OHSU Faculty and Resident Wellness Programs•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 ProgramsServices offered: • Brief evaluation/ consultation • Coaching/ Counseling • Psychiatric medical consultation • Referrals to community resources – counseling, psychiatric, primary care
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
OHSU Resident Wellness ProgramConfidentiality/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‖
Anonymous Resident Survey (Spring 2006 )n=133; 20% response rate What factors limit residents ability to access services50% at RWP?40%30%20%10% 0% Unable to break Confidentiality Would it even Other help?
Anonymous Resident Survey (Spring 2006) n=133; 20% response rate Can residents ask for an one hour break for self-care?45%40%35%30%25%20%15%10% 5% 0% Yes No Dont 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%
Feedback: Anonymous Resident Survey (Spring 2006)―The RWP is a special program. It made a huge difference in my life and I amvery 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‖(The RWP provider) ―was extremely helpful to me. I amvery grateful to her. Her flexibility in scheduling wasessential to our success.‖
Scheduling an Appointment• Contact Mary Moffit or any of the other providers • Email: firstname.lastname@example.org • Pager 1-2047 • Voice-mail: 4-1208 • Urgent/ After Hours: (503) 330-7880 • Other Providers: • Mark Kinzie, M.D., Ph.D. • Email: email@example.com ; pager 1-4559 • Sydney Ey, Ph.D.: • Email: firstname.lastname@example.org ; 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
1. Learn a bit about the Safety & Risk side of healthcare2. Know who to call when you need someone right away3. 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
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 20
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 Identification Communication Medication Safety and Reconciliation Infection Falls Population Risks Response to Patient Condition 21
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 22
Critical Tests and Critical ResultsPolicy: 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 23
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 24
Finally …• We have an TEAM PAUSE Rapid Response Team CONTENT OF THE amazing (RRT); use them! the two identifiers Patient identification; use• The Universal Protocol applies to all high risk Procedure(s) as listed on the consent Site/side marked … which is ALWAYS done by the Provider or Resident and/or invasive procedures in any location of involved in the case OHSU position of the patient Correct Relevant – Even if images aretest resultsit alone, displayed? to you and doing labeled and you need Need to administer antibiotics or fluids for irrigation? • Complete the ‗pre-procedural checklist‘ in EPIC Have we taken all safety precautions based on patient’s history and • Mark use? medicationthe site using your INITIALS with a permanent ADDITIONAL(and visible when draped) marker QUESTIONS OR CONCERNS? • And do the ‗team pause‘ AND DOCUMENT IT (with dot phrase or Epic record), verifying the following: 25
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! 26
1. Electronic Reporting system used since 20062. Know how to access it3. And then ACCESS it! 27
Monthly – Total Number of Patient Event ReportsJune 2009 – May 2010 500 450 400 350 # of reported events 300 250 437 425 417 375 200 373 361 350 340 339 331 329 325 150 100 50 0 Month Monthly Average (366.8) Confidential document for the improvement of patient care protected pursuant to ORS 41.675
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. 32
Human Error Swiss Cheese Effect• 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 33
Case Study Sept. 2008 Root Cause Analysis conducted Three-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 Average Number of Unread Exams 2 Weeks Post Completion 160 141 140 119 117 120 100 90 86 80 67 70 55 60 40 23 18 15 20 13 0
“The strength of the team is in each individual member… the strength of each member is the team.” Phil Jackson as coach of the Chicago BullsI am from Massachusetts and NOT a Lakers fan… that is why the print is so very small 37
One more story• 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
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
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 40
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 41
