August 2018

In this issue

Meshing the pursuit of high-value care with the front-line realities of the medical staff

A message from Thomas Balcezak, MD, Chief Medical Officer

For the past several years, leadership across the Yale New Haven Health System has prepared an annual business plan, performance improvement plan and unified corporate objectives. These create alignment across our system and articulate a coherent strategy to enhance quality and safety in all our operational areas. 

As we approach the beginning of a new fiscal year in October, our health system’s clinical leaders have identified quality and safety objectives most likely to materially enhance patient care, and improve our publicly reported quality metrics and national rankings.

When we started to create cross-system clinical governance, we created the System Quality Council, which is comprised of the chief nursing and medical officers across the system and key individuals with responsibilities over functions involved in front line care. That group has developed goals that fall into four key areas: quality of care, patient and staff safety, infection prevention, and readiness for accreditation and regulatory visits. 

For the coming fiscal year, the system’s objectives for those areas are reducing readmissions; encouraging and increasing event report classification and employee injury reporting; reducing hospital acquired infections; and reducing utilization and prescription of opioid medications, respectively. These goals will build on groundwork already in place and are completely aligned with our journey towards high reliability, our work to reduce employee and physician burnout, and efforts to combat the national epidemic of opioid abuse.

Readmission reduction has been a focus of performance improvement for nearly a decade, and we have made progress. We have made great strides in enhancing the quality of transitions of care, by requiring that discharge summaries be completed within 24 hours of discharge, automatically transmitting discharge summaries to outpatient physicians, dramatically enhancing the reliability and accuracy of medication reconciliation, and redesigning workflows to enhance quality in handoffs in care. Our readmission rates have improved, but opportunities for additional creativity to reduce readmissions remain. At Yale-New Haven Hospital, for example, we continue to lag in COPD readmissions, so our corporate objective for this year will focus on analysis and performance improvement to identify patients with COPD rapidly, and then deploy resources and plans to address the root causes that result in COPD readmissions. The other hospitals in our system have challenges in readmission rates for the other diagnoses, and their annual objectives reflect these issues.

I have previously written about how our journey towards high reliability has yielded enormous enhancements in patient safety. That work has resulted in an 80 percent reduction in serious safety events across our health system, and has facilitated a shift in our institutional culture such that we focus on designing reliable systems of care rather than focusing on mitigating individual failures. Event reporting is a bedrock of high reliability, since problems can only be fixed if they are identified and communicated. It is equally important that all event reports be accurately classified to help prioritize performance improvement efforts. As such, our health system goal for the year is to classify all the events reported reliably at all of our hospitals, to increase the quality of our data streams, and thus make it easier for us to identify and mitigate risks to safety. Additionally, we have recognized that many of our front-line caregivers are exposed to environments where their personal safety is at risk. To enhance systemic supports for our employees and medical staff, we have also made increased reporting of provider injuries and safety events a goal for the year. That reporting will drive an increased awareness of risks to our employees and medical staff as we continue to overhaul our systems of care.

A key risk to patient safety is in-hospital complications and infections. As such, the reduction of hospital acquired infections across the system will be another focus in the coming fiscal year. In particular, while we have made progress in reducing cases of hospital acquired c. difficile infections, that rate has plateaued. Therefore, a systemwide focus on reducing the contributing factors to c. diff infections – antimicrobial stewardship, hand hygiene, adherence to containment protocols and others – will create additional efforts to address this important issue. 

Lastly, we are all aware of the gravity of the national epidemic of opiate abuse, and it is clear that over-prescription and overutilization of these medications by the healthcare system is a key contributor. Over the past two years, at Yale New Haven Hospital, a committed group of internal medicine physicians and nurses led by Dr. Adam Ackerman and Deirdre Doyle, RN, developed and piloted a novel, practical protocol to reduce substantially the utilization of parenteral opioids in favor of subcutaneous and oral opioids and non-opiate analgesics. This pilot was hugely successful in reducing opiate utilization and enhancing patient pain scores, and created a roadmap for expanding this approach across the hospital and health system. This nationally recognized work will be a linchpin in our systemwide approach to reduce opiate utilization in a way that is patient-centered and sensitive to front-line providers’ workflows.

