Medical Staff Bulletin

September - October 2019

In this issue:

• Creating seamless transitions for the post-acute patient journey
• Patient Safety and Quality Metrics
• Yale School of Medicine names dean
• YNHH Heart and Vascular Center featured in Connecticut Hospital Association's Quality Excellence Report
• New Medical Staff categories
• The five rights of decision support
• New CMS Rules for Imaging Requests start in January
• Initiative makes it easier for YNHHS to help patients who can’t speak for themselves
• Upcoming Events
• In memoriam

Creating seamless transitions for the post-acute patient journey

A message from Thomas Balcezak, MD, Chief Medical Officer

Our single focus for several years has been on providing care of the highest value to the patients we serve. As a result of successful initiatives such as our journey towards high reliability, clinical redesign and other work, we have made material progress in enhancing value in the hospital setting.

That said, the practice of medicine continues to evolve, and our patients receive increasingly complex care in the post-hospital and ambulatory setting. Moving forward, we must also build systems to deliver our innovative care in the most patient-centered and cost-effective setting, which often means outside our hospital’s four walls.

To that end, we have been developing a roadmap for the systems of care needed to support our patients as they navigate transitions, and ensure that clinical plans are followed seamlessly as patients move from the hospital to lower-acuity settings. Success hinges on having the right leadership team, building the infrastructure to facilitate communication between skilled nursing facilities, home health agencies, and community clinicians, and forging strong relationships with partners in the community who share our commitment to providing high value care.

Successfully enhancing post-acute care requires that we encourage closer collaboration between the physicians, skilled nursing facilities, homecare agencies, hospices, rehab hospitals and others who care for patients in our geography. We will need skilled clinical leaders to build partnerships and teams, and to develop systems that provide the right clinician with the right information at the right time such that clinical interventions can be made to maintain patients on the road to recovery despite their clinical complexity.

We are not starting from scratch. We have long recognized that certain skilled nursing facilities provide more coordinated care, and some years ago developed a coordinated care network of skilled nursing facilities. The facilities are ranked based upon objective and transparent criteria, and commit to working closely with us to ensure our complex patients receive the best care possible in the post-acute setting. We plan to invest in these relationships, and deploy resources to improve connectivity and help our partners build the clinical capacity to manage our most complex patients after they leave the hospital.

Most patients prefer their hospital stays to be as short as possible and to return home as quickly as possible. Thus, improved collaboration with the homecare agencies in our geography is critical to support the availability of excellent support services in the home. We have heard clearly from members of our medical staff and our care coordinators that access to timely and effective home nursing, rehabilitation and other home-based services impedes the speedy return of our patients to their homes. As such, we will support expanded access for our patients and ambulatory clinicians to coordinated nursing, rehab, wound care, and infusion services in the home that our providers can easily tap into through a central calling system or Epic.

These concerted efforts, as well as increased engagement with our hospice and specialty hospital partners, will serve to better match the setting of care to our patients’ clinical needs. Improved stewardship of skilled nursing facility care and utilization and enhanced access to home-based services will reduce unnecessary readmissions, enhance communication between our patient’s physicians, reduce redundant testing and procedures, and generally enhance the provision of reliably high value care.

Your engagement and feedback will be critical in ensuring our plans meet the needs of our patients and the medical staff, and I welcome your thoughts. As ever, I can be reached at [email protected]. Happy fall!

Patient Safety and Quality Metrics

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.

Yale School of Medicine names dean

Nancy J. Brown, MD, has been named dean of Yale School of Medicine, effective Feb. 1. She will succeed Robert Alpern, MD. Dr. Brown is currently the Hugh Jackson Morgan Professor and chair of the Department of Medicine at Vanderbilt University. She earned her BA in molecular biophysics and biochemistry from Yale University and her MD from Harvard Medical School. After completing her internship and residency at Vanderbilt University, she joined the faculty and has played vital roles in clinical care and research.

YNHH Heart and Vascular Center featured in Connecticut Hospital Association's Quality Excellence Report

The Connecticut Hospital Association has published Quality Excellence, a report showcasing some of the many quality and patient safety projects under way in Connecticut hospitals and health systems. Yale New Haven’s Heart and Vascular Center was included for work to reduce deep sternal wound infections in the isolated coronary artery bypass (CABG) patient population.

In fall 2017, the Heart and Vascular Center (HVC) quality and safety department received reports of increased incidence of deep sternal wound infections. Reports were confirmed through review of contemporary Society of Thoracic Surgeons (STS) registry data, and we convened a multidisciplinary group to reduce sternal wound infections following CABG surgery.

Engagement of key clinical and administrative leaders assisted in creating a shared benefit. Internal hospital and specific patient data along with STS reports were used to create a data story that tracked the reduction of deep sternal wound infections (mediastinitis) in the isolated CABG patient population.

The projects highlighted in Quality Excellence were solicited from those who applied for the John D. Thompson Award, an annual award that celebrates excellence in patient care through the use of data. The projects span a range of topics but all share a common element – improvement demonstrated by a change in internal operations, procedures, and outcomes.

For the complete report, visit CHA’s website at Quality Excellence.

New Medical Staff categories

Upon the recommendation of the Bylaws Committee, Medical Executive Committee and voting Medical Staff, the Yale New Haven Hospital Patient Safety & Clinical Quality Committee of the Board of Trustees recently approved changes to the Bylaws to rename the Medical Staff categories, effective Oct. 1, 2019.

