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Medical Staff Bulletin

Contents — July- August 2012

A message from the Chief of Staff

Attention Medical Staff
and Affiliated Medical Staff

If you have changed your office address, phone or fax number, home address or phone number, mobile phone number or pager number, please contact the Department of Physician Services at 203-688-2615 or email the information to: physiciansvcs@ynhh.org

Almost daily, I hear concerns about discontinuity in care of patients presenting to our Hospital. Manifestations include failure to notify personal physicians that their patients have come for emergency care or that they have been admitted to hospital, have died, or have been discharged expecting responsible post-acute care.

I have contributed to this discontinuity as often as others. I focus on the acute event that has brought a patient under my care, which has led me to ignore other physicians who have delivered ambulatory care for years or who have been consulted during previous hospitalizations. I have failed to ask patients or families who should be notified of their current status. I have consulted a surgeon or cardiologist who differed from the specialists rendering care during a recent admission for the same problem. I have repeatedly depended on others to inform my patients' physicians of changes. Without communicating, I have made changes in current medications, kept to myself new information emerging from diagnostic evaluations, and failed to clarify what patients needed from community physicians in the days and weeks after hospital discharge.

Attendings, residents and fellows, who mostly work in the Hospital, easily lose sight of the continuum of care. Our perspective is hospital-centric. We generally ask others to make connections for us, sometimes viewing such communication as a clerical task. We fail to model good communication for our trainees who, in turn, neither value nor practice such communication. Even within the Hospital, we often leave hand-offs to others and do not share with other attendings, except through cryptic notes, our views of patient issues.

We cannot anticipate that electronic information systems, trainees or clerical staff will fill the current gaps in our communication system. Each physician, nurse practitioner and physician assistant must take personal ownership on the continuum of care. Patient-centered care requires that we do so.

YNHH expects to close HSR transaction week of Sept. 9

The transaction with the Hospital of Saint Raphael is now expected to close the week of September 9. The postponement allowed YNHH to complete due diligence concerning how it will be paid for Medicare and Medicaid services after the closing.

"Yale-New Haven Hospital and the Hospital of Saint Raphael remain fully committed to integration and the transaction continues to make sense for all the reasons we have articulated," said Marna P. Borgstrom, YNHH CEO. "In the meantime, we continue to work on Day One preparations and operational planning to ensure a smooth transition."

Performance Management update

January-Apr. 2012 CMS/TJC
Core Measures Performance


AMI
#
YNHH%
Nat’l 90th%
ASA at arriv.
171172
99
100
ASA at D/C
157/165
95
100
B-Block at D/C
148/153
97
100
ACEI at D/C
18/19
95
100
PCI
11/13
85
100
Smoking cess
21/22
95
100
 
CHF
#
YNHH%
Nat’l 90th%
LVEF assess.
164/164
100
100
ACEI at D/C
39/39
100
100
Smoking cess.
15/15
100
100
D/C instr. given
92/117
79
100
 
Pneumonia
#
YNHH
% Nat’l 90th%
Pneum. vac. given
17/22
77
100
Abx given
24/27
89
100
Smoking cess.
19/19
100
100
Init. (non-ICU)
Blood cx before abx
66/73
90
100
Selection Abx
25/25
83
99
Influenza vaccine
25/37
68
100
 
SIP
#
YNHH%
Nat’l 90th%
Proph Abx 1 hr
182/185
98
100
Abx selection
182/85
98
100
Proph Abx D/C
166/170
98
100
DVT proph ordered
259/264
98
100
DVT proph given
259/264
98
100
6 am glucose
80/86
93
99
BB Periop period
175/183
96
100
 
Pedi asthma
#
YNHH%
Nat’l 90th%
Inpatient relievers
112/112
100
100
Inpatient steroids
112/112
100
100
Home manag plan
86/111
86
90

At left are our familiar performance measures that we report to TJC and CMS each month. The ones in bold determine part of our value-based purchasing performance payments.

We are measured in many other ways as well, and by many other agencies and organizations. In the past month, three major groups have issued press releases regarding YNHH data. Our core measure data, our mortality/readmission data for heart failure, pneumonia, and acute myocardial infarction (through Q4 of 2011) were published on Hospital Compare. Our safety and quality performance, as assessed by the Leapfrog group, was announced, and Consumer Reports announced the results of similar analyses of our performance.

