Physician Newsletter Feb 2021

In the Know with the CEO:
Physician Newsletter

HCA Houston Healthcare Northwest

February 2021

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

Mission Statement

HCA’s Mission Statement:
Above all else, we are
committed to the care and
improvement of human life.

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Welcome!

Colleagues,

I am excited to release our year in review edition of our “In the Know with
the CEO physician newsletter.” This edition continues to detail all of the
great things that are happening at HCA Houston Healthcare Northwest.
Please take some time to review all of the exciting things happening at
our hospital.

Scott J. Davis, FACHE This newsletter will highlight the construction and safety/security updates
Chief Executive Officer throughout the hospital in making HCA Northwest a better place for our
employees, our physicians, our patients, our visitors, and our community.
These projects are creating a great impression for our facility and create a
safer and more secure environment for everyone that comes to our
facility. I am excited for all of these changes and the benefit it will bring to
all of us.

We also have updates on our patient experience and quality initiatives. I
am extremely proud of the quality care we have provided in our
organization, especially given the acuity of the COVID-19 disease. We
have saved many lives that were expected to pass away with their
conditions.

Finally, thank you to each of you for your efforts during this unique time of
the pandemic. All of you have stepped up in many different ways and I
appreciate your commitment to our organization. Thank you!

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CMO Update

HCA Houston Healthcare Northwest

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Congratulations!

Ahmad Maarouf, M.D. Named Chief Medical Officer
at HCA Houston Healthcare Northwest

Ahmad Maarouf, M.D., has been named chief medical officer (CMO) of HCA Houston
Healthcare Northwest, effective March 1, 2021. As CMO, Maarouf will ensure high quality, patient-
centered care by leading clinical and quality initiatives that support the provision of consistent clinical
performance and practice standards across the hospital.

Maarouf received his medical degree from Damascus University College of Medicine in
Damascus, Syria. He went on to complete a residency in Internal Medicine at Western Reserve Care
System / Forum Health. Maarouf furthered his education at the University of Pittsburgh Medical
Center (UPMC) as a visiting scholar where he also conducted research. He went on to complete a
nephrology fellowship in 2009 and a critical care fellowship in 2011, both at UPMC. Maarouf
advanced his educations by receiving a master’s degree in business administration from Case Western
Reserve University in 2018.

From 2009 – 2010, Maarouf served as a faculty member at Henry Ford Hospital’s Nephrology
and Hypertension Division. For nine years, from 2011 until his move to HCA Houston Healthcare
Northwest earlier this year, he held numerous medical directorships, committee chairmanships, and
staff positions at Beaumont Health, Michigan’s largest health system. Maarouf also served as a clinical
assistant professor at Michigan State University from 2016 until present, and also as the associate
program director for the Internal Medicine Residency Program at Beaumont Health – Trenton. While
in Michigan, he served as an advisory board member for Life Gift. Earlier this year, Maarouf made the
move to Houston, becoming the medical director of critical care at HCA Houston Healthcare
Northwest.

An accomplished lecturer and teacher, Maarouf has received many awards and accolades. He
has also authored numerous published articles and abstracts, as well as posters and invited talks.

Maarouf is a member of American College of Physicians, the American Society of
Nephrology, and the Society of Critical Care Medicine. He is board certified in internal medicine,
nephrology and critical care.

“Dr. Maarouf is dedicated to meticulous quality. He believes in fostering data driven, patient-
centered, collaborative care for every hospitalized person,” said Scott Davis, CEO of HCA Houston
Healthcare Northwest. “We are excited to have him as our new chief medical officer and are looking
forward to how he will further his impact on our colleagues and community.”

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COVID-19 Update

HCA Houston Healthcare Northwest

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COVID-19 Update

• Census – we have maintained a census in the 40s/50s over the last couple months as
our community experienced another surge. However, we have dropped to the 30s
this week which is good news. Thank you for your efforts in managing this census
with our great work with discharges.

• Screening process – we will be making some adjustments to our screening process
with some facial recognition scanners/thermometers. On entering the campus, we
are asking all employees and physicians to attest to not having symptoms. Thank
you for your help in this process.

• Resources - we are continuing to add staffing resources from a nursing and
physician perspective to help with the surge.

