Physician Newsletter - Dec 2019 Final

In the Know with the CEO:

Quarterly Physician
Newsletter

HCA Houston Healthcare Northwest

January 2020

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution.

Hello and Happy New Year!

Physicians,

Scott J. Davis, FACHE I am pleased to present the 1st edition of our HCA Houston
Chief Executive Officer Healthcare Northwest physician newsletter, “In the know with the
CEO”. Our goal will be to send a newsletter like this one out each
quarter to keep you updated on all of the exciting things going on
around our hospital. We hope you will take a few minutes to review
this newsletter each quarter to stay informed with everything
happening. There will be a lot of content in this newsletter but we
feel like it will be worthwhile for your review.

I am very excited about the direction our hospital is headed and
grateful to be associated with all of you in this incredible journey.
Inside the newsletter, you will find updates on our strategic goals,
campus improvements, patient experience, quality, and most
importantly, our actions taken from your feedback on our physician
engagement survey. We will also continue to add items to the
newsletter that will be useful to all of you. If you would like to see
something in the newsletter that we have missed, please let me
know.

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 2

From the desk of the CMO

Dear colleagues,

In the Quality arena, 2019 was an exciting year for HCA
Houston Healthcare Northwest.

Augusto (Gus) Sepulveda, I am very excited to share with you the direction our
MD, MPH, FACP hospital has headed, thanks to the engagement of our
Physician Leaders and Medical Staff. I am grateful and
Chief Medical Officer honored to be associated with all of you in this incredible
journey.

Inside the newsletter, you will find a summary of our
quality outcomes for 2019, and an update of the Quality
goals for 2020.

Thank you!

Gus

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 3

Quality / Patient Safety
Update

HCA Houston Healthcare Northwest

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution.

Overall Mortality Index (O/E Ratio) 1Q19-3Q19

National
Benchmark

Lower than benchmark is better

1Q19 2Q19 3Q19

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution.

Overall Complication Index (O/E Ratio) 1Q19-3Q19

National
Benchmark

Lower than benchmark is better

1Q19 2Q19 3Q19

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 6

Septic Shock Mortality (goal <30%) 1Q19-3Q19

Lower than benchmark is better

Benchmark

1Q19 2Q19 3Q19

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 7

Physician Engagement
Actions

“Our Drive to Excellent”

HCA Houston Healthcare Northwest

January 2020

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution.

Physician Survey Action
Communication Board

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 9

Administration

Questions:
• Timeliness of communication
• Involving physicians in strategic

decisions
• Involving physicians in operational

decisions
• Responsiveness to physicians’

concerns and complaints

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution.

Administration

Initiatives:

• All members of executive team available via cell
phone/email and rounding

• Annual physician strategy session held to solicit
physician involvement in strategy discussion

• Developed physician committees to drive
operational decisions by service line

• Hired 2nd physician relations representative to help
make sure we are continuing to be responsive to all
concerns shared with us

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 11

Nursing Care

Questions:
• Care and Treatment of Patients
• Assessment and Monitoring of Patient

Status
• Collaboration with Physicians
• Responsiveness to Patient and Family

Needs

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution.

Nursing Care

Initiatives:

• Dedicated educators hired and assigned to

continue competency growth for new and tenured

nurses
• RN turnover excellent at all time low below 10%
• New monitors installed in the facility
• I-Mobile installed to enhance communication

between nursing, physicians, and other caregivers
• Continued emphasis on patient experience with

nurse leader rounding and hourly caregiver

rounding.
• Patient experience finished 4th quarter 2019 at all

time high for this facility

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 13

Patient Safety

Questions:
• Appropriateness of safety measures
• Environment of staff to report errors

and concerns
• Initiatives to improve patient care

relative to patient safety issues

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution.

