June 2018

In this issue:

Unifying the patient experience to enhance our signature of care

A message from Thomas Balcezak, MD, Chief Medical Officer

We have made enormous strides to provide our patients with the safest and highest quality care possible. Our journey towards high reliability has changed how we understand, discuss and change our processes to minimize the risk of patient harm.

The culture and behaviors of high reliability, however, do not apply only to patient safety and quality of care. High reliability enhances all the components that go into the provision of high value care. A key component is how our patients experience receiving care from the thousands of clinicians and staff across our health system.

Patients’ perceptions of care are formed through every interaction with members of the healthcare team. Behaviors of our caregivers, the environment within our walls, and, in essence, our institutional culture, directly relates to their level of trust or distrust in us, their ability to comprehend what is happening to them, their engagement in their care, and ultimately, their health outcomes. This is how we describe our patient care experience. The quality of our patients’ experience--and our steadfast focus on alleviating suffering--is as important as making a successful diagnosis and formulating an appropriate treatment plan. Without ensuring patient engagement, that therapeutic plan is much less likely to succeed.

Where, then, do we stand as an institution in providing a reliably exceptional patient experience?

We have not improved our patient experience as rapidly as we have our patient safety and healthcare quality metrics. The complexity of our systems, our balkanized disciplines, high patient acuity, far flung geography and countless institutional micro-cultures all contribute to a situation where our patients often experience incomplete, conflicting, or misunderstood communication, excessive wait times, a lack of transparency and an inconsistent, unfamiliar feel to care across our health system. Perhaps unconsciously, we dismiss these indignities and inconveniences as unavoidable given the complexity of health care. Interestingly, we often dismissed medical error and variable healthcare quality in the same way before we embarked on the journey towards high reliability.

The way forward to achieve an exceptional patient experience is thus long, but also familiar. As with patient safety, we know we have areas of excellence where our patients reliably report a superlative experience. We know it can be done. To build on those successes and methodically apply them, we are unifying the management and oversight of the patient experience across the health system to create a signature standard of exceptional patient care. We are also investing in the resources and staff required to apply well established best practices along with our Standards of Professional Behavior to our daily work. We are fortunate to have Susan Haufe, our inaugural Health System chief experience officer, and Dr. Michael Bennick, medical director of the Patient Experience, leading a methodical, system-wide approach to enhancing how we care for our patients.

Know that our current challenges with patient experience do not stem from uncaring caregivers or staff. Indeed, our employee and medical staff engagement surveys tell us that the majority have a deep commitment to enhancing the lives of our patients. Yet, our patient experience surveys show we have significant opportunities to improve how we communicate with our patients. We must harness our caregivers’ commitment to our mission by identifying patient dissatisfiers, providing a supportive framework to address those challenges, and carrying out changes that ensure all elements of our care remain centered on the patient.

This work cannot require our front-line caregivers and staff to work harder. Indeed, that would lead to burnout, and in turn, negatively affect the care and experience of our patients. Rather, we must create opportunities for our caregivers to spend more time with our patients, since those moments generate a sense of fulfillment in the caregiver as well as the patient. We as caregivers must embrace these efforts. Our medical staff wields an enormous, positive influence in modeling patient-centered behavior, which is essential if we are to succeed in our existential work to provide health care of the highest value to the patients we are privileged to serve.

As always, I welcome your questions and feedback, and can be reached via email at thomas.balcezak@ynhh.org.

 

Patient Safety and Quality Metrics

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
C. diff
150
 150 160
154
149
153
160 162
164 167
167
159
CAUTI
72
78
82
89
83
81
83 84
84 80
77
73
CLABSI 100
95
87
84
83
83
81 82
82 79
80
78
SSE 41
37
34
29
27
24
24 25
22 19
18
17
                         
12-Month Period
 
 3/16-2/17  4/16-3/17  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
Colon SSI
48
52
56
52
49
52
50 52
49 47
46
44
Hysterectomy SSI
9
8
8 6
6
4
4
6
5 7
8
10
PE/DVT 112
105
97
102
81
81
85
85
81 78
67
71
Iatrogenic Pneumothorax
15
 15 13
12
11
10
10 10
11 8
6
7

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 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.

