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Medical Staff Bulletin

October/November 2010

Contents


A message from the Chief of Staff

Our Medical Staff Bylaws, Rules and Regulations are available on the internet at YNHH.org, retrieved by clicking under "Medical Professionals" among the menu items across the top of the page. This new and very attractive site is worth access, even if you are not seeking information about Patient Transfers, Medical Staff Applications, Continuing Medical Education, Publications or Resources.

Over the last two months, the Medical Board recommended changes to both the Bylaws and Rules/Regulations. Most important among these is the stipulation in Rule 15:

It is the responsibility of an attending surgeon to evaluate, examine and counsel patients and/or their legal guardians prior to elective surgical procedures. Documentation of these interactions in the form of an attending surgeon's preoperative evaluation note is required in advance of the day of elective surgery. This responsibility may not be delegated. Screening endoscopic procedures are excluded from this requirement.

Perioperative Services will require verification that patients having elective procedures have been examined by an attending surgeon.

A number of other changes were made to the Bylaws, specifically addressing CMS regulation and expanding the scope of Medical Board oversight of clinical activities at YNHH. Significantly, the "Operating Room Committee" has gone the bye, replaced by the Perioperative Executive Leadership Committee (PELC). The Chief of Surgery and Senior Vice President responsible for Surgical Services co-chair PELC, which has strong representation from all operative services. PELC has three sub-committees to monitor and drive key performance indicators in safety/quality, satisfaction/service and operations.

Future editions of this publication will report on PELC activities. Most recently the PELC Safety/Quality Sub-committee, chaired by Drs. Larry Moss and Doug Vaughn, developed, piloted and has ratified a new time-out/checklist protocol. The Department of Neurosurgery piloted this process over the last several weeks and this tightly scripted procedure will be implemented in all of our operating areas by the end of November. Shortly, a related, structured approach will be disseminated to all laboratories and patient care areas outside of the Operating Room. Emergency

Department opens new "Section E" on East Pavilion 4-6

In an effort to address over-crowding and create patient space during construction, the Adult Emergency Department (AED) will begin to utilize space on 4-6 to care for their patients. The new 14-bed "Section E" will open on Tuesday, Nov. 30 and, after triage in the AED on the first floor, will treat moderate acuity emergency patients. The unit will function identically to the main Emergency Department. It is fully equipped and patients will get diagnostic imaging, labs and consults in the same way that they do in the main ED. The unit will be open from 11 a.m. to 11 p.m. seven days a week.

Performance management update

Our familiar Joint Commission and CMS measures have been released for the most recent three-month period. Also published is our performance in preventing central line-associated bloodstream infections (CLABSI) reported as days since last infection for each of our eight ICUs. It's exciting and rewarding to see these numbers grow larger as the initiatives spearheaded by Francine LoRusso, RN, and Jonathan Siner, MD, take root across the organization. To date there has been a standardization of the "insertion bundle" as well as the "line maintenance bundle." These efforts are clearly making headway. But, we can and must do better.

With regard to CORE measures, our challenges continue to be in the areas of PCI within 90 minutes, pneumococcal vaccination in patients with pneumonia, and home management plan for patients with pediatric asthma (although there has been dramatic improvement here). There are active improvement projects around all of these and we should be seeing improvements over the next couple months.

Last month we discussed the recent Center for Medicare and Medicaid services (CMS) survey. I'm happy to note that this survey has been completed and we have been found to be in full compliance with all of the conditions of participation. Nevertheless, continuous readiness for regulatory visits from CMS and the Joint Commission remain integral to clinical quality and patient safety. Over the next couple of months, we anticipate our triennial survey from The Joint Commission (TJC). For physicians, PAs, APRNs, CRNAs and other licensed practitioners, this survey will focus on issues that are central to patient care and patient safety.

Many thanks for your care of our patients. If you have any questions of concerns, please do not hesitate to contact Tom Balcezak, MD, at 203-688-1343.

Renovations to front entrance, Atrium and Emergency Department

Renovations are well underway to update the 20 York Street entrance to the hospital and refurbish the Atrium. The project, which is being financed by savings achieved when Smilow Cancer Hospital construction came in under budget, also includes improvements to the Children's Hospital entrance and establishing an employee entrance into the South Pavilion. The work should be completed in late February.

