March 2008

Medical Staff Bulletin

Contents

Message from the Chief of Staff
Most of our Medical Staff are aware that YNHH had an unannounced, full accreditation survey by the Joint Commission (TJC) during the first week of February. We will receive full accreditation, and the reviewers noted that our number of requirements for improvement is low for a hospital of this size and complexity.

Several of the areas cited by TJC, and requiring verification of improvement in the next four months, related to physician practice. Medication reconciliation must be standardized and complete in virtually every inpatient and outpatient setting. It will be possible to do this electronically within a year, but for now, this must be largely accomplished on paper. This is new work for clinicians, very time-consuming on several services, and a non-negotiable requirement.

Like medication reconciliation, the universal protocol for time-outs before surgeries/procedures must be standardized and executed in every setting. Time-outs must include certain essential elements: correct patient identity, correct side and site, agreement on the procedure to be done, correct patient position, and availability of correct implants and/or special equipment or special requirements. All members of the operative team must be present during the time-out, and all must direct their full attention to the protocol. We will be disseminating a video demonstrating the elements of the universal protocol.

Medical record documentation of physicians and other licensed independent practitioners will receive special attention to verify absence of banned abbreviations (with QD at top of list), adequacy of preoperative and admission histories and physicals, and timing and content of operative notes. Before patients leave the OR/PACU, the record should include a brief op note recording the operator and assistants, procedure(s) performed, estimated blood loss, specimens removed, and post-operative diagnosis. The complete operative note is to be dictated the day of the procedure. Finally, during the review and recommendation of privileges, chiefs and associate chiefs are cautioned not to continue privileges that are very infrequently exercised.

Our director of Performance Management, Dr. Thomas Balcezak, and Victoria Dahl-Vickers, RN, MBA, deserve special thanks — together with a large supporting cast — for the compliance readiness which they led and this most successful TJC survey.

2008 Doctor’s Day celebrated on March 25
YNHH will celebrate National Doctor’s Day with a buffet lunch in the special events area of the East Pavilion cafeteria on Tuesday, March 25, at noon. If you are interested in attending, please RSVP to the Department of Physician Services at 688-2615.

Performance management update
Each January, Connecticut hospitals submit a Clinical Performance Improvement Plan to the Connecticut Department of Public Health (DPH). In 2007, YNHH undertook a number of initiatives, including participation in the Five Million Lives Campaign, standardizing hand-offs with the Ticket-to-Ride and a new emergency department sign-out program, participation in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, and an initiative to standardize venous thromboembolism (VTE) prophylaxis. These initiatives joined a robust set of quality and safety initiatives which includes work to improve our publicly-reported measures that we communicate each month to CMS/TJC. The most recent month’s results are to the left.

What’s new in 2008? We anticipated a large body of work leading up to a potential Joint Commission visit sometime in early summer of 2008. With the Joint Commission visit in the first week of February, however, we no longer need to speculate about what we might need to accomplish, and instead now know exactly where to focus. These areas, reported in our Performance Improvement Plan and validated by the Joint Commission visit, are outlined by Dr. Peter Herbert in this month’s Chief of Staff message. A common underlying theme is our need to standardize our processes to eliminate banned abbreviations; in dating, timing and providing legible signatures to notes; in medication reconciliation; and in time-outs — something that is very challenging to do across multiple, clinical services and care settings. It is not adequate for us to perform idiosyncratic time-outs. We must do so in a consistent manner where all patients are served. In the coming months, you will see many changes in this regard; we will be discussing these initiatives in this space. Please call Dr. Tom Balcezak with any questions at 688-1343.

