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Medical Staff Bulletin

Contents - June - July 2013

A message from the Chief of Staff

This week we had opportunity to welcome several hundred new residents to Yale-New Haven Hospital. They were regaled with the storied legacies of our clinical departments. Simultaneously, we acknowledged that they are our future. We committed to provide them the supervision and experience to realize their full professional development.

Two aspects of role-modeling for trainees deserve special mention. First is the need to be clear about our chain of responsibility and accountability for patient care. While progressively increasing resident independence with advancing years, it must also be known that the Attending of Record has ultimate responsibility for patient welfare and outcome. Every team member, nurses and physicians alike, must feel obliged to turn to the Attending when there is evidence or suspicion that things are not proceeding as expected. The buck stops with us.

Of equal importance is to be vigilant and carefully monitor our own deportment, even in the most stressful or annoying circumstances. Our Medical Staff has a fully elaborated code of conduct. It demands respectful and collegial behavior, interdicts profanity and demeaning conduct, truly holds all, especially Attendings, to very high standards. Abusive and disruptive behavior has no place in our repertoire. Trainees are acutely aware of our professionalism and adapt our norms as they witness how we treat them and other Hospital staff. We must be aware that we are always on stage and in the spotlight, since we play the lead roles.

First physician open forum held

For the first time, physicians from both YNHH campuses, Yale Medical Group and Northeast Medical Group were invited to an open forum in Fitkin auditorium, co-hosted by YNHH President Richard D'Aquila and Chief of Staff Peter Herbert. Joining them for the 90-minute discussion were Associate Chief of Staff Tom Balcezak, MD, and Chief Financial Officer Jim Staten. The four gave updates on the state of the hospital, year-to-date performance, the financial climate, cost and value positioning, clinical redesign and opportunities for physicians to get involved. There was time for questions afterward. About 80 members of the Medical Staff attended the inaugural forum on May 28; future open forums will be scheduled quarterly, alternating on both campuses. All members of the Medical Staff are encouraged to attend.

Medical Staff/House Staff picnic to be held on August 1

The Medical Staff will sponsor a picnic for Medical and House Staff on Thursday, August 1 from 4:30-9:30 p.m. at Holiday Hill in Prospect, CT. This event is free of charge to Medical Staff and House Staff, their spouses and children. There is a cost of $30 for other guests. RSVP is required before Wednesday, July 24. Watch your email and mail for the invitation. RSVP to Helene Williams in the Department of Physician Services at 203-688-2615 or helene.williams@ynhh.org.

Performance Management update

January-June 2012
CMS/TJC Core Measures Performance


AMI
#
YNHH%
Nat’l 90th%
ASA at arriv.
321/321
100
100
ASA at D/C
294/302
97
100
B-Block at D/C
173/177
98
100
Statin D/C
286/294
97
100
PCI <90 min
30/30
100
100
       
CHF
#
YNHH%
Nat’l 90th%
LVEF assess.
329/329
100
100
ACEI at D/C
79/85
93
100
D/C instr. given
199/239
83
100
       
Pneumonia
#
YNHH%
Nat’l 90th%
Blood Cx before Abx
176/190
93
100
Initial (ICU and non-ICU)
Selection Abx
60/63
95
100
       
SIP
#
YNHH%
Nat’l 90th%
Proph Abx 1 hr
388/399
97
100
Abx selection
395/398
99
100
Proph Abx D/C
369/375
98
100
DVT proph ordered
382/386
99
100
DVT proph given
412/417
99
99
6 am glucose
117/123
95
100
BB Periop period
265/265
100
100
Foley removal POD2
412/417
93
100
       
Pedi asthma
#
YNHH%
Nat’l 90th%
Inpatient relievers
202/202
100
100
Inpatient steroids
202/203
99
100
Home manag plan
139/203
69
90

With summer's arrival, we have new energy in terms of quality, safety and accreditation activities. Epic is now live on both campuses. Our evidence of standards compliance for The Joint Commission extension survey was submitted and we doubled efforts to prepare for our next survey activity, the Department of Public Health full licensure survey.

As you look at the chart, you will see a 12-month performance summary for Yale- New Haven Hospital (February 2012 to February 2013). This includes the Saint Raphael Campus (SRC) in the denominator of all the performance measures and the registries beginning September 12, 2012. We are pleased to note that there has been no significant change in performance with the integration of SRC data and that the Missed Opportunity group has blended well to resolve issues of performance and documentation variance between the campuses. Drs. Bill Crede and Sam Hahn have done an exceptional job regarding this.