Professional Liability Claims Team Jilma Meneses Risk Management Director Extension 4-8819 Renee Wenger Lori Davis Chas Lopez Monique Parker Professional Liability Professional Liability Professional Liability Professional Liability Claims Manager Claims Manager Claims Manager Claims Examiner Extension 4-8314 Extension 4-7911 Extension 8-3365 Extension 4-4257 Risk Management Main Line 4-7189 Risk Management Pager 12273 42
What should you report?Unexpected patient deathMajor permanent loss of functionUnexpected outcome/complicationSerious adverse eventAnytime you have a concernCharting a patient‘s dissatisfactionIf you are contacted by an attorneyIf patient threatens a lawsuit 43
Medication Use System & Pharmacy Services Joseph Bubalo, PharmD, BCPS, BCOP June 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 CPOECPOE – 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 notedocumentation 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 • Micromedex – In the pharmacies – Online at all clinical • Central 24/7 workstations – On the units- 0700- • Type “micromedex” in 2100 address line of web browser – Drug Information Center • x 4-7530 • Monday-Friday 8:30 am – 4:00 pm
Hospital Formulary• Pharmacy & • Available on Ozone Therapeutics Committee of the – Physician’s page Medical Staff – Pharmacy page• Information available: – Icon on all clinical – Black box warnings workstations – Restrictions – Safety recommendations – Drugs in short supply• Can be downloaded to PDA
LIP orders anticoagulation and designates therapy management process Pharmacist to manage Treatment team to manage Pharmacist orders Team doses and monitors medication and per standard of care. Team monitoring and responsible for meeting coordinates process* NPSG standards Pharmacist writes notes Pharmacist and interacts with team to monitors and communicate interacts with team recommendations and per normal changes procedures* Note: RN communicates with pharmacy asLIP managing dosing and critical valuesDepartment of Pharmacy Services
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, Antimi crobial Management
Pain in the house: Managing pain in the hospital Grace Chen, MD Pamela 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: continuesafter expected healing• Cancer: related tocancer 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 Pain Higher pain levels & treatment requirements Especially NPO/withdrawal Substance abuse Neuropathic Pain May resist treatment Sleep Apnea Vulnerable to respiratory depression Depression/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 opioidconcentration 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 settingsOpioid 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: 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 Pediatric Pain Pain Medicine Service Division Pager 12987 Outpatient Inpatient Adult Comprehensive Pain ServicePain Center (CPC) (APS)Ph: 4-PAIN (7246) Pager 11707
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 the OREGON MEDICAL BOARD is to protect the health, safety and well-being of Oregon citizens by regulating the practice of medicinein a manner that promotes quality care.
THE OMB IN 2010 CHAIR Lisa Cornelius, DPM, Corvallis John P. Kopetski, Pendleton* VICE CHAIR George Koval, MD, Portland Roger McKimmy, MD, Eugene Ralph Yates, DO, Gresham Lewis Neace, DO, Hillsboro SECRETARY Keith White, MD, Salem Linda Johnson, MD, Salem Kent Williamson, MD, PortlandRamiro Gaitán, Portland* ________________________Donald Girard, MD, Portland * Public MembersDouglas Kirkpatrick, MD, Medford
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 Statistics current to March 15, 2010 PHYSICIAN ASSISTANTS ACUPUNCTURISTS 975 1104 PODIATRISTS 188 14,442 MDs – DOs
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
‘… 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
OREGON MEDICAL BOARD - LICENSING PROCESS APPLICATION Applicant fills online application and submits with photograph and fees to the Board Applicants Must Meet Licensing requirements Applications Received and State of Oregon Processed in Date Order (Rural Locations given Priority) ORS Chapter 677 OAR Chapter 847 LETTER TO APPLICANT (1-2 weeks after submission) Referred to Online Status Report OR Informed of Ineligibility for Licensure Ongoing processing of Documents File Contains Derogatory InformationYes ADMINISTRATIVE AFFAIRS COMMITTEE No LICENSE GRANTED Meets quarterly Weekly 1 month before full Board meeting File must be complete 30 days prior to meeting (average 21/2 Months after submission) FULL BOARD Unfavorable LICENSE GRANTED INVESTIGATIVE COMMITTEE Favorable Weekly (several months to FULL BOARD more than a year) LICENSE DENIED
