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Medical Staff Bulletin

Contents - October/November 2012

A message from the Chief of Staff

This last year, preceding the union of YNHH and HSR, demanded intense effort by leadership of both hospitals, resolution of innumerable issues, successful navigation of a regulatory maze, and absorption of more than a few bumps. The September 12, 2012 signing of an agreement by Marna Borgstrom and Christopher O'Connor was a monumental event for both hospitals, and it marked the start of a transition that will transform healthcare in our region.

Our first order of business now is to be certain that the cultures of our two campuses can be melded and our clinical services rationalized with no loss of the qualities held dear by our patients, our doctors and our staffs. An element critical to this will be creation of a true sense of partnership between hospital and physicians. Economic and political pressures will challenge us to remain focused on the welfare of our patients. We are being asked to develop systems that preserve health as well as treat disease, and we must extend our vision of "healthier together" to include not just two campuses but hospital and doctors.

We are certain to have more patients and less reimbursement for their care. We will not do well unless we work together more efficiently, remove the obvious waste in our traditional practices, and minimize the adverse happenings that often attend our care. Physicians and hospitals cannot do this independent of each other. Moreover, if either of us is left behind as we drive for true accountable care, the entire enterprise will suffer. If we are driven to compete for limited resources, there surely will be losers and no winners. University and community physicians are now asked to join YNHH in planning for clinical services on our new dual-inpatient-campus hospital. Many of us will be asked to change where and how we practice as services are reorganized and integrated to achieve required efficiencies. Change is always difficult. However, we have promised full participation in related deliberations with all constituencies at the table. We will not forget the mandate to create a hospital greater than the sum of the once separate institutions. Change to Medical Staff rules & regulations: podiatrists and history & physical examinations

In September, the Patient Safety & Clinical Quality Committee of the Board of Trustees approved changes to the Medical Staff Rules & Regulations which now allow podiatrists who are qualified or certified by the American Board of Podiatric Surgery to perform pre-operative and admission history and physical examinations. Podiatrists must ensure, however, that patients with active non-podiatric disease have a consulting physician to follow them if they are admitted and to seek consultation if medical conditions arise during a patient's hospitalization.

Performance Management update

January-June 2012
CMS/TJC Core Measures Performance


AMI
#
YNHH%
Nat’l 90th%
ASA at arriv.
147/147
100
100
ASA at D/C
135/139
97
100
B-Block at D/C
84/88
95
100
Statin D/C
130/134
97
100
PCI
10/12
83
100
Smoking cess
45/45
100
100
 
CHF
#
YNHH%
Nat’l 90th%
LVEF assess.
144/144
100
100
ACEI at D/C
42/43
98
100
D/C instr. given
80/99
81
100
 
Pneumonia
#
YNHH%
Nat’l 90th%
Pneum. vac. given
98/155
63
100
Abx given
24/27
89
100
Blood Cx before Abx
Initial (ICU and non-ICU)
57/64
89
100
Selection Abx
17/18
94
100
 
SIP
#
YNHH%
Nat’l 90th%
Proph Abx 1 hr
178/180
99
100
Abx selection
178/180
99
100
Proph Abx D/C
169/174
97
100
DVT proph ordered
172/174
99
100
DVT proph given
172/174
99
99
6 am glucose
57/62
92
100
BB Periop period
243/247
98
100
Foleyremoval by POD2
173/185
94
100
 
Pedi asthma
#
YNHH%
Nat’l 90th%
Inpatient relievers
184/184
100
100
Inpatient steroids
184/184
100
100
Home manag plan
133/181
86
90

It is an exciting time in Performance Management with the addition of the St. Raphael campus (SRC) and the prospect of standardizing our performance across two campuses. On the right are the familiar Yale-New Haven Hospital performance measures for January-June 2012 with the measures that impact our payments in bold. Beginning with September data, YNHH will begin to sample SRC cases into the denominator of all the performance measures and the registries. Key activities are taking place to make the logistics of these transitions seamless. It is important to note that the issues of practice normalization may contribute to performance results. To this end, Quality Improvement Support Services (QISS) is working to standardize concurrent review processes while Accreditation, Safety and Regulatory Affairs (ASRA) is working with clinical staff to normalize practices to policy changes, education and competency assessment.

