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June 2017 Edition 


Announcement: Mary Geary, PhD, RN, Executive Director of Quality:

I’m pleased to announce that we have now completed that recruitment, and our new Executive Director of Quality will be Mary Geary, PhD, RN.  She will join us on June 19th.  

Most recently, Ms. Geary served as Vice President of Quality, Safety and Risk in the Sacred Heart Health System in Pensacola.   Prior to that, she was Vice President of Quality and Patient Safety at Infirmary Health System in Mobile.  Additionally, she has worked as a surveyor consultant for Joint Commission International, participating in hospital and health system surveys around the world.  Earlier in her career, she worked as Director of Quality, Patient Safety and Accreditation at Lakeland Regional, where she had also been an RN Clinical Nurse Specialist.  

Special Recognition: Sharon Cropper, Interim Director of Quality: 

I would also like to publicly recognize and thank Sharon Cropper for her valued service as Interim Director of Quality.  Sharon has basically held two jobs for the past year, and has maintained the high standards of the entire Quality Department, and for the Quality “mission” of the entire organization.  Great job, Sharon! 

R. Stephen Taylor, M.D., M.B.A.
Chief Medical Operations Officer

Continuing Medical Education Schedule Grand Rounds Schedule

Summer Schedule SMHCS Grand Rounds are scheduled monthly at 8:00 a.m.
June 16, 2017 Antibiotic Stewardship
July 21, 2017 American College of Cardiology, "Optimizing Medical Therapy for Chronic Heart Failure” 2 Hours
August 18, 2017 Electrolytes Abnormalitlies in Hematological Malignancies
September 15, 2017  Treatment of Chronic Low Back Pain

Neuroscience Grand Rounds are Scheduled at 12:00pm
• June 21, 2017 Interesting Stroke Stores: From Bedside to Pathophysiology

Trauma Grand Rounds are scheduled the 2nd Thursday Monthly at 12:00pm

• July 13, 2017 "Inferior Vena Cava Filter Use in the Trauma Patient" presented by Justin Lee, MD, Interventional Radiologist & Clinical Professor, Florida State University College of Medicine

ED-U-CATION: Your Responsibility for Patient Consent 

Reminder to all Medical Staff:  Please note that any time we perform ANY invasive procedure in the hospital; we must obtain informed consent from the patient.  A few examples include, but are not limited to: steroid injections, Incision & Drainage and needle aspiration.  Given the scrutiny we are always under by CMS and accrediting bodies, we need your assistance with compliance regarding informed consents.

ED-U-CATION: Your Responsibility to Report Action by Government Agency or Insurer 
A reminder to keep your SMHCS Medical Staff status current by informing the Hospital, through the Chief Medical Officer, Chief of Staff, (or designee Medical Staff Services), of any changes in the information provided, including, but not limited to, any investigations by a state licensure agency, any change in my professional liability insurance coverage, the filing of a professional liability lawsuit against me, any change in my status at any other hospital, any change in my eligibility for participation in the Medicare or Medicaid program, and any change in my ability to safely and competently exercise my clinical privileges because of health status issues, including impairment.   

Contact or call (941)917-1500 for more detail. 

ED-U-CATION: SMH Blood Component Criteria and Indications Screening Guidelines (view document here)  
Using evidence-based recommendations, the Blood Usage Committee has updated the Blood Component Criteria and Indications Screening Guidelines which was approved by Medical Executive Committee.  Attached you will find a copy of these guidelines.  A copy of this is also available on the Physician Resource site on for reference.

In addition, the blood order default has changed from “2” units and was replaced with an asterisk requiring the physicians to specify the number of units to be ordered.  This change was made in efforts to reduce blood wastage.

ED-U-CATION: Lab Technical Updates  (view document here
Effective June 1, 2017, Sarasota Memorial Laboratory Services has implemented changes to the reference ranges for the following tests:

  • Total Testosterone
  • Free Testosterone
  • Sex Hormone Binding Globulin (SHBG)
  • Free Androgen Index (FAI)

ED-U-CATION: ePrescribe and Meaningful Use 2 to YOU
We are strongly encouraging all physicians to register with Clinical Systems and begin to ePrescribe here at SMH, we have support staff ready to train and assist.

