April/May 2008

Medical Staff Bulletin

Contents

Message from the Chief of Staff
Two recent initiatives at Yale-New Haven Hospital have received considerable comment from the Medical Staff and deserve mention in this space. The first concerns Medication Reconciliation, since improvement of this process has been requested by The Joint Commission. While this process requires repeated reconciliation of the patient’s medication list across the continuum of care — and providing the patient with the reconciled list on discharge — the major challenge is the creation of the list in the first place. This typically takes a doctor, nurse or pharmacist from 10-15 minutes, depending on whether the list is created by hand or is computer generated.

Nationwide, this has been a great challenge because this is true added work for clinicians. For just the 140,000 patients yearly presenting to our Emergency Departments, this entails more than 23,000 hours of work. There are many barriers to completing the task, including capacity of patient or family to adequately describe current medications, inaccuracy of archived lists, multiple providers and pharmacies and unavailability of information after hours. Success in this effort, however, has been shown to reduce nosocomial adverse drug events and is greatly appreciated by patients.

YNHH is in the process of developing systems to accomplish medication reconciliations at every site of contact with our Hospital. This will require considerable commitment and resources, but the challenge will be met.

The second initiative relates to increasing the percentage of patients discharged by 11 a.m. each day. This has been considered "mission impossible" by most U.S. hospitals, and most of our efforts over the last three years have had little effect. Average discharge time has been stuck at 3 p.m. However, YNHH has been operating at near capacity for several months and deferring discharges to 3-4 p.m. has resulted in gridlock in our Emergency Departments and Operating Rooms. To achieve an 11 a.m. discharge, there must be great coordination and communication between Attending physicians, House Staff, Nursing, Care Coordinators, and the patient and family.

After two-plus years with little traction, this initiative is gaining momentum. In the last week, about 15 percent of patients have completed discharge by 11 a.m. Some units have done exceedingly well. The Orthopedic Unit increased 11 a.m. discharges from nine percent to 26 percent, with leadership from Drs. Dieter Lindskog, Brandon Laurence and Eaman Mahoney, clinical manager Brooke Spadaccino, RN, and patient service manager Sue Arbo-Givens, RN. They are our current standard bearers! Others, hopefully, can gain insight from their efforts.

Expansion of physician workspace in East Pavilion
YNHH is creating additional workspace for physicians in the East Pavilion. New space in patient care areas will be outfitted with computer workstations and dedicated to physicians charting. The work is expected to be completed by late spring.

Performance management update

December 2007 Performance
AMI	#	YNHH%	Nat. 90%
ASA at arriv.	5/5	100	100
ASA at D/C	15/15	100	94
B-Block at arriv.	6/6	100	100
B-Block at D/C	13/15	87	100
ACEI at D/C	4/4	100	100
PCI <90 min	no eligible cases
Smoking cess.	10/10	100	100
CHF	#	YNHH%	Nat. 90%
LVEF assess.	25/25	100	100
ACEI at D/C	6/8	75	100
Smoking cess.	3/3	100	100
D/C instr. given	10/20	50	96
Pneumonia	#	YNHH %	Nat. 90%
02 assess. at arriv.	12/12	100	100
Pneum. vac. given	8/8	100	96
Abx given <4 hrs	11/12	94	92
Smoking cess.	4/4	100	100
Blood cx before abx	11/11	100	100
Initial (non-ICU)
Selection Abx	1/1	100	96
Influenza vaccine	12/12	100	98
SIP	#	YNHH %	Nat. 90%
Proph Abx 1 hr	25/31	81	96
Abx selection	27/30	90	99
Proph Abx D/C	22/29	76	96
DVT proph ordered	23/24	96	97
DVT proph given	22/24	92	95

At left are our familiar CORE measures that we report to Medicare and the Joint Commission each month. We continue to do very well on these measures; congestive heart failure discharge instructions is one exception. As noted above, we have begun merging discharge instructions and discharge summaries. This should very much improve our overall discharge process as well as our measures.