LICENSING IMPROVEMENTS Online Licensure Online renewal MD Licensing DO forms, information, “FA DPM Qs,” and license status PA reports are now available on the Web: LAc 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
INDEPENDENT LICENSE– INTERNATIONAL MED SCHOOL GRAD Applicant Requirements*: • Speak English fluently and write English legibly • Medical School • ECFMG certification • Post Graduate – Successfully completed 3 years of progressive training*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)
WHAT HAPPENS WITH…• Written explanation(s) of ‘Yes’ answers to personal history questions on application
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
ANATOMY OF A COMPLAINT Written Complaint Patient, family member, other provider, insurance company, pharmacy, hospital, malpractice review, other Board, self Health Professionals Program (HPP) Preliminary Review Investigations staff, and/or Medical Director, and/or Executive Director, and/or Board Counsel No Violation Open Investigation Gather Information No Jurisdiction Case review/summary by Medical Director Interim Stipulated Order •Close Case Licensee voluntarily withdraws from •Letter of Concern Practice due to public safety concerns. •Referral Review by Investigative Committee (IC) Comprised of 5 Board members. Attorneys and consultants also present. Reviews cases and refers them to the full Board Emergency Suspension Immediate threat to public safety Review by full Board 12 member Board reviews IC case referrals Contested Case Hearing with Administrative Law Judge Waiver of Hearing Complaint & Notice of Proposed Disciplinary Action Proposed Settlement Discussions Final Order Board Order Issued Board Order Issued Terms of Board Orders May Include: Board Accepts/Amends/Rejects ProposedStipulated Order, Voluntary Limitation, Revocation, Suspension, Reprimand, Probation, Final Order and issues a Final Order Corrective Action Agreement Remedial Education, Monitoring (i.e. UA’s, chart review), Practice Limitation, Chaperone, Fine Oregon Court of AppealsYellow boxes constitute public Board actions Oregon Supreme Court
PATIENTS AND THEIR ADVOCATES FILE THE MOST COMPLAINTS January 1 - December 31, 2009Malpractice - 11 *Other – 40Other Providers - 31 123 OMB - 47 *‘Other’ includes hospitals, pharmacies, payers, other boards and licensees who self-report.
CATEGORIES OF INVESTIGATIONS January 1 - December 31, 2009 Sexual Mental Health/ Misconduct - 20 Inappropriate Impaired – 3 Prescribing Quality of Care Other - 43 55Violation 201of Law - 27SubstanceAbuse - 18 Unprofessional Conduct
Investigation Outcomes2004-2008 Data – 1752 Total Cases Public Orders: 270 Closed – Letters of no violation concern: 357 1125
THE OMB TAKES THESETYPES OF ACTIONS • Reprimand • Fine • Suspension • Corrective Action • Revocation Agreement • Probation • Letter of Concern* *Not a public document
AVOID COMPLAINTS• Learn, practice effective • Professional communication skills boundaries – With – Know them … patients, colleagues, sta – Respect them! ff • Don’t become isolated• Stay current – Isolation = Vulnerability – Medicine changes, new • ‘You’re human!’ standards are developed – Get help when needed• Know and abide by community standards
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 All licensees who wish to renew their active license must have demonstrated ongoing competency to practice medicine.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) AND…• 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.
MAINTENANCE OF LICENSURE What if I don’t keep up on CME? • 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. Am I exempt? • Licensees with Emeritus status • Licensees in residency training • Licensees serving in the military who are deployed outside Oregon for 90 days
THE OMB IS HERE TO HELPPatient Safety also meanstaking proactive, positive steps √ Early problem identification √ Remediation
HEALTH PROFESSIONALS SERVICES PROGRAMSaving Good Doctors and Their Patients • Reliant Behavioral Health • July 1, 2010 start date • Monitoring not treatment – Substance Abuse and Dependence – Mental Health Disorders
PATIENT SAFETY BEGINS WITH YOU State law requires doctors and institutions to report potentially harmful conduct to the Oregon 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.
