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YNHH

July/August 2010

Contents


A message from the Chief of Staff

We are in the process of welcoming a new cohort of resident physicians and it is important to acknowledge how much they renew our hospital each year. Relevant to them, we are reviewing the report of the ACGME Quality Care and Professionalism Task Force, a 16-member group that included Dr. Rosemarie Fisher, our designated institutional official (DIO) and current Residency Review Committee (RRC) chair for Internal Medicine. Comment period for the task force ended on August 9 and the recommended "draft standards" will be implemented in July 2011.

Our own review of this group's conclusions is favorable although some standards will challenge current residency scheduling. There is a firm 16-hour limit on direct patient care and in-hospital work by first year (PGY-1) residents. This is an acknowledgement of the reality that "decrement of performance tends to occur at about 16 to 18 hours of continuous wakefulness," and first-year residents are most vulnerable. Moreover, PGY-1s may not alone cover a hospital service; they must have an in-house supervising faculty or senior resident; and they are not permitted to moonlight. PGY-2 residents cannot overnight in house more often than every third night, and this duty cannot be averaged over a month as previously permitted.

Recognizing the importance of care continuity to physician professionalism, a resident may volunteer to remain with a single patient after signing out all other care responsibilities.

Individual programs must ensure and monitor effective hand-off processes in the interest of care continuity and patient safety. Programs must set guidelines for circumstances and events in which residents must communicate with supervising faculty members. Residents must be encouraged and expected to participate with other health professionals in the design of systems of care safeguarding our patients. YNHH has already made significant progress in addressing these new program standards.

The ACGME Task Force (which included our own Dr. Fisher) is to be commended for resisting some of the more aggressive recommendations of other agencies which could compromise resident education and experience and which are unsupported by published evidence. Nationally, resident weekly duty now averages less than 60 hours and YNHH must have no tolerance for hours exceeding the current 80-hour standard on any services or rotations. We must pay comparable attention to modeling and developing resident professionalism and altruism in a humanistic learning environment.

Care of family members

Members of the Medical Staff may not serve as the responsible attending of record for any member of their own family. Similarly, Medical Staff and Affiliated Medical Staff members may not schedule or perform operations or procedures on members of their own families in the operating rooms, procedure rooms or laboratories except in extreme emergencies (when no other qualified member of the Medical Staff is available) or with explicit approval by the department chief and Chief of Staff.

Performance management update

At left are our familiar Joint Commission and CMS measures for the most recent three-month period. Additionally noted here this month is our performance in preventing central line-associated blood stream infections (CLABSI). We will now be reporting to you our days between infections for each of our ICUs. While this doesn't give us any risk adjusted rates, it does give us some sense of our performance, over time, in preventing CLABSIs. Most of you have already heard that the Center for Medicare and Medicaid Services (CMS) has completed a full conditions of participation (COPS) survey at YNHH. Hopefully, most of you have also seen copies of "Frontline MD News," describing commonly surveyed and high-risk issues that physicians can directly impact. The highlights of these are as follows:

Restraints: Restraints are recognized as a high-risk intervention, and our goal is to reduce restraint use to the minimum possible amount. Especially high-risk are restraints used in patients with violent and/or self-destructive behavior. Restraint utilization of this type is highly regulated and requires a face-to-face evaluation of the patient within one hour of each episode of restraint, a re-order of restraint every four hours in adult patients and documentation of the need for restrain and the behavior that precipitated it. The exact requirements are specified on the order entry pages in our computerized order entry system.

Admissions, H&Ps and procedure notes: All patients admitted to the institution require an admission order and a history and physical within 24 hours of admission. History and physicals must be done within 24 hours after admission and patients admitted for elective surgery must have a history and physical performed within 30 days of admission and an update performed immediately before the operation. A brief post-op note must be recorded on every patient after surgery and it is our policy that a full operative note be dictated within the next day.

Time-outs: Our policy requires there to be a time-out prior to any invasive procedure. In the procedural areas and the ORs, the documentation of this time-out is recorded by the nursing staff. In the other areas, including the emergency department, the outpatient setting, the ICUs and the general floors; it is the responsibility of the physician or other LIP to document the performance of this time-out.

