Common Ground Newsletter
Feb. 28, 2014


Updates from 2/20 Physician Leadership Council: 

CICThe CIC Update: Launching Communication System  
  • E-newsletter launching; latest draft is here.
  • Designed as a single communication tool for news 
  • Click headlines to jump to stories important to you
  • Bldg A, 2nd floor will have a visible communication board
  • CEO Norm Gruber continues to hold medical staff forums

More Details 

Welcome to the latest draft of the Common Ground newsletter. This e-newsletter is being designed as a single communication tool for medical staff and hospital teams to rely on for news and two-way communication. This system is intended to help us continue partnering effectively to serve our community with the highest of healthcare quality and using resources efficiently.  


By making this e-newsletter a single system to communicate, or a one-stop shop, we hope to reduce the flood of email into your box and corral important, relevant, & timely information here.  


Please note the quick links, the Top Reads, and the email directly to for questions and feedback. We plan to continue to improve this vehicle over time, incorporating your ideas and technology that works. 


We are also trying to implement ways to help you see at a glance which articles might interest you, determine how often this newsletter would be useful, and  offer a consistent platform for medical staff to get relevant and timely news out.


In addition, the Medical Staff Engagement Committee is creating a Communication Board in Building A, second floor, as another approach to increase communication to medical staff. The CIC will have a section on this wall to share updates. 

We've already gotten a number of Compact deliverables underway.  For example, both the QOC and the new Peer Review system are straight out of the Compact: "Physician-led, patient-centered, data-driven."


Lastly, CEO Norm Gruber is holding forums and inviting medical staff to discuss their perspectives on the current affiliation activity. He's holding several round-tables specifically for physicians, facilitated by a third party. This is called out in the Compact: "Prior to making significant decisions, provide opportunities for Medical Staff physician leaders and Administration to be engaged and have perspectives understood and considered."  

DistSalem Hospital: In the national top 5 percent
  • Healthgrades awarded us Distinguished Hospital Award
  • Based on superior performance in clinical outcomes in a variety of metrics
  • Five Star awards in joint replacement, bariatric surgery, critical care, and heart attack care

Congratulations! You practice at one of the nation's finest hospitals ­ and much of the credit belongs to you. We just received the 2014 Distinguished Hospital Award for Clinical Excellence from Healthgrades, placing us in the top five percent of hospitals nationwide. Healthgrades is the leading online resource for comprehensive information about physicians and hospitals. You can learn more from our news release here.


This ranking -- among 4,500 hospitals nationwide -- demonstrates we're a leader in clinical excellence through superior performance in clinical outcomes across a broad spectrum of care.


This recognition matters to the local medical community. In our news release, Dr. Michael Hanslits, president of the Salem Hospital Medical Staff, said "Any doctor you ask will tell you that he or she really cares about availability of top-notch health care in Salem."


"Salem Hospital established the Quality Operations Committee with oversight over quality and safety, financial performance, patient satisfaction, and engagement," Hanslits noted. "The committee prioritizes improvement projects, using an organizational dashboard which compares the organization's performance on specific quality and patient experience indicators, such as post-operative infections, to national benchmarks," he said. "The committee also focuses on national efforts that target specific problems such as readmission rates that are too high for diseases like pneumonia and congestive heart failure."


Hospitals earning the Distinguished Hospital Award showed superior performance in clinical outcomes for patients in the Medicare population across at least 21 of 30 of the most common inpatient conditions and procedures.


Salem Hospital was also recognized by Healthgrades for excellence in many specialty areas including joint replacement, treatment of heart attacks, overall critical care, and bariatric surgery.Our care was so exceptional that Healthgrades ranked Salem among America"s 100 Best hospitals for critical care services and the top 15 percent in the nation for patient experience.


To learn more about how Healthgrades determines these awards, please visit

YQAWe want to hear from you!
You might be familiar with Rumor Has It, our regular postings on the Salem Health intranet of questions submitted by staff and answered by the appropriate member of leadership.
We'd love to hear your questions and provide answers in this regular column.
Feedback on this newsletter is also welcome! Help us improve this communication model to be effective and efficient.
Email us at
CanCancer Symposium for Primary Care April 11


We welcome your attendance at these symposiums:
April 11 from 12:30 to 6 p.m.

Cancer Symposium for Primary Care

Managing your cancer patient-we can help


Thanks for your patience during the closure of the physician parking between Building D and Building E from 5:00 pm on Thursday, 4/10/14, through midnight 4/11/14. Nearby parking in the garage and other designated physician parking will be available.