Another noteworthy improvement is in the readmission data. When we look at the performance in FY 2012, we see that our pooled rate of readmissions was about 16.9 percent . Performance year to date for readmissions is about 15.5 percent. This is an impressive improvement. Again, largely due to the diligent work of a large interdisciplinary team led by Drs. Leora Horowitz, Grace Jenq and Sam Hahn, with strong support from performance leaders such as Diane Collins, RN, and Tom Donohue, MD. Considering this is a measurement for our PIP, we are extremely pleased with this performance and look forward to sustaining this gain.

In the realm of accreditation and regulatory, the Department of Public Health licensure survey is anticipated at any time before the end of summer, to be followed by a full, 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. Please direct any questions to Tom Balcezak, MD, 203-688-1343.

Physician parking update

When the Hospital of Saint Raphael became part of YNHH, all physicians who were assigned to parking at either campus kept that parking as their primary space. Physicians who need to park at their "non-primary" campus have access to the George Street Garage at SRC and the Children's Hospital underground garage on York Street. Physicians who have parking through Yale University will need to use their Yale parking at York Street Campus, and will need to set up a parking program to have parking at SRC.

YNHH provides a free intercampus shuttle 24 hours a day, 7 days a week, with two stops — at the corner of York/Cedar streets and at the McGivney Cancer Center. The "RideSystems" shuttle bus tracking system shows where the shuttle bus is at any given moment. You can access RideSystems on the website at www.ynhhbus.org or from any smart phone at www.ynhhbus.org/m. You can also download a free iPhone App from the iTunes store or Android App from Google Play by searching Ridesystems. Once downloaded, select "YNHH" from locations and "Intercampus" from the route options. You should then see that route and bus tracker. If the bus indicator has a square inside the circle, the bus is stopped, and if the bus indicator has an arrow, the bus is moving on the route.

Contact Parking and Transportation at 688- RIDE (2623) with any questions.

Yale-New Haven Children's Hospital expands pediatric services to Greenwich Hospital

Pediatric services at Greenwich Hospital are now part of Yale-New Haven Children's Hospital. YNHCH pediatric specialists offer evaluation and follow-up care in endocrinology, gastroenterology, hepatology, orthopedics and respiratory. Patients are seen at 5 Perryridge Road in Greenwich, Monday-Fridays from 8 a.m to 4 p.m.

Clinical Integration between both YNHH campuses

The Saint Raphael Campus has experienced steady volume growth since September 12, due to direct transfers from the Shoreline Medical Center and main ED. About 1,000 patients have been directed or transferred to the SRC since the integration. This has been facilitated by the extensive renovation and re-opening of 24 beds with telemetry capacity on Sister Louise Anthony-3. Verdi 4 North is now under renovation.

Children's psychiatric services Child and adolescent psychiatry services were reorganized in February. We sought to use developmental age as the guiding principal and to facilitate rapid triaging of children and adolescents from referral sources and our Emergency Departments. As of February 1, elementary school-aged children (typically under age 12) will be hospitalized on Winchester One (YSC), middle school and junior high aged children (typically 12-15 years) on the 20-bed Celentano 5 (SRC), and adolescents 16 and older on LB2 at YNH Psychiatric Hospital. It is likely that this reorganization will have the additional benefit of reducing the need to place these children in medical and surgical nursing units in the Children's Hospital.

Trauma Center: YNHH has worked with local emergency medical services and ambulance providers to coordinate the transport of major trauma patients to YNHH's Level One Trauma Center on York Street. Patients who present to the ED at SRC will be evaluated, stabilized and transported to the YNHH Trauma Center, depending on the extent of injuries and special needs. Emergency general surgical coverage on the SRC will continue to be provided by a core group of SRC ATLS-certified general surgeons. Stroke program integration: The Neurology staffs on both campuses have collaborated to ensure delivery of the same standard of stroke care for patients presenting to the EDs with acute stroke signs and symptoms. Both protocol integration and specific criteria have been developed to determine the optimal care location for each patient, including the effective use of the YNHH Neurosciences Intensive Care Unit. Telestroke services have been implemented on the SRC to complement 24/7 call coverage on each campus, and focus has been on timely administration of tPA. Y-Access is used to facilitate prompt transfer for neuro-intervention procedures, intensive care and operative intervention.

Musculoskeletal Center: An executive steering committee has been formed to work on the planning process for a Musculoskeletal Center (MSC) at the Saint Raphael Campus. With representation from Yale School of Medicine, including the Dean, and community specialists, the committee has hired a consultant to facilitate the development of a comprehensive MSC with collaboration from Physical Medicine and Rehabilitation, Rheumatology, Orthopedics and Neurosurgery, Pain Management, Endocrinology, Neurology and other disciplines.

