involved patients• Who doesn’t like PCA: passive patients• Patients as young as 5 (or so) can use PCA• Inadequate pain relief:

– most common reason is patient underutilization– educate, loading dose– decrease lockout, increase dose

• Side effects: change drug rather than stop it• Opioid consumption decreases as patients heal, they “self-wean”

PCA settings Opioid naïve patients

Equianalgesic Doses of Opioid Analgesics

Naloxone = Narcan

• OHSU naloxone protocol• In adults, the usual starting dose is 40

micrograms, titrate to effect. • Do not give “an amp” to patients who are

breathing or awake• Remember the ½ life is shorter than most

opioids

Epidural Analgesia

• Local anesthetic + Opioid• Regional effect• Improved breathing &

moving with PT• Adverse effects

– Hypotension– Nausea/vomiting– Pruritus– Respiratory depression

Epidural Analgesia: When?

Major abdominal surgery

Thoracic surgery

Major pelvic surgery

Vascular surgery

Rib Fractures, trauma

Major orthopedic cases

Continuous Regional Analgesia

• Peripheral catheters for plexus analgesia

• Improved pain, sleep, less opioid use

• Block only the affected extremity• Better outcomes than systemic opioids • Can be continued at home

Ilfeld Anesthesiology 2002; Stevens Anesthesiology 2000

Interscalene block for shoulder surgery

Department of Anesthesiology

and Perioperative Medicine

Pain Medicine Division

Outpatient Comprehensive

Pain Center (CPC)Ph: 4-PAIN (7246)

Inpatient Adult Pain Service

(APS)Pager 11707

Pediatric Pain Service

Pager 12987

What to do????

• Plan ahead– Anticipate problems– Have a Plan B if Plan A isn’t working!

• Coordinate care within & between services• Ask for help

– Place a consult order in EPIC and call:• Inpatient Adult Pain Service pager #: 11707• Pediatric Acute Pain Service pager #: 12987• Outpatient Comprehensive Pain Center #: 4-PAIN (7246)

OREGON MEDICAL BOARD

• ‘Licensure: What Does It Mean?’• Kathleen Haley, JD Executive Director

Presenting News and Information

• About the Medical Board• Licensure • Investigations and Discipline• Reporting Requirements• Statistics• Services, Contact Information

Mission Statement

The mission of theOREGON MEDICAL BOARD

is to protect the health, safetyand well-being of Oregon citizens

by regulating the practice of medicinein a manner that promotes quality care.

THE OMB IN 2010

CHAIRLisa Cornelius, DPM, Corvallis

VICE CHAIRRalph Yates, DO, Gresham

SECRETARYLinda Johnson, MD, Salem

Ramiro Gaitán, Portland*Donald Girard, MD, PortlandDouglas Kirkpatrick, MD, Medford

John P. Kopetski, Pendleton*George Koval, MD, PortlandRoger McKimmy, MD, EugeneLewis Neace, DO, HillsboroKeith White, MD, SalemKent Williamson, MD, Portland________________________

* Public Members

BOARD MEMBERSHIP

• Members of the Board are appointed by the Governor.• Board members are paid per diem for their time spent at

meetings.• Each Board member serves one 3-year term, with the

possibility of a second term.• Each federal congressional district is represented on the

Board.• Each member must be a resident of the state, and the

medical licensed members must have been in practice for at least five years immediately preceding their term.

MDs and DOs make up 86%of all licensees

14,442MDs – DOs

ACUPUNCTURISTS1104

PHYSICIAN ASSISTANTS975

PODIATRISTS188

Statistics current to March 15, 2010

STANDARDS OF CARE

• The OMB is the standard-setter– The Board has general supervision over

the practice of medicine in the state (Oregon Revised Statutes Chapter 677)

– Setting “P.C.” standards • Physician Competence• Physician Conduct• Patient Care

– The Board works through committees

COMMITTEES

• Acupuncture Affairs Committee• Administrative Affairs Committee• Editorial Committee• Emergency Medical Technician Advisory Committee• HPP Supervisory Committee• Investigative Committee • Legislative Advisory Committee• OMB-HPP Liaison Committee• Physician Assistant (PA) Committee

‘… regulating the practice of medicine in a manner that promotes quality care.’

