SkipNav
About Us
YNHH

Medical Staff Bulletin

May 2014

Contents

Message from the Chief of Staff

Elsewhere in this issue of the Bulletin is a note about a new YNHHS initiative with the acronym CLEAR (Communication Leads to Early Resolution). Virtually all clinicians who have been in the position to tell patients and families about unexpected adverse clinical outcomes will relate to the background and imperative for this program. The need has been evident at YNHH for many years.

When we teach about behaviors most useful to avoid clinical errors in our High Reliability Organization training, we stress that most clinicians experience unexpected patient outcomes only once or twice in their careers. These can result from failure to correctly interpret clinical cues, idiosyncratic response to a drug, choice of an inappropriate treatment, failure of an implanted device, unrecognized co-morbidities, lapses in attention to details, poor communication, casual hand-offs, puncture of a vessel or viscus, or even mistakes by colleagues. And there are many other etiologies.

While very few of us process how to disclose poor outcomes before they occur and cannot anticipate the impact of such happenings on patients, families and ourselves, we must be clear on how to proceed for the welfare of all concerned. The first step should be to immediately notify the attending physician (if not already involved), those in our chain of command, and Legal and Risk Services (203-688-2291 or through page). Legal and Risk Services will facilitate immediate support by a fellow clinician who has been trained as a "disclosure coach" in the CLEAR program.

Knowing the emotional impact on responsible clinicians, it is rarely good judgment to trust our own instincts in planning disclosures. And the latter should be made as soon as feasible to patients and families who need to know not only current clinical condition but our plans to better understand what occurred and to provide very timely updates. CLEAR is one more step to make YNHH a better hospital.

Performance Management update

February 2013 - January 2014
CMS/TJC Core Measures Performance


AMI
#
YNHH%
Nat’l 90th%
ASA at arriv.
297/298
99
100
ASA at D/C
271/276
98
100
B-Block at D/C 254/259
98
100
Statin D/C
255/263
97
100
PCI <90
32/33
97
100
       
CHF
#
YNHH%
Nat’l 90th%
LVEF assess.
342/342
100
100
ACEI at D/C
69/77
90
100
D/C instr. given
198/206
96
100
       
Pneumonia
#
YNHH%
Nat’l 90th%
Blood Cx before Abx
152/165
92
100
Initial (ICU and non-ICU)
Selection Abx
60/62
97
100
       
SIP
#
YNHH%
Nat’l 90th%
Proph Abx 1 hr
380/389
98
100
Abx selection 380/385
99
100
Proph Abx D/C
360/363
99
100
DVT proph given
383/384
99
99
6 am glucose
101/114
89
100
BB Periop period
240/241
99
100
Foley removal POD2
388/389
97
100

In the chart are the familiar Medicare process measures arrayed for Yale-New Haven Hospital (YNHH). Performance is very stable and we are making a conscious effort to more strongly focus our attention this year on patient safety. This month, Performance Management would like to highlight YNHH's work related to becoming a high reliability organization (HRO).

YNHH committed to training all 12,442 employees in high reliability principles by the end of September 2014. Since February, nearly 30 percent of the staff has been trained. The curriculum focuses on five safety behaviors that all staff are expected to adopt to keep and make patients safer. This is a program that the Connecticut Hospital Association has organized as a statewide collaborative. This is important because, regardless of what organization a physician practices in, the behaviors and language associated with these behaviors remains very consistent. Literature has widely supported how embedding these behaviors in an organizational culture reduces preventable harm by up to 80 percent. During training sessions, a natural question has been "Will the physicians be trained?" Our answer: Yes.

YNHH intends to train all credentialed medical staff members in this curriculum. Without physicians understanding and practicing the same behaviors as nurses, environmental staff, administration, etc., embedding these behaviors will not work. To this end, a two-hour lecture has been developed and will include physician-specific information on safety behaviors designed to prevent errors that can lead to patient harm. The first cluster of evening lectures for physicians are May 7, 14, 28 and June 5 in Harkness Auditorium in the Sterling Hall at Yale School of Medicine from 5-7 pm. A light supper will be served. This schedule is also available through the physician portal. To sign up for a lecture, physicians should email Kathleen.testa@ynhh.org. Please direct any questions to Tom Balcezak, MD, (203) 688-1343.

Medical Staff rule to change: Discharge summaries should be completed within 24 hours

At its April meeting, the Medical Board voted unanimously to change Medical Staff Rule #18 which stated that the responsible attending physicians should complete a discharge summary for each patient "as soon as possible after discharge. This has been changed to "within 24 hours." It is critical to provide timely information about the hospital stay to facilitate postdischarge follow up care in the primary or specialist physician office.

Presently at least 50 percent of discharge summaries are completed within 24 hours. Responsible Attendings can prepare the discharge summary themselves or may ask a member of the House Staff or APRN or PA to prepare it for their authentication. The Medical Board's recommendation will be formalized as a proposed change to the Medical Staff Rules in the near future.

YNHHS participating in Medicare's "Bundled Payments for Care Improvement"

As of April 1, Yale New Haven Health System hospitals are voluntarily participating in the Medicare initiative called Bundled Payments for Care Improvement Model 2. YNHHS has chosen to participate in two major patient care areas of the initiative: Heart and Vascular and Orthopedics. The goal of the initiative is to provide patient-centered, cost-effective care that improves patient outcomes.

Yale New Haven will work with Remedy Partners — a company that coordinates with hospitals and home care agencies to help them improve patient care transitions — and jointly provide care coordination for acute and post-acute services delivered to fee-for-service Medicare beneficiaries from the time of the patient's admission until 90 days after his or her discharge from the hospital.

