February-March 2019

In this issue:

Navigating increased patient acuity and length of stay

A message from Thomas Balcezak, MD, Chief Medical Officer

Over the past year, YNHH has gotten much busier, largely driven by increased patient acuity and length of stay. This has challenged our ability to provide reliably patient-centered care, and has stressed our front-line physicians, advance practice providers (APP), nurses and other clinical staff.

Our increase in volume and acuity is being felt most acutely in our Emergency Departments and on the medicine services. We have noted year-over-year increases in patient boarding time in the Emergency Departments. In the literature, increased ED boarding time has been linked to increased length of stay, adverse events and other undesirable metrics, raising the concern that we may have similar experiences here. In the inpatient setting, we have noted marked increases in patients admitted to the hospitalist service, with accompanying increases in physician-patient ratios, despite increased physician recruitment over the past two years.

We began to note a sustained increase in patient acuity and census last fall, and since then have been working to relieve the pressure and risk associated with such an increase. This work has been truly collaborative. We have high degrees of engagement from our clinical department chiefs, and they have empowered their operational leaders to propose and implement modifications to workflows to enhance smooth, effective and patient-centered care. The work is being supported and driven by our Clinical Redesign team, and the senior clinical and operational leadership is receiving weekly updates on progress.

The findings of this work will not surprise you. There are significant drops in the number of discharges on weekends, and length of stay varies depending on the day of admission. We have compared our length-of-stay data to other academic medical institutions, and while we outperform benchmarks in a few surgical areas, we have higher than expected length of stay in most of our internal medicine and most surgical specialties. Based upon a detailed analysis of the data and a survey of a diverse complement of clinical and operational leaders, we have identified 70 different projects that will provide near and long-term improvements in our systems. We have charged the Clinical Redesign team to be creative and include consideration of judicious resource investment where clearly needed. These projects have been ranked based upon potential impact and feasibility of implementation, and many have begun.

Here are a few examples: We have re-opened the East Pavilion 8-8 unit, which had been an administrative space, as an observation unit, which will decant patients from the EDs and facilitate more effective placement of medicine patients in inpatient beds. We identified beds that are frequently underutilized, and worked with the clinical teams and bed management to re-purpose these beds as flexible swing resources. In order to start reducing the variability of discharges over the weekend, we reshuffled the staffing patterns of care managers to increase staffing on weekends on a few pilot units on both campuses. The pilot units subsequently experienced significant smoothing of their discharge numbers, with weekend discharges higher than their historical trends, and more early discharges at the beginning of the work week. Now we will scale these changes across other high-volume areas in the coming months. Many other projects, including the deployment of scribes on the hospitalist service, rethinking how ED patients are admitted to different clinical teams, optimizing nursing and APP resources to high volume teams, and enhancing post-discharge follow-up, are also in process.

Much of this work builds on longstanding efforts to enhance value in patient care, but our capacity challenges over the past few months have sharpened our focus on efforts that will yield quick results to help our front line provide more patient-centered, high value, and timely care. I hope those of you who regularly practice in the acute setting will start to see meaningful change soon. I thank you for your dedication to providing exceptional care to our patients during this difficult time, and welcome your questions and comments. As always, I can be reached via e-mail at thomas.balcezak@ynhh.org.

 

Patient Safety and Quality Metrics

12-Month Period

1/17-12/17

2/17-1/18

3/17-2/18

4/17-3/18

5/17-4/18

6/17-5/18

 7/17-6/18  8/17-7/18  9/17-8/18 10/17-9/18
 11/17-10/18  12/17-11/18

C. diff

164

167

167

159

169

174

 171  173  176  179  177  179

CAUTI

84

80

77

73

73

66

 59  55  56  59  54  56

CLABSI

82

79

80

78

75

76

 79  73  72  75  74  69

SSE

22

19

18

17

16

18

 16  15  12  11  13  17

 

           

12-Month Period

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  7/17-6/18  8/17-7/18 9/17-8/18
 10/17-9/18

Colon SSI

49

47

46

44

46

41

 41  43  45  44  50  46

Hysterectomy SSI

5

7

8

10

9

12

 12  13  14  16  17  17

PE/DVT

81

78

67

71

70

68

 70  66  69  67  63  66

Iatrogenic Pneumothorax

11

8

6

7

6

6

 5  6  7  6  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.

