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Medical Staff Bulletin

March/April 2013

Contents

 

A message from the Chief of Staff

Significant reimbursement challenges to hospitals will impact our planning and related budget development work and I have asked Rick D'Aquila to comment (below) on these very serious matters. I write briefly about the recent incident concerning mold-contaminated magnesium sulfate preparations obtained from a commercial compounding company. All medical staff were notified of this matter by me on March 18, and I wanted to provide an update on progress in the interim.

All product from the vendor, Med Prep, was removed from patient care areas throughout Yale New Haven Health System on the day mold was identified in the magnesium sulfate preparations. Two different lots were found contaminated, and our microbiology lab, directed by Dr. David Peaper, sequenced the mold genes and found a very unusual fungus of Hamigera species and a form of aspergillus called Neosartorya. CDC has already defined antifungal sensitivities for these.

We do not yet know if any patient received a contaminated preparation of magnesium but have contacted all patients in the "at risk group," as well as their physicians. We believe surveillance of these patients will need to continue for at least six months. Drs. Jeff Topal and John Boyce have been critical advisors as we cooperate and collaborate with the FDA, CDC, and DPH. We will report progress to you as events unfold.

A message from Richard D'Aquila, President and COO

Having worked hard to prepare for the major financial pressures related to cuts in payments from Medicare, Medicaid and other insurers, Yale-New Haven Hospital has managed the uncertainty better than most and has continued to grow and serve more patients. But the rate of change and the extent of the payment reductions have grown more difficult. In February, the Governor proposed more than $550 million in cuts to hospitals, in addition to more than $103 million in cuts which were implemented in December. This means Yale-New Haven Hospital will lose more than $147 million in funding over the next three years.

In light of these dramatic cuts, we need to find ways to deliver higher-quality care in a less expensive way. At the same time, we must maintain our momentum to develop as a destination hospital with national preeminence. We also remain determined to invest in the technology, facilities and systems that promote patient safety and clinical excellence. We must continue to implement our current planned integration strategies on the Saint Raphael Campus.

Last year, in anticipation of some of these challenges, we brought together our physicians, managers and employees to review our labor, supplies, clinical quality and utilization costs and consider ways to drive down costs, while improving outcomes. This is a difficult, but absolutely necessary process. We developed a comprehensive "Cost and Value Positioning" blueprint, made up of hundreds of opportunities to simultaneously eliminate waste and improve our quality. We will implement this work over the next five years.

While the challenges are significant, we will pursue necessary cost reductions in ways that minimize job displacements or service cuts. In the weeks ahead, we will be implementing the first phase of these efforts by instituting a very controlled set of practices, taking advantage of natural attrition in our workforce. We have a significant number of existing vacancies and we plan to aggressively manage those vacancies to minimize any impact on our employees. In addition, we will be focused on waste reduction and the elimination of non-value-added activity while working toward benchmarked productivity targets across the hospital.

As you may be aware, Drs. Tom Balcezak, Robert Udelsman and Victor Morris, are heading up the clinical redesign team for the medical center. They will be chartering a number of physician-led teams focused on decreasing clinical practice variation, while simultaneously improving clinical outcomes and patient safety. This will truly transform care delivery at Yale-New Haven Hospital, and will be the subject of a standalone article in the Medical Staff Bulletin later this spring. One area we have not yet touched upon but that will also change clinical practice is the work being done by the non-labor physician preference teams. If you are asked to serve on one of the clinical redesign teams, I encourage you to become actively involved in this very important effort.

Nineteen physician-led non-labor physician preference teams have been created and have identified more than $100M in product standardization savings across the health system. The teams based their recommendations on evidence-based practice and focused their efforts on areas such as blood utilization, cardiac rhythm management and bone and tissue among others. Standardized products in the nineteen focus areas will be selected and implemented over the next nine months, with an estimated completion date of August 2014. Your cooperation and support are instrumental to the successful adoption of standardized products, and required for the continued long-term success of our medical center. Again, this is a physician-led effort that can only be successful if our physicians are actively engaged.

The challenges before us are real and serious. However, working together as partners coming up with innovative ways of decreasing waste and practice variation, , we know we can meet these challenges and succeed. We will continue to communicate these challenges and our plans to meet them in a frequent and transparent manner. We appreciate your ongoing support for these efforts and your contributions to the success of Yale-New Haven Hospital as we face the challenges ahead.