Saint Raphael transfer line incorporated into Y-Access

To further integrate the ED management functions on both campuses and to simplify processes for our partner physicians, all transfers from other healthcare facilities and emergent direct admissions to any YNHH campus will be handled by Y-Access, Yale-New Haven's single-source phone center exclusively for physicians. The integration of the Saint Raphael transfer line with Y-Access across the hospital's campuses was effective July 1. The Y-Access Transfer Center, which opened in August 2010, has dramatically simplified the transfer process to YNHH. Y-Access operates 24/7 and is staffed by dedicated clinicians who are responsible for facilitating arrangements for patient transfers and emergent direct admissions. You can reach Y-Access by calling 888-966-4233 (888-YNHH-BED). If you have any questions, please feel free to contact Victor Morris at 203-688-4748 or Tamrah Riley at 203-688-2218.

Epic Update

The Saint Raphael Campus (SRC) underwent a highly successful Epic implementation on June 1. In fact, the order verification and cutover process went so smoothly that Epic went live at 1:30 a.m., two hours earlier than expected. At the same time, 17 other major new pieces of technology, including the PACS radiology system and the Soft L System, went live to align clinical operations between both YNHH campuses.

Epic mobile: Haiku and Canto offer information and functionality.

  • Haiku runs on an iPhone, Android phone or iPod Touch.
  • Canto runs on iPad.
  • To request access, go to md.ynhh.org click on the Epic Mobile Apps list, and download and complete the Haiku Canto User Request Form. Please read and sign the wireless policy. Questions: EpicHHeld@ynhh.org.

MyChart: Epic offers a way for patients to collaborate with providers in managing their health through MyChart, the free secure online portal, where patients can access portions of their electronic medical record, communicate with their medical team and renew prescriptions. How MyChart can help physicians in their practice and in the hospital:

  1. MyChart is a faster way to communicate with patients. Because communication can be directed straight through your InBasket, staff can triage and respond to messages when it's convenient for them without leaving Epic. An Epic analysis of multiple healthcare organizations found a 16-17 percent decrease in phone calls after patients began using MyChart. Releasing test results through MyChart instead of writing letters saves staff time and postage fees.
  2. MyChart is secure and confidential. Access to information is controlled through secure activation codes, personal IDs, and passwords. Each patient controls his or her password, and their account cannot be accessed without that password. Unlike conventional e-mail, all MyChart messaging is done while the patient is securely logged on to our website.
  3. MyChart is convenient for patients. Like online banking, MyChart is convenient and available 24/7, offering online access to portions of their personal health records. Patients will also be able to help ensure the accuracy of their own records by alerting their care team about any inaccuracies or concerns. MyChart also simplifies the process of renewing prescriptions.
  4. Read the latest MyChart tip sheet in the md.ynhh.org (Ambulatory folder) on what your patients can see and do once they enroll in MyChart.
  5. If you have questions, or would like a MyChart demonstration at your office, contact Project Epic at: MyChartSupport@ynhh.org.

Epic reminder about dictation on the Saint Raphael Campus

Epic has two central dictation system numbers:

Full dictation dial: 203-688-6406
1. Enter your dictation ID number (you were sent this on May 30, 2013), followed by the # key
2. Enter the Work Type, followed by the # key
3. Enter the CSN number, followed by the # key
4. Begin dictation.

Orders based dictation only: 203-200-6688
1. Enter your Dictation ID number, followed by the # key
2. Enter the Work Type, followed by the # key
3. When prompted for the CSN number, enter the Order Number, followed by the # key
4. Begin dictation

NO dictation for discharge summaries: Complete in Epic

Efforts continue to address state payment cuts to hospitals

Yale New Haven Health System efforts during the 2013 legislative session focused on negotiating solutions that could have avoided damaging reductions in payments to hospitals — about $550 million in cuts to Connecticut hospitals over the next two years. Unfortunately, the final two-year state budget retained significant reductions. The impact of reduced state funding on Yale New Haven Health hospitals remains a great concern, and as FY2014 hospital budgets are being developed, Bridgeport, Greenwich and Yale-New Haven hospitals are in the process of reviewing how to best address the lower Medicaid revenue, as well as reductions being implemented under the federal Medicare program. To help meet these revenue reductions, the hospitals are focusing on continuing a thoughtful vacancy review process and enhanced supply chain management practices, as well as accelerating our cost and value positioning work. All three hospitals are anticipating smaller operating margins for next year. YNHHS remains committed to providing excellent, high-quality patient care, and will continue to work with the state on meaningful reform that will help patients across Connecticut.

Dr. John I. Allen heads clinical GI/Hepatology

John Allen, MD, MBA, a practicing gastroenterologist for more than 30 years, became the new head of clinical Gastroenterology and Hepatology at Yale-New Haven on April 1. Dr. Allen, also a professor of Medicine (Digestive Diseases) at Yale School of Medicine, received his MD from the University of New Mexico, and completed his residency and specialty training in gastroenterology at the University of Minnesota. Dr. Allen later received his MBA from the University of St. Thomas in Minneapolis. Dr. Allen spent 10 years on the faculty in the Department of Medicine in Minnesota, and in 1991 joined Minnesota Gastroenterology and became the associate medical director of the Virginia Piper Cancer Institute at Abbott Northwestern Hospital. His clinical and research interests focus on nutrition, alcoholic liver disease, quality performance in gastroenterology and colon cancer, including prevention and cancer genetics. He is currently president-elect of the American Gastroenterological Association.