On a separate note, Performance Management has been actively working on a number of important initiatives that align with the Hospital corporate objectives. With Dr. John Boyce, Hospital Epidemiologist, lending his experience and expertise in infection prevention, YNHH will be working on a stronger and more proactive program regarding hospital acquired infections. The first initiative will be enhancing the prevention of central line infections. The work that Dr. Boyce and his team actualized at the St. Raphael's Campus recently yielded national recognition in this program. From 2009 to 2011, the Saint Raphael Campus of Yale New Haven Hospital's intensive care unit rate of central line-associated bloodstream infections (CLABSIs) went from among the highest in the state of Connecticut with 3.99 infections/1,000 central line catheter days during the first 15 months of the program to one of the lowest with 0.18 infections/1,000 central line catheter days during the last 18 months of the program. This amazing work is a model for what YNHH would like to accomplish on the York Street Campus.

Another key initiative is a team that is working on a proactive system to review Hospital Acquired Conditions (HACs) before they are publicly reported. A multidisciplinary team, led by Dr. Carol Barsky, Associate Chief Patient Safety and Quality, developed a workflow to prospectively review coded HACs before they are submitted. If there is a deviation in care, a Medical Director, unit or service has the opportunity to review the case and understand the accuracy as well as what can be improved. This program has been well received and also aligns with the CLABSI initiative as blood stream infections are HACs that are often seen as an opportunity in our public reporting. This is an exciting time of new interventions, initiatives and opportunities for continuous improvement. If you have any questions, please contact Tom Balcezak, MD, 203-688-1343.

Hugh S. Taylor to lead OB/GYN & reproductive sciences

Hugh S. Taylor, MD, has been named chief of Obstetrics and Gynecology at Yale-New Haven Hospital (YNHH) and chair of Obstetrics, Gynecology and Reproductive Sciences at Yale School of Medicine (YSM), effective October 1, 2012. Dr. Taylor was previously chief of reproductive endocrinology and infertility and professor and vice-chair of obstetrics, gynecology and reproductive sciences. A graduate of Yale College and the University of Connecticut School of Medicine, he completed his residency at YNHH, followed by a postdoctoral fellowship in molecular biophysics and biochemistry at Yale and a fellowship in reproductive endocrinology and infertility.

Dr. Taylor's research has been continuously funded by the NIH for more than 20 years. He is the editor-in-chief of the journal Reproductive Sciences and editor of Endocrinology. He serves on the board of directors of the American Society for Reproductive Medicine (ASRM), where he is president-elect of the endometriosis interest group and on the governing council of the Society for Gynecologic Investigation (SGI).

We would like to express our deep gratitude to Peter E. Schwartz, MD, who has led the department with his characteristic dedication and excellence as interim chair since last August.

Reminder regarding reportable events related to invasive procedures

Members of the Medical Staff are reminded that they must promptly notify the YNHH Legal and Risk Services at 688-2291 of adverse patient events reportable under state law. Events that must be reported to the Connecticut Department of Public Health (DPH) include:

Surgical/invasive procedure-related events

  • Surgery performed on the wrong body part (surgery does not agree with consent form)
  • Surgery performed on the wrong patient
  • Wrong surgical procedure performed on a patient (not agreeing with consent form)
  • * Unintended retention of a foreign object in a patient after surgery or other procedure
  • Intraoperative or immediate post-operative (within 24 hours or surgery) death in an ASA (American Society of Anesthesiology) Class 1 or 2 patient
  • Patient death or serious disability as a result of surgery including hemorrhage greater than 30% of circulating blood volume
  • * Perforation during open, laparoscopic and/or endoscopic procedures resulting in death or serious disability.

* Please note that some of these events may be discovered at other hospitals. If YNHH was the venue of the initial procedure, it is YNHH's duty to report the events to the DPH.

Product or device events

  • Patient death or serious disability associated with the use of contaminated drugs, devices or biologics provided by the healthcare facility
  • Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended
  • Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility

Care management events

  • Patient death or serious disability associated with a medication error (wrong drug, dose, route, patient, rate or time)
  • Significant medication reactions resulting in death or serious disability
  • Patient death or serious disability associated with a hemolytic reaction due to administration of ABO/HLA incompatible blood or blood products
  • Laboratory or radiologic test results not reported to the treating practitioner or reported incorrectly which result in death or serious disability due to incorrect or missed diagnosis in the emergency department
  • Death or serious disability associated with hypoglycemia when onset occurs in hospital
  • Death or serious disability associated with failure to identify and treat hyperbilirubinemia in neonates

Environmental events

  • Patient death or serious disability associated with a burn incurred from any source while being cared for in healthcare facility
  • Patient death or serious disability associated with a fall in healthcare facility

Obstetrics-related events

  • Obstetrical events resulting in death or serious disability to the neonate
  • Maternal death or serious disability associated with labor or delivery in a low-risk patient