The highlights of the recent Hospital Compare release are no surprise to readers of this column; we have been reporting this data real-time. We still have substantial room to improve in a number of areas. AMI and HF performance is generally quite good, but we continue to see variability in PCI performance. This is due to the small number of qualifying cases. Instructions in HF challenge us due to the complex nature of the metric and our inconsistency in performing medication reconciliation. SCIP measures have been described in detail here before, and we have made remarkable progress over the past year. Our ability to provide vaccinations and select the correct initial antibiotics in patients with pneumonia continue to challenge us. Our colleagues in Nursing and the Pharmacy are working diligently to improve this.

The big news for this release is our continued outstanding performance on the HF, AMI and pneumonia mortality metrics. We remain one of very few hospitals in the nation that can boast lower-than-expected mortality for all three conditions since the introduction of this metric. Also important to note is that our readmission rates continue to improve. With the first release of this metric we had a significantly higher rate of readmission for both pneumonia and HF. With this release, we are not different from US hospitals in any of the three conditions.

Our reported performance on the recently announced Leapfrog and Consumer Reports studies is worthy of careful consideration and serious discussion. Many quality and safety experts have serious concern over the methodology, motivation and conclusions drawn by these two studies. Both rely heavily on billing data, which is not a scientifically validated or proven measure of safety and quality, and there is much evidence that billing data are faulty indicators of quality. Furthermore, we do not participate in the Leapfrog survey, and were penalized 170/200 points for not doing so. This is despite having best-in-class results for the two domains measured (ICU intensivist staffing and computerized physician order entry).

Over the past couple of years, we have made substantial progress at YNHH in improving patient safety and quality of care. We also continue to have many opportunities to improve further. Objective, comparable, scientifically valid measurement and reporting are critical to understanding if our efforts are resulting in gains. Reports such as these from Leapfrog and Consumer Reports are, at best, a distraction from our efforts.

If you have any questions, please contact Tom Balcezak at 203-688-1343.

New Medical Staff officers and board members-at-large elected, effective Sept. 1

The Medical Staff elected Dr. Joni Hansson (Internal Medicine/Nephrology) as the new president-elect of the Medical Staff and Dr. Daniel Boffa (Thoracic Surgery) as the new secretary/credentials committee chair. Dr. Thomas Sweeney (Vascular Surgery) will complete his term and Dr. Alan Friedman (Pediatric Cardiology) will assume the role of president. Dr. Robert McLean will also complete his term as secretary/credentials committee chair this summer. Special thanks to Drs. Sweeney and McLean for their dedication over the past two years.

The Medical Board has elected Drs. Kristin Aversa (OB/GYN), Karen Brown (Internal Medicine) and Joseph Quaranta (Internal Medicine) to serve three-year terms as new members-at-large and Dr. Kai Yang (Endocrinology) was elected to a second term. Drs. Joseph Camilleri (Urology), Susan Levy (Pediatric Neurology), Gary Wanerka (Pediatrics) and Norman Werdiger (Neurology) complete their terms this summer and the Medical Board formally acknowledged their contributions at the meeting in June. The Medical Board welcomes Drs. Ralph DeNatale (Vascular Surgery) and James Farmer (Anesthesiology) from the Hospital of Saint Raphael, who will become new members-at-large.

George Lister, MD, returns to become chief of Pediatrics

George Lister, MD, returns to New Haven in August to become chair and chief of the Department of Pediatrics, respectively, at Yale School of Medicine and Yale-New Haven Hospital, and physician-in-chief at Yale-New Haven Children's Hospital. Dr. Lister was a member of the Department of Pediatrics at Yale-New Haven for 25 years before moving to Texas in 2003. He is the Robert L. Moore Professor of Pediatrics and associate dean for education at the University of Texas Southwestern Medical School (UTSW). From 2003-2011, he served as chair of pediatrics at UTSW and pediatrician-in-chief at the Children's Medical Center of Dallas.

Dr. Lister graduated from Brown University and received his MD from Yale School of Medicine. He completed his pediatric residency at Yale-New Haven Hospital, followed by a fellowship in pediatric cardiology and neonatology at the University of California, San Francisco. There, Dr. Lister began research that led to his specialization in critical care medicine, a field in its formative stages at the time. He returned to Yale-New Haven in 1978. He rose to professor of Pediatrics and Anesthesiology, founded the Section of Critical Care and Applied Physiology at Yale-New Haven and was its chief for more than 20 years. He also created a Pediatric Critical Care Fellowship Program, which has trained a generation of pediatric critical care physicians across the country.

Dr. Lister's longstanding research interest in oxygen transport has contributed significantly to the understanding of cardiopulmonary interaction in congenital heart disease and cardiorespiratory control in infants at risk for sudden infant death syndrome. Throughout his career, Dr. Lister has also played an active role in medical education, for which he has received national recognition.

