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Medical Staff Bulletin

August/September 2013

Contents - August - September 2013

A message from the Chief of Staff
We do not regularly report in the Medical Staff Bulletin our progress reaching Yale New Haven Health System-wide quality and safety objectives, but these are well worth comment. Results include our success in achieving CMS Value-Based Purchasing (VBP) clinical process of care objectives, implementing the HPI (CHA) serious safety event initiative at level 2, and our compliance with hand hygiene. In future Bulletins, we will take up the VBP and HPI initiatives and, this month, consider where we are with hand hygiene compliance and our next steps.

Our drive to achieve universal and 100 percent hand hygiene compliance is now in its 14th year! As a health system (as of July 2013), we are 91 percent compliant with "washing in and out." Bridgeport and Greenwich hospitals drove hand hygiene only in more recent times, but used a very impactful change technique termed the "Influencer Model" to rapidly improve hospital performance. This model, employing several simultaneous "influences," is now in use at YNHH, where our compliance in July was 92 percent.

A major deficiency in our current approach relates to the fact that all observations of hand hygiene are made during the day shift, and only on week days. I have concerns about performance on the remaining 16 of 21 shifts, because our various nosocomial infection rates, while improved, have yet to reach the low levels reported by a few other hospitals nationwide. Starting in September, we began making observations on evenings, nights and weekends. We have enlisted help and are training unit-based hand hygiene champions from the off-shifts to encourage and enforce our standards. We remind all members of the Medical Staff to thank anyone who calls attention to even a momentary lapse in our "wash in, wash out" requirement.

New Medical Board members at large
As a result of the recent election process, Adam Mayerson, MD, and Karen Dufour, MD, both from Internal Medicine, were elected to serve a second three-year term as members at large of the Medical Board. Mary Ellen Flaherty-Hewitt, MD, Pediatrics; David Lima, MD, OB/GYN; Erin Springhorn, MD, Pediatrics; and Ken Yanagisawa, MD, Surgery, were elected to their first term. The Medical Board thanked Stephen Possik, MD, Internal Medicine; John Federico, MD, Surgery; Lee Jung, MD, Internal Medicine; and Harold Tara, MD, Internal Medicine, who completed their terms this June.

Revised Medical Staff bylaws and rules and regulations
The Medical Board, Medical Staff and Patient Safety and Clinical Quality Committee of the YNHH Board of Trustees recently approved changes to the Medical Staff Bylaws and Rules & Regulations. For your reference, the new bylaws and rules are posted on the Yale-New Haven Hospital Internet (www.ynhh.org) under the "Medical Professionals" tab.

Performance Management update

June 2012 - May 2013
CMS/TJC Core Measures Performance


AMI
#
YNHH%
Nat’l 90th%
ASA at arriv.
295/295
100
100
ASA at D/C
268/272
99
100
B-Block at D/C
262/294
99
100
Statin D/C
256/262
98
100
PCI
30/30
100
100
       
CHF
#
YNHH%
Nat’l 90th%
LVEF assess.
322/322
100
100
ACEI at D/C
74/83
89
100
D/C instr. given
202/228
89
100
       
Pneumonia
#
YNHH%
Nat’l 90th%
Blood Cx before Abx
182/192
95
100
Initial (ICU and non-ICU)
Selection Abx
73/75
97
100
       
SIP
#
YNHH%
Nat’l 90th%
Proph Abx 1 hr
364/376
97
100
Abx selection
369/374
99
100
Proph Abx D/C
346/350
99
100
DVT proph ordered
382/386
99
100
DVT proph given
394/397
99
99
6 am glucose
109/115
95
100
BB Periop period
236/236
100
100
Foley removal POD2
362/386
94
100

Traditionally, summer tends to be a slower time with vacations, but not summer 2013! We began with Epic implementation on the Saint Raphael Campus on June 1. On the heels of an extremely successful implementation, Joint Commission Resources arrived for a full mock survey to test our patient safety and quality programming across our 160+ sites of care with York Street and Chapel Street as our main hub. This was the first time that we have comprehensively simulated a full survey since the integration. We are pleased to report that this went extremely well. As with all surveys, there are opportunities for improvement and in terms of implications for the medical staff, there were a few significant issues that were noteworthy. These include some concerns about hand hygiene and proper patient identification, as well as how we manage infection control in ambulatory settings, use personal protective equipment for patients with infections, and how we follow our policies for informed consents and sedation.

