June / July 2007

Medical Staff Bulletin

Contents

Message from the Chief of Staff
The Boston Globe on April 21, 2007, printed a report headlined: “Five Hospitals Release Data on Inspections. Surprise Visits Revealed Some Flaws in Patient Care.” At issue were unannounced visits by reviewers from the Joint Commission (formerly JCAHO) at the Massachusetts General and Brigham & Women’s Hospitals, Boston Medical Center, Dana-Farber Cancer Institute, and Children’s Hospital Boston. Two of the major concerns in Boston related to findings that the Joint Commission has cited in many U.S. hospitals.

The first concerned “time-outs,” the protocols employed before invasive procedures to document patient identification, type of procedure to be performed, and operative site, laterality and level. There has been surprisingly poor compliance and respect for these protocols, despite the occurrence, in virtually every hospital, of related adverse events. It has been particularly challenging to ensure proper time-outs in areas outside the operating room such as in Diagnostic Radiology, procedural laboratories, and both critical care and general nursing units. Even when protocols are followed, there is often poor documentation in the medical record, and this was a finding in Boston.

The second major concern was medication reconciliation. This entails creating a list of all current medications taken before hospital admission, carefully considering this list when prescribing inpatient medications, reviewing and comparing lists at every transition in level of care, and particularly reconciling inpatient medications with discharge medications. At Yale-New Haven Hospital, we have had trouble with discordance between the medication list provided with our patients’ discharge instructions and medications listed in the dictated discharge summary. There are many reasons for this, but primary among them is the decision, at the time of dictation, to actually modify the list provided with instructions to the patient. While this reflects good intentions, it leads to inaccurate description of the true discharge medications. Changes in the latter should be communicated by a vehicle other than the discharge summary.

A change has been made in the front screen of CCSS for each patient and this is a line to “> view discharge meds.” This opens up a list of the medications contained in the patient’s discharge instructions and the dictated discharge summary should contain this list, not one edited after discharge.

Other issues cited in Boston that are also acknowledged nationally to be of concern include assessment and treatment of pain, adequacy of patient hand-offs, proper use and documentation of restraints, medical record legibility, and dangerous and prohibited abbreviations. All of these are subjects of focused initiatives at YNHH.

Policy change: paperless reporting
On April 1, YNHH Medical Records Department converted to a “paperless” system for Laboratory and Diagnostic Imaging results. Under the new policy, paper copies of test results are filed in patient charts only if the result is not available in the computer. Outpatient paper reports designated “Clinic/Practice Copy” are still sent to clinics not using an electronic medical record (Centricity EMR) and to private doctors’ offices for their review. An additional “Physician Copy” of outpatient lab results can be printed and sent to the physician’s office if requested. Clinic names and locations and physician names must be accurate and legible for paper reports to be properly routed. These reports will no longer be filed in patient charts in Medical Records.

DNR/DNI bracelets come to YNHH
Starting July 5, YNHH will start using magenta (bright purple) colored bracelets to identify the subset of patients who wish not to be resuscitated or intubated in the event of cardiac or respiratory arrest. In the past, the only way to identify such patients was to review their charts and look for the DNR order. This occasionally led to incorrect assumptions being made and “codes” being called on patients who did not want them.

The documentation process has also been changed. There are new, simpler CCSS screens and a new DNR Discussion Documentation Form will guide doctors through the process of discussing a patient’s or family’s wishes and translating these into an appropriate order.

The patient’s attending physician must always authorize a DNR order, although a resident, P.A. or A.P.R.N. can do the documentation. Once an order is put into CCSS, nursing will be automatically notified to put the bracelet on the patient and modify the patient’s plan of care to reflect this.

Facts to be aware of:

• Having an advance directive does not make a patient a DNR unless this is specified.
• Being a DNR patient is not the same as “comfort care only” – it just means no code should be called.
• It may still be appropriate to call the Rapid Response Team for a DNR patient.
• Patients who come to the Hospital with an orange DNR transfer bracelet should have it replaced with the purple bracelet while here.
• There are special rules for patients who live in group homes operated by the Department of Mental Retardation (call Legal and Risk Services: 688-2291).

2007 Residency match
For the 2007 National Residency Matching Program (NRMP), YNHH listed 1,938 applicants for 182 residency positions and filled all in the match except for one position in Clinical Pathology. Of the final matched students, 89 (49%) were women, 11 (6%) African Americans, 1 (6%) of Hispanic origin, and 19 (10%) are graduates of international medical schools. YNHH’s 2007 House Staff are coming from 75 U.S. medical colleges, including 15 from Yale, 13 from Boston schools and 18 from New York City schools. All of our program directors, faculty and residents are to be congratulated for all of the hard work that they do in promoting their programs and for the outstanding results!