• Volume – we have been reviewing our cardiac and surgery schedule each day to
try and alleviate volume pressure on our hospital staff and still accommodate
procedures when necessary. This will continue to open up to normal operations now
that our COVID-19 census has declined.

• Vaccine – we have submitted requests to the State for more vaccine to be able to
vaccinate our employee/physician family members, our physician office staff, and
other community partners. We have not received any vaccine yet, but we will send
communication on this availability as soon as we hear if we will get the requested
vaccine.

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

COVID-19 Numbers

HCA Houston Healthcare Northwest

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Physician Engagement Survey

HCA Houston Healthcare Northwest

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Physician Engagement Survey

I want to thank all of our physicians that participated in our physician engagement
survey that we administered in the 1st quarter of 2020. I appreciate your input into
our operations, patient care, quality, and patient safety. We are committed to
continue working diligently in making HCA Houston Northwest a “Great Place to
Practice Medicine” and we will be deliberate in continuing to hear your concerns
and address them immediately.
We also appreciate your involvement in the strategies for our organization. Your
input has been extremely valuable in driving the strategic direction for our hospital
and putting us in the great position in which we now found ourselves.
We have opportunity to still improve every day but I am thankful for all of your
support in our journey together.
In this most recent survey, almost every physician moved to the excellent, very
good, or good categories. With this movement our goal for 2021 will be to move as
many physicians as we can from the very good and good categories to the
excellent category in what we call our “Pathway to Excellence.” Our goal is to be
in the top 10% of the database (referred to as PRC) for every category. We are
very close in many categories and have made great strides in many others to
reach this goal.
Thank you again for your involvement in our actions to achieve our “Pathway to
Excellence” in making this the best place for all of our to practice medicine. The
following slides will share the results from the survey and some of our corresponding
action items.

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Comparing HCA v. PRC

Historical Comparisons & Goals

Survey Areas 2019 % 2020 % Net Change 2019 Exc 2020 Exc HCA 90th PRC 90th
Excellent Excellent  14.8 Ranking Ranking Percentile Percentile
Place to Practice 23.8%
Quality of Care 21.3% 38.6% 15.1 50.1 71.7% 63.1%
Administration 22.2% 70.6% 62.9%
Nursing Care 36.2% 38.1%  16.8 9.3 46.3 66.8% 49.5%
Patient Experience 18.3% 67.2% 54.6%
Patient Safety 26.2% 37.0%  14.8 46.4 75.5 67.7% 57.4%
Surgical Services 18.4% 39.5%  3.3 60.3 66.0 69.7% 59.2%
Anesthesia Services 33.9% 65.3% 50.0%
Hospitalist Services 27.2% 38.9%  20.6 44.2 65.3 75.0% 63.1%
Laboratory Services 36.5% 72.8% 60.4%
Pathology Services 46.4% 45.6%  19.4 14.8 64.9 62.0% 52.6%
Pharmacy Services 69.3% 56.9%
Radiology Services -- 39.8%  21.4 16.5 74.1 68.5% 59.4%
EMR 42.9% 69.8% 58.0%
Emergency Services 10.3% 47.8%  13.9 24.0 61.7 30.1% 24.7%
36.0% 46.3%  19.1 29.6 70.2 66.7% 53.3%

52.3%  15.8 57.3 89.7

62.1%  15.7 73.2 94.4

53.8% -- -- 85.6

56.3%  13.4 61.7 87.1

23.1%  12.8 48.3 86.6

41.9%  5.9 63.6 74.5

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HCA NW Pathway to Excellence
“Moving Towards Excellence”

Areas of Focus:

• Place to Practice
• Patient Experience
• Quality of Care
• Nursing Care
• Administration
• Surgical Services

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Commitment to Excellence Action Plan

• Physician “Big Board” for hospital strategic and operational
updates in the physician lounge

• Annual physician strategy session
• Physician newsletter / weekly physician email
• Ongoing executive touchpoints with our physicians
• Operational improvements throughout the hospital (OR, ER,

nursing units, women’s services, imaging, lab, etc.)
• Physician lounge improvements
• Investment in competency in procedural areas and inpatient

units
• Staff recruitment and retention strategies
• Consistent communication and responsiveness to our physicians

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2021 Physician Engagement Survey
Postponed

After much consideration, HCA will postpone the 2021 Physician
Engagement Survey out of respect for what our physicians are
currently facing with the pandemic. The survey dates are moving
from March 1-31 to May 14-June 14.