We would like to express our deep gratitude to Clifford W. Bogue, MD, who has led the Department of Pediatrics as interim chair. Dr. Bogue has done much to advance the mission of pediatrics at Yale and the Children's Hospital over the last three years and for that we are all very grateful.

YNHHS physician referral service

Yale New Haven's physician referral department provides information on our physicians to patients who contact us by phone or search on the web. For those physicians who are currently listed, please review your profile on the web site (ynhh.org/physician-finder) and notify us of any changes or updates. If you would like to be added to the referral service, please contact us directly at daniel.vener@ynhh.org.

Michael Bennick, MD, named medical director of Patient Experience

Michael Bennick, MD, associate chief of Medicine, has been appointed medical director of Patient Experience at Yale-New Haven Hospital. In this position, Dr. Bennick will work closely with employees, members of the medical staff, clinical chiefs and associate chiefs, medical directors and graduate medical education programs to enhance the patient experience across the continuum of care.

The success of YNHH's Service Excellence initiative has led to a more positive patient experience overall and improvements in patient satisfaction scores. YNHH is transitioning from a focus on Service Excellence to the entire Patient Experience, which reflects the full spectrum of a patient's healthcare interactions. Dr. Bennick will lead the ongoing work of the medical and Hospital staff in enhancing the patient experience.

Dr. Bennick is well prepared for this role. His undergraduate and graduate work focused on how individuals find meaning in the communities in which they reside and this set the stage for his early recognition of the critical importance of patient and family centered care. Early in his career, he was honored with the Terry Guth Award for Excellence and Humanism in Medicine, and for more than 15 years, has been recognized as one of Connecticut's "Top Doctors." His years as a respected clinician, educator and administrator, his proven success as a team player and his passion to improve the patient's experience make him uniquely qualified to fulfill this new role.

Recent recruits at Smilow Cancer Hospital

Lajos Pusztai, MD, joined Yale Cancer Center and Smilow Cancer Hospital from the University of Texas MD Anderson Cancer Center on August 1. Dr. Pusztai has been named head of Breast Medical Oncology, director of the breast cancer research group and co-director of the Cancer Genetics Research Program. He received his MD from the University of Medicine and Pharmacy in Bucharest, and his PhD from the University of Oxford.

Theodore Tsangaris, MD, has been appointed medical director of breast services for the Smilow Cancer Hospital Network as of July 1. He was previously chief of breast surgery and director of the Johns Hopkins Avon Breast Center at the Sidney Kimmel Comprehensive Cancer Center. Dr. Tsangaris received his medical degree from George Washington University School of Medicine.

Paul Eder, MD, is the new director of experimental therapeutics at Yale Cancer Center and Smilow Cancer Hospital as of July 1. Dr. Eder comes from AstraZeneca and the Dana Farber Cancer Institute. Dr. Eder received his medical degree from Georgetown University School of Medicine, where he also completed his internship and residency. He completed a clinical fellowship in hematology and oncology at Beth Israel Hospital and the Dana Farber Cancer Institute.

Daniel P. Petrylak, MD, is professor of Medical Oncology and new head of the genitourinary cancers medical oncology team and director of the prostate cancer research group at Smilow Cancer Hospital, as of September 1. Dr. Petrylak comes from New York Presbyterian Hospital/Columbia University Medical Center. Dr. Petrylak received his MD from Case Western University School of Medicine and completed his residency at Albert Einstein College of Medicine and fellowship in medical oncology at Memorial Sloan-Kettering Cancer Center.

Epic update: What is "meaningful use" of an electronic medical record?

The federal Electronic Health Record Incentive Program, more commonly referred to as "meaningful use," specifies the criteria hospitals and physicians must meet to receive federal incentive payments to implement an EMR. To achieve meaningful use, physicians must capture data in structured fields using a certified EMR. These include height, blood pressure, weight, smoking status and up-to-date medication, problem and allergy lists. Medications must be prescribed electronically and patients must receive a summary of their appointment after each visit.

Demonstrating meaningful use with Epic makes physicians eligible for federal incentive payments in either the Medicare or the Medicaid incentive program, but not both. The maximum first-year incentive payment for eligible professionals is $18,000 for Medicare and $21,500 for Medicaid. In the Medicare incentive program, professionals can earn up to $44,000 over five years for meeting meaningful use criteria.

Physicians who are using Epic in their offices but have not applied for maximum incentive dollars have until September 30, 2012 to begin the attestation process for demonstrating 90 days of meaningful use before the end of the year.

The last year a physician may begin using an EMR to qualify for the incentive payments is 2014 for Medicare and 2016 for the Medicaid program. Physicians unable to demonstrate meaningful EMR use by 2015 will face financial penalties from Medicare and Medicaid.