THE OMB LICENSING PROCESS IS THE FIRST STEP IN PROMOTING QUALITY CARE –THROUGH PHYSICIAN COMPETENCE

APPLICATIONApplicant fills online application and submits with

photograph and fees to the Board

LETTER TO APPLICANT(1-2 weeks after submission)

Referred to Online Status ReportOR

Informed of Ineligibility for Licensure

File Contains Derogatory Information

ADMINISTRATIVE AFFAIRS COMMITTEEMeets quarterly

1 month before full Board meetingFile must be complete 30 days prior to meeting

FULL BOARD

FULL BOARD

INVESTIGATIVE COMMITTEE

LICENSE DENIED

Applicants Must MeetLicensing requirements

State of OregonORS Chapter 677OAR Chapter 847

LICENSE GRANTED Weekly

(average 21/2 Months after submission)

LICENSE GRANTED Weekly

(several months to more than a year)

Applications Received and Processed in Date Order

(Rural Locations given Priority)

Ongoing processing of Documents

OREGON MEDICAL BOARD - LICENSING PROCESS

FavorableUnfavorable

YesNo

LICENSING IMPROVEMENTS

Online Licensure MD DO DPM PA LAc

Online renewal Licensing forms,

information, “FAQs,” and license status reports are now available on the Web:

www.oregon.gov/OMB

RESIDENCY LICENSE

• Limited License, Post Graduate (LL,PG)– Training License– Practice in an accredited training program– NO outside work or moonlighting

• Required for Application:– Letter from training facility OR must be on

GME master list submitted to the Board.

FELLOWSHIP LICENSE

• Limited License, Fellow (LL,F)– Practice in supervised fellowship program– NO outside work or moonlighting– Limit of two LL, F licenses per licensee– Limited Length of 2 consecutive years

• Application Requirements:– Copy of appointment letter or contract– Letter from training program director stating

fellowship position offer and program dates.

INDEPENDENT LICENSE – US MED SCHOOL GRADS

Applicant Requirements*:• Graduated from an LCME or the AOA

accredited US School of Medicine• Completed 1 year of post graduate training• Passed FLEX, National Board

(NBME/NBOME), USMLE or acceptable combination (OAR 847-020-0170)

*Exceptions and waivers apply

Applicant Requirements*:• Speak English fluently and write English legibly• Medical School• ECFMG certification• Post Graduate – Successfully completed 3

years of progressive training

INDEPENDENT LICENSE– INTERNATIONAL MED SCHOOL GRAD

*Exceptions and waivers apply

WHAT DO I SUBMIT?

• American Specialty Board Certificates• Copy of Birth Certificate• Finger Print Card with Identification

Verification Form• Medical/Osteopathic/Podiatric Diploma• Medical Practice Act & DEA open book

laws examination

WHAT DO I SUBMIT? (cont)

• Name Change Documents – Marriage License– Naturalization – Etc.

• Personal History Explanations• Photograph• Request for SPEX Waiver• Translation of Documents (if needed)

• Written explanation(s) of ‘Yes’ answers to personal history questions on application

WHAT HAPPENS WITH…

TAKING USMLE

• Steps 1 & 2 have unlimited pass attempts• All three steps must be passed within seven

years.• Step 3: After failing to pass with three

attempts, one additional year PG required. After fourth non-pass, no Oregon licensure.

Exceptions

Emergency SuspensionImmediate threat to public safety

Board Order IssuedBoard Accepts/Amends/Rejects Proposed

Final Order and issues a Final OrderBoard Order Issued

Stipulated Order, Voluntary Limitation,Corrective Action Agreement

Complaint & Notice of Proposed Disciplinary Action

ANATOMY OF A COMPLAINT

Proposed Final Order

Preliminary ReviewInvestigations staff, and/or Medical Director,

and/or Executive Director, and/or Board Counsel

Contested Case Hearingwith Administrative Law Judge

Review by Investigative Committee (IC)Comprised of 5 Board members. Attorneys and consultants