Preparations on both campuses readied YNHH for Hurricane Sandy

Emergency contingency planning at YNHH began a week before Hurricane Sandy hit land, and at 8:30 a.m., Sunday, October 28, YNHH sent out its first communication about the emergency preparedness plan developed to ensure that normal operations would be possible on both campuses throughout Hurricane Sandy. The Emergency Operations Command Center opened the following morning on the 5th floor of Smilow, where hospital managers coordinated a highly effective, dual-campus preparedness plan. Back-up generators had been tested in advance but were not needed as YNHH experienced no power loss or flooding. Over the two-day storm, more than 600 staff members were housed at the hospital — many reporting to work for their scheduled shifts with their own sleeping bags and pillows. Food and Nutrition prepared more than 1,600 emergency meals for physicians and staff, while food prep for patients and visitors continued uninterrupted. Inpatient staffing levels remained strong and all three emergency departments remained open continuously. Clinic visits were canceled Monday and Tuesday, and some ambulatory sites remained closed due to damage or lack of power.

Monday morning, YNHH received a request for assistance from Hospice in Branford, which had to evacuate all 41 patients in anticipation of record tidal surges along the coast of Long Island Sound. Within hours of the request, 14 ambulances transported all 41 patients to the Saint Raphael Campus emergency room. They were brought to the 4th floor of Verdi, which had not housed patients in more than a year. The unit was cleaned, stocked and prepared to receive the evacuated patients in less than four hours — thanks to quick response and collaboration among a number of departments. Hospice brought its own doctors, nurses, PCAs and Pyxis machine.

Kudos to all those who helped ensure that our merged hospitals operated seamlessly and flawlessly, less than two months after integration.

Dr. John Boyce is appointed director of Hospital Epidemiology & Infection Control

John Boyce, MD, has been named director of YNHH Hospital Epidemiology & Infection Control. Dr. Boyce was hospital epidemiologist at the Hospital of Saint Raphael since 1999 and was chief of the Infectious Disease section there from 1999-2011. He trained in epidemiology at the CDC's Epidemic Intelligence Service and did his infectious disease fellowship training at the University of Texas at Houston. He has held a number of national leadership positions and is a national and international expert on infection prevention and hospital epidemiology.

Partnership in Prevention Award winner honored for achievements in eliminating HAIs

The Saint Raphael Campus of Yale New Haven Hospital received the 2012 Partnership in Prevention Award for achieving the greatest sustainable improvements towards eliminating healthcare-associated infections (HAIs). The award, cosponsored by the U.S. Department of Health and Human Services (HHS), the Association for Professionals in Infection Control and Epidemiology (APIC) and the Society for Healthcare Epidemiology of America (SHEA), is part of the HHS initiative, the National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination.

During the two-year award evaluation period (from 2009 to 2011), the Saint Raphael Campus of Yale New Haven Hospital worked to implement a number of best practices taken from infection control, clinical microbiology and medical and nursing literature. Its intensive care unit rate of central line-associated bloodstream infections (CLABSIs) went from among the highest in Connecticut with 3.99 infections per 1,000 central line catheter days during the first 15 months of the program to one of the lowest with 0.18 infections per 1,000 central line catheter days during the last 18 months of the program.

Epic training begins November 26 for Medical Staff members on York Street Campus

Members of the York Street Medical Staff who have not yet registered for Epic training should do so immediately. Physicians are required to take a minimum of 8 hours of classroom training, either at 300 George Street or in YNHH conference rooms. Inpatient only providers will take Physician-Provider 100-level and Physician-Provider 200-level classes, each 4 hours long. Ambulatory providers will also take those two, plus a five-hour Physician-Provider 300-level class. Training runs from late November through early January 2013. The York Street campus goes live with Epic on February 1, 2013.

Register online at www.ynhhs.skillport.com. When you log in, type in your user ID (which you received by mail), then the password — which is "epictrain." Once in Skillport, click on the Catalog link, then Content for Physicians. Then select your specialty from the list and follow the prompts to register for your course. You will receive a registration confirmation email.. Before you attend the classroom training, please watch the recommended e-learning classes online — from any computer, office or home. Once you complete training, you will have access to the Epic "playground" — the after-class practice venue where you can access and navigate the system, practicing the Epic skills you learned in training. Skillport tracks both classroom attendance and completion of e-learning assignments.

Some physicians may also benefit from Microsoft Windows refresher classes at 300 George Street offered by the Epic Team in November. For those who are interested, please call 203-200-EPIC (3742) or email proejctepic@ynhh.org.

Chapel Street-based physicians will be trained in spring 2013, in preparation for the Saint Raphael Campus implementation date of June 1, 2013.

