Medical Staff Bulletin - Yale-New Haven Hospital

I was privileged, during the month of March, to attend on the Internal Medicine teaching service. I was struck, as never before, by the high percentage of my patients who had no medical insurance and no prospects of obtaining insurance. Most had chronic illnesses that could be ameliorated but not cured. Many had deferred care until critically ill. I was tremendously impressed with how nursing and resident staffs alike were so sensitive to the plight of these patients, so respectful of their dignity, and so committed to easing their suffering. Economic status had no effect on quality of care until time of discharge, when enormous efforts were required to aggregate resources for the outpatient setting. Subspecialty follow up, in particular, was challenging to arrange.

I asked our finance division for data pertaining to uncompensated care at YNHH and found the expense staggering. According to our submissions to the Office for Health Care Access (OHCA) in March 2006 (for FY 2005), the Medicaid losses alone at YNHH were $54 million. The State's second greatest losses were about $28 million at Hartford Hospital. The percent of Medicaid patients as a percent of total patients discharged, 24%, was also greater at YNHH than any other Connecticut hospital. YNHH received about $18 million from the Disproportionate Share Hospital and Urban pools, but the Medicaid and uncompensated shortfall in FY 2005 still totaled more than $51 million. Moreover, charity care between FY 2005 and FY 2006 almost doubled from $15 million to $26 million. The consequence this current fiscal year is that Yale-New Haven Hospital will be most fortunate to develop a 1% operating margin.

Ultimately, YNHH serves as the health care safety net for thousands in our community. This is a central mission of the Hospital and not one that is in any way begrudged. Nevertheless, the cost this entails may eventually have a negative impact on the scope of services our Hospital may provide. Our State legislators are beginning to recognize the pernicious effects of our societal failure to provide universal health care coverage and, hopefully, will begin crafting solutions in this 2007 legislative session.

Include time, as well as date, on all chart notes
Federal regulations now require that all patients' medical record entries must be legible, complete, dated, timed and authenticated in written or electronic form. This stipulation includes "verbal orders."

YNHH quality measures added to Web site
Healthcare consumers expect hospitals to provide top-notch medical services with a compassionate approach. The more they know about how well a hospital performs in key quality measures, the better choices they can make. Yale-New Haven Hospital is committed to reporting our results on process measures, quality standards, benchmarks, research and awards via our Web site. The information shows how we measure up compared to national data and accepted care standards. To learn more, go to: www.ynhh.org and click on "QUALITY."

Performance management update
At left are our familiar publicly-reported performance measures, this time for the month of December 2006. Improving heart failure discharge instructions and timely discontinuation of prophylactic antibiotics on discharge remains a high priority. As of the first week of March, a CCSS change in antibiotic prophylaxis order sets will help hardwire timely discontinuation.

Last month in this column, the Hospital's performance improvement initiatives for 2007 were outlined. Standardization of caregiver hand-offs was noted as a priority. What work is ongoing with regard to this topic? The Patient Safety Steering Committee, chaired by Sally Roumanis, R.N., and Peter Herbert, M.D., has recently completed an inventory of all hand-off-related improvement efforts. The list is impressive, and one highlight includes the nursing-patient transport pilot called a "Ticket to Ride." The concept here is that when a patient is being transported off of a floor, there should be a formal hand-off process between that patient's nurse and the transporter. A "Ticket to Ride" is a formalized hand-off where the transporter asks the floor nurse to give pertinent care information on a preprinted form called a "Ticket to Ride." Information such as a patient's fall risk, IV sites, medications that are running, need for oxygen, etc. are required fields. This pilot has been enthusiastically received by all parties. More importantly, it represents a big improvement in one very frequent hand-off.

Dr. Shin'oka to lead Pediatric Cardiac Surgery
Toshiharu Shin'oka, M.D., has been appointed director of pediatric cardiac surgery for the Yale-New Haven Children's Hospital and Associate Professor of Surgery at the Yale School of Medicine. He is an international expert in the field of cardiovascular tissue engineering, which he expects to pursue in phase 1 clinical trials at Yale-New Haven. Yale is already one of the top three research centers in the country exploring tissue engineering, with a team of about 100 researchers.