also present. Reviews cases and refers them to the full Board

Open InvestigationGather Information

Case review/summary by Medical Director

Review by full Board12 member Board reviews IC case referrals

No ViolationNo Jurisdiction• Close Case• Letter of Concern• Referral

Oregon Court of Appeals

Oregon Supreme Court

Settlement Discussions

Terms of Board Orders May Include:Revocation, Suspension, Reprimand, Probation, Remedial Education, Monitoring (i.e. UA’s, chart

review), Practice Limitation, Chaperone, Fine

Written ComplaintPatient, family member, other provider, insurance company,

pharmacy, hospital, malpractice review, other Board, self

Waiver of Hearing

Health ProfessionalsProgram (HPP)

Yellow boxes constitute public Board actions

Interim Stipulated OrderLicensee voluntarily withdraws from

Practice due to public safety concerns.

PATIENTS AND THEIR ADVOCATESFILE THE MOST COMPLAINTS

123*Other – 40

Malpractice - 11

Other Providers - 31

OMB - 47

January 1 - December 31, 2009

*‘Other’ includes hospitals, pharmacies, payers, other boards and licensees who self-report.

CATEGORIES OF INVESTIGATIONS

Quality of Care

201

Inappropriate Prescribing

Violationof Law - 27

Other - 43

Sexual Misconduct - 20

Unprofessional Conduct

55

January 1 - December 31, 2009

Mental Health/Impaired – 3

Substance Abuse - 18

Investigation Outcomes2004-2008 Data – 1752 Total Cases

Closed –no violation

1125Letters of concern:

357

Public Orders:270

THE OMB TAKES THESETYPES OF ACTIONS

• Reprimand• Suspension• Revocation• Probation

• Fine• Corrective Action

Agreement• Letter of Concern*

*Not a public document

AVOID COMPLAINTS

• Learn, practice effective communication skills– With patients,

colleagues, staff• Stay current

– Medicine changes, new standards are developed

• Know and abide by community standards

• Professional boundaries– Know them …– Respect them!

• Don’t become isolated– Isolation =

Vulnerability• ‘You’re human!’

– Get help when needed

EDUCATION IS KEY …

… to learning the safe practice of medicine at the beginning of one’s career …

… and …

… to continuing to practice safely throughout one’s professional life!

MAINTENANCE OF LICENSURE

• 60 hours of Continuing Medical Education every two years for MDs, DOs and DPMs

• 30 hours of Continuing Medical Education every two years for Acupuncturists.

Ongoing participation in re-certification by one of the following:

• American Board of Medical Specialists (ABMS) (MDs)• American Osteopathic Association’s Bureau of Osteopathic Specialists (AOA-BOS) (DOs) • American Board of Podiatric Orthopedics and Primary Podiatric Medicine (DPMs)• National Commission on Certification of Physician Assistants (PAs)• National Certification Commission for Acupuncture and Oriental Medicine (LAcs)

All licensees who wish to renew their active license must have demonstrated ongoing competency to practice medicine.

AND…

MAINTENANCE OF LICENSURE

• As the result of an audit, if your CME is deficient, you have 90 days to come into compliance with CME requirements and will be fined $250.

• If after 90 days you fail to comply, you will be fined $1000.

• If after 180 days you fail to comply, your license will be suspended for a minimum of 90 days.

What if I don’t keep up on CME?

• Licensees with Emeritus status• Licensees in residency training

• Licensees serving in the military who are deployed outside Oregon for 90 days

Am I exempt?

Patient Safety also meanstaking proactive, positive steps

√ Early problem identification√ Remediation

THE OMB IS HERE TO HELP

Saving Good Doctors and Their Patients• Reliant Behavioral Health• July 1, 2010 start date• Monitoring not treatment

– Substance Abuse and Dependence – Mental Health Disorders

HEALTH PROFESSIONALS SERVICES PROGRAM

PATIENT SAFETY BEGINS WITH YOU

State law requires doctors and institutions

to report potentiallyharmful conduct to theOregon Medical Board.

ORS 677.150 clearly spells out, in detail, those reporting obligations.

