April/May 2002

Medical Staff Bulletin

Message from Dr. Peter N. Herbert,
YNHH Chief of Staff

Medical Staff members undoubtedly have learned that Yale-New Haven Hospital's general surgery residency is threatened with withdrawal of accreditation in July 2003 unless cited deficiencies are corrected and a new program is approved in the interim. The Residency Review Committee (RRC) action was mentioned in an article in The Chronicle of Higher Education, which was picked up by wire services. Considerable media attention was precipitated, most of which was measured and factual. A front-page article in the New Haven Register, unfortunately, exaggerated and sensationalized the story.

YNHH sponsors 28 residency training programs and co-sponsors, with the Yale School of Medicine, approximately another 40 subspecialty residency/fellowship programs. Compliance with standards of the Accreditation Council of Graduate Medical Education (ACGME) and its 28 RRCs is the joint responsibility of our clinical departments, program directors and coordinators, our Graduate Medical Education (GME) Office, and ultimately, my office. The GME Committee reviews all proposals for new programs and regularly conducts internal reviews of all established programs.

In addition to general surgery, YNHH sponsors programs in surgical subspecialties of otolaryngology, pediatrics, plastics, transplant, trauma and critical care, urology and vascular. Only general surgery is threatened with accreditation withdrawal. The RCC cited our programs in five areas, four of which had to do with documentation of the training experience. These issues had all been identified in our internal review and were being remedied at the time of the RCC site visit (however, no credit is given for good intentions and planned changes). The fifth citation addressed resident work hours, and this was the focus of media attention. These citations resulted in threatened withdrawal of accreditation because, after YNHH and Bridgeport Hospital combined their surgical residency program in the mid-90s, the "new" program's accreditation was designated "provisional."

The ACGME mandates that residents not be assigned on-call, in-house duty, more often than every third night, and residents must have one day in seven free of patient care duties. Moreover, six of the 28 RCCs set defined limits on weekly patient care hours, usually averaged over four weeks. We had general surgical rotations at the Veterans Administration Hospital where first-year residents were on-call, on the premises, every other night for a month, and residents sometimes spent 100 hours per week in-house. General Surgery Program Director Dr. John Seashore has moved quickly to eliminate every-other-day schedules and, with success in recruiting more full and part-time help, will bring general surgery resident work hours to or below an 80-hour per week target in the next few weeks.

Surgery Chief/Chair Dr. Robert Udelsman, together with Dr. Seashore, Associate Program Director Dr. Michael Ivy, and the Department of Surgery faculty, has committed to rapid correction of all program shortcomings. They will receive all necessary support from Dr. Rosemarie Fisher, director of GME for Yale-New Haven Medical Center, from me and YNHH administration. The RRC will revisit the new program on August 7, and we are confident a new program will be approved by the RCC in October 2002. We deeply regret the consternation this has caused, particularly to our residents. A much stronger general surgery training curriculum will be in place this spring.

Fax announcements

Please be aware that the Chief of Staff's office has begun utilizing an "auto" fax service to provide notification to Medical Staff members about matters of an urgent nature. Notifications are limited and generally directed to individuals in certain specialties depending upon the content of the information. If you receive a fax from Yale-New Haven Hospital that is boldly marked "URGENT," please take notice as it will contain timely and important information.

Peer Review Privileges

It remains of of the goals of peer review to encouage a full and frank discussion about the care of individual patients. In order to attain that goal, Connecticut protects the discussion and paperwork associated with peer review and M&M meetings. However, the protection of the documents remains important or the privilege may be lost. Recently, we found a peer review case summary filed in a patient's chart. A lawyer requested the file, the protected document was copied and sent; it is now in the possession of the plaintiff in a malpractice case. A recent Connecticut court decision involving Norwalk Hospital confirmed that the peer review privilege may be waived when we do not segregate protected materials and simply treat them as part of a medical record. We are responsible for maintaining the confidentiality of peer review and M&M records, so keep the materials in a protected location. Do not leave paperwork and minutes in hospital or other conference rooms. Do not discuss the conclusion of a peer review group in correspondence about patients.

HIPAA Update

• A summary of the recently released Department of Health and Human Services proposed modifications to the HIPAA privacy regulations can be viewed at www.hhs.gov/ocr/hipaa. Chief among them is a proposal to eliminate the requirement that patients give prior consent on privacy practices before receiving treatment—the concern is that prior consent could interfere with patients' access to health care and have serious unintended consequences.
• In follow-up to the February HIPAA seminar sponsored by the YNH-PHO, answers to 50+ practical questions submitted at the seminar can be found on the YNH-PHO website, along with a brief summary of the potential changes to the Privacy Rule currently under consideration by HHS.

YNHH expanded administrative roles

YNHH recently announced expanded organizational assignments to help strengthen hospital performance. Richard Stahl, MD, associate chief of surgery, is now executive director of perioperative services with additional responsibilities for preadmission testing, all YNHH operating rooms and the post-anesthesia care unit. Dr. Stahl will continue to practice plastic surgery on a limited basis. Richard Lisitano was appointed administrative director of patient services, reporting to Sue Fitzsimons, PhD, RN, with responsibility for care coordination, clinical effectiveness, social work, pharmacy and hospitalwide regulatory compliance. Thomas Balcezak, MD, assistant chief of staff/director of clinical quality, shares responsibility with Dr. Herbert for clinical process improvement initiatives, epidemiology and infection control, quality improvement support services, the Center for Outcomes Research and Evaluation and the Medical Staff office. Victor Morris, MD, assistant chief of staff/director of bed resources, is responsible for hospitalwide inpatient bed utilization and assignments and continues as the medical director for care coordination. Tucker Leary, vice president for physician development, now reports to Dr. Herbert, with responsibilities focusing on Medical Staff initiatives such as MDlink, enhancing general physician integration with key hospital programs and improving services to patients.

Medical Staff reappointment questions

As part of the YNHH reappointment process, the Department of Physician Services requires that Medical Staff members complete a confidential questionnaire.

Question #11 asks if your privileges at a hospital or other health care facility have ever been voluntarily or involuntarily "cancelled, revoked, challenged, suspended, reduced, limited, etc." The intent of this question is to identify health care providers who lose or relinquish privileges for safety or quality of care reasons.

Generally, it is not necessary to reply "yes" to this question under the following circumstances: if privileges for a procedure are not renewed because a required volume threshold is not met, if obstetrical privileges are dropped because an attending has decided to practice gynecology only or if a physician leaves an area and no longer utilizes the hospital in that area.

If you have any questions, please contact the Department of Physician Services at (203) 688-2615.

Refer items for the next issue of Medical Staff Bulletin via phone, fax, E-mail or mail to:
Peter N. Herbert, MD
1063 Clinic Building
P: (203) 688-2604, F: (203) 688-7152
herbertpn@ynhh.org
or
Katie Krauss
Marketing & Communications
GB 443
P: (203) 688-2492, F: (203) 688-2491
krauss@ynhh.org

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Last revised: April 13, 2004 (cfs)

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All information is intended for your general knowledge and is not a substitute for medical advice or treatment for specific medical conditions. You should seek prompt medical care for any specific health issues and consult your physician before starting a new fitness regimen.