October 2007 Performance

AMI	#	YNHH%	Nat'l 90th%
ASA at arriv.	8/8	100	100
ASA at D/C	16/16	100	100
B-Block at arriv.	7/8	88	100
B-Block at D/C	20/20	100	100
ACEI at D/C	3/3	100	100
PCI <90 min	2/3	67	88
Smoking cess.	3/3	100	100

CHF	#	YNHH%	Nat'l 90th%
LVEF assess.	23/23	100	99
ACEI at D/C	7/8	88	100
Smoking cess.	N/A	N/A	100
D/C instr. given	9/18	50	96

Pneumonia	#	YNHH%	Nat'l 90th%
02 assess. at arriv.	11/11	100	100
Pneum. vac. given	9/9	100	96
Abx given <4 hrs	9/10	90	94
Smoking cess.	3/3	100	100
Blood cx before abx	3/3	100	100
Initial (non-ICU)     Selection Abx	6/7	86	96

SIP	#	YNHH%	Nat'l 90th%
Proph Abx 1 hr	36/37	97	96
Abx selection	34/37	92	99
Proph Abx D/C	31/35	89	96
DVT proph ordered	25/26	96	97
DVT proph given	22/26	85	95

Focused professional practice evaluation
At its January meeting, the Medical Board approved a new Medical Staff policy on "Focused Professional Practice Evaluation." The Joint Commission now requires that all privileges for new members of the medical staff and any new privileges requested by existing members of the Medical Staff be subjected to a period of focused review. After 90 days, we will need to determine whether each newly requested privilege has been used by the physician at YNHH and to evaluate patient outcomes and complications. Medical staff members who have privileges which they do not exercise at YNHH will be asked to resign the privileges in question. At the time of re-appointment, please only request the privileges you fully intend to use at YNHH. For a complete copy of the new policy, please go to www.ynhh.org and click "Medical Professionals" or contact the Department of Physician Services at 688.2615.

YNHH appoints executive director of new Smilow Cancer Hospital
Abe Lopman has been appointed vice president and executive director of the new Smilow Cancer Hospital. He joins YNHH after four years as the executive director of the regional care network at Memorial Sloan-Kettering Cancer Center in New York where he directed the strategic and daily operations of the Memorial network of cancer care facilities throughout the metropolitan area. Prior to that, Lopman served as vice president of acute care operations at the Orlando Regional Healthcare System where he planned, built and operated the MD Anderson Cancer Center-Orlando. He has also held positions at MD Anderson Cancer Center in Houston and Montefiore Medical Center in New York. Lopman earned his B.A. in biologic sciences from City University of New York and an M.B.A. from the University of St. Thomas in Houston.

Requests for MRI with intravenous contrast
Due to a new warning from the FDA concerning an association between nephrogenic systemic fibrosis and all brands of Gadolinium-based MRI intravenous contrast agents, a new policy has been instituted for the following patient groups that are referred for an MRI with intravenous contrast:

• Patients on dialysis: MRI cannot be scheduled until it is approved by the patient’s nephrologists
• Patients with severely impaired liver function: MRI cannot be scheduled unless there is a documented eGFR of > 40 ml/min/1.73m2 within 24hrs.
• Patients with impaired renal function: MRI cannot be scheduled unless there is a documented eGFR of >30 ml/min/1.73m2.
• Patients over the age of 60: MRI cannot be scheduled unless there is a documented eGFR of >30 ml/min/1.73m2

For inpatients, the eGFR measurement must have taken place within 72 hours. For outpatients, the eGFR measurement must have taken place within six weeks. The department of Diagnostic Radiology recognizes that this may cause some inconvenience to referring physicians and their patients, but the changes are necessary to ensure patient safety. As an additional safeguard, an eGFR point-of-care device will soon be implemented in MRI; however, conventional eGFR measurements will continue to be required in the patient groups listed above. Queries concerning this policy should be addressed to the MRI manager, Maureen Perrachio at 688-8118, or to Dr. Jeffrey Weinreb, chief of MRI at 785-5913.

Dr. Dhodapkar named section chief of hematology
Madhav V. Dhodapkar, MB, BS, has been appointed chief of the section of hematology in the department of internal medicine at YNHH and Yale School of Medicine. He is a professor of medicine at Yale, and director of hematologic malignancies at Yale Cancer Center.