Cardiology Associates of New Haven now part of YNHH

On May 1, Cardiology Associates of New Haven, a cardiology practice that has served New Haven area patients for the past 36 years, integrated with Yale-New Haven Hospital and Yale Medical Group. The 16 cardiologists, long-standing members of the YNHH medical staff, and 80 other members of the staff are now Yale Medical Group and YNHH employees, repectively. They will continue to treat their patients in their offices located in Orange, North Haven, Guilford and Westbrook. This integration increases patient access to high-quality heart care through multiple, convenient locations across southern Connecticut. Future goals for the general and interventional cardiology and electrophysiology group include developing an outpatient clinic for patients with congestive heart failure, as well as a women's heart and vascular program.

Heart and Vascular Center opens Transitional Care Center

The Transitional Care Center (TCC) is a new outpatient service for patients with heart failure who have been hospitalized. Headed by Lavanya Bellumkonda, MD, the center is designed to prevent health complications and hospital readmissions through one-on-one education, telephone access to cardiac nurses and a cardiologist, medical management, weight monitoring and loop diuretics. The TCC is located in the Heart and Vascular outpatient center on YPB 2.

Hospital debuts Healing Environment training

While patient satisfaction scores for YNHH have steadily increased over the past few years, data show that patients give YNHH low marks related to the hospital's environment of care, which includes both its quietness and cleanliness. And with the Centers for Medicare and Medicaid (CMS) publicly reporting patient responses on the internet (medicare.gov/hospitalcompare/) and beginning to link hospital reimbursements to patient perceptions as demonstrated in HCAHPS scores, YNHH has stepped up its efforts to improve the patient experience.

Michael Bennick, MD, medical director, Patient Experience, and Jeannette Hodge, director, Patient Relations, Volunteer and Guest Services, are leading a new initiative called the Healing Environment. It focuses on three non-negotiable behaviors for all employees and members of the Medical Staff:

  • Using library voices at work 24/7 to keep the hospital quiet.
  • Picking up trash and putting it in a nearby garbage can to keep the hospital clean and neat.
  • Being 200 percent accountable — 100 percent for yourself and 100 percent for others. If you remind someone to be quiet or pick up after themselves, they should say thank you.

The hospital is in the process of training managers to train staff on how they can ensure that YNHH is a healing place for patients. Strategies to improve the overall effort include Healing Environment Assessment Team (HEAT) rounds, in which a dedicated team will conduct HEAT audits on units with low patient satisfaction scores and/or high volumes. Based on the results of the audits, action plans will be created to improve the environment in areas that need attention. In addition, Dr. Bennick is presenting the Healing Environment concept at grand rounds and clinical department meetings and has conducted training at new resident orientations so house staff will know from their first day at Yale-New Haven their roles and responsibilities to help ensure a healing environment for patients.

YNHH invests in new interpreter phone system

YNHH is implementing a new service called Language Line Solutions to supplement the current services provided by in-person spoken language interpreters. Hundreds of automated dual-headset green phones have been installed on both campuses. Simply pick up the phone and press a button to access an over-the-phone medical interpreter for a language other than English. The caller must provide the patient's name and medical record number. For those cases where it is preferable to use an interpreter rather than the over-the-phone service, call YNHH Interpreter Services at 688-7523 for patient conversations that involve explaining complex medical procedures, obtaining consent, family meetings and end-of-life discussions.

Cynthia Wilson, MD, named chief of adolescent psychiatric unit at SRC

Cynthia Wilson, MD, will be the new unit chief for the adolescent psychiatric unit at the Saint Raphael Campus. Dr. Wilson will serve as an inpatient attending on Celentano 5 and provide clinical and administrative services and leadership. Dr. Wilson is a faculty member in Psychiatry with a joint appointment in the Child Study Center. She received her medical degree from Vanderbilt University School of Medicine, and completed an adult psychiatry residency there, followed by a child psychiatry fellowship at Yale Child Study Center. During 2011, after she completed her training, she worked at the Hospital of Saint Raphael, Waterbury Hospital and St. Vincent's Behavioral Health Service, before accepting a position in Canberra, Australia, practicing adult, child and adolescent psychiatry for the mental health service of the Australian Capital Territory government. Frank Fortunati, MD, will continue to serve as the medical director for child and adolescent services at SRC. Special thanks to Theodore Zankar, MD, who is retiring June 1 after more than 50 years of service to children in the New Haven community.

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