Additionally, a much-needed, two-year, $52 million expansion of the Adult Emergency Department began in October to add 18,000 square feet for a total of 48,100 square feet. In 2009, the AED treated more than 133,000 patients — up from 129,700 in 2008. The construction will almost double capacity, growing from 48 beds and stretcher spaces to 74. The expanded ED will house radiology support — including two CT scanners, radiology fluoroscopy, two general X-rays and one ultrasound. The front of the ED will expand into the space where ambulances currently pull in. Work is now under way to move the ambulance bays into the former parking area and to create a drop-off point for patients near Howard Avenue.

Y-ACCESS update

Y-ACCESS, Yale-New Haven Hospital's new transfer service, offers a single toll free phone number — 1-888-964-4233. It is available to physicians around-the-clock and staffed by clinicians to ensure seamless transfer of patients to the hospital, as well as ongoing communication between the referring and receiving physicians. Y-ACCESS can help referring physicians identify an appropriate specialist, ensure a connection with a receiving attending physician, facilitate the arrangements for the actual transfer and obtain patient evaluation and progress reports. For more information about Y-ACCESS, contact Dr. Victor Morris, Associate Chief of Staff, at 203-688-4748 or victor.morris@ynhh.org.

Optimizing compliance in 2011

YNHH has selected six areas for intense focus this year to achieve universal compliance with best practices:

  1. Hand hygiene: We are so close we can almost celebrate. In September, 2010 we achieved 94 percent compliance before patient contact and 97 percent after contact.
  2. Central line-associated blood stream infections (CLABSI): An insertion protocol has been finalized and will lead to a standard approach Hospital-wide. As importantly, strict guidelines will be enforced for line access and maintenance.
  3. Foley catheter-related urinary tract infections: Catheters will not be inserted without clear medical justification (and recall Is and Os are useless outside ICUs) and catheter removal at first appropriate opportunity will be expected.
  4. Physician orders: Verbal orders will be strictly limited to emergency/exceptional circumstances; and all treatments will be based only on licensed provider orders.
  5. University protocol/time out check list: As noted above, adherence to a defined protocol and related documentation will be required within and without the Operating Room.
  6. Restraints: Improvement in compliance with policy and procedures for restraint ordering and safety monitoring has been impressive over the last two years and will be closely monitored and enforced in 2011.

Each of these topics has profound safety implications and will be more fully detailed in future editions of this Bulletin.

Reducing hospital re-admissions

Even before healthcare reform legislation this summer, YNHH had been working to improve its discharge planning coordination and instructions.

At the same time, Medicare and Medicaid (CMS) have made it a national priority to reduce the number of hospital readmissions for patients. National readmission rates have become such a problem that CMS has told providers that it will demand to be reimbursed if hospitals and other caregivers do not drive down readmission rates. In fact, by 2012, a hospital's reimbursement for care will be partially based on its success in keeping its patients from being readmitted.

At YNHH, 38 care coordinators - all registered nurses - work on all inpatient services and the oncology clinics to assess patient readiness for discharge, provide patient/family discharge instructions and work with them to select the best discharge setting.

Care coordinators, in conjunction with the team, will continue to be persistent about assuring all elements of the discharge plan are in place, including proper teaching for medications and making a certain follow-up appointment is made prior to discharge.

Care Coordinators in the emergency department maintain communications with homecare nurses and skilled nursing facilities to help prevent unnecessary readmissions.

EPIC update

The pace of the Epic project rollout has picked up, with new leadership and staff being recruited and trained. Lisa Stump has been named Vice President and Epic Project leader. As the hospital's administrative director of Clinical Informatics since 2008, Stump has coordinated electronic medical record documentation and worked on integrating data transmission between YSM and YNHH systems. Under her direction and that of Daniel Barchi, new Chief Information Officer for Yale School of Medicine and Yale New Haven Health System, other senior executives have been appointed, including:

  • Richard Lisitano, system vice president, responsible for leading the Epic inpatient clinical integration
  • John Skelly, system vice president, responsible for integrating the revenue cycle and related areas across the Enterprise, assisted by Marianne Dess-Santoro, chief operating officer, Yale Medical Group
  • David W. Smith, PhD, executive director, responsible for the ambulatory and community physician integration
  • Kevin McCaffrey, manager of Epic training
  • David Christiano, director for EMR Technology

Most of the Epic team — which will total about 120 employees — has been recruited and is in the process of being trained in Wisconsin and in the new Epic office at 99 Hawley Lane in Stratford.