INSTITUTIONAL RESPONSIBILITY Any licensed healthcare facilitymust report ‘OFFICIAL ACTIONS’ to the OMB
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 Reporting ORS 676.150 If you have cause to believe another licensee has engaged in prohibited or unprofessional conduct, ORS 676.150 requires you to report. Don’t Wait! - Report Immediately!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
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 Changes
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 Services Dr. 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 andAdvanced 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 Records Marjorie Carlson Mario OsarioOverview of the Medical Record
HOA Purpose and Function • Provide a unified H.O. voice • Foster communication among H.O.‘s Communication • Foster communication between H.O.‘s & administration Monitor benefits • Annual retirement benefits: earn an extra 1.5%/yr!! provided to • Time off to seek preventive health care • Salaries house officers • Membership on hospital executive committeesInfluence policies • Quality Improvement Projects:that affect patient •Patient safety net (PSN) reporting •Lab resulting care •Interdisciplinary communication •EPIC
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… Raise knowledge of available health care resources Promote the importance of resident health Increase the number of residents who have PCPs Augment access to preventive care Facilitate the process of making acute care visits
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
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 • email@example.com – Lorien Paulson, MD – ENT Resident • firstname.lastname@example.org• 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 Management Income Based Repayment
Changes in Student Debt Levels $168K ~$115k ~$50k 1993 2003 2009 Debt levels have tripled* Based on data collected by AAMC, AMA and GL internal student database in the last 15 years
Income-Based RepaymentPartial Financial Hardship • Limit monthly payment to 15% of discretionary incomeGovernment Subsidy • Subsidized interest not covered by reduced payment is paid by government • Subsidy is provided for maximum of 3 yearsLoan 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 Subsidized InterestInterest Accrued _ Interest Paid = Subsidy(Standard Repayment) (IBR)$197 _ $55 $142 = IBR Subsidy Year 1 = $1,704 IBR Subsidy Year 2 = $1,677 IBR Subsidy Year 3 = $1,654 Total IBR Subsidy = $5,035Assumptions 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%.
Income-Based Repayment 1st Year 2nd Year 3rd Year 4th Year Salary: $45,000 $46,350 $47,740 $49,173 10-Year Standard Payment: $1,946 $1,946 $1,946 $1,946 Extended Term Payment: $1,189 $1,189 $1,189 $1,189 • Payment unmanageable during residency • New deferment regulations necessitate forbearance $11,662 $11,662 $11,662 $11,662Total AccruedCost = $46,648
Income-Based Repayment 1st Year 2nd Year 3rd Year 4th Year Salary: $45,000 $46,350 $47,740 $49,173 $2,486* $2,486* $2,486* $2,486* 10-Year Standard Payment: $1,946 $1,946 $1,946 $1,946 Extended Term Payment: $1,189 $1,189 $1,189 $1,189 IBR Payment: $272 $281 $291 $300 $6,320 $6,239 $6,142 $7,688 IBR Subsidy $11,662 $11,662 $11,662 $11,662 $1,704 $1,677 $1,654 $0 Tax Savings $374 $374 $374 $374 $3,264 $3,372 $3,492 $3,600 Interest Paid Total Accrued Total Accrued Cost = $46,648 Cost = $26,389 Cost Difference of $20,259*New payment after forbearance interest capitalizes
Public Service Loan ForgivenessFederal program enacted by Congress in 2007Most medical school residents are not aware of theapplicability 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 Approximately 80% of hospitals qualify
Maximizing Loan Forgiveness = Debt $400k 4-Year = Salary Residency $300k $157,755 Forgiven $200k Taxable Equivalent $262,925 $100k ResidencyPublic Service Years: 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10thAssumptions:The taxable equivalent amount assumes a marginal federal tax rate of 35% and a marginal state tax rate of 5%.
Loan Forgiveness – True Cost of Debt Total Debt Payments Total Debt Payments of $298,320 of $122,417$3,000 $2,486$2,000 $1,466$1,000 $272 Residency 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th
Better Off Than Class of 1993 $168K ~$115k ~$50k 1993 2003 2009Adjusted True Cost of Debt = $48,510
If you have any questions or would like a personalized debt assessment, please feel free to call or visit our website. www.glAdvisor.com 877.552.9907GL Advisor currently does not offer all services to residents of New Hampshire, Idaho, Nebraska, Nevada and North Dakota