 

Opioid standards of care, C. diff, team models dominate abstract presentations at Safety, Quality and Patient Experience Conference

Nearly 1,500 YNHHS physicians and employees gathered May 31 at the Oakdale Theatre, Wallingford, for the 2018 Safety, Quality and Experience Conference hosted by Yale New Haven Health and Yale School of Medicine. More than 225 physician and employee teams submitted abstracts for the conference aimed at improving patient safety, quality and the patient experience, with 50 selected for presentation.

YNHH received the Delivery Network award for their project, “Care Team Model,” to replace the primary nurse model, where a unit is divided into teams to allow for proximity of patient assignments and a mix skilled care team. After one year, increased HCAHP and Press Ganey scores reflected improvements in communication, responsiveness and overall satisfaction.

A multidisciplinary team representing YNHH won the General Performance Improvement category for “Using Multidisciplinary Teamwork to Reduce Hospital Acquired C. difficile.” For three years, a performance improvement team implemented several interventions to reduce C. difficile. The interventions included several departments and disciplines, including Pharmacy, Environmental Services, Infection Prevention, Laboratory Medicine and Quality and Safety. The result was a 45 percent decrease in C. difficile rates over two years. Team members included Michelle Whitbread, MPH, Janet Kozakiewicz, PharmD, Scott Sussman, MD, and Sonali Advani, MD, Jill Williams, RN, Christina Murdzek, and Richard Martinello, MD, David Peaper, MD, PhD, Michael Holmes and Jeffrey Topal, MD. A YNHHS team was named Delivery Network winner for “Clinical Redesign for The Adoption of a System-Wide Opioid Standard of Practice.” The goal was to reduce the number of IV opioid doses administered to adult inpatients by 25 percent through the adoption of a system-wide pain standard of practice preferring the oral route of administration of opioids in patients tolerating oral intake, preferring the subcutaneous route of administration when parenteral opioids are required, and maximizing non-opioid analgesia options when appropriate. Optimizing the use of Epic and educating providers, the clinical redesign project resulted in a 21 percent decrease per 1,000 patient days of IV opioid doses over six months. Additional improvements included:

  • Parenteral opioid doses administered decreased by 7 percent per 1,000 patient days
  • Daily rate of patients receiving any parenteral opioid decreased by 13 percent per 1,000 patient days
  • Decrease in patient reported average pain scores from 4.77 to 3.95 (19 percent improvement)
  • Overall 10 percent absolute decrease in percentage of IV opioids being administered

The key objective was to reduce potential harm to patients from opioid adverse effects including nervous system effects, nausea and hypotension while maintaining effective pain management by reducing intravenous (IV) doses administered to patients receiving parenteral opioid therapy. Optimizing the use of opioid medications and maximizing non-opioid analgesics when appropriate in adult inpatients was correlated with decreased use of IV opioids, reduction of adverse effects from IV opioid administration and effective pain control. Additionally these measures reduced parenteral opioid doses administered to hospitalized medical patients and reduced the rate of patients administered any parenteral opioid. The subcutaneous route is an approved method of administration for most opioids and currently exists as a route in order set for the health system. The team looked at standardizing the approach of using oral pain medication as first attempt for pain control when patients are able to tolerate oral intake to change the way the health system stands in opioid dispensing and administration practices. With this evidence, the team expected to see improved patient experience scores in the areas of HCAHPS that ask about pain control.

The team’s data suggest these interventions are helpful in reducing exposure to IV opioids while still providing effective pain control to hospitalized adults. Development of a standard of practice is helpful in reducing not only exposure to IV opioids but opioids overall, since an important part of this redesign was also to encourage use of non-opioid analgesics as well. The work of the team allowed patients to experience consistent delivery of pain medication, better pain control with decreased unwanted side effects.

opioid project team
 

Team members: front row (l-r): Deirdre Doyle, RN, Connie Cholewczynski, Rockman Ferrigno, MD, and Anesta Williams. Back row: Scott Sussman, MD, Christopher Zemaitis, Adam Ackerman, MD, and Bill Sotire. Missing from photo: Christine Day, Jennifer Healy, RN, Ryan Telford, Christopher Lorentz, MD, Catherine Fanning, RN and Alia Mahmood.