Medication Security: No medication or syringes are to be left unattended at work stations, patient rooms or elsewhere on nursing units. Ensure orders are accurate: Orders for all restraints, medications, respiratory treatments, IV infusions and other treatments and therapies must be complete and accurate. It is critically important that orders exactly define the treatments that are given to patients.

Interpreter services: YNHH provides free interpretation services for patients and/or their companions of limited English proficiency and for deaf or hard-of-hearing. Clinicians must make every effort to anticipate the need for an interpreter so that patient care will neither be delayed nor compromised in any way. Only trained interpreters who are registered through YNHH may be used. Relying on bilingual staff, family members or friends is not acceptable. The need and request for an interpreter must be documented.

HIPAA privacy reminder: When a family member/friend is with the patient, before discussing and disclosing medical information, please request the family member to step out for a moment, and then verify with the patient whether it is acceptable to discuss the patient's information with the family member present. If so, you can invite the family member back in. This is especially critical when discussing matters such as drug use, alcohol use, HIV status or other sexually transmitted diseases.

Many thanks for you your help with these important matters.

System and hospital boards approve adoption of EPIC information software

The Yale New Haven Health System and the Bridgeport, Greenwich and Yale-New Haven Boards approved implementation of a comprehensive package of patient care and business software products developed by Epic, the most highly ranked company in the healthcare information technology industry. The Epic system will provide each patient with one patient record number across all points of YNHHS care so a patient's full record — including tests, diagnoses and other critical information — will travel with the patient from the community to the hospital setting. Epic will allow physicians who are on the Epic system to fully and appropriately access that data, eliminating redundant tests so diagnoses can be clearly communicated.

In addition to supporting and enhancing the delivery of safe, effective patient care more cost-effectively, the Epic system will also include a new patient portal that will allow patients themselves to access and track their medical care through a secure website where they can monitor their health. This fall, the system will begin to tailor Epic to the needs of those who deliver care at the bedside and in office settings. This process will last for approximately a year. Initial ambulatory roll-outs will begin next fall through the Northeast Medical Group, Yale Medical Group and in community physician practices. At the same time, Greenwich Hospital will be the first System hospital to undergo the full Epic inpatient implementation.

Medical Staff education concerning National Patient Safety Goals

In 2009, The Joint Commission announced three new National Patient Safety Goals related to healthcare-associated infection (HAI):

  • Reduce the incidence and transmission of multi-drug resistant organisms (MDRO)
  • Reduce central line-associated blood stream infections (CLA-BSI)
  • Reduce Surgical Site Infections (SSI)

Education of medical staff about these topics is an important component of reducing these HAIs at YNHH. All members of the Medical Staff were recently mailed copies of presentations on each of these three topics. Additionally, for your convenience, these are posted on our website (www.ynhh.org) under "For medical professionals"/"Medical Staff education." Please review any that are relevant to your practice at YNHH.

Medical Staff elects new officers

The Medical Staff has elected new officers beginning September 1, 2010: Alan Friedman, MD, Pediatrics, President-Elect; and Robert McLean, MD, Internal Medicine, Secretary/Credentials Chair.

Additionally, Dr. Thomas Sweeney, Surgery, current President-Elect, will assume the role of President and Medical Board Chair and Dr. Leo Cooney, Internal Medicine, will become Past-President and Chair of the Medical Board Finance Committee. Dr. Brett Gerstenhaber, Internal Medicine, and Dr. Lynda Rosenfeld, Internal Medicine, will complete their terms, respectively, as Past-President and Secretary.

In addition, new Medical Board members-at-large were elected. In June, the community-based Medical Staff elected the following new individuals to serve on the Medical Board as of September 1: Karen Dufour, MD, Internal Medicine; Adam Mayerson, MD, Internal Medicine; Stephen Possick, MD, Internal Medicine; and Kai Yang, MD, Internal Medicine. Reelected to a second term as members-at-large as of August 31, are: John Federico, MD, Surgery; Lee Jung, MD, Internal Medicine; and Harold Tara, MD, Internal Medicine. Completing terms were Drs. Suzanne Lagarde, Internal Medicine; Marc Mann, Internal Medicine; and Michael Murphy, Orthopedic Surgery.