Shortly after this visit, we received an unannounced visit from the Department of Public Health. Although we are due for a triennial licensure survey anytime, the focus of this survey was to review some 40+ complaints and reports provided to DPH regarding quality and safety issues. Again, opportunities were identified but, all in all, we were extremely pleased with the outcome. Medical Staff implications from this survey include similar items as cited above. Additionally, some surgical practices showed opportunities for improvement as did infection control practices. As we move into the fall, we must be vigilant regarding our efforts to remain prepared for our unannounced triennial Joint Commission Survey before the end of the year. As mentioned previously, both campuses are working hard to maintain everyday readiness for survey but, more importantly, the next patient.

As you look at the chart, you will see the 12-month performance for Yale-New Haven Hospital (June 2012 to May 2013). This includes the Saint Raphael Campus in the denominator of all the performance measures and the registries effective Sept. 12, 2012, as well as Epic implementation for York Street Campus effective Feb. 1, 2013. We are pleased to note that there continues to be a positive change in performance of these measures over time. Please direct any questions to Tom Balcezak, MD, (203) 688-1343.

"Ongoing" and "focused" professional practice evaluation
In accordance with requirements of The Joint Commission, all members of the Medical Staff holding clinical privileges are subject to Ongoing Professional Practice Evaluation (OPPE). The OPPE process occurs every six months and includes a review of certain measures associated with your practice at YNHH. Examples of these measures include length of stay, morbidity, complications and compliance with Medical Staff Rules surrounding timely completion of operative notes. Hospital-based departments use measures that are specifically relevant to their practice. New members of the Medical Staff and any current Medical Staff member requesting any new privilege are subject to Focused Professional Practice Evaluation (FPPE). Six months after any new privileges are approved for individual members of the Medical Staff, the practitioner's activity at YNHH must be reviewed to determine whether the privilege has been used and, if used, confirm that competence has been demonstrated. Depending upon the circumstances, privileges that are not exercised may not be continued or may be subject to proctoring.

Medical Staff without clinical privileges who are appointed to the "Refer & Follow Attending/Associate" category are not subject to OPPE or FPPE.

Medical Staff policies concerning Ongoing and Focused Professional Practice Evaluation are posted on the Yale-New Haven Hospital website (www.ynhh.org). Click the link for "Policies" under the "Medical Professionals" header. If you have any questions concerning the "OPPE" or "FPPE" process, please contact Theresa Zinck Lederer or Jon Wrubel in the Department of Physician Services at (203) 688-2615.

YNHHS signs letters of intent with both Vanguard and Eastern CT Health Network
Yale New Haven Health System has signed two separate, but related, letters of intent (LOI) — one with Vanguard Health and the other with Eastern Connecticut Health Network (ECHN).

Yale New Haven Health System and Vanguard Health have signed a letter of intent which will create an innovative new partnership blending the strengths of both nationally recognized organizations. The alliance would give YNHHS access to Vanguard's management expertise, resources and capital, while Yale New Haven Health System and all of its delivery networks (Yale-New Haven Hospital, Bridgeport Hospital, Greenwich Hospital and Northeast Medical Group) remain not-for-profit.

Under the proposed partnership, Vanguard and Yale New Haven would remain separate organizations but would create a new organization dedicated to population health management and aligning selected hospitals and physicians in the region.

Under the terms of the LOI, the Vanguard/Yale New Haven alliance would purchase the assets of ECHN and provide the capital necessary to ensure the ongoing local delivery of care. Vanguard would manage and operate both Rockville General and Manchester Memorial hospitals and commit to an investment of capital that will enhance the long-term financial stability of ECHN. Yale New Haven Health System would provide ongoing clinical support, quality and service line management. The strategic relationship provides a unique opportunity for ECHN to develop a strong clinical partnership with a leading academic medical center like Yale-New Haven to preserve local access and scope of care. In both transactions, the LOI represents the first of many steps that the organizations must go through, leading up to a definitive agreement that, once signed, would initiate a broader regulatory review by appropriate state and federal agencies. Connecticut's governor recently vetoed legislation that would enable non-profits like Vanguard to operate medical foundations. In addition, Tenet Healthcare Corporation announced in June that it planned to purchase Vanguard. That transaction is expected to close by the end of the year.

Podiatry becomes a YNHH clinical department
YNHH will be transitioning the section of Podiatry in the department of Orthopedics and Rehabilitation to an independent department within the Hospital, in conjunction with the creation of the Musculoskeletal Center on the Yale-New Haven Saint Raphael Campus (SRC). Academic faculty appointments, when appropriate, will continue to be considered through the department of Orthopedics and Rehabilitation. Stephen Vyce, DPM, assistant clinical professor in Yale's department of Orthopedics and Rehabilitation, has been recruited to be chief of the new department and will be responsible for credentialing and re-credentialing department members, overseeing the development and direction of the YNHH inpatient and ambulatory Podiatry services, develop a robust Podiatry practice as part of the Saint Raphael Campus (SRC) Musculoskeletal Center, and serve on the SRC Clinical Leadership Group.