Remedy Partners works closely with patients and their outpatient providers to monitor status throughout their 90-day episode, whether the patient goes home or to a skilled nursing facility. Remedy Partners tracks the patient's medications and treatment plan goals, coordinates follow-up appointments and updates the patient's status. Remedy Partners has a 24/7 nurse call center to help the patient avoid emergency department visits and unnecessary hospitalizations. Although all physician, hospital and post-acute payments continue to be paid at Medicare rates, Medicare will eventually settle the actual payment experience with the targeted bundled rate.

Participating in this important Medicare initiative will help us develop evidence-based care that improves outcomes and is truly more-patient centered. Yale New Haven and its physicians will be rewarded for care that prevents readmissions and provides the highest quality post-acute care during the 90 days.

This reimbursement model, while currently only a Medicare demonstration project, is likely to be a major driver for accountable care reform. Yale New Haven is participating early in this initiative to learn from the experiences with heart and vascular and orthopedic patients in order to provide better population health and disease management for all patients in the years ahead.

ICD-10 provider training to continue towards May 19 clinical go-live

While national implementation of ICD-10 has been delayed by at least a year, Yale New Haven Health System has decided to continue to move forward with ICD-10 implementation with a planned Clinical Go-Live date of May 19, 2014. Yale New Haven, along with many other institutions, has decided to move forward with implementation in order to have the time to prepare for these important changes. An earlier conversion will also have multiple immediate benefits for documentation and the reporting of quality data.

ICD-10 training for YNHHS and Yale Medical Group physicians is under way and will continue through May 19. The cornerstone of this education is a set of online modules through Healthstream. These modules are tailored to each specialty and should take under an hour to complete. They are required for all YNHHS and YMG providers.

There are additional educational materials for community providers as well as for those YNHHS and YMG providers. Starting May 1, there will be a series of specialty-specific online webinars that review the key documentation requirements with ICD-10. Links to this content will be sent along to providers from the Physician Services offices. Included in this communication will be a link to a short video that details changes to Epic specific to ICD-10 for those providers who use Epic. These changes are quite minor, very intuitive and should have little impact on overall provider workflow.

YNHHS will also be distributing specialty-specific one-page tip sheets that provide the key documentation elements required with the ICD-10 adoption. For non-Epic community providers who order labs and radiology through Yale-New Haven, supporting diagnoses will need to be ICD-10 compliant by the May 19 date. New ordering forms that are ICD-10 compliant will soon be delivered to your offices.

There will be additional provider education and support before and after the May 19 Clinical Go-Live. Any questions can be directed to Ian Schwartz, MD, who leads the ICD-10 Physician Adoption Committee, at ian.schwartz@ynhh.org.

CLEAR program: Disclosure and apology

About five years ago, evidence emerged that disclosure and apologies in the face of unexpected clinical outcomes can help patients, families and clinicians heal. YNHHS developed a working group called Responding to Unexpected Clinical Outcomes with representation from Bridgeport, Greenwich and Yale-New Haven hospitals, Yale School of Medicine, Northeast Medical Group, nursing and MCIC, YNHHS' malpractice insurance company. The group looked at best practices at other academic medical centers and developed a new program called CLEAR — Communication Leads to Early Resolution.

CLEAR offers resources for clinicians who have a patient with an unexpected outcome — how to approach patient or family, what to say, and an understanding of why disclosure and an apology is generally the right action. Using the YNHHS SYN:APSE simulation training center, more than 60 hospital-based "disclosure coaches" — primarily physicians and some nurses — have been trained throughout the system, to assist clinicians in these conversations.

If a member of the Medical Staff needs help, information about the CLEAR program (Disclosure/ Apology) is posted on the Legal and Risk Services page of the YNHHS intranet. Go to the YNHHS intranet, click on departments/Legal and Risk Services/FAQs and you will find several CLEAR-related resources, including a list of disclosure coaches' names and a PDF handout about the CLEAR program. You can also call YNHHS Legal and Risk Services at (203) 688-2291 for help or with questions.

New surgical time-out policy

In his book "Checklist Manifesto," Atul Gawande drove the concept of check lists into the practice of medicine. This is a safety tool employing a brief pause prior to starting a procedure. The pre-procedure time-out was instituted at YNHH many years ago. At a minimum, it consists of patient identification, site verification and agreement by the surgeon, anesthesiologist and the OR team as to the procedure to be performed. Accuracy of the consent form, medication allergies and availability of blood products and implants are also important elements. More than one operative case has been delayed or the patient awakened from anesthesia because blood was not yet ready or the implant had not yet arrived. The last item on the check list is to introduce everyone in the room who is involved in the procedure.

The Perioperative Executive Leadership Committee (PELC) has recently approved a change in the time-out procedure. To further improve patient safety, we have directed that the time-out be done in the OR with the patient awake. The surgeon, anesthesiologist, circulating nurse, scrub tech and the patient are all expected to take part in the process. Once completed, induction of anesthesia can begin.

In general, this process, instituted on April 1, has been well received by our patients. On a few occasions, patients have been so anxious about the procedure that mild sedation was necessary. Clearly, the wording used in the time-out can usually put the patient at ease but there are cases where sedation is appropriate.

Our Physicians

Use our online tool to find a doctor

annual report 2012
Yale School of Medicine
Magnet Recognition Best Hospitals 2012-2013

Video Library

Video Library