U.S.News & World Report ranks YNHH in 12 specialties

YNHH has been named one of the top hospitals in the United States in the 2010 U.S. News & World Report's annual "America's Best Hospitals." YNHH was ranked in 12 of the 16 specialties surveyed. For the first time, YNHH had a total of three specialties ranked in the nation's top 10: diabetes and endocrinology (#8), geriatrics (#9) and psychiatry (#10). YNHH is the only hospital in Connecticut to be ranked as a top hospital in any of the 16 medical specialties. In addition to its three top 10 ranked specialties, Yale-New Haven also ranked among the very best in the nation in nine additional medical specialties: cancer; ear, nose and throat; gastroenterology; gynecology; heart and heart surgery; kidney disorders; neurology and neurosurgery; pulmonology and urology.

Dr. Greer named vice chair of Neurology

David M. Greer, MD, has been named vice chair of Neurology at YNHH/YSM. He came to Yale from Massachusetts General Hospital (MGH), where he was an attending physician in Neurology, associate professor of Neurology at Harvard Medical School and program director of the MGH Neurology residency program. In addition, he directed the MGH inpatient stroke service, and Neurology consultative services. Dr. Greer received his MD from the University of Florida and served his residency in Neurology and a fellowship in NeuroCritical Care and Stroke, both at MGH.

School of Medicine to host Bicentennial Community Day on October 16

As part of it 200th anniversary festivities this year, Yale School of Medicine will welcome community members from the Greater New Haven area, along with alumni, staff, students, faculty and family members for a Community Day celebration on Saturday, October 16, from noon to 4 p.m. Cedar Street — between Congress Avenue and York Street — will be closed to traffic and open as a pedestrian walkway with a host of activities for children and adults. There will be medical lectures and demonstrations, interactive health booths, health screenings, photo exhibits, music, face painting, entertainment and lab and campus tours. The highlight of the afternoon will be a blowing out of candles on a Bicentennial birthday cake in front of Sterling Hall of Medicine.

For more information, please view the website at medicine.yale.edu/ysm200 or contact Deborah Dunn (Deborah.dunn@yale.edu), phone 203-737-3354.

Code of Conduct available

Yale New Haven Health System's Office of Privacy & Corporate Compliance (OPCC) is a resource available to staff and physicians for questions and concerns related to ethical business practices, compliance with laws, regulations and organizational policies and procedures. The OPCC provides guidance on issues such as objective decision-making/avoiding conflicts of interest; appropriately giving or receiving gifts and business courtesies; and compliance related to medical record documentation, coding and claim submission.

Yale New Haven Health System has published a Code of Conduct, which includes an overview of the organization's conduct expectations, guidance in making choices that may seem unclear or questionable to you and tools for reporting a concern or a suspected violation. The Code of Conduct is published on the home page of the Intranet (click on "Corp. Compliance/Privacy" in the dark blue bar at the top of the page). The web address is: http://intranet/ynhhs/opcc/Default.aspx

If you would like a hard copy of the booklet mailed to you, please call Corporate Compliance at 203-688-8416.

New leadership for Pediatrics

Clifford Bogue, MD, was appointed as the interim chief of Pediatrics in August, when Margaret K. Hostetter, MD, left to become the Albert Sabin chair and chief of Infectious Diseases at Cincinnati Children's Hospital Medical Center. Dr. Bogue is chief of the section of Critical Care Medicine and medical director of the Yale-New Haven Children's Hospital Pediatric Intensive Care Unit. He is associate professor of pediatrics and associate chair of the department at Yale School of Medicine. Dr. Bogue, a well regarded clinician and strong advocate for enhanced patient safety, received his bachelor's and medical degrees from the University of Virginia. He came to Yale-New Haven in 1989 as a fellow in pediatric critical care medicine after a residency and chief residency at Vanderbilt.