Patient Safety

Initiatives:

• Hired dedicated patient safety director to
encourage reporting, improve follow-up and
establish culture of safety

• Safety reporting for the facility have steadily
increased since hiring patient safety director

• Medication diversion prevention strategies and
multi-disciplinary team

• Hired experienced VP of quality and Director of
Infection Control to continue to drive quality and
safety improvement

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 15

Surgical Services

Questions:

• Competency of Surgical Staff
• Turnover Time Between Surgical Cases
• Administration of Pre-Operative Orders
• Ease of Scheduling Surgery
• Ease of Scheduling Urgent or Emergency

Procedures
• Post-Op Care Provided in the PACU
• Availability of Surgical Equipment
• Well-Maintained Surgical Equipment
• Dept. Leadership’s Responsiveness to

Concerns/Complaints

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution.

Surgical Services

Initiatives:

• Hired experienced Administrative Director for

Surgical Services to drive improvements
• Augmenting scope and operation of physician

surgical advisory committee to enhance operations
• Continuing to invest in OR equipment ($3.7 million

invested in OR in 2019)
• Dedicated education plan for both new and

tenured employees
• Implementing tactics such as turnover teams and

paging overhead to drive turnover down
• Improving block utilization and adding resources to

scheduling to improve responsiveness and

availability

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 17

Patient Experience

Questions:
• Patient Experience is a Top Priority
• Have Access to Patient Satisfaction

Data/Information
• Use HCAHPS/Other Patient

Satisfaction Results

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution.

Patient Experience

Initiatives:

• Daily nurse leader rounding to ensure all patients
connect with a leader during their stay

• Monthly Patient Perception of Quality meeting with
all leaders across the organization to drive patient
experience

• Working on flow and leadership presence in the
emergency department to improve operations and
experience

• Patient experience data shared in physician
committees and departmental meetings to create
transparency around our performance

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 19

Facility Updates

HCA Houston Healthcare Northwest

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution.

Front Entrance Beautification Project

The MRI Building has been demolished. This area will soon be converted into
a dedicated parking lot for our patients that are visiting our facility for
diagnostic procedures, pre-surgical preparation, medical records, and
registration & account services.

South Tower Former MRI Building
Front Entrance

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 21

Front Entrance Beautification Project

The demolition of the FM 1960 Strip Center building has been completed. This
newly fenced area will become a temporary green space and a future Medical

Office Building and parking lot. Cali building will be demolished in coming
months for our new helipad and parking lot. Dunkin Donuts & Ace Checks

Cashed will remain.

Cali Building Former FM 1960
Strip Center

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 22

New HCA Signage

Our new HCA exterior signage has been successfully installed as of 11/20/2019.
Phase 2 will consist of updating the exterior directional signage, as well as the

interior wayfinding signage to better assist our guests in reaching their
destinations. We will also implement color coded parking lots.

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 23

Safety & Security

HCA Houston Healthcare Northwest

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution.

Safety & Security

It is important that our employees, patients and visitors have a safe place to work
and receive excellent care. As a result of voiced concerns, we have recently
incorporated the following:
 Rover/Taser officers that routinely patrol the campus

– This team also monitors crowd control at the SICU entrance
 Garage patrol 24/7, once every hour

– You may also see the team on golf-carts

Coming Soon:

 Parking garage enhancements: installation of gates at the entrances, fencing
upgrades in employee parking garage, camera at entry, etc.

 ED Parking lot fence repairs
 Brighter Exterior Campus Lighting

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 25

Service Line Update

HCA Houston Healthcare Northwest

January 2020

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution.

Neurosciences

HCA Houston Healthcare Northwest is growing and we are adding a designated
BiPlane Cath Lab suite! We have also recently welcomed a new

neuroendovascular physician who will help us expand Northwest’s neurological
services, Dr. Shamaelah Javed. The expected completion of this construction
project is before the close of January 2020.

Shamaelah Javed, MD 27
Interventional Neurology

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution.

Cardiovascular Services

HCA Houston Healthcare Northwest is pleased to welcome a new CV surgeon,
Dr. Keshava Rajagopal, who joined us on January 2, 2020 and will be located on
the 5th floor of the Peakwood Building. We are excited to have him on campus to

join our other CV surgery providers in growing our comprehensive program.