These goals communicate the institution’s commitment to the dogged pursuit of high-value care in a way that is sensitive to the front-line realities of our physicians, nurses and advanced practice providers. Additionally, success on these objectives will drive improvement in our publicly reported metrics and, indirectly, in our national rankings. I ask you to continue your critical engagement in this work, and encourage you to send me questions and feedback via email at thomas.balcezak@ynhh.org.

Patient Safety and Quality Metrics

12-Month Period 7/16-6/17 8/16-7/17 9/16-8/17 10/16-9/17 11/16-10/17 12/16-11/17 1/17-12/17 2/17-1/18 3/17-2/18 4/17-3/18 5/17-4/18 6/17-5/18
C. diff 160 154 149 153 160 162 164 167 167 159 169 174
CAUTI 82 89 83 81 83 84 84 80 77 73 73 66
CLABSI 87 84 83 83 81 82 82 79 80 78 75 76
SSE 34 29 27 24 24 25 22 19 18 17 16 18
 
12-Month Period 5/16-4/17 6/16-5/17 7/16-6/17 8/16-7/17 9/16-8/17 10/16-9/17 11/16-10/17 12/16-11/17 1/17-12/17 2/17-1/18 3/17-2/18 4/17-3/18
Colon SSI 56 52 49 52 50 52 49 47 46 44 46 41
Hysterectomy SSI 8 6 6 4 4 6 5 7 8 10 9 12
PE/DVT 97 92 81 81 85 85 81 78 67 71 70 68
Iatrogenic Pneumothorax 13 12 11 10 10 10 11 8 6 7 6 6

The Patient Safety and Quality metrics are reported on a 12-month rolling timeframe. The most recent timeframes differ based upon the various databases reporting the metrics. 12-month rolling total updated with AHRQ v6.0 definition starting January 2017. 

Patient Safety and Quality Metric Definitions

Colon and Hysterectomy SSI: A surgical site infection within 30 days of the operative procedure, classified as superficial, deep, or organ/space infections based on CDC/NHSN surveillance definitions.

C. diff (Clostridium difficile): A patient who develops diarrhea greater than 48 hours after admission to an inpatient unit and for whom the C. diff testing (either rapid toxin, cytotoxin or PCR) is positive.

CAUTI (Catheter Associated Urinary Tract Infection):
A patient who has an indwelling urinary catheter in place for over two days, with at least one of the following signs or symptoms: fever > 38? C, suprapubic tenderness (with no other recognized cause), costovertebral angle pain/tenderness (with no other recognized cause), urinary urgency (not while catheter in place), urinary frequency (not while catheter in place), or dysuria (not while catheter in place).

CLABSI (Central Line Associated Blood Stream Infection): A primary bloodstream infection (not related to an infection at another site) that develops in a patient with a central line in place over two days before onset of the infection. Culturing the catheter tip is not a criterion for a CLABSI.

Iatrogenic Pneumothorax:
A pneumothorax caused by medical care, with certain exclusions for trauma, cardiac and thoracic surgery patients.

PE/DVT (Pulmonary Embolism/Deep Vein Thrombosis): Any PE/DVT that occurs postoperatively.

Serious Safety Event: A deviation from generally expected care that results in moderate to severe patient harm.

Mortality Improvement Project 

By Alan Friedman, MD

Three years ago, the Yale New Haven Hospital Mortality Review Committee (MRC) formed to improve the quality of care that the medical staff provides to patients. Part of the YNHH peer review process, the MRC follows collaborative processes to identify gaps in care and opportunities for improved efficiency and safety in our systems of care. The MRC reports to the Institutional Practice Quality and Peer Review Committee (IPQPRC) twice annually. 

Initially, the MRC was comprised of four physicians from the medical staff and one nurse from the Quality Services Team. Meeting weekly, the MRC reviewed more than 1,000 mortalities each year of patients who died at YNHH. In 2017, the MRC adopted a structure to allow for more localized review of cases by physicians who oversee the clinical operations of our busiest services. These early “agent committees” of the MRC included Mortality Review Sub-Committees in the MICU, Heart and Vascular and Smilow areas of care. The group identified and addressed a number of gaps in care from the review of these “observed” mortalities leading to the implementation of several system changes. 

In February 2018, the Clinical Operations Group charged the MRC with additional goals to:

  • further its “hub and spoke” model for observed mortality review to include 12 additional major service lines
  • provide more accurate and timely clinical documentation of the diagnoses assigned to each patient at YNHH

The former goal represents an expansion of our current processes to allow for a more meaningful case review performed by physicians who are involved with the patients for review. The latter identifies the need to better calculate our Case Mix Index (CMI). The CMI is often higher in busy tertiary medical centers like YNHH than it is in a smaller community hospital. Accurate calculation, however, depends on if all diagnoses are included in the clinical documentation by the medical staff for all patients. 