 

 

Changes to medical staff reappointment process

New, common reappointment dates have been established for practitioners who hold membership and clinical privileges at more than one YNHHS-affiliated hospital. The change was announced by the respective medical staffs at Bridgeport, Greenwich, Lawrence + Memorial, Westerly and Yale New Haven hospitals) in cooperation with the Medical Staff Administration department.

Concurrent with this change, Bridgeport and Greenwich Hospital medical staff re-appointment cycles will be distributed throughout the year on a monthly basis that more evenly distributes the work.

What does this mean to you?

  • If you have an appointment at more than one YNHHS-affiliated hospital, going forward, you will complete a single reappointment application that will be used for all facilities.
  • A reappointment date that was previously communicated to you at the time of your last reappointment may have been changed. You may receive a reappointment application earlier than you expect. This is due to the hospital’s obligation to comply with regulatory requirements related to the maximum length of medical staff appointments and the realignment process that is underway.
  • Your reappointment date may have changed even if you only have a single hospital appointment. This is so that all hospitals within YNHHS can conduct reappointment on a monthly cycle.

This new process will streamline the credentialing and privileging processes and minimize redundancy for the medical staffs. Medical Staff Administration respectfully requests your patience during implementation.

 

Late reappointment application fee

Beginning August 1, 2019, reappointment applications returned after the due date indicated on the application will be subject to a $250 processing charge.

Reappointment applications are distributed via email and expected to be returned within one month.

If you are on vacation, leave of absence, or have other extenuating circumstances and need a deadline extension, contact your local Medical Staff Administration site to avoid being subject to a late fee. The staff is available to help answer questions assist you with any questions you may have in order to complete the process.

Medical Staff members who return reappointment applications too late to be processed before the expiration of the current appointment may be subject to automatic termination or higher late fees.

 

Mobile Heartbeat adds imaging modalities

Radiology and Biomedical Imaging is fully active on the Mobile Heartbeat communication platform. All imaging modalities now have the capability to be communicated with directly via the software. This includes the departments of CT, MRI, Nuclear Medicine/PET, Ultrasound and X-ray. If you have any questions, contact David Facchini for more information.

 

Integrated care models optimize care and patient experience

Imagine that two patients visit urologists who are part of the same health system. Both patients are close in age, with comparable medical histories. Testing reveals similar, abnormal levels of prostate-specific antigen (PSA). One patient’s physician recommends a biopsy; the other patient is told to wait two years and return for a recheck, since prostate cancer often progresses slowly.

This type of scenario has occurred nationally and at Yale New Haven Health medical centers. Why would physicians make such different recommendations for follow-up care?

That question prompted Rogerio Lilenbaum, MD, chief medical integration officer of Ambulatory Services for Yale New Haven Health, Northeast Medical Group and Yale Medicine, to engage with Clinical Redesign, in Yale New Haven Health’s Office of Strategy Management.

They led four Integrated Care Model (ICM) initiatives that aimed to establish consistent care pathways – patient care which is directed by evidence-based clinical practice – for four types of patients. These are: children diagnosed with asthma, patients with abnormal PSA levels, patients with abnormal mammograms and those scheduled for screening colonoscopies.

By Feb. 28, these ICMs were scheduled to be implemented in at least one ambulatory practice at four Yale New Haven sites. The ICMs will be in practices managed by Yale Medicine, Northeast Medical Group and Community Medical Group.

The ICM project brought together – for the first time – physicians from these practices. Clinical Redesign teams for each of the four areas also included other clinicians and representatives from Care Coordination, Clinical Integration, Information Technology Services, Patient Experience, Pharmacy and operations.

“Members of these interdisciplinary teams reviewed extensive research and contributed their own experience and expertise to jointly develop these care pathways,” Dr. Lilenbaum said. “These are true best practices that will improve the quality, safety and efficiency of care, and translate into a superior patient experience.”

For example, under the ICMs, patients whose mammograms show possible or probable cancer will have biopsies within seven days (in 2017, these patients waited an average of 17 days). Patients who receive their first abnormal PSA results will be scheduled for follow up with a specialist within 14 to 28 days, vs. waiting months or longer. Pediatric patients in the asthma ICM will require fewer emergency department visits. The new ICM care pathways will be embedded into Epic.

“The ICMs reduce variations in care among different providers and sites,” said Stephanie Amport, Office of Strategy Management. “This helps ensure we’re providing the right care to the right patient at the right time.”