Dr. Shin'oka, a native of Hiroshima, Japan, received his medical degree from Hiroshima University School of Medicine and completed his residency in cardiovascular surgery at the Heart Institute of Japan, Tokyo Women's Medical University. He was a research fellow at Children's Hospital, Boston, at Harvard Medical School. He has held positions as associate professor in the Department of Engineering Science at Tokyo University; associate professor for the Institute of Advanced Biomedical Engineering & Science; and professor in the Division of Cardiovascular Tissue Engineering at Tokyo Women's Medical University.

Dr. Gary S. Kopf, who has led the Pediatric Surgery Program for almost two decades, will continue to work with Dr. Shin'oka in developing the clinical and research programs of the Section. We owe Dr. Kopf a great deal of gratitude for his past and continuing service.

Marjorie Guglin, R.N., named VP, Surgical Services
Marjorie Guglin, M.P.H., R.N., has been named Vice President, Surgical Services. She will assume the responsibilities formerly held by Richard Stahl, M.D., who is now heading up the Ambulatory Services Division. In addition to Surgical Services, Guglin will oversee Perioperative Services and coordinate strategic planning, bed coordination and clinical initiatives for Surgical Services. Before joining YNHH, Guglin served as the VP of perioperative services at the Weill Cornell Center of New York Presbyterian Hospital. Prior to that, she was the corporate VP of strategic planning and ambulatory development at St. Vincent's Medical Center in Bridgeport. Guglin earned her B.S.N. at the State University of New York at Albany and M.P.H. - Health Administration at the Graduate School of Public Health, University of Pittsburgh.

New ID badges issued
Members of the Medical Staff were scheduled to get new photo I.D. badges between March 5 and April 5. If you have not gotten your new badge yet, please take the time to do so. For the most up-to-date hours of the Photo ID Center, call 688-6094. Shortly, your old badge will no longer provide you with appropriate access to YNHH facilities. If you have any questions about this process, please contact the Department of Physician Services at (203) 688-2615.

YNHH policy on disclosure of unanticipated outcomes
Yale-New Haven Hospital's new policy affirms our commitment to disclose unanticipated outcomes to patients and families. This is now a Joint Commission requirement. Moreover, there is evidence that open, honest communication throughout the process of care increases patient satisfaction. Such communication is particularly important when care may have caused significant harm due to an error. The new policy (available on the Hospital's intranet as clinical administrative policy D-1) provides guidance to medical staff who are involved in the care of patients harmed during the process of being cared for at the Hospital. It discusses whom to contact for advice and provides general advice about the content of the conversations an attending should be having with patients or their families.

Dr. Edward Chu named deputy director of Yale Cancer Center
Following Dr. Jos� Costa's completion of ten years of outstanding service as Deputy Director of Yale Cancer Center, Dr. Edward Chu has been appointed Deputy Director of the Center, effective January 1. Dr. Chu has held positions of increasing responsibility at Yale Cancer Center since 1996 and is professor of Medicine and Pharmacology and Chief of Medical Oncology. In his new role, Chu will continue to lead the Section of Medical Oncology and will also direct the clinical research initiatives for the Center. Dr. Chu is a graduate of Brown University with B.S., M.M.S., and M.D. degrees. He also completed his residency training in Internal Medicine at Brown before moving to the National Cancer Institute where he completed a fellowship in Medical Oncology and subsequently served as a tenured senior clinical investigator. In 1996, Dr. Chu was recruited to Yale to assume the positions of Chief of Medical Oncology and Director of the VACT Cancer Center at the West Haven Veterans Administration Hospital and Co-director of the Developmental Therapeutics Research Program at Yale Cancer Center.

Two new appointments in OB/GYN
Thomas Rutherford, M.D., has been named Chief of the Section of Gynecology Oncology in the Department of OB/GYN, and Hugh Taylor, M.D., has been appointed Chief of the Section of Reproductive Endocrinology and Infertility.

Dr. Rutherford received his undergraduate degree at Roanoke College in Virginia and his M.D. and Ph.D. from the Medical College of Ohio at Toledo. He completed his residency in OB/GYN at the Cooper Hospital University Medical Center in New Jersey. His current research includes determining the chemo-sensitivity of recurrent ovarian cancer.