This process is separate and distinct from the billing process and is essential to the accurate calculation of the “expected mortality rate” for patients, services and hospitals. The ratio of Observed Mortality Rate/Expected Mortality Rate is an important quality metric employed by several organizations that attempt to compare hospitals to one another. It is clear that we want to decrease our observed mortality rate. We commit to this process by learning from the practice of case review and shared learning of our findings. We do this because it is the right thing to do. We are equally obliged to include accurately the variety of diagnoses that represent the patients who seek care at YNHH, and as responsible stewards of this process, our CMI and thus our expected mortality rate will only increase.

Currently, 14 specialty review teams are working to better address the accurate reporting of our CMI. These teams will report to the MRC. Each team leader completed an orientation that included dedicated time with our Clinical Documentation Team (CDT), which provides near real-time review of our patients. Based on notes, procedures and testing, the team validates current diagnoses and sends queries to the clinician if it appears that additional diagnoses can be added to the patient’s record. we have found happens more than 90 percent of the time. However, our clinicians respond to these queries only 65 percent of the time. Our Specialty Review Team Leaders will partner with their physician staff to improve responsiveness to the queries and with this, we will more accurately identify the complexity and “degree of illness” of our patients. This assessment will inform us of our expected mortality rate. 

On August 6, the specialty review teams received the first set of individualized, twice monthly, mortality review lists. Teams will complete reviews on a uniform electronic form for ease of reporting. 

We are indebted to each of the 14 specialty leaders and their teams for their commitment and dedication to a process of case review and shared learning to close identified gaps in care and deliver the highest quality of clinical care at YNHH.

 The Mortality Improvement Project Team members are: Alan Friedman, MD, co-leader; Christian Pettker, MD, co-leader; Tonia Catapano, Clinical Documentation; Leif Lafromboise, Clinical Documentation; Danielle Zawatsky, Quality Services; Heather Love, Quality Services; Heather Scott, Quality Services. 

Physician leaders of the Specialty Mortality Review Teams are: Dr. Adelson (Cancer); Drs. Mangi and Curtis (Heart and Heart Surgery); Dr. Schilsky (Gastroenterology); Dr. Marottoli (Geriatrics); Dr. Ratner (Gynecology); Dr. Inzucchi (Diabetes and Endocrinology); Dr. Brewster (Kidney Disorders); Dr. Matouk (Neurology and Neurosurgery); Dr. O’Connor (Musculoskeletal); Dr. Osborn (Ear, Nose and Throat); Dr. Siner (Pulmonology); Dr. Chai (Urology).

YNHHS prepares for third year of mandatory vaccination

With the 2018-2019 influenza season approaching, members of the medical staff are expected to lead our organization’s efforts in improving patient safety by demonstrating their commitment to receiving the flu vaccine and promoting vaccination for patients, colleagues and family. The flu vaccination program will continue to be mandatory at Bridgeport, Greenwich and Yale New Haven hospitals, as well as NEMG. All employees at these organizations must receive an annual flu vaccination as a condition of continued employment, and medical staff members must receive it to maintain privileges.

The deadline to receive flu vaccination is Dec. 1, 2018. 

If you have a legitimate medical or religious reason why you cannot receive the flu vaccine and are employed by Bridgeport, Greenwich or Yale New Haven hospitals or NEMG, you must formally request an exemption by September 30 through the Human Resources process. Medical staff who are not employed by one of these organizations and who would like to request an exemption will must do so via a survey that will be distributed by email in the late fall. Members of the medical staff are encouraged to receive the flu vaccine at flu clinics scheduled at all YNHHS hospitals this fall. Watch your email and the Medical Staff newsletter for a schedule of flu vaccine locations and times after Labor Day. Flu vaccination at all Yale New Haven Health flu fairs is free for all employees, volunteers and members of the medical staffs. 

If you elect to be vaccinated anywhere other than a Yale New Haven Health facility, you will be asked to attest to having done so via a survey that will be distributed by email in the late fall. 