YNHH physicians who use Epic, a federally certified EMR, are achieving meaningful use compliance through adjustments to their practice workflows. As of July 1, 2012, 10 physicians who have implemented Epic — from Yale Medical Group, Northeast Medical Group and a Fairfield-based community practice — have successfully attested to meeting 90 days of meaningful use criteria under the Medicare portion of the stimulus program. Already over 200 YNHHS physicians are using Epic's EMR in their practices and another 100 will be using the system by the end of summer.

YNHH is scheduled to go live on Epic in February 2013, and the Saint Raphael Campus in June 2013. For more information about Epic and the meaningful use incentive program, contact Amber Patterson, meaningful use coordinator on the Epic project, at 203-502-4902.

Geriatrics and Cardiology establish outpatient syncope and falls evaluation centers

The Adler Geriatric Assessment Center and Yale Cardiology have established a joint syncope and falls evaluation program to assess and treat patients with these conditions. Patients with syncope will be evaluated by Yale-New Haven cardiologists in the Yale Physicians Building. Patients with recurring falls, without loss of consciousness, will be assessed by geriatricians in the Adler Geriatric Assessment Center on Howard Avenue. YNHH healthcare providers may refer patients to the appropriate evaluation center. For syncope evaluation, call 203-785-4126 and press #1. For falls evaluation, call the Adler Center at 203-688-6361.

New process for conducting discharge

Yale-New Haven Hospital has improved its post-visit discharge telephone call process — with the goal of improving patient satisfaction and clinical outcomes and decreasing readmission rates. Interdisciplinary teams of YNHH clinicians call patients within 48 hours of an inpatient stay, outpatient procedure or an emergency room visit. Clinicians ask patients key questions that reinforce their discharge instructions and the importance of taking their medications and following up with their medical providers. Patients are also asked if there are any areas that the hospital can improve on, and if there are any employees or physicians they would like to recognize for exceptional care. If a discharge call reveals that a patient needs an intervention to prevent a readmission or decompensation in their clinical status, the clinicians may seek consultation with physicians.

Yale-New Haven Hospital is recognized again by U.S. News & World Report

Yale-New Haven Hospital continues to be ranked among the top hospitals in the United States by U.S. News & World Report in its 2012-13 "America's Best Hospitals" listing. Of the 5,000 hospitals and nearly 10,000 specialists surveyed nationwide, only 140 hospitals were nationally ranked in more than one specialty. YNHH ranked at the national level in 10 of the 16 specialties surveyed.

YNHH had one specialty ranked in the nation's top five: diabetes and endocrinology at #5, while psychiatry at #11 and gynecology at #13 also ranked extremely high. YNHH is the only hospital in Connecticut to be included in the U.S. News & World Report national listings and among the highest ranked in the region.

Yale-New Haven also ranked among the very best in the nation in seven additional medical specialties: cancer; heart and heart surgery, gastroenterology, geriatrics, kidney disorders, ear, nose and throat 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. Responses to a national survey in which physicians were asked to name hospitals they consider best in their specialty for the toughest cases also were factored in. The entire national listing is available online at www.usnews.com/besthospitals

Updated visitor policy 2012

YNHH has updated its visitor policy to better serve patients, family members and guests, and to respect patient privacy, while preserving the safety and integrity of patient care. General visiting hours are 10 a.m.—8 p.m., and children must be accompanied by a (non-patient) adult at all times. In general, the policy is more relaxed; however visitation in labor and delivery, the neonatal intensive care unit, the children's psychiatric inpatient service, adult psychiatric units and emergency department has limitations.

What is new is that each patient may now identify a "support person" — an adult who is the primary source of physical, psychological, emotional and/or spiritual support. A patient may have as many support persons as desired but only one may stay beyond visiting hours. The support person should speak to the patient's nurse to receive a wristband which will include the name of the support person, the patient's last name and unit number and the date of issue.

YNHH reserves the right to restrict or limit the presence and number of visitors and/or support person(s) for a variety of reasons, including health, safety or infection control, disruptive behavior, the need for privacy or rest by the patient or roommate, treatment or patient-staff interaction.

The policy will be implemented on a unit-by-unit basis over the next few weeks.

YNHH mobile MRI unit in Hamden

Until the new YNHH medical building opens on Devine Street in North Haven in 2013, YNHH has a mobile MRI unit available at 2560 Dixwell Avenue in Hamden. The Hamden facility offers MRI, bone density, CT scan, mammography, ultrasound, X-ray and blood draw, as well as free parking. Office hours are Monday through Friday from 8 a.m. to 4:30 p.m. To schedule an appointment, please call 203-688-1010.

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