Dr. Vyce is certified in both foot surgery and reconstructive rear foot/ankle surgery by the American Board of Podiatric Surgery. Since 2007, he has led the Podiatry Section at the VA Connecticut Healthcare System in West Haven and, in 2008, was appointed program director of the Yale Podiatric Medicine and Surgery Program. Dr. Vyce is a graduate of the New York College of Podiatric Medicine and was a resident and chief resident in podiatric surgery at University of Medicine and Dentistry of New Jersey.

David Mulligan, MD, named new chief of Transplant
David Mulligan, MD, has been appointed director of the YNHH transplantation center, chief of transplantation and immunology, and professor of surgery at Yale School of Medicine, as of September 1. Mulligan succeeds Sukru Emre, MD, a renowned adult and pediatric abdominal organ transplant surgeon who transformed the Yale transplant program into a regional leader in the evaluation and the treatment of liver disease.

Dr. Mulligan is also a liver transplant specialist with international acclaim for his work in living donor liver transplantation. He spent 15 years with the Mayo Clinic in Arizona, and was involved in the establishment of a solid organ transplant program. He worked with a team that is famous for steroid-sparing immunosuppression, protocol biopsies to study early inflammatory markers that lead to chronic kidney damage, and using donor kidneys with acute kidney injury for successful transplantation. Collaboratively, Dr. Mulligan and his colleagues performed nearly 3,000 solid organ transplants with outstanding clinical outcomes. He is a devoted champion for organ donations on a national scale.

Gary Desir, MD, named interim chief of Internal Medicine
Gary V. Desir, MD, chief of the medical service at the VA Connecticut Healthcare System in West Haven since 2004, will become interim chief/chair of the YNHH, Yale School of Medicine department of Internal Medicine. Dr. Desir will serve in the interim position while a national search is conducted. He fills the vacancy left by Jack A. Elias, MD, who became the dean of Brown University's Alpert Medical School.

Dr. Desir received his MD from Yale in 1980 and completed his residency and fellowship in nephrology at YNHH. After postdoctoral work at the School of Medicine, he joined the faculty in 1987 as an assistant professor. Dr. Desir also is a member of the faculty at Yale School of Forestry and Environmental Studies, where he has co-taught a course in sustainable development in post-disaster Haiti. He was part of a team of clinicians who traveled to Haiti after the January 2010 earthquake.

David Greer named director YNHH Stroke Service
David M. Greer, MD, vice chairman of Neurology, has been named director of the Stroke Service at Yale-New Haven Hospital. In this new position, Dr. Greer is responsible for the clinical, educational and research endeavors of the Stroke Service, including in the emergency, inpatient and outpatient settings. Dr. Greer expects to establish a dedicated inpatient stroke unit and expand outpatient services. He will continue to serve as residency program director and director of medical services for the department of Neurology at Yale School of Medicine. Joseph Schindler, MD, continues to serve as the director of the Acute Stroke Service, Karin Nyström, APRN, as the clinical coordinator, and Anne Froelich, RN, as stroke coordinator, Saint Raphael Campus.

New YNHH blood draw station opens in Wallingford
Yale-New Haven Hospital has opened its 18th blood draw station offering services for adults and children at 665 North Colony Road, Wallingford. The station is open Monday-Friday, 7 a.m.-5:30 p.m. (closed daily 12:30-1 p.m.) and Saturdays, 8 a.m.-noon. No appointment is necessary; most major insurance plans are accepted. For information, call (203) 265-5409. The hospital has other blood draw stations in Branford, Clinton, East Haven, Guilford, Hamden, Madison, New Haven, North Haven, Norwalk and West Haven.

Urology Center now part of YNHH
On July 15, the Urology Center, which has served patients in Greater New Haven since 1969, integrated with Yale-New Haven Hospital and Yale Medical Group. Six urologists and 30 staff members are now affiliated with Yale Medical Group and YNHH, respectively. The urologists are: Richard J. Dean, MD, Ralph J. DeVito MD, David G. Hesse, MD, Stanton C. Honig, MD, Mary Grey Maher, MD, and Thomas V. Martin, MD. The physicians treat a wide range of conditions, including bladder and kidney cancer, erectile dysfunction, renal stones, incontinence, kidney conditions, prostate conditions and urinary tract infection. Their specialty areas include female urology, robotic surgery and male infertility.