Keshava Rajagopal, MD, PhD Keshava Rajagopal, MD, PhD, has joined Houston Heart and
CV Surgery HCA Houston Healthcare Northwest from the University of
Texas-Houston, as a cardiac surgeon. Dr. Rajagopal’s surgical
practice encompasses a broad range of adult cardiac
operations to treat the majority of adult cardiopulmonary
diseases. These include: coronary artery bypass grafting,
aortic valve repair and replacement, aortic root
replacement, ascending thoracic aortic replacement, mitral
valve replacement, pulmonary thromboembolectomy and
thromboendarterectomy, ventricular assist device
implantation, heart transplantation, lung transplantation, and
cannulation for short-term mechanical cardiac and
pulmonary support.

Dr. Rajagopal received his undergraduate education at the
University of Pittsburgh, with a B.S. in Chemistry. His medical
and graduate education were obtained at The University of
Chicago, as part of the Medical Scientist Training Program.
After graduation, he undertook training in general surgery
inclusive of a postdoctoral research fellowship, and in
cardiothoracic surgery, at Duke University Medical Center. Dr.
Rajagopal then became an Assistant Professor at the
University of Maryland. Thereafter, he was recruited to the
University of Texas-Houston to found a new lung transplant
program, where he was most recently an Associate Professor.

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 28

Women’s Services

HCA Houston Healthcare Northwest is excited to announce some great
accomplishments in our Women’s Services Program in 2019.

• Level III NICU – we are excited to promote this
certification to the community and affiliated
physicians in growing our NICU service line

• OB Hospitalist program – Dr. Xydas and his group will
be recruiting dedicated OB/GYN physicians to stand
up a dedicated OB hospitalist program at Northwest
effective April 1, 2020.

• MFM coverage – we are working through details
with a few providers to recruit a Full-Time MFM
physician to join our community by August 2020 for
both clinic and hospital coverage.

• OB/GYN recruitment – we continue to recruit
additional OB/GYN providers for our community

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 29

Breast Center

HCA Houston Healthcare Northwest is excited to announce the movement of our
Breast Center to the 1st floor of the Peakwood Medical Office Building and our
partnership with Solis Mammography.
We are excited for the growth that this new partnership will allow for our Breast
Center service line and the convenience and aesthetics of this new location.
We will continue to invest our efforts in this service line with our patient care
navigators and other resources.

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 30

Bariatrics

Certifications
 MBSAQIP Accredited Center
 Blue Distinction Center+
 Aetna Institute of Quality (IOQ)
 Cigna 3 Star Facility
Program Coordinator

– Nicole Horvath, RN, MSN
– Worked with Bariatric patients for over 10 years and over 8 years as coordinator.

Program Details
 Talented group of affiliated bariatric surgeons
 Dedicated bariatric unit with knowledgeable, caring staff
 In-house dieticians and physical therapists
 Interdisciplinary team to address any and all pre-op and post-op concerns
 One of the most qualified facilities in the area with over 15 years of bariatric

surgery experience

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 31

Nursing Update

HCA Houston Healthcare Northwest

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution.

Pathway to Excellence

On October 14,, 2019, the American Nurses Credentialing Center (ANCC) redesignated
Northwest as a Pathways to Excellence hospital! The ANCC’s Pathway to

Excellence Program recognizes a healthcare organization’s commitment to creating a
positive practice environment that empowers and engages staff.

We are the only hospital to have this designation in HCA Gulf Coast Division (total of 17
hospitals). Over 300 of our nurses took the survey!

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 33

New Providers

HCA Houston Healthcare Northwest

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution.

