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	James L. Holly, M.D.

About SETMA Joint Commission Contact Information History Mission Statement Medical Home Scope of Services I-CARE Initiative Infusion Center The SETMA Way - What is it? SETMA's Model of Care Patient-Centered Medical Home The SETMA Approach to Patient Care	In The News Letters Vital Signs - Examiner Publication SETMA's Providers as of January, 2015 SETMA Knows - Abraham Lincoln and Healthcare Analytics SETMA – 1999 – Four Seminal Events PC-PCC Award January, 2015 Vital Signs Spring 2015 Vital Signs Q&A for PC-PCC Award Links to SETMA 2012 eHealth Innovator Award for LESS initiative Handout for Attendees eHealth Conference January 12, 2012 eHealth Initiative 2012 Award Program Application The eHealth Initiative's 2012 Award Letter 2012 National Quality Forum National Healthcare Improvement Award Effective prioritization of performance improvement goals Dashboard to Measure and Manage Whole System Performance Commitment to transparency Date-driven improvement of NQS priorities Demonstration of readiness to assume responsibilities of an ACO Demonstrated results on publicly reported performance measures Public Reporting Quality Metrics for 2009, 2010, 2011 Internally Tracked Reporting Quality Metrics for 2009, 2010, 2011 Complete Application in PDF Format SETMA's Medical Home Pilgrimage 2009 Medical Home Series I 2010 Medical Home Series II 2011 Medical Home Series Two 2009, 2010, 2011 Medical Home Miscellaneous Articles The Dr. and Mrs. James L. Holly Distinguished Professorship Universal American Letter of Transmittal for Support Dr. Holly's Acceptance Address for the 2012 Distinguished Alumnus Award CMS Medical Home Feedback Report Qualify & Cost SETMA questions Influenza Data SETMA I - October 2011 SETMA II - October 2011 Mark A. Wilson Clinic SETMA West - October 2011 SETMA and Fox 4 News - Healthy Living Videos SETMA Advertisements - Display and Video SETMA Announcements Featured Content Archive	Syllabus PC-MH Externship SETMA's MS4 Patient-Center Medical Home Selective Syllabus Introduction to SETMA's Senior Externship and Syllabus An Introduction to the Origins and Beginnings of Southeast Texas Medical Associates, LLP Patient-Centered Communication PC-MH Health Affairs August 15, 2013 Policy Brief -- Health Gap SETMA 8.20.13 Provider Training -- Health Affairs 2.14.13 -- Patient Engagement SETMA Provider Training 8.20.13 during First Senior Medical Student PC-MH Externship Medical Home Coordination Review Tutorial 2011 Medical Home Series Two Teaching Tool for PC-MH Course - Patient Care Activation, Engagement, Shared-Decision Making	Patient Information What Does Patient-Centered Medical Home Mean to You? What Does Patient-Centered Medical Home Mean to You? Health information exchange Patient Rights and Responsibilities Patient Directions Contact SETMA – Secure Texting What is HIPAA? Authorization To Release or Obtain Medical Records Complete Privacy Policy Website Privacy Policy	Presentations Invited Presentations SETMA Provider Training
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Governance Board - Harassment, Neglect, Abuse, Exploitation – Role of HCAHPS & CAHPS

R3.01.06.03 the patient has the right to be free from neglect,
exploitation and verbal, mental, physical and sexual abuse

Sexual, Mental, Physical Abuse

SETMA has a zero-tolerance of inappropriate physical contact between providers and/or employees and patients. All contact between patients and providers of opposite sex requires a chaperone to be present when disrobing is required or where examinations of an intimate are required. Where possible or at the patient’s request such examinations will be completed with a provider of the same sex.

Complaints

SETMA investigates all patient complaints and allegations. The process involves all complaints being reported to SETMA’s Director of Care Coordination who performs and investigation. The report is then sent to the CEO and COO who determine a plan of action which is carried out.

When the com0laint is about quality of care, a report is made to the patient and provider about the outcome of the investigation. If the complaint is substantiated and it rises to the level of patient endangerment, it is referred to the appropriate licensing agency for their investigation. All complaints which are substantiated are also reviewed by SETMA’s Risk Management Committee.

When the compliant is about sexual harassment or physical abuse, the complaint is sent directly to the CElO, who immediately, with a witness, investigates and prepares a plan of action. If the allegations are substantiated as they were once, summary dismissal tales place as we have a zero tolerance for such behavior

SETMA’s Employee Handbook explicitly deals with harassment, complaints, abuse and neglect.

Neglect

Neglect is avoided in SETMA by our daily auditing of provider conduct as to reviewing test results, answer telephone calls and answering patient inquiries. Patient safety and quality are assured by the timely review of the evaluation of patients via consultations, laboratory results.

If a complaint of neglect is made, SETMA’s Chief Medical Officer reviews the patient care to determine if neglect took place. The result of the investigation is communicated to the CEO and to the patient. In that such an accusation has resulted from the breakdown of the relationship between the patient and the provider, every attempt is made to reconcile that relationship and when and if that is not possible, the patient is offered the opportunity to see another provider within SETMA. If that is not desire, SETMA offers to help the patient find another provider outside of SETMA and facilitates the transfer of records and healthcare information with a summary of the patient’s current care and on-going healthcare needs.

Exploitation

SETMA does not allow solicitation of patients by providers or staff for commercial reasons outside the scope of their healthcare needs. SETMA providers and staff do not offer items for sale and no unprofessional commercialization of the provider/patient relation is allowed. SETMA complies with all Stark regulations and other Texas Medical Board, State and Federal statues which regulate patient-provider relationships.

As part of the ethical training of SETMA’s staff, we regularly discuss the tension between professionalism and entrepreneurism. The following two publications highlight some of those discussions:

Other safe guards against abuse and/or misuse of the patient-provider relationship are in place at SETMA by:

Our Care Coordination Department’s completion of the Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS) on every patient who leaves the hospital. An explanation of this program is made on SEMTA’s website for review by our patients and community at Hospital Consumer Assessment Of Healthcare Providers and Systems (HCAHPS).
SETMA’s employment of an independent, NCQA-endorsed agency for the quarterly completion of the Consumer Assessment of Healthcare Providers and Systems (CAHPS). An explanation of this program is made on SETMA’s website for review by our patients and community at Consumer Assessment of Health Care Provider and Systems.

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