New universal protocol adopted for surgical/invasive procedures

In 2011, YNHHS standardized the OR time-out policy and time-out elements across all three hospitals — Bridgeport, Greenwich and YNHH. The System Perioperative Leadership Committee, with representatives from the three hospitals, finalized the Universal Protocol in early 2012, and each hospital was responsible for implementation and local education. YNHH implemented the policy on January 1, 2013.

The universal protocol provides a standardized approach for verification of correct site, correct procedure and correct patient before any and all surgical/invasive procedure begins. This includes perioperative/pre-procedure verification and site marking. All components of the Universal Protocol must be followed and documented in any location in which invasive procedures occur, including procedures that involve puncture or incision of the skin, insertion of an instrument or insertion of foreign material into the body.

The policy does not apply to "minor" procedures, including but not limited to peripheral IV line placement, NG tube insertion and Foley catheter placement.

The System Perioperative Leadership Committee will undertake a post-implementation review of the Universal Protocol in the first half of 2013 to consider and include suggested changes that the surgical staff has raised.

For a copy of the policy, go to https://ynhh.ellucid.com/manuals/binder/205. For information or comments, contact Max Laurans, MD, maxwell.laurans@yale.edu.

Performance Management update

January and February were extremely busy months in terms of quality, safety and accreditation activities. Epic was implemented on the York Street Campus on February 1, and the unannounced Joint Commission extension survey at the Saint Raphael Campus began on February 20.

YNHH anticipated that The Joint Commission would arrive before May to complete an extension survey for the Saint Raphael Campus (SRC), but we did not think they would arrive as early as February. However, we were ready and the survey results were outstanding. In terms of opportunities for improvement for the medical staff, we were cited in three areas for which we will need to demonstrate improvement in the upcoming months.

First, it is expected that all notes have the appropriate date and timing. Although this largely pertains to the mostly paper record at SRC, there are still paper forms at York Street Campus. Both campuses should be diligent at dating and timing all notes within the medical record whether electronic or hard copy.

Second, YNHH was cited on lack of completeness of the brief operative note. When completing a brief operative note it must include all of the following elements: name(s) of the primary surgeon and his/her assistant(s); procedure performed; and a description of each procedure finding, estimated blood loss, specimens removed and postoperative diagnosis.

Third, YNHH was cited on the incompleteness of the time-out process performed prior to the procedure. It is important to note that when a time-out is to be conducted, all members of the team must suspend activities and be fully engaged in the process of actively confirming the correct patient, site and procedure. The surveyor reminded us that each week 40 wrong site surgeries are performed in the United States.

A 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. Considering these two additional surveys will be privy to the findings of the extension survey, we should anticipate additional scrutiny in the areas noted above. All of the survey activities were led by Victoria Dahl Vickers, RN, and her diligent team from Accreditation, Safety and Regulatory Affairs, as well as a volunteer army of scribes and escorts. We thank them for an outstanding process and outcome.

Lastly, please look at the left hand column with Yale-New Haven Hospital's performance measures for January 2012-November 2012. Beginning with September data, the Saint Raphael Campus is now included in the denominator of all the performance measures and the registries. So far, there has been no change in apparent performance with the integration of this data. In fact, we are starting to see a small uptick in measures although a trend has not been established.

Please direct any questions to Tom Balcezak, MD, (203)688-1343.

Both YNHH campuses now using 1-5-5 emergency phone number; new codes in use

The emergency phone number on both YNHH campuses is now 1-5-5. Employees do not need to dial 9 before the 155, since 155 is an internal number only. YNHH moved to use of the 1-5-5 emergency phone number in 2011; the Saint Raphael Campus transitioned to it on April 15, and stickers with the new phone number have been placed on all SRC phones.

The 1-5-5 emergency phone number applies to all YNHH buildings in New Haven. Hospital properties in towns outside New Haven will continue to access their local police and fire departments in an emergency by calling 911.