Medical Directors Leadership Council update

The YNHH Medical Directors Leadership Council (MDLC) is a standing committee composed of physician leadership from every clinical department at YNHH, including medical directors of information technology and simulation. The group meets semi-monthly to work on hospital-wide quality improvement projects, resolve quality concerns among departments, organize educational events and serve as an academic working group preparing work for publication in peer-reviewed journals. This fall, MDLC offered two educational events for physician leaders throughout YNHH. On October 25, Thomas Kolditz, PhD, Retired Brigadier General and Professor in the Practice of Leadership and Management at the Yale School of Management, led a seminar on leadership skill development with a focus on decision-making in conditions of extreme uncertainty when lives are at stake. On November 16-17, "The Business of Medicine: A Course for Physician Leaders" was presented by faculty from the Yale Schools of Medicine and Management, the Leonard N. Stern School of Business at New York University, Rush University Medical Center, and the Thomas J. Watson Research Center at IBM. Over the coming year, MDLC will update you on the three quality improvement projects: Consultation Timeliness and Effectiveness, Re-engineering of the Discharge Process, and, in preparation for EPIC, the Clinical Dashboard Committee. MDLC will also be working closely with the EPIC Implementation Committee to oversee the implementation of EPIC among physicians.

Organ and tissue donation

Over 900 YNHH patients are currently waiting for life-saving organ transplants. Referrals to New England Organ Bank (NEOB) will be made in compliance with CMS conditions of participation.

Avoid pre-screening, use these clinical triggers only:

  • G — Glasgow Coma Scale (GCS) is low, indicating cerebral insult from a catastrophic or irreversible condition.
  • I — Intubated, unable to maintain patent airway independently.
  • V — Ventilatory support required due to absence of, or ineffective, spontaneous respiratory effort.
  • E — End of life discussion anticipated with potential for discussion re: brain death or comfort measures

Referrals to NEOB should occur prior to initiating brain death testing, and prior to discussing withdrawal of life-sustaining therapies. If a family brings up donation, please refer to NEOB at 800-446-6362. For tissue donation, all deaths will be referred to NEOB within one hour of asystole. The Centers for Medicare and Medicaid Services (CMS) conditions of participation, listed below, are mandatory.

  • Within one hour, notify the Organ Procurement Organization (OPO) of all individuals whose death is imminent or who have died in the hospital.
  • OPO determines medical suitability.
  • In collaboration with the designated OPO, ensure that the family of each potential donor is informed of its options to donate or decline donation of organs and tissues.
  • The individual who initiates the request to the family must be an organ procurement representative or a designated requestor (completed a course approved by the OPO

Based on these CMS conditions and YNHH policy, YNHH has identified that a missed referral, late referral or a donation discussion without collaboration with NEOB will be NEVER EVENTS. All missed opportunities are reviewed by unit and organ donation committee. For more information, contact Linda L. Maerz, MD, medical director, YNHH Surgical Intensive Care Unit, 203-785-2572 or linda.maerz@yale.edu

Jensa Morris, MD, receives national Hospitalist award

The American College of Physicians (ACP) recently named Jensa Morris, MD, a top hospitalist in the United States. This honor is awarded to only 10 hospitalists in the country for significant contributions to the medical field through their innovation, leadership and clinical skills. The award also considers contributions in the areas of patient safety, community involvement and quality improvement. Dr. Morris, assistant clinical professor of medicine at Yale School of Medicine, has been a hospitalist at YNHH since 2002. She received her bachelor's degree from Princeton University and her medical degree from Mount Sinai School of Medicine. She completed her internship and residency at Brigham and Women's Hospital in Boston.

Annual Joint Commission accreditation update held on November 20

The YNHHS Performance Management Department again engaged VHA to provide a custom education program for Yale New Haven Health System on Joint Commission Accreditation. The day-long November 20 session was held live at Harkness Auditorium on the YNHH campus, and simultaneously videocast at Cronin Auditorium, Saint Raphael Campus, and Noble Auditorium, Greenwich Hospital. The program was designed to help participants identify changes in the continuous accreditation process, learn about new and revised hospital standards, and describe the National Patient Safety Goals for hospitals. For additional information, contact Ella McGhee, YNHHS Performance Management, 688-8692 or ella.mcghee@ynhh.org.