Only about 66% of all residency positions offered are filled by U.S. medical graduates and approximately 27% by international graduates. The adult primary care specialties continue to attract disproportionately fewer American graduates: Family Practice (42%), Internal Medicine (56%), and Primary Care Internal Medicine (61%), in addition to Psychiatry (60%). General Surgery continued its strong recruitment of U.S. seniors (78%). Interest in OB-GYN increased with 99.5% of positions filled, 72.5% with U.S. seniors. Dermatology, Anesthesiology, Emergency Medicine, Orthopedics, Radiation Oncology and Plastic Surgery all remain extremely competitive, with >95% of positions filled with >75% U.S. graduates.

We have received initial accreditation for two new fellowship programs – one in Sleep Medicine with Dr. Francois Roux as the program director, and the other in Psychosomatic Medicine, directed by Dr. Paul Desan. Congratulations to both programs for these new endeavors!

YNHH listed among top 15 major U.S. teaching hospitals
For the third year, YNHH has been named one of the top 15 major teaching hospitals in the country in a national study conducted by Solucient Leadership Institute, an Evanston, IL-based company that provides tools to analyze healthcare cost and quality. The 2006 “Solucient 100 Top Hospitals: National Benchmarks for Success” study objectively identified hospitals that are the highest performers in the nation, classified according to bed size and teaching status.

Solucient’s top 100 hospitals demonstrated higher survival rates, kept more patients complication-free, and attracted more patients, all while maintaining positive financial bottom-lines.

The Solucient study used a balanced scorecard approach, centered on nine key organization-wide measures: risk-adjusted mortality, risk-adjusted complications, risk-adjusted patient safety, core measures score, severity-adjusted average length of stay, expense-per-adjusted-discharge, profitability, cash-to-debt ratio and growth in patient volume.

Single sign-on (SSI) name/password for YNHH clinical information systems
In June, Information Systems and Technology (IS&T) piloted “Single Sign-On” (SSO) to access SCM, Softmed, Centricity EMR (Logician), Synapse, MDLink and Novell. Single Sign-On will be available Hospital-wide at YNHH this summer. Single Sign-On offers these features: one login ID and password, self-service password re-sets, decreased login time, faster logout and improved security.

You will be able to access Single Sign-On by clicking on the SSO icon which on the Clinical Workstation and designated Business Workstations and following the prompts to enroll. You only need to do this once. You will also find more information on the Intranet on Single Sign-On.

You will also be able to reset your Single Sign-On password at any time without calling the Help Desk. You will find answers to FAQs on the YNHH Intranet at: http://intranet.mis.ynhh.com/ynhh/
Marketing_&_Communications/docs/ssoFAQs.doc.

If you need assistance, please call the Help Desk at 688-HELP.

Welcome, new Medical Staff:

May
Roberto Bernardino, M.D., Attending, Ophthalmology
Marsha Guess, M.D., Attending, OB/GYN
Michael G. Palladino, D.P.M., Associate, Orthopedics
Graig N. Sanders, P.A. , Affiliated, Internal Medicine
Mary Lou Siefert, A.P.R..N., Affiliated, Internal Medicine
Virginia Tierney, A.P.R.N., Affiliated, Anesthesiology

Chief of Staff
Peter N. Herbert, M.D.

Assistant Chiefs of Staff
Thomas J. Balcezak, M.D.
Victor A. Morris, M.D.

Elected Medical Staff Officers

President
Brett J. Gerstenhaber, M.D.
President-Elect
Leo M. Cooney, Jr., M.D.
Immediate Past President/Treasurer
Robert M. Weiss, M.D.
Secretary
Gordon Reid, M.D.

Medical Board Officers

Chairperson
Brett J. Gerstenhaber, M.D.
Vice Chairperson
Leo M. Cooney, Jr., M.D.

Medical Board Members

Stephen Ariyan, M.D.
Michael C. Bennick, M.D.
James A. Brink, M.D.
Benjamin S. Bunney, M.D.
Christopher R. Canny, M.D.
David A. Coleman, M.D.
Richard D’Aquila
Richard L. Edelson, M.D.
Fredric O. Finkelstein, M.D.
Patricia Sue Fitzsimons, R.N., Ph.D.
Gary E. Friedlaender, M.D.
Peter M. Glazer, M.D.
Peter N. Herbert, M.D.
David G. Hesse, M.D.
Roberta L. Hines, M.D.
Margaret K. Hostetter, M.D.
Karen A. Johnson, M.D.
Suzanne P. LaGarde, M.D.
Charles J. Lockwood, M.D.
Marc E. Mann, M.D.
Jon S. Morrow, M.D., Ph.D.
Michael O’Brien, M.D., Ph.D.
M. Bruce Shields, M.D.
Joel S. Silidker, M.D.
Brian K. Singletary, D.M.D.
Brian R. Smith, M.D.
Dennis D. Spencer, M.D.
Thomas F. Sweeney, M.D.
Robert Udelsman, M.D.
Fred R. Volkmar, M.D.
Gary R. Wanerka, M.D.
Lawrence J. Wartel, M.D.
Stephen G. Waxman, M.D., Ph.D.
Norman S. Werdiger, M.D.
Joseph H. Zelson, M.D.

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:

• 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: April 13, 2007 (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.