 

U.S. News & World Report ranks YNHCH in nine specialties

Yale New Haven Children’s Hospital has been ranked among the best in the nation for nine out of a possible 10 pediatric subspecialties in the 2018 Best Children’s Hospitals rankings, published by U.S. News & World Report. YNHCH ranked in cancer (#43); cardiology and heart surgery (#49); diabetes and endocrinology (#8); gastroenterology (#43); neonatology (#36); nephrology (#45); neurology and neurosurgery (#48); pulmonology (#49) and urology (#30).

“We are honored to have so many of our children’s hospital specialties ranked among the best in the United States,” said Clifford Bogue, MD, physician-in-chief and chief medical officer, Yale New Haven Children’s Hospital (YNHCH), and chair of pediatrics, Yale School of Medicine. “This demonstrates the amazing commitment of our talented staff in providing care that continues to reach new levels. Our goal is simply to be the best we can be for the children of our region. Our growth, our quality and safety initiatives, and our commitment to recruiting and retaining top medical talent are vital to improving outcomes.”

Yale New Haven Children’s Hospital has campuses in New Haven and Bridgeport. The network of seven Pediatric Specialty Centers across the region provides access to more than 35 pediatric medical and surgical subspecialties. The centers include: West Pavilion 2, Smilow 7 and One Long Wharf in New Haven; 747 Belden Avenue in Norwalk; 5 Perryridge Road in Greenwich; 633 Middlesex Turnpike in Old Saybrook and 5520 Park Avenue in Trumbull.

 

Dr. Steven Choi named inaugural chief quality officer

Steven Choi, MD, currently with Montifore Health System, has accepted the position of chief quality officer for Yale Medicine and Yale New Haven Health, effective September 4, 2018. In this new role, Dr. Choi will develop and oversee the implementation of a common safety and quality agenda across all inpatient and ambulatory Yale Medicine and Yale New Haven Health practice sites.

Dr. Choi comes to New Haven via the Montifore Health System – an academic health system comprised of 11 hospitals and over180 ambulatory locations across Westchester County and the Hudson Valley and academic affiliations with the Albert Einstein College of Medicine and Montefiore School of Nursing. He currently serves as assistant vice president, Montefiore Health System; performance improvement director, Montefiore Network; and executive director, Montefiore Institute for Performance Improvement. In his role at Montefiore, he has been instrumental in the development of an integrated comprehensive performance improvement plan for the health system and improved performance against publicly reported quality indicators.

Dr. Choi obtained his medical degree from Robert Wood Johnson Medical School, completed pediatric residency training at Columbia University/Babies and Children’s Hospital of New York and a critical care fellowship at University of Southern California School of Medicine/Children’s Hospital Los Angeles.

 

Smilow Cancer Hospital appoints Pickens as new senior leader

Lori Pickens has been named Smilow Cancer Hospital senior vice president and executive director, effective Aug. 6. She is currently associate vice president for Oncology Services at Duke University Health System, associate dean and administrator of the Duke Cancer Institute at Duke University School of Medicine and service line executive of the Cancer Care Collaboration with Wake Medical Health System. Pickens earned her BS in business administration from Clark University and a master’s of healthcare administration from Washington University School of Medicine, and completed an administrative fellowship at the Henry Ford Health System.

 

Women in medicine at YNHH and YSM

Yale School of Medicine recently celebrated 100 years of women at YSM through a daylong symposium, June 1. The event honored the contributions of women faculty and alumnae. Featured speakers discussed their work, challenges faced by women in their fields and hurdles encountered on the pathway to work-life balance.

Lynn Tanoue, MD, president, YNHH Medical Staff, also noted that for the first time in the hospital’s history, women currently fill all leadership positions on the YNHH Medical Staff this past term. Pictured, left to right: Joni Hansson, MD, past president; Michele Johnson, MD, secretary; Lynn Tanoue, MD, president; Eugenia Vining, MD, president elect.

medstaff leadership 2018 

Structural Heart Team introduces cerebral embolic protection device during TAVR

On June 3, the Structural Heart Team at Yale New Haven Hospital began commercial use of a cerebral embolic protection device during transcatheter aortic valve replacement (TAVR). This device can potentially lower rates of stroke and mortality during a TAVR procedure. The hospital’s Heart and Vascular Center is the first and only TAVR site in Connecticut offering this advanced therapy.