WHAT MUST BE REPORTED?

The OMB must know if a licensee is,or may be:

Medically incompetent Guilty of unprofessional or dishonorable

conduct Impaired and thus unable to safely practice

medicine, podiatry or acupuncture, or serve as a physician assistant.

Any licensedhealthcare facility

must report ‘OFFICIAL ACTIONS’ to the OMB

INSTITUTIONAL RESPONSIBILITY

Fear a lawsuit for reporting?NOT TO WORRY …

… Persons who make ‘good faith’ reports to the OMB

regarding licensee actions are protected from civil liability!

(ORS 677.150)

Cross Profession ReportingORS 676.150

Prohibited or unprofessional conduct means:• Criminal acts against a patient or client • Criminal acts that create a risk of harm to a patient or client• Conduct unbecoming a licensee or detrimental to the best interests of the

public• Conduct contrary to recognized standards of ethics of the licensee’s

profession • Conduct that endangers the health, safety or welfare of a patient or client

Don’t Wait! - Report Immediately!

If you have cause to believe another licensee has engaged in prohibited or unprofessional conduct, ORS 676.150 requires you to report.

THE OMB HAS A FIRST-RATE WEBSITE

• Licensee Info Available to Public

• OMB Report Newsletter• Online Licensure• Online Renewal• Status Reports• Change of Address • Committee Meeting

Minutes• Rule Changeswww.oregon.gov/OMB

CALL THE OMB ON THE TELEPHONE

• GENERAL INFORMATION: (971) 673-2700, or toll-free in Oregon, 877-254-6263

• LICENSE VERIFICATION INFORMATION LINE: (971) 673-2700

• Health Professionals Program: (503) 620-9117

Oregon Medical Board

Over 120 years of ensuring

PATIENT SAFETY

Intro to Laboratory ServicesDr. Jim MacLowry

Steve Osgood

Phlebotomy Services

• Inpatient—scheduled draws during day and evening only, no timed or stat draws, or draws from lines—these done by nursing staff. 24/7 coverage (selected units) projected to being in 2011.

• Outpatient—services provided at PPV 300, and CHH, M-F and some weekend hours.

• All Phlebotomy services requested via an order in Epic by an authorized health care provider.

• See www.ohsulabs.com for detailed info.

Ordering of Lab Tests

• ALL orders must be placed in Epic system.• Complete test information available at

www.ohsulabs.com, including links to the Transfusion Manual, and Point-of-Care info.

• Epic screens also display hyperlinks to the same site.

• Avoid duplicate testing, unnecessary testing.

Test Result Availability

• Results sent electronically to Epic immediately after verification in the laboratory.

• Test directory at www.ohsulabs.com includes testing schedule so users know how long before results available.

• Check Epic first, before calling lab for results. • Phone 4-7383 if questions about results,

testing procedures, policies, etc.

Basic Test Panels

• OHSU uses the AMA Standard Panels listed in CPT 2010.• www.ohsulabs.com lists components of each test panel.• Electrolyte Set: CL, CO2, K, Na.• Basic Metabolic Set: BUN, Ca, Cl, CO2, Creatinine,

Glucose, K, Na.• Comprehensive Metabolic Set: Albumin, ALT, AST, Alk

phos, Total Bili, BUN, Ca, Cl, CO2, Creatinine, Glucose, K, Na, Protein.

• Renal Function Set: Albumin, BUN, Ca, Cl, CO2, Creatinine, Glucose, K, Na, PO4.

• Liver Set: Albumin, ALT, AST, Alk phos, Direct Bili, Total Bili, Protein.

• Lipid Set: Triglycerides, Cholesterol, HDL, calculated LDL

Critical Results

• Results which exceed defined “critical” limits are repeated to confirm.

• All Critical Results are called to the requesting provider or designee.

• Read-back required.• See Core Lab Section www.ohsulabs.com

for more information.

Specimen Labeling

• Unlabeled or mislabeled specimens will not be tested, subject to laboratory and hospital policies.

• Within very strict policy guidelines, testing will occasionally be performed after consultation between a pathologist and the ordering provider.

• Mislabeled specimens for Transfusion Services will NEVER be accepted.