The Grimes Center now part of YNHH

The Grimes Center, a licensed 120-bed skilled rehabilitation facility located at 1354 Chapel Street in New Haven, is now affiliated with Yale-New Haven Hospital. The Center will play an important role for providers and patients at both the Saint Raphael and York Street campuses in providing short-term rehabilitation for patients who have experienced elective surgery, an injury or traumatic major illness. For more information or patient referrals contact Grimes Center at 203-867-8328 or email, carol.capecelatro@ynhh.org or john.tarutis@ynhh.org

State changes HIV testing guidelines

As of December 2012, YNHH will no longer offer anonymous HIV testing, due to the Connecticut Department of Public Health's new guidelines which affect all testing sites in Connecticut. The new guidelines eliminate anonymous testing and allow only confidential testing. YNHH will continue to provide confidential (using name, address, etc.) HIV testing for patients seen at our York Street and Chapel Street campuses. YNHH strongly encourages HIV testing as early detection results in better health outcomes. Please call 203-688-3184 (York St.) or 203-789-4135 (Chapel St.) for more information.

YNHH Phototherapy Center moves to Prince Street in New Haven

YNHH's Phototherapy Center has moved from the Hunter Building on York Street to 46 Prince Street, New Haven, Suite 109. The Phototherapy Center offers narrow-band UVA and UVB light treatment for a variety of skin conditions including dermatitis, eczema, psoriasis, scleroderma, vitiligo and other skin ailments for infants, adults and children. Insurance coverage may vary and pre-authorization is required. Office hours: Monday-Thursday, 7 a.m.-4 p.m. and Friday, 7 a.m.-3 p.m. To schedule, call 203-688-1199.

YNHH Spine Center opens at Long Wharf

A YNHH Spine Center opened at 1 Long Wharf in New Haven on October 1, under the direction of Khalid Abbed, MD, neurosurgeon and Jonathan Grauer, MD, orthopedics. The Center provides comprehensive non-surgical and surgical treatments for the full spectrum of spine disorders from initial diagnosis through rehabilitative care, in one convenient location. A collaborative team, composed of experts from neurosurgery, orthopedics, pain management and physical therapy, develops individualized treatment plans

Charlotte Hungerford Hospital considers cancer services affiliation

Charlotte Hungerford Hospital has signed a letter of intent with Yale-New Haven Hospital and Yale Cancer Center to improve outpatient cancer services in Litchfield County by enhancing Charlotte Hungerford's Center for Cancer Care. A new, jointly-developed outpatient facility will offer medical oncology services, including infusion, radiation oncology, laboratory medicine, diagnostic imaging and support services, as well as enhanced access to cancer experts, diagnosis and treatment modalities and clinical trials. Over the coming months, the three organizations will evaluate logistics and shared considerations for the future collaboration, including the feasibility of locally expanding and relocating services. This past June, Connecticut Oncology and Hematology (COH), a medical oncology physician practice based in Litchfield County, integrated into Smilow Cancer Hospital. The five physicians of COH have been appointed to the Yale Cancer Center medical oncology faculty and continue to be members of the Charlotte Hungerford medical staff.

YNHCH NBSCU name changes to Neonatal Intensive Care Unit

YNHCH's Newborn Special Care Unit (NBSCU) on the York Street campus officially became the Neonatal Intensive Care Unit (NNICU) to more accurately reflect its Level 1 intensive care unit status. The title is also standard at hospitals within the Northeast region of the country. YNHH's unit opened as the world's first NBSCU in 1960. It is on the fourth floor of the Children's Hospital, with a six-bed satellite unit on West Pavilion 10.

Cultural Integration Oversight Committee helps align two campuses

A new Cultural Integration Oversight Committee (CIOC), with representatives from both the Saint Raphael and York Street campuses, has formed to help the integration process between the two hospitals. The group — which is co-chaired by Kevin Myatt, senior vice president, Humans Resources, and Jim Staten, executive vice president, Finance — discusses traditions, behaviors, similarities and differences between the once-separate hospitals and helps drive changes that will bring about a smooth integration over time. Representing the Medical Staff are Gary Kaml, MD, Department of Surgery, and Michael Bennick, MD, Associate Chief of Internal Medicine and director of Patient Experience. Operational co-chairs for the CIOC are Yollanda London and Cindy vonBeren.

The Committee discusses ideas, issues and concerns brought to it by employees and physicians from both campuses, facilitating discourse, setting strategic direction and providing guidance to work toward the unifying the now 1,541-bed hospital. Drs. Kaml and Bennick have involved other physicians from both campuses to participate and help provide guidance for the CIOC regarding the unity of the Medical Staff at various levels — HSR/YNHH, employed/private, medicine/surgery/OB/GYN, etc. If you have ideas or suggestions about the cultural integration of the two campuses, please contact Drs. Kaml or Bennick at gary.kaml@ynhh.org or michael.bennick@ynhh.org

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