Now also reported on the Hospital Compare Website are our patient satisfaction survey results. These represent discharges from July 2006 through March 2007. This public reporting initiative, officially termed HCAHPS, uses a standardized 27-question instrument to evaluate 10 domains of care. Reported below are our results together with the national average. We have substantial work to do in order to bring our performance up to the level we expect for YNHH. Our Service Excellence Committee, together with an initiative around patient- and family-centered care, and our ongoing efforts around institutional cleanliness, should be the vehicles to get us there. If you have any questions, please contact Dr. Tom Balcezak at 688-1343.

HCAHPS — July 2006 — March 2007

New ICU triage policy adopted
In March 2008, the medical board of YNHH approved a new policy to accomplish fair allocation of ICU beds and resources when demand exceeds availability. The hospital will enter "triage mode" when there are less than three ICU beds available or at the discretion of the Chief of Staff or designee when shortages are anticipated. In that case, a surgical and medical triage officer (board certified or eligible in Critical Care), appointed by the chiefs in Surgery and Medicine on a rotating basis, will oversee triage of the respective surgical and medical ICU and step-down beds. The triage officers will work closely with one another, with clinical advisors and ICU medical directors to assign and continuously update patients’ triage scores (levels 1-5) and place or transfer patients appropriately. Please refer to the new ICU Triage Protocol (C: I-4) on the Intranet at http://intranet.mis.ynhh.com/assets/files/YNHH/Policies/Clinical/c-i-4.pdf or call the department of Physician Services at 688-2615 for a copy.

YNHH physician referral service updates
The annual physician updates for YNHH attending and associate staff members have been sent to the participating physicians in the YNHH physician referral service. Please review, edit and return any changes to the referral service at 688-5444. If there are no changes, please verify the accuracy by faxing the cover sheet indicating no changes. If you have any questions or you are a physician who would like to be enrolled in the Physician Referral Service, please contact Ann Marie Bonvini, manager, at 688-8403.

Changes related to dictating discharge instructions and medications

Effective with patients discharged April 15 and thereafter (excluding Psychiatry, Obstetrics and Newborn), you will no longer need to dictate discharge instructions and medications as part of the discharge summary — excluding psychiatry, obstetrics and newborn patients. Discharge instructions generated through the clinical information system (CCSS or SCM, depending on department) and given to the patient at discharge, will be electronically forwarded and merged with the dictated discharge summary. This is being done to support medication reconciliation and ensure that the discharge instructions medication list given to the patient at discharge agrees with the discharge medications in the discharge summary. Any post-discharge changes in instructions or medications must be communicated directly to the patient and this should be dictated as a separate addendum to the discharge summary. The medication list in the discharge instructions should not be edited. For patients discharged prior to April 15, 2008, you will need to dictate discharge instructions and medications.

Update on Veriphy critical result communication software
A new, multidisciplinary team met in April to begin planning for September implementation of Veriphy, the new communication system which notifies the ordering clinician that a critical or urgent diagnostic radiology test result is pending. Veriphy will be able to provide proof of physician-to-physician communication for critical diagnostic radiology results.

Once Veriphy is implemented, the computer system will automatically begin a physician tracking system when a radiologist dictates a report involving critical results. Veriphy will continue to notify that physician until the message has been communicated. Members of the Veriphy team will contact Medical Staff members to obtain the specific notification preferences of each individual physician. The various notification requirements will need to be developed by individuals, practices, sections and departments. In addition, the team will be resolving various issues that have been raised about the notification process. Future issues of Medical Staff Bulletin will provide regular updates on the progress of Veriphy. For more information, contact Mike Matthews, director, clinical imaging information systems, at 688-3916 or michael.matthews@ynhh.org

Tom Balcezak named vice president
Dr. Tom Balcezak has been promoted to the position of Vice President. Previously he served as Administrative Director, Performance Management and Associate Chief of Staff at Yale-New Haven Hospital, a position he has held since 2004. Dr. Balcezak started his career as an Internal Medicine resident at Yale-New Haven Hospital in 1992, and was a chief medical resident. In 1996, he joined the full-time faculty in the Department of Medicine as Assistant Professor, Co-Director of the Medical Consult Service and Assistant to the Chief of Staff. Prior to his current role, he led several initiatives in clinical process improvement, clinical quality and documentation management. Dr. Balcezak assumed additional responsibility for hospital quality, Regulatory Compliance and Readiness in 2004, and most recently, responsibility for the Neuroscience Service Line, as well as clinical service coordination for the Department of Medicine.