A search for the permanent chief/chair will begin this summer under the leadership of Brian Smith, MD, chief of the Department of Laboratory Medicine. Cynthia N. Sparer has been named the interim executive director of Yale-New Haven Children's Hospital, replacing Dr. Michael Apkon, who is now senior vice president and chief medical officer at Children's Hospital of Philadelphia. Sparer has assumed ongoing operational responsibilities and strategic positioning for the Children's Hospital. She was recently vice president and chief operating officer of New York-Presbyterian Hospital (NYP) and executive director of NYP's Morgan Stanley Children's Hospital. She was also responsible for the women's and children's service lines for the Columbia and Cornell campuses. Sparer previously served as executive director of Monmouth (NJ) Medical Center and Schneider Children's Hospital in New York and as vice president of University Hospitals of Cleveland, where she was responsible for Rainbow Babies and Children's Hospital. Sparer earned her BA degree at American University and her MPA in health policy, planning and administration at New York University.

Reminder about YNHH 911 emergency call procedures

In case of a hospital emergency (unconscious person, fire, etc.), please call 911 — not 688-3111 and not 9-911. Calling 911 bypasses all other calls; both the hospital's emergency operator and YNHH Protective Services answer each call.

New Haven Emergency Medical Services — not the hospital's internal code teams — will now respond to calls in selected low-risk areas, such as 55 Park Street, Yale Physicians Building and the Dana basement clinics.

When you dial 911, please specify the type of emergency — adult medical emergency (Code 5), pediatric medical emergency (Code 7), fire or smoke (Order # 1), or police/security emergency. Please give the specific location, your full name and your telephone number in case the emergency operator or protective services officer needs to verify information.

Dr. Karlovsky retires after nearly 60 years

Dr. Emil Karlovsky was appointed to the YNHH Medical Staff in 1952 and is retiring after nearly 60 years of service to patients in the New Haven community. Dr. Karlovsky received his MD from Albany Medical College in 1946. He trained at Grace-New Haven Hospital. After serving in the armed forces, he began practice in 1955 until semi-retirement in 2003. Since 2003 Dr. Karlovsky has been working with County Obstetrics and Gynecology. Dr. Karlovsky delivered over 6,000 babies between 1955 and 1985 and was a mentor to every YNHH resident during that time. Dr. Karlovsky is also a remarkable athlete and sailed competitively until he was 92, winning both national and international acclaim.

Northeast Medical Group forms, hires new executive director

Yale New Haven Health System has created a new, system-wide physician group to create opportunities for better collaboration, quality of care and physician alignment. The Northeast Medical Group (NEMG) now includes clinicians throughout the system, including hospital-employed physicians at Greenwich and Bridgeport Hospitals; members of the Mill Hill Medical Group based at Bridgeport Hospital; and YNHH's hospitalist team.

NEMG, a nonprofit medical foundation, was created as a result of enabling legislation passed last year by the Connecticut General Assembly. It will create cost efficiencies through economies of scale, clinical information systems and unified administrative functions, such as billing and practice management.

Robert A. Nordgren, MD, will become the first chief executive officer of NEMG, as of September 27. Dr. Nordgren was previously associate medical director at Dartmouth-Hitchcock Manchester in New Hampshire and an adjunct faculty member of the Dartmouth Medical School department of Pediatrics. He was very active in community and statewide health initiatives, health care reform and children's health programs in New Hampshire. Dr. Nordgren received his undergraduate degree from Williams College and his MPH and MD from Columbia University. He trained at the Children's Hospital of Philadelphia, serving in his final year as chief resident in Pediatrics. He is currently enrolled in the University of Massachusetts Amherst Isenberg School of Management/American College of Physician Executives MBA program and expects to receive his MBA in 2011.

Special thanks to Dr. Bruce McDonald, who served almost two decades as CEO of the Mill Hill Medical Group, and Dr. Victor Morris who has served with distinction as the interim CEO of NEMG. He and Dr. Nordgren will work on a transition plan in September.

Dr. Lee appointed interim chair of Pulmonary and Critical Care

Patty Lee, MD, associate professor of Medicine (Pulmonary), has been appointed interim section chief, Pulmonary & Critical Care Medicine. Dr. Lee received her undergraduate and MD degrees from Brown University. She was a resident and postdoctoral fellow in pulmonary and critical care medicine fellowship at Johns Hopkins School of Medicine. In 1998, she joined Yale School of Medicine as an instructor in medicine, and became an associate research assistant and director of respiratory therapy at the VA Medical Center in West Haven.

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