In addition, both campuses now use the same Emergency Codes for overhead paging:

  • CODE D: Internal/External Disaster-Emergency Management (Mass Casualty Incident)
  • CODE RED: Fire
  • CODE BLUE: Adult Medical Emergency/Resuscitate Patient
  • CODE WHITE: Pediatric Medical Emergency/Resuscitate Patient
  • CODE SILVER: Hostile/Violent Individual
  • CODE AMBER: Infant/Child Abduction

The Code Silver and Code Amber overhead paging codes are also new to the York Street Campus. When you call 1-5-5 to report an emergency, please give your name, location and the nature of the emergency (fire, need for emergency resuscitation, hostile individual, infant or child abduction, rapid response team, etc.).

Patient Experience efforts broadened

In the fall, YNHH transitioned from a focus on Service Excellence to one on the entire Patient Experience, including the full spectrum of a patient's healthcare interactions. The Hospital has been working for the past two years on restructuring its efforts and as a result has been seeing sustained, strong improvements in Press Ganey and HCAHPS patient satisfaction scores on the York Street Campus over multiple quarters. The revised Patient Experience program has already been introduced on the Saint Raphael Campus featuring the same investments and improvements, and benefiting from strong SRC physician leadership headed by Drs. Thomas Sweeney and Prescott Wiske.

Michael Bennick, MD, associate chief of Medicine, was appointed YNHH medical director of Patient Experience last summer. He is a valuable resource to members of the Medical Staff on both campuses, working closely with physicians, clinical and associate chiefs, medical directors and graduate medical education programs to enhance the patient experience across the continuum of care. This summer, for the first time, all incoming new members of the House Staff will receive Patient Experience training as part of their new employee orientation.

To steer the Patient Experience effort at YNHH, Dr. Bennick has been working as a member of the Patient Experience leadership group, which includes Peter Schulam, MD, Cynthia Sparer, Ena Williams, RN, Diane Vorio, RN, and Jeannette Hodge. The success of YNHH's Patient Experience program has led to a more positive patient experience overall and improvements in patient satisfaction scores. Medical Staff members with new contact information

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.

YNHCH/CCMC join together for Pediatric Cardiothoracic Surgery program

Yale-New Haven Children's Hospital and Connecticut Children's Medical Center in Hartford established a joint congenital cardiac surgery program in 2012 under the umbrella of Northeast Pediatric Specialties, Inc. (NEPS). The program includes specialized pediatric cardiologists, neonatologists, intensivists, anesthesiologists, perfusionists and postoperative support groups dedicated to provide the best quality care for children and adults with congenital heart diseases. The goals of the program are to improve understanding, prevention and treatment of all aspects of the cardiac disease in children and adults with congenital cardiac defects and provide better care closer to home for young patients.

Paul Kirshbom, MD, chief of Pediatric Cardiac Surgery at YNHCH, became the first chief to hold the title at both YNHCH and CCMC. He came to Connecticut from Children's Healthcare of Atlanta. His clinical interests include neonatal and cardiac repairs; congenital heart disease; neurological protection; pediatric cardiac surgery; pediatric cardiovascular surgery; and pediatric thoracic surgery.

Mohsen Karimi, MD, is the associate chief of Pediatric Cardiac Surgery at the combined program. Board-certified in surgery, thoracic surgery and congenital cardiac surgery, Dr. Karimi's clinical research interests include the development of improved surgical techniques and blood conservation measures to improve outcomes in pediatric cardiac operations.

Drs. Remetz and Muhs elected co-chairs of HVC Operations Leadership Committee

Michael Remetz, MD, medical director, Heart and Vascular outpatient centers, and Bart Muhs, MD, clinical chief of Vascular Surgery, have been elected co-chairs of the newly-formed Heart and Vascular Center Operations Leadership Committee.

The vision of the Operations Leadership Committee is to establish YNHH Heart and Vascular Center as a world-class destination center that offers extraordinary patient experience, multi-disciplinary teams of superb clinicians and educators, state-of-the-art facilities, and cutting edge treatment. Its mission is to use these strengths, to bolster the national reputation of YNHH.

Ronald Vender, MD, chief medical officer, YMG, and Tucker Leary, vice president, physician development, YNHH, established the committee in November. Members meet monthly and include leadership from key service line areas.