RecMedical Staff Meeting
March 3rd is the date of the next Quarterly General Medical Staff meeting, in Building D, Creekside Overflow (first floor). Topics are being solicited for this meeting, and attendees were encouraged to bring topics forward to the MEC members for discussion.
FoleyNew Foley Catheter Order Sets
  • New SCIP order sets will begin March 11. These replace existing orders for Foley catheters.
  • A Best Practice Alert (BPA) will prompt you on options.
  • Dr. Raj Nair presented the new order sets to Physician Leadership Council. Consensus was to move forward.
  • Dr. Nair and Dr. Logan Priollaud are happy to attend your section meeting to demo the new workflow.
More Details
Foley catheters are required by SCIP to either be removed by midnight post-operative day 2, or have a documented, CMS-approved reason for retaining. This documentation must happen on either post-op day 1 or 2, not day of surgery. CMS requires us to comply with SCIP measures 100% of the time. Up to $2M may be at risk if we do not bring our overall Appropriate Care Score up to 96% from current 85%.
In our work, we've found 15 failure opportunities. The team has thus created two order panels--one surgical, one non-surgical, modeling after a Epic system in the Midwest that succeeded in this measure. Both panels standardize insertion, care, and removal/retain orders. This reduces the list of free-standing and duplicate orders, reducing error potential.
Both order sets will include best practice advisories that will prompt you to document a reason for retaining or enter a removal order.
A full communication plan will begin March 11th.
Questions can go to Dr. Raj Nair.
LabChanging Lab Test Window for Orthopedic Surgery
  • Orthopedic elective surgeries testing a 90-day window for pre-surgical labs.
  • May be extended to other surgeries if successful.  

More Details 

The 10-day window for blood bank testing has inadvertently placed unnecessary time stress on our blood bank system. Patients don't want to make multiple trips, resulting in 30% of elective orthopedic surgeries lab testing being done day-of, which risks delays and creates boluses of work. However, there's no clinical reason to limit this blood bank testing to 10 days prior to surgery unless the patient is pregnant or has received a transfusion in the 30 days prior to surgery. Lab is partnering with Anesthesia and Orthopedics to determine which patients require blood bank testing, and extending the pre-surgical lab test window to 90 days prior to surgery. Lab & Imaging director Mary Ransome can answer any questions.

MedsRestricted Medication Ordering Proposal
  • Current inconsistency in accurately applying medication restrictions from P&T committee.
  • A verification question will be embedded in Epic orders for restricted medication, requiring name of authorized provider.

More Details 

Medications with restrictions (regarding who can order them or for what indication) should be readily available to be ordered when use is appropriate to any provider working with an allowed provider. Currently, pharmacists are struggling to accurately and quickly identify which restricted medications should be available and when. Embedding a question within orders in Epic would give consistent application of these P&T restrictions and prevent an order in error, by requiring entry of an authorized provider name (answer options would be restricted to those providers). MEC approved this to increase our accuracy and consistency of application of these restrictions. Pharmacist Matthew Tanner can answer questions. 

RenalRenal Dose Potassium Replacement Order for Adult Health
  •  Renal Dose Potassium Replacement Order for Adult Health (Building B) use was approved by MEC 
  • Will utilize same protocol as currently active in Critical Care.
  • Use of protocol order will be at provider's discretion 

More Details 

Patients with low potassium and impaired renal function currently do not have potassium replacement by protocol. These patients currently require a provider call and entering a specific, one-time order. If this proposal is accepted, and providers in Adult Health choose, they could enter a protocol order that would allow potassium replacement to the same standard as in Critical Care, resulting in prompt addressing of hypokalemia. RNs will be educated on this protocol.

PolUpdated Policies
Two updated policies were shared February 20th Physician Leadership Council meeting. They include:
  • Chain of Command policy updated to clarify and expand focus to all members of healthcare team.
  • Swallow Screen policy updated to allow for NP & PA orders. A patient that fails an RN-administered swallow screen will get NPO and a speech eval order, and you will be notified. 
treatTreating Yourself or Family Rules Revision
Proposed revision to the Medical Staff Rules & Regulations, Article II, Treatment of Patients.
  • Include specific language about it being inappropriate for a physician to write a prescription for controlled substances for themselves, members of their household, or any first-degree relative of a household member
  • Clarify that there are times it may be appropriate for physician to provide care to themselves, members of their household, or first-degree relatives of household members, though generally it should not be done.