Dr. Dhodapkar earned his medical degree from All India Institute of Medical Sciences in New Delhi, and completed his internal medicine residency at St. Louis University Hospitals in Missouri. He served a fellowship in hematology and medical oncology at the Mayo Clinic. Dr. Dhodapkar was assistant professor, hematology/oncology, at the Myeloma Institute at the University of Arkansas Medical Sciences, Little Rock, AR. Prior to his recruitment to YNHH, he was the Leon Hess associate professor at Rockefeller University, New York, NY, where he headed the laboratory of tumor immunology and immunotherapy. He was also a faculty member in the hematology/transplantation service at Memorial Sloan-Kettering Cancer Center in New York. His clinical interest and expertise is in multiple myeloma and related disorders. His laboratory is trying to develop novel biologic approaches, including vaccines, to prevent and treat myeloma and other cancers.

Dr. Norwitz named co-section chief of maternal fetal medicine
Dr. Errol Norwitz, associate professor of obstetrics, gynecology and reproductive sciences at Yale School of Medicine, has been appointed co-chief of the section of Maternal-Fetal Medicine and director of the Maternal-Fetal Medicine fellowship program at Yale-New Haven Hospital. He completed his medical training at the University of Cape Town, South Africa, and his Ph.D. at Oxford University on a Rhodes Scholarship. Dr. Norwitz served his Ob/Gyn residency and maternal-fetal medicine fellowship at Harvard University. His research has been supported by N.I.H./N.I.C.H.D. by way of the Reproductive Scientist Development Program and the Women’s Reproductive Health Research Scholarship and, most recently, by March of Dimes. His areas of research interest include the regulation of GnRH receptor gene expression and the molecular regulation of parturition, both term and pre-term.

New critical result communication software to be installed in Diagnostic Radiology
YNHH will be implementing a new communication system called Veriphy which notifies the ordering clinician that a critical or urgent diagnostic radiology test result is pending. Veriphy has been recognized by the Joint Commission and is in use at 130 hospitals nationwide. Attributes of the software include:

• Color coding which indicates urgency of the finding;
• Continuous alerts until message is retrieved;
• Escalation of notification according to pre-set rules;
• Verification to sender that message was received;
• Automatic tracking and monitoring of the communication;
• Documentation of the communication process from beginning to end;
• Storage of the original voice message and record in a searchable archive for years;
• Automatic compliance with Joint Commission national patient safety goals for critical result communication.

YNHH is forming a multidisciplinary team to help with implementation process. For more information, contact Mike Matthews, director, clinical imaging information systems, at 688-3916 or michael.matthews.org

NCI renews Yale Cancer Center’s designation; Dr. Edelson returns to Dermatology
Yale Cancer Center’s designation as a comprehensive cancer center by the National Cancer Institute (NCI) was recently extended for an additional five years. The award includes $1.87 million in funding per year to support the Center’s research initiatives, and continuation of the Center’s comprehensive status, the most prestigious level of designation from the NCI. Yale Cancer Center received an excellent evaluation from peer reviewers and the National Cancer Institute during its most recent grant submission.

Dr. Richard Edelson, who has served as director of the YCC since 2003, has announced that he will transition the Cancer Center leadership after a national search for a new director has been completed. He will return full-time to his position as chief/chair of Dermatology and to his work in cancer immunology research. Under his leadership, YCC has completely reorganized itself, recruited close to a dozen top-level clinicians in medical oncology and surgery, and aided with the plans and approval process for the new Smilow Cancer Hospital.

Upcoming health-related walks
Please consider supporting various walk-a-thons YNHH is participating in this spring.

• Apr. 27: March of Dimes, at Lighthouse Point Park. Contact Dr. Michael Apkon, 203.688.3296.
• May 11: Y-Me National Breast Cancer Organization, Lighthouse Point Park. Contact: Debbie Klotzer, 203.688.8824.
• May 17-18: American Cancer Society Relay for Life, Cancer Survivor Tent Sponsor, Guilford Fairgrounds. Contact Patricia Harvey, YNH Shoreline Medical Center, 203.453.7254.
• May 18: Greater New Haven American Heart Association at Lighthouse Point Park. Contact Marianne Carna at 203.688.8993.