The integration increases patients' access to YNHH resources, including advanced screening and diagnostic services, genetic counseling, psychosocial support and pain management for all urologic conditions, as well as access to Smilow Cancer Hospital.

Achieving "Meaningful Use:" The After Visit Summary and MyChart
One of the standards for meeting "Meaningful Use" for a provider is the ability to give After Visit Summaries (AVS) to patients at the end of an office or hospital visit. The AVS improves the ability of patients to remember, and, if necessary, tell their family members what happened with their care team during an office or hospital visit.

Another way to meet "Meaningful Use" is to communicate with your patients electronically. The best way to do this is through the Epic patient portal MyChart. Patients can request prescription renewals through their MyChart account and you can e-prescribe the renewal to their preferred pharmacy. You and your team should encourage patients to enroll in MyChart. The activation code that allows a patient to enroll in MyChart appears at the bottom of the AVS and you can give each patient a MyChart brochure to explain the program features. You will not receive direct emails from patients since everything is done via InBasket within the Epic application. Practice staff are encouraged to share responsibility to triage these InBasket messages before they reach you. Since launching Epic across the health system, more than 20,000 patients have already registered for their EMR access through their primary care doctors. If you have questions or want a MyChart demonstration or MyChart patient brochures, please contact MyChartsupport@ynhh.org

Saint Raphael's Neonatal Intensive Care Unit
On July 1, the Neonatal Intensive Care Unit on the Saint Raphael Campus transitioned to a Level I newborn nursery. As a consequence, on those unusual times when a woman delivers before 35 weeks, babies will be triaged to the 54-bed level IV Neonatal Intensive Care Unit at the 20 York Street facility. This change allows for a consolidation of critical care resources and reflects a broader national trend of fewer deliveries of multiples and fewer very low birth weight babies. The number of SRC deliveries affected by this change is estimated to be only 1-2 per month. At SRC, there will be 24/7 neonatal APRN/physician assistant coverage to attend deliveries and care for any infant who needs short term neonatal care. Neonatology at YNHCH will maintain 24/7 on-call coverage of SRC to consult and respond as needed.

New online YNHCH Pediatric Update physician newsletter available
Yale-New Haven Children's Hospital Pediatric Update is now available online. Each issue highlights a clinical service in addition to news of YNHCH programs and events. To subscribe to the bi-monthly newsletter email: site editor@ynhh.org and please include Pediatric Update in the subject line.

YNHH again recognized by U.S. News & World Report
Yale-New Haven Hospital is the only Connecticut hospital to rank among the top U.S. hospitals, according to U.S. News & World Report's annual "America's Best Hospital's." Of the nearly 5,000 hospitals surveyed, YNHH ranks nationally in 10 of 16 specialties.

Diabetes and endocrinology ranks in the nation's top 10 at #6, while psychiatry is at #11, gynecology at #14, and gastroenterology and GI surgery at #18. In addition, Yale-New Haven is ranked among the best nationally in six other medical specialties: cancer, cardiology and heart surgery, ear, nose and throat, geriatrics, nephrology and pulmonology. According to U.S. News, hard numbers support the rankings in most specialties — death rates, patient safety, procedure volume and other objective data. The national listing is available online at www.usnews.com/besthospitals

Changes to requirements for licensure renewal
Effective July 1, 2013, the Connecticut Department of Public Health requires that physicians have at least one contact hour of education or training in behavioral health. This is in addition to training already required on the topics of infectious disease, risk management, sexual assault, domestic violence and cultural competency.

Requirements have also changed in that after July 1 training in these areas is necessary every six years rather than every two years. Fifty CME credits in an area of the physician's practice and reflecting his/her professional needs and needs of the public is still required every two years.

YNHHS nationally recognized for healthcare equality
The national Human Rights Campaign (HRC) Foundation has recognized Yale New Haven Health member hospitals for their commitment to equitable, inclusive care for lesbian, gay, bisexual and transgender (LGBT) patients and their families, who can face significant challenges in securing adequate health care.

Leaders in LGBT Healthcare Equality meet key criteria for equitable care, including non-discrimination policies for LGBT patients and employees, a guarantee of equal visitation for same-sex partners and parents, and LGBT health education for key staff members. Bridgeport, Greenwich and Yale-New Haven hospitals are among 464 healthcare facilities nationwide named "Leaders in LGBT Healthcare Equality" in the Healthcare Equality Index 2013, an annual survey conducted by the HRC Foundation.

 

 

 

 

 

 

 

 

 

 

 

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