Epic will create a common electronic medical record across the continuum of care — inpatient, ambulatory, physician practices, all three System hospital and their affiliated organizations. It will be implemented first in outpatient settings - including Yale Medical Group, Northeast Medical Group and YNHH community physician practices in late fall 2011. Between January and April 2011, numerous subject experts — including members of the Medical Staff — will be invited to sessions designed to solicit input for the development of the EMR which will be built and validated during the summer for a fall roll-out in the ambulatory physician practices.

Additionally, YNHHS is focused on making Epic a tool that all members of the medical community can use. Physicians who practice at YNHH and other YNHHS hospitals will have onsite and remote access to Epic for management of their inpatients. Furthermore, YNHHS is offering Epic at a subsidized rate to physicians to use in their own practices. Dr. Herbert sent a letter to physicians in the community in late October outlining the cost and time line for Epic availability and the role it can play in helping physicians achieve meaningful use of an EMR in order to qualify for federal stimulus funds.

For more information about Epic, contact Daniel Barchi, CIO, at 203-688-2100, daniel.barchi@ynhh.org or Dr. Steven Schlossberg, CMIO, 688-2100, steven.schlossberg@ynhh.org , or Lisa Stump, vice president, at 203.502.4810, lisa.stump@ynhh.org.

Recycling containers placed on patient care units

Since April, when YNHH installed three recycling machines in the cafeterias, 8,000 bottles and cans have been redeemed. The hospital is now placing "single-source" recycling containers in patient care unit conference rooms and/or staff lounges. These receptacles accept all recyclable materials (paper, cardboard, plastic, glass and aluminum). Environmental Services staff will collect the contents from the new containers and All-American Waste, the hospital's vendor, will take the material to its plant where it will be automatically separated for recycling. Employees and staff are reminded that patient information is NOT to be recycled in these containers.

New clinical recruits at Smilow Cancer Hospital

New recruits related to the opening the Smilow Cancer Hospital include:

  • Anees Chagpar, MD, section of Surgical Oncology, is the new director of the Smilow Breast Center. Dr. Chagpar joins us from the University of Louisville School of Medicine.
  • Deborah Chirnomas, MD, assistant professor of Pediatrics, is director of pediatric bone marrow transplantation at Smilow Cancer Hospital. She joins us from Children's Hospital Boston.
  • Leonard Farber, MD, clinical professor of Medicine, Medical Oncology, has joined the YCC and Smilow Cancer Hospital clinical staff from Medical Oncology & Hematology, P.C. of New Haven.
  • Mark Faries, MD, associate professor of Surgical Oncology, has joined the Smilow Melanoma Program. Dr. Faries, who specializes in the surgical treatment of melanoma, comes to us from the John Wayne Cancer Institute.
  • Howard Hochster, MD, professor of Medicine, Medical Oncology, is the new medical director of Smilow Gastrointestinal Oncology Program. Dr. Hochster joins us from New York University School of Medicine and the NYU Cancer Institute.
  • Erin Hofstatter, MD, assistant professor of Medicine, Medical Oncology, has joined the Smilow Breast Cancer Program in high-risk cancer genetics. She was chief resident in Medicine at Mount Auburn Hospital/Harvard Medical School.
  • Nina Horowitz, MD, has joined the Smilow Breast Center and the Surgical Oncology faculty. Dr. Horowitz has built a strong practice in New Haven and been affiliated with YNHH and YSM for the last 26 years.
  • Michael Hurwitz, MD, PhD, assistant professor of Medicine, Medical Oncology, has joined the Smilow Prostate and Urologic Cancers Program and will care for patients with genitourinary cancers. He joins us from Massachusetts General Hospital and Harvard Medical School.
  • Benjamin Judson, MD, assistant professor of Otolaryngology in the department of Surgery, has joined the Smilow Head and Neck Cancer Program. He was an assistant instructor at Memorial Sloan-Kettering Cancer Center and a research fellow at Weill Medical College of Cornell University.
  • Arthur Levy, MD, associate clinical professor of Medicine, Medical Oncology, has joined the YCC and Smilow Cancer Hospital clinical staff from Medical Oncology & Hematology, P.C. of New Haven.
  • Miguel Materin, MD, professor of Ophthalmology, is the director of Ocular Oncology, a specialty that involves diagnosis and treatment of patients with ocular tumors, including benign and malignant tumors of the eye. Dr. Materin comes to us from Wills Eye Hospital at Thomas Jefferson University in Philadelphia.
  • Abhijit Patel , MD, has joined the department of Therapeutic Radiology, with clinical interests in prostate, lung, breast cancer and GI cancers and general radiation therapy. Dr. Patel trained at Massachusetts General Hospital and Memorial Sloan-Kettering Cancer Center.
  • Nikolai Podoltsev, MD, has joined the Smilow Hematology Program after completing a fellowship at Yale School of Medicine earlier this year. His clinical interests are myeloprolipherative disease, myelodysplastic syndrome and leukemia.
  • Katerina Politi, MD, is an assistant professor in Pathology (tissue and organ diseases) and the Yale Cancer Center with research interests in cancer biology, molecular basis of lung cancer, epidermal growth factor receptor and targeted therapy.
  • Tara Sanft, MD, assistant professor of Medicine, Medical Oncology, is the new medical director of adult survivorship for the Connecticut Challenge Survivorship Clinic at Yale Cancer Center. She was previously the chief fellow in oncology and palliative care at Northwestern University Feinberg School of Medicine.
  • Stacey Stein, MD, assistant professor of Medicine, Medical Oncology, has joined the Smilow Gastrointestinal Cancers Program. She was the chief fellow in Hematology/Oncology at New York University Medical Center

Patty Lee, new interim chief of Pulmonary and Critical Care

Patty J. Lee, MD, has been named interim chief of pulmonary and critical care, replacing Lynn Tanoue, MD, who is the new vice chair for clinical affairs in the department of Medicine. Dr. Lee came to YNHH as an associate research scientist and instructor in Medicine in 1998, after completing her residency and serving a fellowship in pulmonary and critical care at Johns Hopkins. She received her undergraduate and MD degrees from Brown University. Dr. Lee's clinical interests include acute lung injury and adult respiratory distress syndrome and her research centers on lung injury and repair. She is an associate professor of Medicine at Yale and was previously director of Respiratory Therapy at the VA Medical Center in West Haven.

YNHH creates new Off-Shift Executive (OSE) role

This summer, under the direction of Sue Fitzsimons, RN, PhD, and Norman Roth, YNHH has implemented a new process to better oversee patient safety and quality, as well as engage and recognize employees during off-shift hours. YNHH created a new position of off-shift executive (OSE) — individuals work through the "off-shifts" — Monday through Thursday between 7 pm and 7 am and from Friday 7 pm until 7 am Monday. The OSEs work in partnership with the Centralized Staffing and Scheduling Department to ensure adequate staffing on every inpatient unit; the Clinical Bed Management office to ensure placement of the right patient in the right bed the first time; and the Off-Shift Nurse Leaders (OSNLs) as they engage staff in clinical decision-making and education. Since July, nearly two dozen department heads have piloted the new overnight OSE role and will continue to journey with the newly hired OSEs during the upcoming months to fully orient and train them. Paula Crombie, MSW, and Tahiry Sanchez, RN, MS, have synchronized and actualized the new role. Three new OSEs have been hired: Jeff Maloney, Gary Smart and Gonzalo Solis. Sanchez and Crombie are currently leading the group through the orientation process and the OSE implementation.

To contact:

  • Off-shift Executive: 203-430-9734
  • Clinical Bed Manager: 203-688-5050
  • Centralized Staffing and Scheduling: 203-430-9716
  • Off-shift Nurse Leader: 203-430-8204

Phone coverage 24/7 for physician calls for bed management/transfer will remain as follows:

  • Medicine: 688-4520
  • Surgery: 688-4538
  • Pedi/OB: 688-4442

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