SCM training update
Members of the Medical Staff and other patient contact employees throughout the hospital are now being trained on the new Sunrise Clinical Manager (SCM) clinical information system. All physicians who enter orders are required to complete the training course if they wish to continue doing so in the new system.

The mandatory SCM training program includes two components: Web-based online modules and practice scenarios which are conducted in SCM training classrooms. Depending on job function, total training time ranges between one and four hours. Users must complete both training components before they receive security access to enter orders in SCM. All current users will continue to be able to retrieve results, view and create documents, and make patient lists whether or not they complete order-entry training.

The new system was implemented in the Psychiatric Hospital at the end of February, to be followed by Obstetrics and Newborn Special Care by the end of March, Pediatrics in early April and all other inpatient areas by June 1.

The new SCM applications will replace the current CCSS system that was introduced in 1992. For more information about how to complete training, please have your office manager contact Janet Betta by email at Janet.Betta@ynhh.org or by phone at 688.3042.

YNHH Auxiliary seeking men and women
Yale-New Haven Hospital’s Auxiliary — which has supported hospital programs for more than 55 years, during which it has contributed nearly $5 million to the hospital — is seeking new members, including members of the Medical Staff and / or their spouses. Members can be as active as their schedules permit, and there are various Auxiliary committees that members can opt to join. If you are interested in more information on joining the hospital Auxiliary, contact the Auxiliary at auxiliary@ynhh.org or 688.5717.

Welcome, new Medical Staff:

Chief of Staff
Peter N. Herbert, MD

Associate Chief of Staff
Thomas J. Balcezak, MD

Assistant Chief of Staff
Victor A. Morris, MD

Medical Board Officers
President
Brett J. Gerstenhaber, MD
President-Elect
Leo M. Cooney, MD
Secretary
Gordon V. Reid, MD
Past President
Robert M. Weiss, MD

Medical Board Members
Stephan Ariyan, MD
Michael C. Bennick, MD
James A. Brink, MD
Richard D’Aquila
Richard L. Edelson, MD
Jack A. Elias, MD
John A. Federico, MD
Patricia Sue Fitzsimons, RN, PhD
Gary E. Friedlaender, MD
Peter M. Glazer, MD
Peter N. Herbert, MD
David G. Hesse, MD
Roberta L. Hines, MD
Margaret K. Hostetter, MD
Lee Jung, MD
Suzanne P. LaGarde, MD
Charles J. Lockwood, MD
Marc E. Mann, MD
Jon S. Morrow, MD, PhD
Michael J. Murphy, MD
Michael K. O’Brien, MD, PhD
Joel S. Silidker, MD
Brian K. Singletary, D.MD
William H. Sledge, MD
Brian R. Smith, MD
Dennis D. Spencer, MD
Thomas F. Sweeney, MD
Harold H. Tara, MD
James C. Tsai, MD
Robert Udelsman, MD
Fred R. Volkmar, MD
Gary R. Wanerka, MD
Lawrence J. Wartel, MD
Stephen G. Waxman, MD, PhD
Norman S. Werdiger, MD
Joseph H. Zelson, MD

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 Murphy
Marketing & Communications
GB 443
P: (203) 688-2492, F: (203) 688-2491
Katie.Murphy@ynhh.org

Back issues of the Medical Staff Bulletin:

• January/February 2008
• November/December 2007
• October 2007
• August 2007
• June/July 2007
• May 2007
• March/April 2007
• February 2007
• January 2007
• November 2006
• September 2006
• July 2006
• June 2006
• May 2006
• March 2006
• January 2006
• December 2005
• November 2005
• September 2005
• August 2005
• June 2005
• March 2005
• January 2005
• December 2004
• November 2004
• October 2004
• September 2004
• July 2004
• June 2004
• May 2004
• April 2004
• March 2004
• February 2004
• January 2004
• January/February 2003
• October/November 2002
• August/September 2002
• April/May 2002
• February/March 2002
• January 2002
• November 2001
• July/August 2001

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Last revised: March 14, 2008 (dh)

Home page URL: http://www.ynhh.org

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.