 

Learning more about disclosure

What is disclosure?

Disclosure refers to a communication philosophy and process that is used when there has been an unexpected or unanticipated outcome. This may result from a medical error or a complication, and this may not be known at the time of the conversation. The communication is patient/family-centered where physicians speak with patients and families with transparency, honesty and compassion about the outcome.

Why do we use the process of disclosure?

Disclosure is a communication and resolution tool that allows patients and families to have a clear understanding of what occurred, how it occurred and what will be done moving forward. It is the beginning of a recovery process for patients, families and members of the care team. There are a number of benefits to the disclosure process: it is consistent with our standards of professional behavior including putting patients and families first, our integrity and our sense of accountability. It allows for strengthening of the relationship between patient, family, clinicians and the hospital. It is part of the culture of YNHHS. And it is the right thing to do, even if it is not easy.

What are the key components of disclosure?

A disclosure emphasizes three elements:

  • What happened
  • Why the event happened, to the best of our current understanding
  • How recurrences of such an event will be prevented

Is it OK to apologize?

Yes. In fact, it is always appropriate to apologize in communications with patients and families, even if there has not been medical error at the root of the unanticipated outcome. It is never wrong to say, “I’m sorry for what you’ve experienced.”

Does an apology imply responsibility or guilt?

No. An apology is always the right thing to do. We often apologize to friends, acquaintances and even strangers as an expression of our human compassion, for events and experiences in which we were not involved (a new diagnosis, death of a loved one, a significant unfortunate life event). Beginning and perhaps ending a disclosure conversation with a sincere apology is important and always right.

What if we are not sure that an error occurred, should we still have a disclosure?

Disclosure communications are never wrong. However, statements about medical error should only be made when we know, as the result of a review, that an error was made. If, after a review, an error was discovered to have affected the patient, then we make a statement of responsibility for the error in addition to our sincere apology: “I’m sorry for what you have experienced. I gave you the wrong dose of medication.”

Who does the disclosure? Who leads it? Who is there from the team?

As a general rule, the attending physician for the patient leads the disclosure as they have the strongest relationship with the patient and provide oversight for their care. All those who lead disclosure discussions have the ready availability of coaching from a group of physician peers who have undergone specific training, including simulation, for these important communication processes. A coach will always be offered to the physician before the disclosure occurs. Other attendees at a disclosure may include the primary nurse, a member of the patient relations team and a member of our housestaff who has been primarily involved in the patient’s care. The decision about attendees rests with the patient, family and the attending physician.

What is the disclosure process at YNHHS?

Our disclosure process is called CLEAR and it is an acronym from the phrase: Communication Leads to EArly Resolution.

The process flips the historic physician/hospital behaviors of “deny and defend” to those that are open, transparent and based in honest communication. The purpose is to help the patient and the family on their path toward closure. This is facilitated by learning the truth about what, how and why events occurred.

Does CLEAR expose YNHHS and our medical staff to an increased likelihood of medical malpractice?

Literature supports both sides of this question. There is evidence to suggest that disclosure processes, like the YNHHS CLEAR program, reduces the likelihood of medical legal suit, and when there is litigation, it resolves more quickly, costs less to litigate and settles for less money.

What do patients and families want to hear?

While every experience is unique and not predictable, almost all patients and families value the sincere apology for the unanticipated outcome. They want to know what happened, why it happened, and how recurrences that might affect others in the future will be prevented.

What does YNHHS expect from a CLEAR disclosure?

It is expected that the discussions will be timely, led by the attending of record, include the patient and the people that the patient chooses to be present, and focus on a:

  • sincere apology
  • clear and honest statement of what happened
  • commitment to review how and why it happened
  • commitment to share what is learned and what will be done to prevent further incidents
  • commitment to meet again

A CLEAR disclosure is an opportunity to further build the relationship between the patient, family, our medical teams and our hospital.

How do I know what to say and do in a disclosure?

YNHHS has developed and invested in creating a robust team of “coaches” who are clinicians trained through experience, didactics and simulation, to provide us with the best advice on how to approach disclosure. They will provide real-time answers to questions.

How do I initiate a disclosure if I think one might be indicated?

There is a uniform process throughout the YNHHS. It starts with a phone call to 203-688-2291. Some basic information will be gathered and the process will begin.

What do we do if members of our team are very upset by what has occurred?