In a January 2018 review, the New England Journal of Medicine reported that placement of the device during TAVR is beneficial in preventing valve and aortic debris from getting to the brain. In the reviewed single-center study, 280 patients successfully receiving embolic protection (91.8 percent of 305 consecutive patients) were compared with a propensity-score-matched cohort from among 522 consecutive patients treated without embolic protection just prior to the device's availability. At seven days, use of embolic protection significantly reduced all stroke and mortality from 6.8 percent to 2.1 percent (odds ratio, 0.30), all stroke from 4.6 percent to 1.4 percent (OR, 0.29), and disabling stroke from 3.2 percent to 0.4 percent (OR, 0.11).

 

DEA clarifies federal and state registration requirements for practitioners

Under The Controlled Substances Act (21 U.S.C. 822 (e)) (CSA), practitioners who work in multiple states should hold a valid Federal Drug Enforcement Administration (DEA) registration for every state where they practice and prescribe controlled substances.

Currently, practitioners who work in multiple states (for example, Connecticut and New York) have separate state medical licenses and state Controlled Substances Registrations. However, many may have only one Federal DEA registration. A separate Federal DEA registration, however, is required for each state. Federal DEA is required for e-prescribing, and pharmacies are enforcing the requirement. The DEA Diversion Control Division reports multiple incidences where pharmacies have rejected e-prescriptions due to the Federal DEA and prescription site addresses mismatch.

If a physician’s office practice is in New York, for example, and the physician prescribes medications in a Connecticut hospital, the physician must have a Connecticut DEA with the Connecticut hospital address.

With e-prescribing under the CSA, pharmacies are enforcing the requirement that individual practitioners who practice in more than one state hold a separate federal DEA registration in all relevant states as well as the relevant state narcotic certificates.

Yale New Haven Health recommends that providers who currently practice in more than one state should hold a valid Federal DEA for every state where they practice and prescribe controlled substances. Providers who do not have separate Federal DEA for each state should immediately register with the DEA and select the appropriate form. The online, non-refundable application fee is $731, payable via Visa, MasterCard, American Express or Discover. Providers at Yale New Haven Hospital should also contact the Medical Staff Administration Office.

 

Connecticut eliminates ratio restriction on PAs

With the recent enactment of Public Act No. 18-168 (HB 5163), Connecticut eliminated the restriction on the number of physician assistants (PAs) with whom a physician may practice. Gov. Dannel P. Malloy signed the legislation into law, which goes into effect July 1, 2018. In addition to eliminating the ratio restriction, Public Act No. 18-168 also allows PAs to provide oral health assessments for public school students.

“The law in my view essentially recognizes that PAs constitute an integral workforce that provides highly skilled, comprehensive patient care in their areas of practice,” said Sheri Orr, director of advanced practice providers, Yale New Haven Hospital. “Eliminating the ratio of physicians to PAs enhances the ability for PAs to continue to work collaboratively with their physician partners while removing a restriction that historically had potential to impede best practices. Connecticut is one a few states in this country that have achieved this best practice success which is immensely exciting for us at YNHH. Practice and care teams benefit from this by allowing more APPs to practice at the top of their licensure without this particular ratio restriction any longer."

Orr said that the law also removes the heavy administrative burden required to track and maintain the ratio of supervising physicians to PAs which is added value to hiring managers of PAs.

 

YNHHS Outpatient Pharmacy Services earns URAC accreditation in Specialty Pharmacy

Outpatient Pharmacy Services at Yale New Haven Health has earned full URAC accreditation in Specialty Pharmacy. URAC is an independent, nonprofit healthcare accrediting organization dedicated to promoting healthcare quality through accreditation, education and measurement. By achieving this status, Outpatient Pharmacy Services at Yale New Haven Health has demonstrated a comprehensive commitment to quality care, improved processes and better patient outcomes.

“Outpatient Pharmacy Services at Yale New Haven Health is proud to have earned full URAC accreditation for Specialty Pharmacy after a rigorous two-year preparation process,” said Lorraine Lee, chief pharmacy officer, Yale New Haven Health. “This designation demonstrates that Outpatient Pharmacy Services at Yale New Haven Health is dedicated to quality and safety, and that we strive for continual improvement of the services we offer to our patients."