We will get you additional information regarding the 2021 survey as
we get closer to the month of May.

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Interesting Facts

HCA Houston Healthcare Northwest

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2020 Interesting Facts

• Credentialed 79 New Physicians
• Physician Dining Room consumed 360 pounds of coffee in 2020
• Ice cream order increased by 25% to keep up with the

pandemic ice cream “afternoon snack”
• HNW performed 21,761 COVID tests - 13,167 were PCR and 8,144

were Antigen tests
• COVID test passivity rate varied between 5% to 26%.
• Vaccinated more than 1,200 employees and physicians for

COVID-19

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

Safety & Security

HCA Houston Healthcare Northwest

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Security at HCA Northwest

Brad Korth, Director of Security Hello HCA Northwest Team,
[email protected]
281-631-8765 Your Security team is here to support you and ensure that everyone is safe.
Most recently, HNW secured a new patrol vehicle to help raise visibility of
security rounds as well as provide a comfortable form of transportation for
taking patients/visitors or staff to their vehicles. We will respond to calls for
service on the campus and investigate any suspicious activities reported to
or observed by Security. At the entrances, we are assisting the screeners with
enforcing our new COVID restrictions and are always willing to assist in
educating visitors and others when the screeners can use additional support.
Security is constantly tasked with rounding throughout the entire facility as
well as assisting with lost/found, patient property and evidence retrieved in
the Operating Room. If weapons are brought into the facility we seize them
and place them in a safe, locked area until a time is determined on when
they can be safely returned to their owner, or released to police. When
codes are called overhead, we always place that as a first priority and
respond appropriately to assist. We are all TEAM or CPI-trained and ready to
respond to volatile patients/visitors.

Outside of all of the ‘duties’ of Security at Houston Northwest, we are here
daily to greet you, be your friend and ally to each of you. Our #1 goal each
day is to keep you safe and help you. Please never hesitate to reach out!

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Security Camera System

We are finalizing the installation of the new, 350+
security camera system. Camera views are
being uploaded to the server/system and the
views are being validated for appropriateness.
Here are some examples of our live views

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Security Camera System

The features of this new camera system are
fantastic! Here a couple illustrations of the zoom
capabilities and movement tracing.

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Facility & Construction
Updates

HCA Houston Healthcare Northwest

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Generator Replacement

Our 5 emergency backup generators are
expected to be safe and ready-for-use in
March 2021. These units will assist us in
providing emergency power throughout the
hospital in various scenarios such as
hurricanes, tropical storms, power blips,
etc.

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Waterproofing (Visitors Parking Garage)

This project will span from Oct. 2020 – Feb. 2021. Improvements include the replacement
of joint sealants, horizontal concrete repairs, spandrel repairs, new traffic coating & line

and new parking wheel stops and a fresh coat of paint for stairwell handrails.

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Front Entrance Beautification

Remaining Scope of Work (March 2021 Completion)

Helipad Fencing/gates, striping of lot,
code blue cabling, water
meter installation, lighting

MRI Lot Fencing/gates, striping of lot,
landscaping/irrigation
St. Edwards Drive &
Strip Center Lot Fencing/gates, electric/water
meter installation,
landscaping/irrigation

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Flooring Improvements

Anti-slip
material
applied
for safety

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Landscaping Improvements

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Front Entry Project - Completion March 2021

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Aerial View
Project
Completion
March 2021
South Lobby
Reopens
Mar-Apr 2021

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Service Line Update

HCA Houston Healthcare Northwest

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Business Development

• Full-time Maternal Fetal Medicine coverage began January 1, 2021 at
Northwest. Our MFM physicians are on-site each day for consults and high-
risk deliveries. At this time they have outpatient offices located in The
Woodlands and Willowbrook. They are looking for clinic space near HNW
campus.

• Critical Care Intensivists – we are recruiting more permanent providers and a
medical director to replace Dr. Maarouf who will start his CMO role with us
March 1st. Please stay tuned for announcements on these providers.

• HNW has hired a cardiac navigator through our Care Assure program. Our
navigator will start February 15th and will work with inpatient cardiac
patients, follow up for outpatients and be a valuable resource to our
patients as they work through their medical needs.