In summary, as a member of medical staff of Bridgeport, Greenwich or Yale New Haven hospitals, or of NEMG, and in order to fulfill your obligation to receive flu vaccination, you are required to do one of the following:

  • receive vaccination at a Yale New Haven Health flu vaccine fair
  • receive vaccination elsewhere and provide proof of vaccination through Employee Self-Service or by emailing it to fluinfo@ynhh.org (applies to YNHHS employed providers only) 
  • receive vaccination elsewhere and attest to having done so via the survey that will be emailed to you in the late fall (non-employeed providers only) 
  • document a legitimate medical or religious exemption via the survey that will be emailed to you in the late fall. (non-employed providers only)

Hand hygiene champions to receive additional training

On Sept. 13, nearly 100 YNHH hand hygiene champions will participate in a refresher course on workflows, data collection and proper glove use. The champions, who work in in inpatient units and ambulatory sites, serve as liaisons between their areas and the Hand Hygiene Performance Improvement (HHPI) Team. The team created the champion program last spring as part of its efforts to achieve 100 percent hand hygiene compliance. The program also includes hand hygiene leads, who will continue to support champions’ efforts on different shifts. Each area’s manager identifies a physician, staff member or student to serve as hand hygiene lead for that shift. The lead conducts at least three hand hygiene observations, providing feedback and, when necessary, coaching. 

Release of laboratory and radiology results via MyChart

With the development of electronic medical records, patients expect to see their medical information via patient portals. Epic’s patient portal is MyChart. Community practitioners who are not on Epic but send their patients to a Yale New Haven Health provider, including laboratory and radiology providers, should be aware that results will be available via MyChart directly to the patient, and no practitioner action is required to release these results.

The current release strategy for laboratory and radiology results is: - Immediate release: point-of-care testing, most basic hematology and chemistry testing (CBC, BMP, CMP and components), cultures and other infectious disease testing that may indicate a need for antibiotic treatment or infection transmission precautions - Three business days release: most standard lab tests not noted above - Seven business days release: sensitive blood tests such as tumor markers, genetic testing, flow cytometry, pathology and radiology results - HIV testing is subject to legal requirements for release and is not shared via MyChart

Additional billing and patient care information generated by participating Epic providers, along with ambulatory and inpatient information related to services at a YNHHS facility will also be available.

Modification of use of pre-existing specimen lab list

However, a number of tests do not default, such as antibiotic and other drug levels. These default to a “new draw,” to better fit their most common clinical usage.

Recently, patient safety events have occurred as the result of a laboratory result value measured on a pre-existing specimen, when the ordering provider intended to order a new draw, rather than an add-on. As a result, the Medical Informatics Officers (MIOs) and Laboratory MIOs reviewed and proposed a number of additional tests to default to “new draw.” 

The group is sensitive to the impact on patient experience, but feels the risk of defaulting to previous specimen outweighs that consideration for this additional group of studies. 

As an ordering provider, if you are comfortable that a test defaulted to “new draw” can be done on an existing specimen, simply change the default checkbox in the order. The presence of an acceptable specimen will continue to show in the order composer, but the default behavior will be to order a new draw.

If you are interested in reviewing the full list of default-new-draw tests, the list is available by following the "BEAKER Updates" link on the lower right of the Epic splash screen.

Clinicians discuss biologics, best practices in adult and pediatric asthma

Over 100 staff from Yale New Haven Health (YNHHS), Northeast Medical Group (NEMG), Yale Medicine (YM), and Community Medical Group (CMG) attended “Beyond the Clinical Practice Guidelines: Caring for the Severe Asthmatic in a New Era,” at two dinner sessions conducted in June.

Yale Medicine pulmonologist Lauren Cohn, MD, discussed the use of biologics for asthma. “Monoclonal antibody biologic therapies have been life-changing for patients with arthritis and inflammatory bowel diseases,” she said. “Finally, biologics are available to treat severe asthma. More are on the way to FDA approval. They are improving the lives of our most severe patients since they reduce asthma exacerbations and hospitalizations.” Supporting clinicians in adopting evidence-based treatment, like the use of biologics, is the goal of Clinical Integration workgroups coordinated by Clinical Integration and Population Health at YNHHS. Clinicians from across the medical groups comprise nine disease-specific workgroups and review clinical quality metrics to identify improvement areas. 