We believe strongly that to provide the very best care for our patients and their families, we must also provide care and support for our teams that provide that care. YNHHS has a variety of resources (crisis management, Employee Assistance Program and others) that may be of assistance to our teams after an unanticipated outcome in patient care.

 

YNHHS Laboratory Formulary Committee approves change to FOBT

As of Jan. 29, 2019, Fecal Occult Blood Testing (FOBT) is no longer orderable for YNHHS inpatients. Physical locations (i.e. ED and outpatient offices) that use Point of Care testing may continue to use it at this time. FOBT is commonly performed on hospitalized patients, though this test is only indicated for outpatient colorectal cancer screening.

Inappropriate FOBT use can lead to endoscopic testing that carries risks, and false negatives lead to unfounded reassurance. FOBT does not add clinical value working up hospitalized patients for GI bleed. History, CBC, iron panel and physical exam are critical to ensure appropriate evaluation.

“significant misuse,” “inappropriate” and “obsolete.” Inappropriate use (and even appropriate use) of FOBT may cause harm to patients and to subjects in a clinical trial: false positive results lead to endoscopic testing that carries inconvenience and risk for patients, and false negatives provide unfounded reassurance to physicians and patients. For these reasons, multiple authors indicate that FOBT should not be used for purposes other than colorectal cancer screening, with some recommending that FOBTs should not be available to physicians outside of colorectal cancer screening programs.

FOBTs are well documented to have relatively poor sensitivity and specificity for GI tract lesions even when used for colorectal cancer screening. As mentioned, FOBT is neither recommended nor validated as a screening or diagnostic test for upper GI lesions, and recent trials suggest a positive FOBT is not associated with a significant increase in the incidence of upper GI lesions as compared to a negative FOBT.

Direct questions or comments to: Labs@ynhh.org.

 

Safety, Quality and Experience Conference issues Call for Abstracts

The YNHH medical staff and staff from across Yale New Haven Health System, Yale Medicine and Yale School of Medicine are invited to submit abstracts for presentation at the 2019 Safety, Quality and Experience Conference slated for June 5 at the Oakdale Theatre, Wallingford.

Abstracts are due March 29. Visit the intranet (https://jdat.ynhh.org/SQEConf) for submission criteria and instructions. (Press control + click to follow the link. At log-in, users will be prompted to enter their Yale University or Yale New Haven Health network ID and password.) All abstracts will be evaluated based on the following criteria:

  • Project has clear implications for impacting safety, quality or experience of care.
  • Project purpose is identified and clearly defined.
  • Project is based on data that are rigorously collected and analyzed.
  • Outcomes/results are evident.
  • Lessons learned from this project can be applied to other patient populations, departments or hospitals.
  • Content is clearly presented, including methods, measures and interventions.
  • Project demonstrated a multidisciplinary, collaborative approach.

Registration details will be announced soon. For more information, email SQEconference@ynhh.org

 

System Readmissions Performance Improvement Team

The Performance Improvement (PI) Team structure has become essential in bringing together multidisciplinary teams to help Yale New Haven Health improve quality and safety outcomes. Olukemi Akande, MD, medical director, YNHHS Care Management, and Patricia Babcock, YNHHS system director, Care Management, announced that 2019 will be the inaugural year for the System Readmissions PI Team. This team will coordinate the readmissions work and provide strategic oversight and guidance for all hospital readmission performance improvement teams, with the understanding and respect of cultural and structural differences. The team, sponsored by the health system CMOs, will report to the System Quality Subcommittee.

Medicare readmissions adversely affect our patients and invoke penalties for the entire health system. There is opportunity to improve this by identifying and effectively addressing deficits as well as social needs at transition points, using interventions that anticipate risk, harness resources and prevent readmissions through better managed, coordinated care.

The team aims to achieve the corporate objective goal of incremental reduction in 30-day readmissions of Medicare patients by the end of the fiscal year through focus by these performance improvement teams:

  • Pneumonia at Greenwich Hospital, led by Dr. Archer
  • Heart Failure at Bridgeport Hospital, led by Dr. Gupta, Dr. Hoq and Dr. Schussheim
  • COPD at Yale New Haven Hospital and Greenwich Hospital, led by Dr. Rochester and Dr. Archer
  • All Cause at Westerly Hospital and Lawrence + Memorial Hospital, led by Dr. Donovan and Dr. Song

Efforts are already underway. The teams are responding with innovative themes of improving processes related to medication reconciliation, effective discharge and disposition, follow-up appointments and transitions of care. Many of these efforts will also involve our communities by strengthening our partnerships with cross continuum providers, which will be vital to prevent avoidable readmissions.

