October/November 2002

Medical Staff Bulletin

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

On Monday morning, October 6, 2002, six surveyors from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) came for a scheduled visit to YNHH; and that same day about 20 surveyors from the Connecticut State Department of Public Health paid us an unscheduled visit. For the next five days, YNHH had opportunity to observe itself through the eyes of others. This was an informative experience.

The state's unannounced hospital surveys are being conducted throughout Connecticut and are very comprehensive. Our survey results have not been returned, but no major compliance problems were identified in their closing conference. The JCAHO survey was equally thorough, but educational, as well. I had the privilege of accompanying Dr. Crede and the physician surveyor for most of the week and learned a great deal about the morale and commitment of our staff, our progress in process improvement at the unit level, and particularly our culture.

The JCAHO surveyors reported they were tremendously impressed with YNHH. They reflected positively on virtually every aspect of the organization, from physical facilities to programs and staff. Every area visited demonstrated to the surveyors meaningful progress in improving hand hygiene and medication safety. Questions about interdisciplinary care elicited impressive testimony regarding teamwork and shared vision. The single compliance matter that received critical JCAHO comment concerned physician documentation related to restraint use. Physician orders for restraint application are necessary but not sufficient. Physician progress notes must daily acknowledge justification for continuing restraints. Recently, we have improved the clarity of guidelines for restraints and will be much more active informing physicians of their responsibility and monitoring our progress.

The provisional JCAHO score received was 93. The surveyors reported that typical scores in large academic medical centers are in the mid-80s. As an organization, we can be very proud of this result

Peri-Operative Service leadership changes

Dr. Richard S. Stahl, Executive Director of Peri-Operative Services, announced that Dr. Douglas Vaughn has been named Medical Director of Peri-Operative Services, succeeding Dr. Charles Kopriva. Dr. Kopriva retired in August after 26 years of dedicated service to the patients of Yale-New Haven Hospital and its Operating Rooms. Dr. Vaughn, formerly Clinical Director of Anesthesiology, is a highly respected clinical anesthesiologist with prior experience as an oral surgeon. He is fully committed to responsive service for both physicians and patients.

Peer Review Privilege

One of the goals of peer review is to encourage a full and frank discussion about the care of particular patients. To attain that goal, Connecticut protects the discussion and paperwork associated with peer review and M & M meetings. This protection is lost if peer review cases summaries are place in the medical record. A recent Connecticut court decision involving another 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. The materials must be kept in a protected location. Paperwork and minutes cannot be left in hospital or other conference rooms. The conclusion of the peer review group should not be referenced in letters to referring physicians, or again, the peer review privilege is lost.

New adverse event reporting requirement

All practitioners at Yale-New Haven Hospital should be aware of a new state law, which took effect on October 1, 2002. This law requires all hospitals and surgery centers to report certain adverse events to the State Department of Public Health (DPH). Events that fall into the more serious categories (A, B or C) must be reported by telephone to DPH within 24 hours, with a written report to follow within 72 hours and a corrective action plan to be sent within seven days.

Events requiring reporting within 24 hours include:
Class A–An event resulting in or associated with a patient’s death or immediate danger of death.
Class B–An event that has resulted in or is associated with a patient’s serious injury or disability or the immediate danger of serious injury or disability.
Class C–An event that has resulted in or is associated with the physical or sexual abuse of a patient (in the hospital).

Another, less serious class of Events (Class D) is reportable, but on a quarterly basis. These are events that lead to a “measurable disability.” To determine if an event is reportable, ask yourself:

1. Did the patient sustain an injury?
2. Was the injury related to medical management?
3. Was the injury due to the natural course of the patient’s illness or underlying condition or a foreseeable effect of the patient’s planned treatment? (In making this determination you should consider whether appropriate precautions were taken to avoid certain foreseeable complications).
4. Did the injury result in death, immediate danger of death, serious injury or disability or the immediate danger of serious disability, or measurable disability?

At YNHH, all of these reports will be made by the Office of Legal Affairs. Therefore, if you identify an event that you believe may be reportable, please contact Legal Affairs by phone at 688-2291. On off shifts or weekends/holidays please call the clinical advisors and involve them in the process. They can page the on-call Legal Affairs attorney. On off-shifts, Legal Affairs asks to be called 90 minutes before the end of a shift (e.g., 6 a.m. rather than 2 a.m. where possible.) If necessary, a physician consultant will be asked to review medical information and speak to involved staff.

Under this law, we will also be required to internally collect the names of clinical personnel who have knowledge of or are involved in an event. However, be assured that this information is protected by Peer Review and will not be included on the forms we submit to DPH.

Please contact the Office of Legal Affairs at 688-2291 if you have questions about this reporting law.

Conscious Sedation Privileges

A recent mailing addresses the criteria and requirements for Medical Staff members to maintain conscious sedation privileges. If you wish to perform conscious sedation at Y-NHH, please provide the documentation as outlined in the mailing. Contact Physician Services at 688-2615 if you have any questions concerning this matter.

2002 Quality Conference set for December 16

Yale New Haven Health System's annual quality conference, this year entitled, A Culture of Quality and Safety for YNHHS, will be held Monday, December 16, at Harkness Auditorium from 8 a.m. to 3:30 p.m. Keynote speakers will be Paul Plsek, a consultant widely recognized for his work in quality improvement in health care, and Harlan Krumholz, professor of Medicine and Epidemiology and Public Health. Please call Diane Collins at 203-688-8692 for a registration form or information about the agenda or poster submission process. The registration deadline is November 30.

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.