Your rights and privileges will not change as a result. We have simplified the names and reduced the number of overall categories. The changes to medical staff category names have been made across all five Yale New Haven Health affiliated hospitals so that the naming convention will now be consistent. Below is a list of the former category names mapped to the new category names.

For full descriptions of these categories, please see the Yale New Haven Hospital Medical Staff Bylaws.

The five rights of decision support

Yale New Haven Health’s Decision Support Committee curates tools that help make it easier for healthcare practitioners to do the right thing. By following the five rights of decision support -- the right information delivered to the right person in the right intervention format through the right channel at the right point in the workflow -- practitioners see fewer pop up alerts, which helps mitigate alert fatigue. Well-crafted decision support can be an order set that has all of the appropriate tests for a specific patient, a medication prescribing screen that includes evidence based guidelines, or naming a lab test so that it is clear which test should be ordered.

To better understand how end users interact with decision support, the committee conducted a survey in 2017 and received feedback about which decision support was most helpful along with the decision support that was least helpful. This information was used to improve multiple alerts, and compared to 2017, on average the number of pop-up alerts in 2019 has decreased by over 200,000 per month, and at five seconds per alert, that equates to 278 hours saved per month.

A new survey aimed at gathering additional feedback is available here and feedback will be used to further improve decision support with Epic.

New CMS rules for imaging requests start in January

From January 2020, all outpatient requests for CT, MRI and Nuclear Medicine must consult "appropriate use criteria" through a Clinical Decision Support tool at the time of ordering.

This CMS mandate is federally legislated by the Protecting Access to Medicare Act (2014) and will apply to all imaging providers across the United States.

Yale New Haven Health Radiology, Cardiology and IT departments have been working together over the past three years on the most effective and seamless way possible for its providers to satisfy this mandate.

From January, Epic users will now see a best practice alert giving them a score for the request’s “appropriateness.” Users can continue with this original request or change to a more appropriate study with one click. For non-Epic users, a stand-alone web based tool for clinical decision support will be made available. Additional details will be sent to all requestors between now and January.

Although there are currently no penalties for ordering clinicians who request studies of low appropriateness, CMS has plans to identify outliers from 2023/2024.

Feel free to contact System Radiology at 203-785-6938 or email Dr. Rob Goodman, Radiologist-in-Chief, at [email protected] with questions.

Initiative makes it easier for YNHHS to help patients who can't speak for themselves

What happens when a patient becomes too ill make medical decisions for him- or herself?

If the patient previously completed advance directives forms and named a healthcare representative to make those decisions, hospital staff work with the representative to provide the kind of care the patient desires. (Learn more about advance directives and download forms at ynhhs.org).

But a number of patients don’t have advance directives. In those situations, the family and/or hospital may have to ask the probate court to appoint a conservator to make decisions on the patient’s behalf about medical care and the resources needed to support the discharge plan. The process of obtaining a conservator takes time, and can result in longer hospital stays.

In March, the Office of Strategy Management began working with physicians and representatives from Social Work, Care Coordination, Legal, Behavioral Health and other departments on a clinical redesign initiative to develop a more consistent and efficient conservatorship process. It’s the first project involving Social Work systemwide. Previously, each delivery network had its own guidelines for identifying the need for a conservator and steps for obtaining conservatorship for patients.

The new YNHHS conservatorship process, which launched Aug. 1, combines elements from each delivery network with best practices from other healthcare organizations. Key components include a checklist that helps clinicians and other healthcare professionals determine whether a conservator is needed; one lead person – usually a social worker or care coordinator – who oversees the conservatorship process from beginning to end; communication with and education for family members about the process; and Epic tools that make it easier to document and track conservatorship-related information.

Upcoming Events

Evaluation and Management of Fatty Liver Disease and Obesity: Clinical Update

Learn about the latest in clinical management and advances in the management of fatty liver disease and patients with obesity on Saturday, Oct. 5, 11 am - 3 pm at the Mystic Hilton. CME credit available for eligible attendees. This free event is hosted in partnership with the American Liver Foundation and the Yale Fatty Liver Disease Program. RSVP is required. Lunch will be provided. For more information and to RSVP, contact Antonio Trombino at [email protected] or email [email protected].

Caring for the elderly patient

Primary care clinicians are invited to join Mary Tinetti, MD, chief of Geriatrics, Yale School of Medicine, when she presents, “Moving the Focus from the Disease to the Patient,” on Oct. 16. The presentation will also touch on helping identify a patient’s priorities in their care and how to provide the care they wish to receive. The event will take place at Amarante’s Sea Cliff, 62 Cove St., New Haven from 6 – 8 pm. Hors d’oeuvres and beverages will be served. To attend, RSVP at https://tinetticipophealth.eventbrite.com and use the password: CIPopHealth. For more information, contact Via Abolencia, program specialist, Clinical Integration, at [email protected].

In memoriam

Allan Toole, MD, 87, died Sept. 2, 2019. A dedicated member of the medical staffs at Yale New Haven Hospital and the Hospital of Saint Raphael for 35 years, Dr. Toole performed one the first pulmonary embolectomy procedures during open-heart surgery. After completing his undergraduate education at Yale University, he received his Doctor of Medicine from Columbia University College of Physicians and Surgeons. His professional internship, fellowship and residency were spent at Yale followed by his chief residency of surgery at the Veterans Administration Hospital in West Haven. Following his residency, he opened a private practice, Thoracic and Cardiovascular Associates of New Haven, with Dr. Harold Stern. He also was an associate professor at Yale School of Medicine, where he mentored many surgical residents, interns and colleagues.