 

YNHHS accreditation conference scheduled for March 7

The 2019 Yale New Haven Health System Accreditation Update: Focused Challenges and Expectations conference will be held 9 am - 3:30 pm Thursday, March 7 (lunch will be provided).

Hosted by YNHHS Accreditation and Regulatory Affairs, the conference will include presentations by Vizient consultants Diana Scott, RN, and Mitch Gesinger, RN, along with YNHHS staff. The event will be live at Yale New Haven Hospital’s York Street Campus Harkness auditorium, with livestreaming at the YNHH Saint Raphael Campus Cronin auditorium, Bridgeport Hospital School of Nursing auditorium, Lawrence + Memorial Baker auditorium, Westerly Hospital Nardone conference room and Greenwich Hospital Noble auditorium.

The conference is recommended for clinical managers, clinical directors, physicians, quality and safety leads, clinical staff, clinical educators and other staff responsible for The Joint Commission accreditation processes. Topics will include:

  • The national regulatory landscape
  • Joint Commission trends, initiatives and patient safety high-focus areas
  • Assessing and managing suicide-risk patients in designated and undesignated areas
  • Emergency management strategies
  • Medication management
  • Infection prevention compliance challenges

An overview of YNHHS experiences related to these topics also will be included. Space is limited; registration required through the Infor Learning Management System. For more information, contact Jennifer Daricek.

 

Expert panel discusses how to address comorbidities in primary care

Most clinical practice guidelines describe management of a single diagnosis, but so many patients have multiple diagnoses. As a primary care physician, what is the best approach to caring for patients with multiple conditions when there is not always a clear guideline?

The issue was addressed at “Reading between the Guidelines: Managing the Patient with Comorbidities.” Case-based discussions conducted Nov. 28 and Dec. 3 showcased a panel of experts in endocrinology, cardiology, nephrology and internal medicine. Attendees learned about the clinical practice guidelines for treatment of diseases such as diabetes, coronary artery disease and chronic kidney disease. Discussion also focused on how to make clinical decisions for patients who might have a combination of these diagnoses.

"Using clinical practice guidelines is like using a two-dimensional chessboard to play three-dimensional chess. How do you apply best-practice recommendations for BP control to patients with CAD, CHF, CKD and PVD? The panel of a cardiologist, endocrinologist, nephrologist and general internist discussing the real-life issues of care management and application of practice guidelines was great, highlighting the challenges and subtleties of real-life multisystem disease management," said Alan Kliger, MD, YNHHS vice president and medical director, Clinical Integration and Population Health.

Email pophealthci@ynhh.org for clinical practice guidelines. They are also available in Epic Tools.

 

Information security tip: Sharing isn't always caring

The user name and or password you use to sign on to your work computer should never be shared, even with your supervisor. You may be the only person authorized to access specific patient information, and sharing user names and passwords is a violation of HIPAA and Yale New Haven Health policy.

 

Infor Learning Management System reminder

To make the Infor LMS user experience as easy as possible, a guide is now available to all staff. Designed to direct users to their assigned (required) learning and provide clear instructions for enrolling in elective (non-required) courses, the “Accessing Required and Elective Training in Infor LMS guide” is available on everyone’s Infor learner dashboard.

 

Yale Scleroderma program appoints new director

Monique Hinchcliff, MD, MS, was named director of the Yale Scleroderma program. Patients receive comprehensive care at three Yale New Haven Health sites, the Interventional Immunology Center at the North Haven Medical Center, the Winchester Clinic and Temple Medical Center.

A team of pulmonologists, cardiologists, dermatologists and gastroenterologists provides care for patients with scleroderma clinical manifestations including lung, heart, skin, renal and gastrointestinal involvement while addressing functional, nutritional, psychological, gynecological, urological and/or sexual health challenges. For more information, contact Marie Frank.

 

In memoriam

The Medical Staff Administration Office is saddened to report the passing of Jacob Loke, MD, and David Dreyfus, MD, PhD. Dr. Loke, 78, internal medicine/pulmonary and critical care, died Jan 9, 2019. Dr. Dreyfus, 59, pediatrics/immunology, died Jan. 14, 2019.