Oct-Dec DEGREE SPECIALTY GROUP
MD Physical Medicine & Rehabilitation
FULL NAME MD Cardiology Cyfair Cardiology Associates PA
David Nathaniel Adams, MD MD Cardiology
Ravinder Agusala, MD MD Ophthalmology Anderson Eye General Ophthalmology
Yasir Akram, MD MD Radiology - Interventional Radiology & Diagnostic Radiolog Houston Northwest Radiology Association
John William Anderson, MD MD Orthopaedic Surgery Baylor College of Medicine Department of Orthopedics
Palam Annamalai, MD MD Otolaryngology
Omar Hammad Atassi, MD MD General Surgery / Bariatrics Turnquest Surgical Solutions
Kevin Caceres, MD MD Orthopaedic Surgery Baylor Faculty Group Practice
Victoria Chen-Feng Chang, MD MD Plastic Surgery Aesthetic Center for Plastic Surgery
John Rapier Dawson, MD MD Pediatrics - Pediatric Cardiology UT Physicians
Olivier Aikpa Deigni, MD MD Neuro Endovascular Neurosurgery of Kingwood, PLLC
Unnati Hemat Doshi, MD MD Anesthesiology USAP
Mohamad Ezzeldin, MD MD Ophthalmology Houston Eye Associates, P.A.
William Paul Flinn, MD MD Physical Medicine & Rehabilitation Post-Acute Physicians of Texas, PLLC
Charity Halphen Grannis, MD MD General Surgery / Bariatrics GENERAL LAPAROSCOPIC & BARIATRIC SURGERY
Yana Grigoreff, MD MD Obstetrics & Gynecology Womens Clinic Of Houston
Taher Mustafa Gulamhusein, MD MD Neuro Endovascular
Veronica Hurtado, MD MD Orthopaedic Surgery Baylor College of Medicine Department of Orthopedics
Shamaelah Javed, MD MD Emergency Medicine
Anastassios Karistinos, MD MD Internal Medicine - Medical Oncology Genesis Medical Group
Daniel Rhodes Kievlan, MD MD Internal Medicine - Gastroenterology
James David Mackey, MD MD Internal Medicine - Critical Care Medicine Wael Asi MDPA Group
Amit Babulal Mori, MD DO Internal Medicine Envision HNMC Hospitalist
Suhair Mugawish, MD MD Internal Medicine Genesis Medical Group
Thu Anh Nguyen, DO DPM Podiatric Surgery Genesis Medical Group
Sharon Tiwalola Ogidan, MD MD Thoracic & Cardiac Surgery Houston Heart
Thomas Minh-Ngoc Pham, DPM MD Cardiology Baylor St. Luke's Medical Group WNNHC
Keshava Rajagopal, MD MD Anesthesiology US Anesthesia Partners of Texas
Kelly Shum, MD MD Plastic Surgery Lift Plastic Surgery
Robert John Tom, MD MD Colon and Rectal Surgery UT Physicians Colon and Rectal Clinic
Tuan A Truong, MD CRNA US Anesthesia Partners of Texas, P.A.
Jeffrey Luke Van Eps, MD NP
James Michael Carson, CRNA CRNA US Anesthesia Partners of Texas
Hana Chung, NP PA
Razvan Dumitru, CRNA NP Advanced Orthopaedics and Sports Medicine
Travis Lee Lockwood, PA PA Baylor St. Luke's Medical Group WNNHC
Magdalena Marrufo, NP CRNA US Anesthesia Partners of Texas, P.A.
Blair Peterson, PA ACNP
Renato Phua, CRNA PEDIATRIC INFECTIOUS DISEASE SPECIALISTS OF HOUSTON
Mallory Lynne Smith, ACNP FNP Millennium Physician Association PA
NP
Farah Emboy Villanueva, FNP
Shealynn Walker, NP

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 35

Patient Experience

HCA Houston Healthcare Northwest

January 2020

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution.

Patient Experience

Inpatient Goal Inpatient Rehab

Q2'18 Q3'18 Q4'18 Q1'19 Q2'19 Q3'19 Q4'19 Q1 '18 Q2 '18 Q3 '18 Q4 '18 Q1 '19 Q2'19 Q3'19
Goal

Above Green Goal Line (Higher) is Better

“This is the first hospital who has given me a warm blanket and an inflatable plastic
blanket. Seems like common sense, but most places don't do this. Also everyone was so
nice and knew what they were doing. I had been asked multiple times if I needed
anything, which I was very thankful for. They work very hard in this hospital and it shows”

“While visiting from FL for our grandsons birthday, my wife started feeling very ill.
Ambulance took her here. The staff in ER and on the floor were very caring and taking the
time to help her out during her overnight stay. We wouldn’t hesitate to send anyone here.”

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution. 37

Care. Above All Else.

HCA Houston Healthcare Northwest

© 2019. CONFIDENTIAL – Contains proprietary information. Not intended for external distribution.