Dr. Taylor received his undergraduate training at Yale and his medical degree from the University of Connecticut School of Medicine. He completed his residency in OB/GYN at Yale and his postdoctoral training included a fellowship in reproductive endocrinology and infertility as well as a fellowship in molecular biology, both at Yale. A recipient of four National Institutes of Health research grants, Dr. Taylor's clinical research centers on implantation and endometrial disorders, as well as menopause and hormone therapy. He is currently the Editor-in-Chief of Reproductive Sciences.

"For Medical Professionals" section of YNHH web site updated
The "Medical Professionals" section of the YNHH website (www.ynhh.org) has been significantly improved to include reference and access to a wide range of information such as Medical Staff Bylaws, Rules & Regulations, CME activities, medical staff leadership and contact and other information for the Department of Physician Services.

Most importantly, the site now includes complete application materials and instructions for prospective new medical staff, affiliated medical staff and clinical fellows. All application materials can now be obtained via this site.

Creating a clean and safe environment for patients
In November 2006, YNHH began piloting weekly clean and safe rounds on seven patient care units, and the effort has been so successful that it is being expanded to every area of the Hospital. A multidisciplinary team, made up of the patient service manager and a physician partner, plus representation from various support services such as environmental services, plant engineering, biomedical services, logistics, materials and pharmacy, makes rounds on the unit to identify and resolve issues related to cleanliness and safety. Not all of the issues are technical or physical - some are process-related. In the first month of 2007, the clean and safe rounds identified 1,600 issues on various patient care units and resolved almost 1,300 at the team level - 72% of those within seven days and 84% within 14 days. Physicians and nurses agree that these environmental rounds benefit patient and employee safety and satisfaction.

YNHH offers new prescription discount program to patients; expands pharmacy hours
YNHH now offers wide-scale prescription discounts to help YNHH patients afford their prescription medications. Through the Yale-New Haven Prescription Assistance Program, inpatients who are being discharged or outpatients at the YNHH Emergency Department or any Hospital-based clinic may take a prescription written by a YNHH provider to the Medical Center Pharmacy at 50 York Street, and they will receive the discounted price automatically. The discount varies for each prescription, but the biggest discounts are for generic drugs - which, in some cases, are discounted up to 40-60 % of the cost. Many generic prescriptions are available for a flat $5 fee. The discounts also apply to some diabetes and asthma supplies and some over-the-counter medications (if prescribed by a YNHH provider for a YNHH patient.)

YNHH qualifies for special federal prescription drug pricing discounts because it treats a disproportionately large share of uninsured and underinsured patients. To date, YNHH is the only Hospital in the State to extend this benefit directly to patients.

To make the program accessible to more patients, the Medical Center Pharmacy has expanded its hours (at the 50 York Street store only) so that it is now open from 8 a.m.-7 p.m. on weekdays and from 9 a.m.-5 p.m. on weekends. For more information, contact Emmett Sullivan, Medical Center Pharmacy manager at 688-9675 or emmett.sullivan@ynhh.org.

Yale-New Haven Shoreline Medical Center expands mammography hours
Yale-New Haven Hospital - Temple Radiology at Yale-New Haven Shoreline Medical Center has expanded its mammography hours to include two evenings per week. On Monday and Wednesday, the Center will be open from 8 a.m. to 8 p.m. On Tuesday, Thursday and Friday, the hours are 8 a.m. to 5 p.m. Located on the lower level of the building at 111 Goose Lane in Guilford, the Center offers advanced digital mammography technology which provids increased image quality and reduced time for testing.

HIPAA Tip of the Month
Conversations about patients should not occur in elevators, cafeterias and other public places.

At its January meeting, the Medical Board approved several programs for continuing support from the Medical Staff dues fund as well as some new programs. Ongoing funding was approved for: educational stipends for house staff and fellows; Harkness Gymnasium membership for house staff and fellows; a tailgating party for Medical Staff, house staff and fellows every other year at the Yale / Harvard Football game; third world missionary trips by Drs. Mark Weinstein, Serle Epstein and James Thomson; community health care van's AIDS outreach and the Primary Care Center's home visitation program. New programs approved include an "Entering the Workforce" educational program for house staff; the Pediatric Department's "adopt-a-doc" program and the Department of Medicine's outreach efforts to Mulago Hospital in Uganda.