Please provide feedback by March 5th to MEC. 

icdICD-10 Education
  • All active medical staff will be required to complete ICD-10 education by Aug 31, 2014.
  • Education will be via online module; general plus specialty or specialties.
  • Modules will include exam and CME credit and may take 2.5-5 hours.
  • Modules will be available via Healthstream on May 1, 2014.
  • Education was recommended by Physician Coalition and approved by MEC.
More Details
The Physician Coalition recommends and MEC approved mandatory education and demonstration of competency for ICD-10 for all active medical staff who may enter documentation in the chart supporting ICD-10 billing, including locums, employed outpatient physicians, and West Valley active medical staff.
A general module plus one or more specialty module will be available by May 1 and must be completed by August 31, 2014 via Healthstream. Precyse is the vendor delivering content, which will offer CME credit. This course will take 2.5-5 hours and each module has a competency exam which must be passed for CME credit.
ICD-10 is a mandatory move on October 1, 2014. Failure to document with ICD-10 specificity will result in inaccuracies which will risk delayed or denied payment or lower reimbursement.
Dr. Claire Norton can answer your questions.
Copy"Copy & Paste" Rules Revision
Proposed revision to Medical Staff Rules & regulations, Article VII, Part B.
Clarifies that it is acceptable to copy and paste from a source document, but:
  • A provider may not copy another provider's document verbatim and use as  if it were their own work; if done, it must be stated as such and credit given to the author. This does not replace a provider's own documentation.
  • A provider may not copy forward their own document unless updated/edited to reflect the unique patient encounter
  • If a copied and pasted or cloned document is unchanged/unedited and cannot be used for billing, the document will be considered "incomplete" and a deficiency created.

Please provide feedback prior to March 13 to MEC.  

AnswAnswering Service
  • Review completed on quality and cost of Salem Health answering service.
  • Status quo not acceptable. 
  • Considering discontinuing or restructuring--your feedback is wanted. 
More Details
Salem Health provides an answering service to clinics and hospitals throughout the community at a flat rate. A review of quality and pricing was done, and a change is recommended. Currently, 138 customers with 452 pagers in total pay $70 per month for answering, or $25 for paging only.  Status quo is not appropriate to continue for three reasons:
  • Quality concerns as evidenced by PSAs.
  •  Per Stark laws, service cannot be provided free; Salem Health is subsidizing at $84,000 per year currently. 
  • Salem Health cannot meet industry standard service without increasing costs.

Two options are being considered--either discontinuing the service, with customers provided with information on local service providers, and Salem Health continuing to note which provider is with which vendor, so calls and pages could go through Salem Health operators to vendors, or increasing positions, structures, and technology to bring existing services up to standard, but would result in increased prices.  


Your feedback is desired! Dr. Ken Graven presented this information to PLC.  


acaMedical Students--Growing great physicians
  • 10% increase in medical student program last year and 10% more expected this year.
  • Will be limiting placements to OHSU & Pacific-Northwest Western Univ. of Health Science
  • Requests for other placements or students may be directed to Office of Medical Education.

More Details 

Good news: Salem Hospital's Medical Student Program has had a 10% increase for Medical Student enrollment in the last six months. We expect an additional 10% increase in the 2013-2014 Academic year.  


As we continue to grow, it has become necessary to limit the participants in our program. To meet student requests with available preceptors, Salem Health has been limiting student placements from only two medical schools, College of Osteopathic Medicine of the Pacific-Northwest Western University of Health Sciences and Oregon Health & Science University. 


At this time Salem Health will be placing students from these medical schools with our available preceptors.


To accommodate recent requests by members of our medical staff for placement of students who are not affiliated with Western University or OHSU, the Medical Education Steering Committee will consider other student placements on a case by case basis depending on the availability of preceptors.


Medical students need to register through the Office of Medical Education to be accepted into Salem Health's Medical Student Program.  If you are contacted by a student who desires a clinical rotation with you at Salem Health, please refer them to this office at 503-561-3905.   Contact Yelena Seroshtan, Medical Student Program Coordinator, if you have any questions regarding student enrollment.


Several federal regulations cover medical education and it is the job of this Steering Committee, and our Program Coordinator, to make sure those regulatory requirements are met.  


--Medical Education Steering Committee: David Holloway, MD, CMO, Chair; Kendall Graven, MD; Preethi Prakash, MD; John Hannig, MD; Martin Johnson, MD; Raj Nair, MD; Michelle Rasmussen, MD; Jay Wung, MD


danDancing in the snow!
The physicians and staff of Salem Health Heart & Vascular Center created a dance video to celebrate the American Heart Association's 'National Wear Red Day,' designed to raise awareness of heart health. Your toes will be tapping as you recognize friends who willingly wore red and danced for this important cause. Check this out!
Reducing ED usage through Coordinated Care
Cheryl Nester Wolfe, Salem Health COO, and Dr. William "Bud" Pierce served as panelists for the Salem City Club luncheon on Friday, Feb. 14th.

 Read the story at the Statesman.
A $200 million state bond request from OHSU

An Oregon lawmaker has called it "the mother of all asks"-OHSU outlined its request for $200 million in state bonds for cancer center.

More on this story.
Common Ground Newsletter Editorial Board 
Email us anytime with feedback, suggestions, or something for the next issue!
Dr. David Holloway, CMO, Dr. Michael Hanslits, Medical Staff President
 Dr. Ian Loewen-Thomas, Chair, Compact Implementation Committee

Salem Health