Outpatient Pharmacy Services at Yale New Haven Health provides a comprehensive case-managed program customized for complex diseases such as cancer, hepatitis C, HIV, cystic fibrosis, multiple sclerosis, rheumatoid arthritis, inflammatory diseases, growth hormone and transplant. The specialty pharmacy team works closely with care providers to create the safest, most effective treatment program for patients; ensures timely delivery of monthly refills of specialty medications; and offers education and support from specialty pharmacists with years of experience.

“It’s necessary for specialty pharmacies to provide a higher level of treatment for patients so desired outcomes are achieved. Outpatient Pharmacy Services at Yale New Haven Health shows a dedication to patient education and safety through the recognition of quality it received with URAC’s independent accreditation,” said URAC President and CEO Kylanne Green. “With URAC accreditation, people know that Yale New Haven Health strives to adhere to industry best practices.”

 

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.

Date Time Location
Monday, July 9, 2018
12:30-2 pm
300 George St., IFE Auditorium
Monday, July 23, 2018
12:30-2 pm
300 George St., IFE Auditorium
Monday, August 6, 2018
12:30-2 pm
300 George St., IFE Auditorium
Monday, August 20, 2018
12:30-2 pm
300 George St., IFE Auditorium
Tuesday, September 4, 2018
12:30-2 pm
300 George St., IFE Auditorium
Thursday, September 13, 2018
12-2 pm
YSC - Clinic Building 1058
Monday, September 17, 2018
12:30-2 pm
300 George St., IFE Auditorium

 

Newsmakers

Loren Laine, MD, interim chief, section of Digestive Diseases, won the American Gastroenterology Association’s highest honor, the Julius Friedenwald award. Bestowed annually since 1941, the Friedenwald Medal recognizes physicians for their lifelong contributions to the field of gastroenterology. The AGA acknowledges Dr. Lane for his clinical research achievements and as a leading expert on gastrointestinal bleeding and upper gastrointestinal tract injury. The organization also credits him with the establishment of the AGA Center for Gut Microbiome Research and Education, where he still serves as a chair and a principal investigator of the AGA National Fecal Microbiota Transplant Registry.

At the Yale School of Medicine, Dr. Laine is also director of clinical research. He practices clinical-translational care at the Yale Digestive Disease Center in Fairfield.

Robert McLean, MD, was recently named president-elect of the American College of Physicians. Dr. McLean, an associate clinical professor of Medicine at Yale School of Medicine, has served as an attending physician at Yale New Haven Hospital since 1994. He practices internal medicine and rheumatology with Northeast Medical Group, where he is the medical director for clinical quality.

Sheri Orr, PA, has been appointed as the inaugural director of Advanced Practice Providers (APP) at Yale New Haven Hospital. She joined YNHH in the spring after working at Memorial Sloan Kettering Cancer Center where she helped create successful APP programs at both the departmental and health system level. Orr earned her PA and MBA degrees from Hofstra University and received her BA from the George Washington University.

 

Upcoming Events

The Medical and House Staff Picnic will be Thursday, July 19, from 4:30 - 9:30 pm, rain or shine, at Holiday Hill, 43 Candee Road, Prospect. The event features seafood, salads, steak, lobster, beer, wine, fruit and desserts, and numerous activities for adults and children, including sand volleyball, basketball, horseshoes, canoeing, kayaking and rowing on the lake, baseball, shuffleboard, bocce, tennis, arts and crafts and face-painting for children. There is no cost for Medical and House Staff and their immediate family members.

Please RSVP by July 10 (no late reservations will be accepted), including number and names of attendees and ages of children.

 

Pediatric specialty campaign advertising

Advertising showcasing Yale New Haven Children’s Hospital’s Pediatric Specialty Centers can now be seen in Fairfield and Westchester counties until the end of August. The media mix includes billboard, online display, paid social media and print and highlights the three locations in Fairfield County and the more than 35 pediatric specialties available to patients.

pediatrics ad campaign 

Is your website information up-to-date?

The most visited section of the Yale New Haven Health hospital websites are physician profile pages. To ensure your online information is current and accurate so potential patients can find you, please take a few minutes to review your profile. If changes are needed, email the YNHH Physician and Services Referral Center.