Please call our Clinical Systems Analyst physician number – 302-7808 or Voalte Jessica Gould, Clinical Systems Analyst to set up a time for one of our analyst to register you and get you started ePrescribing.

The Meaningful Use 2 requirement this year related to ePrescribe requires that 11% of all Inpatient and Observation patient’s discharge prescriptions, (excluding controlled substances) will be electronically prescribed to a local pharmacy.
Currently SMH is at a YTD percentage of 7%.
Should we not reach the goal of 11% we stand to lose $3,000,000 in hospital revenue reimbursement. .

ED-U-CATION: CMS Regulatory Compliance for Unsigned Inpatient Placement Orders at Discharge 
Due to CMS regulatory guidelines the admission order must be signed, dated and documented in the EMR, by a physician prior to discharge. Advanced Practice Professionals are not authorized to sign or co-sign the admission order for the physician. We regret that this has impacted many in their workflows and due to the urgent need for this to be corrected, the information we sent out was limited to the error itself as opposed to how to resolve the issue if you encountered it. 

How to Handle Unsigned Admission Orders at Discharge: 

As an Advanced Practice Professional: Should you encounter the hard stop where the alerts says there is an unsigned admission order on the chart:
If the Admitting physician is available, then: 
1. Call them and have them sign in to SCM and their Signature Manager should prompt them at that point to sign any unsigned admission orders (just like it does for unsigned restraint orders). 
2. Once that is signed, then the Advanced Practice Professional can refresh SCM and is then free to proceed with placing the discharge order.

If the Admitting physician is not available, then: 
1. Contact the covering physician to sign into SCM and place a discharge order, which will contain a statement that acts as a cosign for the admission order. 

As the Physician: You will not be stopped when placing a discharge order.
If you are the admitting physician and are contacted to sign the admission order:
1. Log into SCM and you will be prompted to sign your unsigned restraint and admission orders in Signature Manager.
If you are a covering physician and are contacted to sign the admission order
1. You are not able to sign the actual admission order
2. However, once you log in to SCM, you ocan place the discharge order which will contain a statement that acts as a cosign for the admission order. 

*** For any additional questions/concerns please contact the ICM Systems Educator at (941) 917-4245 ***

ED-U-CATION: Restraint Update 
One of the priorities throughout the hospital is to minimize restraint utilization. The next initiative is to greatly reduce the use of Posey Beds, with the plan to eliminate Posey Beds in the near future. The reason for this is to prevent both patient and nursing injuries, which can and have occurred with these beds.  

As a reminder, Posey Beds cannot be used in the following situations: To prevent falls nor To restrain patients with violent and/or aggressive behavior – This is for staff and patient safety! 

Before using restraints, nursing will explore alternative measures for patient safety, such as: 

  • Medication Management- Consult PHysician and Pharmacy if current medication is not proving to be effective.
  • Place patient of camera observation. 
  • Utilization of Patient Safety Attendants (Sitters)- may be used in conjunction with the above interventions.
  • Encourage family to stay with the patient when possible. 

Hurricane Season and YOUR Responsibility 
Those physicians and physician specialties named on SMHCS “Emergency Medical Treatment and Labor Act EMTALA Call Schedule” may be selected to participate in the response and recovery teams as part of the hurricane plan.

What Does This Mean?
Physicians will be asked to participate and remain at SMH during the various hurricane stages. It is the responsibility of all physicians to develop personal and/or family hurricane plans that will assist Sarasota Memorial Health Care System (SMHCS) with staffing and planning efforts. During a hurricane, Sarasota Memorial Hospital (SMH) will shelter physicians and the immediate family members of those physicians who have been selected to care for patients.