Important changes in requirements for Medicaid prescriptions
New federal Medicaid requirements call for all written or computer-printed prescriptions to include tamper-proofing elements, whether Medicaid is the primary or secondary payor of the prescription. As of April 1, a prescription must contain at least one industry-recognized feature designed to prevent: 1) unauthorized copying of a completed or blank prescription; 2) erasure or modification of information written or printed on the prescription; or 3) counterfeit of the prescription forms. As of October 1, all three elements will be required. For full details, visit the Medicaid Provider Bulletin (PB2008-12) at www.csms.org/upload/files/DSSbulletinmarch_2008.pdf.

All Yale-New Haven Hospital prescriptions have been modified to include at least one element of tamper-proofing — including computer-printed prescriptions from CCSS, SCM and Logician/Centricity. New "Yale-New Haven Hospital" prescription pads are also available from the hospital document center (F7395).

YNHH Pharmacy Services has sent communication about tamper-proofing in the hospital prescription forms to many greater New Haven and shoreline retail pharmacies and to the Medicaid Provider Assistance Center (EDS). If you purchase and use individualized prescription pads in your office or practice, please ensure the pads meet these requirements. When presented with a non-tamper proof prescription, a pharmacist must call the prescriber for clarification, resulting in delays for the patient and avoidable calls for the prescriber. These requirements do NOT apply to faxed, phone/verbal, or electronically transmitted (e-prescribed) prescriptions.

Another significant change for Medicare prescriptions and other billing transactions requires the use of the National Provider Identifier (NPI) number on claims submitted on or after May 23, 2008. The Drug Enforcement Administration (DEA) number or other identifiers will no longer be accepted for this purpose. Note the DEA number is still required to meet state and federal drug control regulations on all prescriptions for controlled substances and the NPI is needed for claims adjudication on all prescriptions or other claims.

Questions on these or other Medicaid/Medicare related claims questions may be referred to EDS at 800-842-8440.

SCM training update
Over the past two months, Sunrise Clinical Manager (SCM) order entry – YNHH’s new clinical information system – was successfully implemented in the Yale-New Haven Psychiatric Hospital, Obstetrics, Well-baby nurseries and NBSCU. Pediatrics was implemented on April 27 and all other inpatient areas (including medicine and surgery) will be on Sunday, June 8.

Physicians must be trained on SCM to be able to do order entry. To schedule training (held in Max Taffel or 300 George Street), please have your office manager contact Janet Betta at janet.betta@ynhh.org or 688-3042. In addition, SCM staff members will be in the Medical Staff Lounge on May 13 and 22 and June 5 and 6 from 6:30-8:30 a.m. to assist physicians with the use of SCM.

Welcome, new Medical Staff:

Refer items for the next issue of Medical Staff Bulletin via phone, fax, e-mail or mail to:
Peter N. Herbert, MD
1063 Clinic Building
P: (203) 688-2604, F: (203) 688-7152
herbertpn@ynhh.org
or
Katie Murphy
Marketing & Communications
GB 443
P: (203) 688-2492, F: (203) 688-2491
Katie.Murphy@ynhh.org

Back issues of the Medical Staff Bulletin:

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Last revised: May 20, 2008 (dh)

Home page URL: http://www.ynhh.org

All information is intended for your general knowledge and is not a substitute for medical advice or treatment for specific medical conditions. You should seek prompt medical care for any specific health issues and consult your physician before starting a new fitness regimen.