Michael Holmes named senior administrative officer at Saint Raphael Campus

Michael D. Holmes has been hired as senior vice president, operations, and Saint Raphael Campus chief integration officer. Holmes joined YNHH March 18 with over 25 years of experience in senior leadership positions in multi-hospital Catholic healthcare systems. Most recently, as the executive vice president and chief operating officer at Franciscan St. James Health in Chicago, he managed the daily operations of a two-hospital integrated delivery system. Prior leadership appointments included Ascension Health and Trinity Health. Holmes holds a Bachelor of Science in public health administration from Indiana University and a Master of Science in administration from the University of Notre Dame. He will work closely with the Saint Raphael Campus site leadership team and managers with cross-campus responsibilities, providing implementation oversight for the multi-year plan to integrate the Saint Raphael Campus with YNHH.

YNHH opens North Haven Medical Center

On February 28, YNHH dedicated the North Haven Medical Center at 6 Devine Street, in a 120,000-square foot, four-story building formerly owned by AT&T. The new center offers a range of outpatient services from a walk-in care center for non life-threatening conditions to an interventional immunology center for treatment of autoimmune diseases such as lupus, rheumatoid arthritis and multiple sclerosis, as well as a Smilow Cancer Hospital Care Center, on-site diagnostic radiology, blood draw and laboratory services.

Interim Chair/Chief of Diagnostic Radiology named

T. Robin Goodman, MD, has been named interim chair/chief of Diagnostic Radiology at Yale-New Haven Hospital and Yale School of Medicine, replacing Dr. James Brink, who left to lead radiology at Massachusetts General Hospital. Dr. Goodman, vice chair for clinical affairs in Diagnostic Radiology and chief of Pediatric Radiology, joined Yale School of Medicine faculty in 2003 as an assistant professor in Pediatric Radiology and became associate professor in 2006. He received his undergraduate degree from Dundee University in the United Kingdom and his medical degree from Cambridge University. Congratulations to Dr. Goodman and appreciation to Dr. Brink for his years of leadership and service.

Epic update

York Street Campus: Yale-New Haven Hospital's long-awaited Epic implementation at the York Street Campus in February went smoothly, and represented the third largest implementation in the Epic Corporation's history. YNHH was the second YNHHS hospital to go live with the EMR software; Greenwich began using it in April 2012 and on June 1, the Saint Raphael Campus will go-live on Epic. Before February, nearly 500 physicians were using Epic EMR. There are now more than 900 physicians using it. Members of the Medical Staff are reminded to make sure patients receive their copy of the After Visit Summary (AVS) after an inpatient discharge or office visit. To avoid a HIPAA violation, make sure to verify the name on the upper left corner of the AVS before giving it to the patient. The bottom of the AVS contains the patient's personal MyChart activation access code, which allows them to enroll in MyChart. If you would like copies of the MyChart brochures for your patients, please contact MyChartSupport@ynhh.org.

Saint Raphael Campus: The Saint Raphael Campus is on schedule to go live with Epic on June 1. An impressive 95 percent of staff registered for their courses. SRC super users began training in mid-March, and the rest of the staff train in April. Training for medical staff will be held on campus in the following rooms: Verdi 5 (V548c) and Selena Lewis (H302) and the second floor of the Convent Building (N206). Physicians earn CME credits for every hour of Epic class time; depending upon the physician's specialty, classroom sessions can take up 15 hours.

Providers from both campuses who have questions or who are looking for Epic information can go to the MD portal: https://md.ynhh.org/md/Pages/Home.aspx. Epic Help Line: If you need assistance with Epic including password resets, please contact the physician help line at 502-4357 (502-help).

Grimes Center — a new resource for YNHH physicians

The Grimes Center on the Saint Raphael Campus has become a strong resource for the Yale-New Haven medical community — with a convenient location, a comprehensive rehabilitation program, and a committed, specially trained staff. With a dedicated and experienced nursing staff, t he Center specializes in orthopedic, stroke, oncology, pulmonary and cardiac rehabilitation and provides a wide range of post-acute care clinical services including physical, occupational and speech therapy, medication management including IVs,. In patient surveys, an impressive 98 percent of former Grimes Center patients recommend the facility.

The goal of the Grimes Center staff is to offer high quality, intensive rehabilitative care so patients can return home to begin their life again at the highest possible level of functioning and quality of life. They focus on two customers: the patient being treated and the referring physician.

For more information or to arrange a tour, contact John Tarutis, executive director of Grimes, at john.tarutis@ynhh.org or Gerald Kerins, MD, medical director, at gerald.kerins@ynhh.org.

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