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Comprehensive Stroke

Did you hear? HCA Houston Healthcare Northwest is now in pursuit
of Comprehensive Stroke Care . This means EMS agencies will now
have the ability to access these additional services without the
need to transport to more distant hospitals. We now have 24/7
coverage with Dr. Shamaelah Javed and Dr. Fawad Shaheen.

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Northwest Urgent Cares are Care Now
Urgent Cares: Klein and 2920 Locations

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Direct Admit Options

Physician Relations is
working with physician
offices to promote use of
direct admits. Patients that
need to be admitted will
bypass the ED and admit
directly to one of our units.
We have multiple options
to Direct Admit a patient
including
• DASH
• Direct Admit form
• Call house supervisor at

346-285-9261

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Women's Services Welcomes Community
with Virtual Tour

Please go to our website to view the
tour:
https://hcahoustonhealthcare.com/
locations/northwest/patients-and-
visitors/maternity-tour.dot

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New Providers

HCA Houston Healthcare Northwest

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September 2020

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October 2020

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November 2020

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December 2020

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January 2021

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Patient Experience

HCA Houston Healthcare Northwest

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Patient Experience

Inpatient Emergency Department Surgical Services

100 100 100 99

80 80 80

60 60 60 61
40
20 22 46 55 40 40

0 34 27 20 9 2 13 7 20 20 16 4 16 9
06 0
13
Q4'19 Q1 '20 Q2'20 Q3'20 Q4'20 Q1'21 Q4'19 Q1 '20 Q2'20 Q3'20 Q4'20 Q1'21

Q4'19 Q1 '20 Q2'20 Q3'20 Q4'20 Q1'21

Goal Goal Goal

Outpatient Test & Treat 100 Inpatient Rehab 99

100 80 81
80 71
60
40 60

20 29 24 20 40 48
07 4 1 30

Q4'19 Q1 '20 Q2'20 Q3'20 Q4'20 Q1'21 20

Goal 0

Q4'19 Q1 '20 Q2'20 Q3'20 Q4'20
Goal

“I had my baby here on December 22 and I am honestly very surprised with this hospital. I had never been here before
so it was my first time, the staff was so amazing and polite and they were quick to acknowledge my needs during my

stay. It was such a beautiful experience.”
- Patient comment from Google in December 2020

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Patient Quality

HCA HOUSTON HEALTHCARE NORTHWEST

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“Bricks and mortar do not make a hospital. People do.”
Dr. Thomas Frist, Sr.

Your efforts have not gone unnoticed. Take a look at all of the great
accomplishments Northwest achieved during a challenging and
unpredictable year.
• Leap Frog Safety Grade of A (Fall 2020)
• 2020 Get with the Guidelines Gold Plus for Stroke
• NICU Level III Designation
• HCA Model Staff Bylaws
• Ongoing, real time disaster privilege credentialing in the wake of COVID-19
• Adoption of a new Medical Staff Organizational chart
• And the list goes on………………
Despite the many challenges faced, the Northwest family continued to make
great strides in Quality, Medical Staffing and Patient Safety. Thank you for your
commitment to improving the care and improvement of human life.
Quality Resources, Infection Prevention, Patient Safety, Risk Management &
Medical Staffing

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Northwest Clinical Excellence and Quality Achievements 2020

Fall

Unit of
Distinction
OR # 2 in HCA

2020- NICU Level III
21 Designated

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Clinical Excellence Quality Celebration

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Other Updates

HCA HOUSTON HEALTHCARE NORTHWEST

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Other Updates

• Physician party – due to COVID-19 restrictions our annual physician social is still on hold
until further notice. We will update everyone as soon as we get to a point where we
can host all of you together.

• Ed Roberson / Employee Recognition Walls – you may have noticed we took down the
Ed Roberson and employee recognition walls. We are installing updated and new
formats for all of these recognitions due to their importance to our organization. They
will be installed over the month of February.

• Physician Headshot Day – February 22nd 8:00 am – 4:00 pm in Atrium A&B. Please stop
by and get a professional headshot if you would like.

• Doctor’s Day Events – we will have some socially distanced celebrations/food, etc.
during our Doctor’s Day celebrations in March.

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Care. Above All Else.

HCA Houston Healthcare Northwest

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