“We have brought together clinicians to study evidence of how to best diagnose and treat diseases which put a huge financial and resource burden on our society. Through this quality journey, we hope to improve the lives of people who have placed their trust in us,” noted NEMG pulmonologist Kevin Twohig, MD, who co-chairs the Pulmonary Workgroup with Dr. Cohn. Clinicians and health systems are increasingly accountable for delivering high quality, well-coordinated care at reasonable costs. With overlapping patient populations, YNHH, NEMG, YM and CMG are collaborating to care for these populations through shared clinical practice guidelines. 

Clinical Integration places patient needs in the center. Clinicians find clinical integration dinners useful – not only to hear the rationale for best-evidence clinical practice guidelines, but to network, hear about challenges from other clinicians and share experiences. When all agree on best evidence approach to care, patients are the winners,” said Alan Kliger, MD, medical director, YNHHS Clinical Integration. Clinical Practice Guidelines are available under Epic “Tools,” on the Physician Portal or from pophealthci@ynhh.org.

Newsmakers

Eric Jose Velazquez, MD, was recently named as the Robert W. Berliner Professor of Cardiology. He is globally recognized as an authority in heart failure, cardiovascular clinical trials and cardiac imaging. Dr. Velazquez came to Yale in June, when he was appointed chief of the section of Cardiovascular Medicine in the department of Internal Medicine, chief of cardiovascular medicine at Yale New Haven Hospital, and physician-in-chief of the Heart and Vascular Center for the Yale New Haven Health System. He previously served as professor of medicine in the division of Cardiology at Duke University, and held appointments at the Duke Clinical Research Institute and Duke Global Health Institute. A graduate of Williams College, Velazquez earned his MD from the Albert Einstein College of Medicine. He completed his internal medicine and cardiology training at Duke University, including holding fellowships in clinical research and echocardiography.

Clinical Redesign Hackathon: Save the Date

With more and more in the news about precision medicine and its benefits to patient treatment and recovery, is it too far off to think about what a precision hospital could mean to patient care?

That’s what the Clinical Redesign Hackathon will address on October 19-20 at 55 Park St., New Haven. The hackathon is open to Yale New Haven Health employees across the system, Yale School of Medicine and Yale Medicine. The event’s organizers are looking for clinical and non-clinical participants to help form diverse groups that will encourage new ideas. If interested, apply online at or email Melissa Davis, MD, at Melissa.davis@yale.edu.

HRO training schedule for newly credentialed practitioners

High Reliability Organization (HRO) training is required for newly credentialed practitioners. Medical Staff members can attend training on any of the dates listed below. To register for any of the sessions below, please contact Jolie Boran or Ellen Macone.

  • Tuesday, Sept. 4: 12:30 - 2 pm, 300 George St., IFE Auditorium
  • Thursday, Sept. 13: noon - 2 pm, YSC - Clinic Building 1058
  • Monday, Sept. 17: 12:30 - 2 pm, 300 George St., IFE Auditorium

In memoriam

Richard A. Ehrenkranz, MD, 72, of Hamden, CT, died peacefully at Connecticut Hospice on August 8, 2018 from complications related to metastatic rectal cancer. Dr. Ehrenkranz was a neonatologist and an international leader in the field of infant nutrition and clinical research. He spent his 42-year academic and clinical career at Yale University School of Medicine. 

Following medical school, he trained in pediatrics at Yale New Haven Hospital (1972-1974) and then spent two years at the Pregnancy Research Center, National Institute of Child Health and Human Development, National Institute of Health, Bethesda, MD.

Dr. Ehrenkranz returned to New Haven in July 1976 and performed a neonatology fellowship in the department of Pediatrics, Yale University School of Medicine. He joined the faculty of Yale Medical School in July 1978, was promoted to professor of pediatrics in 1988, and remained an active member of the department until June 2018. He directed the Neonatal Intensive Care Unit's (NICU) Clinical Research Program and was the NICU's clinical director and medical director. 

He is remembered as a generous colleague who had a remarkable ability to present complex topics in a clear and memorable way. As news of his advancing illness spread, he received countless emails from mentees, students and peers thanking him for being an inspirational leader who was always willing to share his time and knowledge. Read the full obituary

Request for patient stories

Yale New Haven Health often features patient stories to highlight the work and dedication of our physicians, nurses and staff in its print publications, websites and advertising campaigns. If you have a patient that you think would make a great story -- and who is willing to share his or her experience -- please contact Cynthia Whitcomb at 203-688-9440, cynthia.whitcomb@ynhh.org.