• Links to labeling policies available at www.ohsulabs.com.

Medical Necessity Documentation and Advanced Beneficiary Notice (ABN)

• ICD-9 diagnosis codes must accurately reflect condition of the patient.

• Screening of the appropriateness of the ICD-9 code as it relates to the tests ordered is automatically done in Epic.

• It is the responsibility of the ordering provider to explain the need for testing and request the patient sign the ABN if medical necessity requirements not met.

Laboratory Contact Information

• Transfusion Medicine – 48537• Lab Central Receiving and Processing – 47383• Phlebotomy Services – 44214• Administrative Director, Pathology and Genetics Labs,

– Juanita Petersen – 48606• Medical Director, Laboratory Medicine,

– Dr. James MacLowry – 41545• Medical Director, Anatomical Pathology,

– Dr. Ken Gatter – 43562• Medical Director, Transfusion Medicine,

– Dr. Richard Scanlan – 49082• Most Important contact: www.ohsulabs.com

Medical RecordsMarjorie Carlson

Mario OsarioOverview of the Medical Record

Care Management Dr. Dan Handel Nancy Trumbo

Lorien paulson, MDTan Ngo, MDHOA Co-presidentsClea Lopez, MDHOA Secretary

OHSU House Officers’

Association2010-2011

OHSU House Officers’ Association

2010-2011

HOA Purpose and Function

•Provide a unified H.O. voice•Foster communication among H.O.’s•Foster communication between H.O.’s & administration

Communication•Annual retirement benefits: earn an extra 1.5%/yr!!•Time off to seek preventive health care•SalariesMonitor benefits

provided to house officers

•Membership on hospital executive committees•Quality Improvement Projects:•Patient safety net (PSN) reporting•Lab resulting•Interdisciplinary communication•EPIC

Influence policies that affect patient

care

HOA Membership

• Two resident and/or fellow representatives from each department are voting members of the HOA.

• Departments vote for representatives each July

• Any and all OHSU interns, residents, and fellows are invited to attend/contribute to HOA/HRF meetings

Listen to this!!!

You have access to 4 ½-days off per year to seek preventive care!!!

Spread the word!!(your seniors might not have heard)

Summary of HOA Wellness Survey Results (2009-2010)

• Response rate 311/764 = 41%

• 51% have not established care with a PCP

• 77% (232) have delayed or not sought care

• 90% cited the inability to get off of work during business hours as the most important factor prohibiting their seeking care

Goals for improving resident health

• The administration and your departments want to…

Facilitate the process of making acute care visits

Augment access to preventive care

Increase the number of residents who have PCPs

Promote the importance of resident health

Raise knowledge of available health care resources

Why Establish Care?

• Residents are 47% less like than their cohorts to have a PCP – OHSU’s culture is changing!

• You don’t need to have a problem to establish care!• Use your ½-days off per quarter to schedule appts 4-6

wks in advance, esp with faculty• Mental health needs should still go through Resident

Wellness

How to Access Health Care

• Call FM, Peds, OB or IM clinics directly

– Preventive or urgent appointments

– Faculty have opened their schedules: • Check out Who’s Who on individual clinic websites

– Say you’re a resident when you call

– If there are problems, contact the dept contact person

www.ohsu.edu/gme

Hold onto your brochure!

How you can help!

• Get involved … join HOA!• Tell HOA leadership about your concerns• Come to HOA and HRF meetings• Volunteer to sit on a hospital committee• Work towards the 2010-2011 Retirement Benefit• Promote the Resident Health Access Initiative

– Among your peers– With your program directors

2010-2011 Leadership

• Co-Presidents– Tan Ngo, MD – Psych Resident

• ngot@ohsu.edu

– Lorien Paulson, MD – ENT Resident• paulsonl@ohsu.edu

• Secretary– Clea Lopez, MD – Family Medicine Resident

• Lopezcle@ohsu.edu

• Forgot how to find us?? www.ohsu.edu/gme

Student Loan Management

Jason DiLorenzo, GL Advisor

Student Loan ManagementIncome Based Repayment

* Based on data collected by AAMC, AMA and GL internal student database

Changes in Student Debt Levels

Debt levels have tripled in the last 15 years

~$50k

~$115k

1993 2003

$168K

2009

Income-Based Repayment

Partial Financial Hardship• Limit monthly payment to 15% of discretionary income

Government Subsidy• Subsidized interest not covered by reduced payment is

paid by government• Subsidy is provided for maximum of 3 years

Loan Forgiveness• After 25 years any outstanding balance is forgiven

How is IBR calculated?