Bed planning status update
Until the Cancer Hospital provides additional inpatient capacity in late 2009, YNHH will be challenged to accommodate increased demand, especially for intensive care. Eighteen medical-surgical beds have been opened in the last several months and another 24 should be available by year's end. Consolidating medical intensive care is an imperative and, in a few months, the current Coronary Intensive Care Unit (CICU) on South Pavilion 5 will be converted to a second MICU, bringing the MICU bed complement from 14 to 28. The CICU will move to the current location of the Transplant Intensive Care Unit (TICU), with increase of the bed capacity from eight to 10 beds. Transplant patients will be accommodated in the Surgical Intensive Care Unit.

Physician parking in Children's Hospital garage
The Children's Hospital garage is dedicated to parking for members of the medical staff who have purchased parking and for immediate family members of pediatric patients. Both levels (L1 and L2) are available to physicians. Four spaces on P1 have been marked as "emergency parking for physicians only." Please respect the use of these spots so that they can be available for true emergencies rather than parking for routine business. The garage has recently undergone a complete renovation with new lighting, upgraded video surveillance, additional duress alarms and parking space stripes. The garage is monitored 24 hours a day by Protective Services Staff. If you have any questions or concerns about parking or security at YNHH, please contact the Parking Office at 688-2623.

December 2006 Performance

AMI	#	YNHH%	Nat'l 90th%

ASA at arriv.	14/14	100	100
ASA at D/C	27/27	100	100
B-Block at arriv.	8/8	100	100
B-Block at D/C	26/26	100	100
ACEI at D/C	4/4	100	100
PCI <90 min	2/4	50	88
Smoking cess.	7/7	100	100

CHF	#	YNHH%	Nat'l 90th%

LVEF assess.	25/26	96	98
ACEI at D/C	10/10	100	100
Smoking cess.	10/10	100	100
D/C instr. given	14/22	64	86

Pneumonia	#	YNHH%	Nat'l 90th%

0₂ assess. at arriv.	17/17	100	100
Pneum. vac. given	12/13	92	86
Abx given <4 hrs	10/12	83	91
Smoking cess.	8/8	100	97
Blood cx before abx	15/15	100	93
Initial (non-ICU) Selection Abx	7/7	100	89

SIP	#	YNHH%	Nat'l 90th%

Antibiotic start	36/36	100	94
Antibiotic D/C	20/32	63	95

Welcome, new Medical Staff:

February
Ami Acharya, M.D. Associate, Obstetrics & Gynecology
Alexandria Garino, P.A. Affiliated, Internal Medicine
Lucille Lynn A. Gerona, M.D. Associate, Pediatrics
Kenneth M. Gheen, M.D. Attending, Pediatrics
Charles Evans Glass, M.D. Attending, Internal Medicine
Aliza Leah Leiser, M.D. Associate, Obstetrics & Gynecology
Mark David Lorenze, M.D. Attending, Orthopedics
Megan Elizabeth McCabe, M.D. Attending, Pediatrics
Marta Rivera, M.D. Associate, Internal Medicine
Marisa Spann, Ph.D. Affiliated, Neurosurgery
Shawn L. Tittle, M.D. Attending, Surgery

March
Hannah Morgan Castrucci, M.D. Associate, Orthopedics
Lisa Nadine Chin-Lue, M.D. Attending, Internal Medicine
Christopher Chow, D.P.M. Courtesy, Orthopedics
Gerald Jay Forman, D.M.D. Attending, Dentistry
Courtney Hill, P.A. Affiliated, Internal Medicine
Andrea Laudano, A.P.N. Affiliated, Obstetrics & Gynecology
Paula Masto, A.P.N. Affiliated, Pediatrics
Shanon Murillo, P.A. Affiliated, Internal Medicine
Nicole Carolyn Rabidou, M.D. Visiting, Internal Medicine
Elena Schjavland, A.P.N. Affiliated, Internal Medicine
Kati S. Sylvester, P.A. Affiliated, Surgery
Anthony J. Tomassoni, M.D. Attending, Surgery
Anne Vanderburg, P.A. Affiliated, Internal Medicine

All information is intended for your general knowledge and is not a substitute for medical advice or treatment for specific medical conditions. You should seek prompt medical care for any specific health issues and consult your physician before starting a new fitness regimen.