RESPONSE TEAM: He/she arrives on campus after the hospital calls a lock down for an eminent Hurricane 
Physicians will be asked to return home and quickly prepare for a possible multiple overnight stays at work.  Physicians identified on the included grid and/or scheduled for call coverage will be asked to participate as response team members and proceed to the physician command center when an emergency is called>

RECOVERY TEAM: He/she arrives after the Hurricane has passed and the lock down is lifted
Physicians will be asked to help maintain the operations until they will be relieved of duties to return home and prepare to report following the conclusion of the storm event, as needed.  Physicians identified on the included grid and/or scheduled for call coverage will be asked to participate as recovery team members and proceed to the physician command center when the hurricane has passed and it is safe to travel.

IF NO COMMUNICATION IS AVAILABLE then physicians should come to the hospital physician command center – SMH Main Campus third floor physician’s lounge when road traveling is deemed to be safe. The Physician Command Team will help the relief physicians find their partners or physician they are relieving for report. 


Hurricane Season and Emergency Communication: ACTION: Update Your Information (download/print form here
SMH Mass emergency communication to on-staff physicians will be completed by, but not limited to, use of e-mail, text message, Voale Me, and signage. It is the responsibility of on-staff physicians to provide current contact information to Medical Staff Services via email at, fax (941) 917-1555 or call (941) 917-2204.  

Information Security: DocNet Wifi Network 
Sarasota Memorial is encouraging all Medical Staff members to use the “DocNet” Wi-Fi network as your connection to the internet at the main campus and off-site facilities. Guestnet sessions time out after 12 hours and users will be required to accept a terms of use screen again each time. DocNet gives you a continuous connection to the internet once you gain initial access. 

Call the Call Center at (941) 917-6107 and a technician will be dispatched to set up your mobile device to use DocNet

Information Security: 90-Day Password Resets are Coming Soon

Beginning in July, 90-day password resets will be phased in over several months for all SMHCS employees and physicians using SMHCS desktop computers.  This is an important component of Sarasota Memorial’s overall security strategy to minimize risks associated with cyber- attacks and shared passwords. It aligns with industry standards, and protects against user names and passwords that have been used on personal accounts that may have been compromised.  Hacked information is sold on the black market and used by criminals to gain access to institutions. 

How will I know when to reset my password and what do I need to do? 
1. Between July and September 2017, staff and physicians will be prompted to reset their passwords when they initially log in to an SMHCS computer. 
2. New passwords must have 8 characters that include three of the following four requirements: Upper case letters, lower case letters, numbers and special characters (!@#$%^&*).
3. After the initial password reset, staff and physicians will be prompted to create a new password every 90 days. They will receive pop-up reminders 20, 10, 5, 3 and 1 day before each 90-day expiration date. The reminders will include directions for resetting passwords. 

Please contact the Call Center (941) 917-6107 for assistance or questions. Thank you!

Internal Medicine PGY1 Residents begin July 1, 2017- Helpful Information  
The Florida State University Internal Medicine Residency Program at Sarasota Memorial Hospital welcomes its inaugural class of resident physicians starting on July 1, 2017. 
• What privileges does a resident have?
You can look in pulse (MSOW) application link-MSOW- e-Delineate Privileging
• If I am uncomfortable or have concerns who do I call? The Attending Physician on call

Click here for additional helpful information about our residents. 

Physician Communication is Important to CMS (view slide 

Physician Communication is Important to SMHCS Physicians- Take a Seat! (view slide

Physician Communication is Important to SMHCS Physicians- Best Practices (view slide


Recognition for Center of Excellence for Hip and Knee Replacement! Great Job! 
Sarasota Memorial has been named a Center of Excellence for hip and knee replacement by DNV-GL Healthcare USA, Inc., one of the nation's leading hospital accrediting organizations. The prestigious certification recognizes our excellence in orthopedic surgery within the scope of hip and knee replacement and related procedures. Earlier this year, the national publication Modern Healthcare ranked SMH as America’s highest performing safety net hospital for total hip and knee replacements. Congratulations to the Orthopedics team for the newest honor!
David Verinder, President & CEO

Recognition to SMH Open Heart Team! Great Job (view photo)


Scott Stevens, MD

Chief of Staff