(AGI – 150% Poverty Level) x 15%12 months

($38,000 – $16,245) x 15%12 months = $272 / mo.

How is the IBR Subsidy Calculated?

Subsidized Interest Accrued (Standard Repayment)

Subsidized Interest Paid (IBR)

IBR Subsidy Year 1 = $1,704

Interest Subsidy_ =

$197 $55 $142_ =

IBR Subsidy Year 2 = $1,677IBR Subsidy Year 3 = $1,654 Total IBR Subsidy = $5,035

Assumptions for this and other scenarios in the presentation: Loan Portfolio: $34,000 Subsidized at 6.8%, $120,000 Unsubsidized at 6.8%, and $14,000 Grad PLUS at 8.5%. AGI Assumptions: $38,000 increasing at 3%. Post Residency Salary begins at $150,000 increasing at 3%.

$11,662

Total AccruedCost = $46,648

Income-Based Repayment

Extended Term Payment: $1,189 $1,189 $1,189 $1,189

10-Year Standard Payment: $1,946 $1,946 $1,946 $1,946

1st Year 2nd Year 3rd Year 4th YearSalary: $45,000 $46,350 $47,740 $49,173

$11,662 $11,662 $11,662

• Payment unmanageable during residency • New deferment regulations necessitate forbearance

$11,662 $11,662 $11,662 $11,662IBR Subsidy

Total AccruedCost = $46,648

Tax Savings

Interest Paid

Total AccruedCost = $26,389 Cost Difference

of $20,259

Income-Based Repayment

Extended Term Payment: $1,189 $1,189 $1,189 $1,189

IBR Payment: $272 $281 $291 $300

10-Year Standard Payment: $1,946 $1,946 $1,946 $1,946

1st Year 2nd Year 3rd Year 4th YearSalary: $45,000 $46,350 $47,740 $49,173

$3,264 $3,372 $3,492

$374 $374 $374

$1,704 $1,677 $1,654

$6,320 $6,239 $6,142

$3,600

$374

$7,688

$2,486* $2,486* $2,486* $2,486*

$0

*New payment after forbearance interest capitalizes

Approximately 80% of hospitals qualify

Public Service Loan Forgiveness

Federal program enacted by Congress in 2007Most medical school residents are not aware of the applicability and immense valueSpecific requirements:

• Borrower must make 120 qualifying payments on a Federal Direct Loan

• Borrower must work for a public service entity as defined by the program, such as a Federal, State, Local, or non-profit organization

$200k

Public Service Years: 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th

Residency

= Debt

= Salary

Maximizing Loan Forgiveness

$100k

$400k

$300k$157,755 Forgiven

Taxable Equivalent $262,925

4-Year Residency

Assumptions:The taxable equivalent amount assumes a marginal federal tax rate of 35% and a marginal state tax rate of 5%.

= Standard

= IBR

$2,000

$1,000

$3,000

$272

$1,466

$1,946

Loan Forgiveness – True Cost of Debt

4-Year Residency

1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th

Residency

$2,000

$1,000

$3,000

$272

$1,466

Loan Forgiveness – True Cost of Debt

1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th

Residency

$2,486

Total Debt Payments of $298,320

Total Debt Payments of $122,417

~$50k

~$115k

1993 2003

$168K

2009

Adjusted True Cost of Debt = $48,510

Better Off Than Class of 1993

If you have any questions or would like a personalized debt assessment, please feel free to call or visit our website.

www.glAdvisor.com877.552.9907

GL Advisor currently does not offer all services to residents of New Hampshire, Idaho, Nebraska, Nevada and North Dakota

Oregon Medical Association