Progress Notes Summer 2013 A publication of the Medical Staff of Children’s Hospital Central California In this issue 2 Improving Patient Care 3 Patient Safety Rounds 4 Half-Time 5 Melody Valve 6 New Pediatric Housestaff 8 Announcements New VP Position Targets Quality It goes without saying that the highest quality of care for our patients and their safety is paramount to our mission. Our low rates of hospital-acquired infections and medication errors continue to demonstrate the outstanding efforts of our physicians and staff to keep patients free from preventable harm. Todd Suntrapak In this era of healthcare reform, it’s imperative that Children’s Hospital continues its focus on quality improvement. While we’ve made great strides toward our goal of achieving – and sustaining – zero incidents of patient harm, there’s more work to be done. President and Chief Executive Officer So, to that end, as we look to strengthen our longstanding commitment to the highest quality of care for our patients and their families, and as we position our organization for continued success in the new healthcare environment, we’ve developed and are actively recruiting for a new leadership position: Vice President, Quality. Medical Staff Officers Timothy Hansen, MD Chief of Staff Sahar Barayan, MD Vice Chief of Staff Gary Magram, MD Secretary / Treasurer Reporting to the Chief Medical Officer, the VP Quality will provide oversight, planning and direction for all clinical quality and performance improvement programs in accordance with the Hospital’s strategic plan. Specifically, the VP Quality will be responsible for developing an organizational quality plan that will improve patient outcomes, patient satisfaction and patient safety, including developing standardization, improving efficiency and adjusting workflows to enhance system performance. We’re looking for an innovative leader who brings strong clinical experience and an excellent track record of advancing quality; someone who will play an integral role in quality and outcomes strategy development and implementation, as well as work with many different constituencies both internally and externally and on a national, state, regional and local level. We hope to have this new executive team member on board by fiscal year-end and we are excited to see how this role will complement an already outstanding team. Thank you for your support and active participation, and I look forward to sharing an update with you soon. Department Chairs Anesthesia & Critical Care Medicine Adam Holmes, MD, Chair Marty Clayman, MD, Vice Chair Tim Hansen, MD Chief of Staff Cardiology & Cardiothoracic Surgery Narakesari Heragu MD, Chair Valeriano Simbre, MD, Vice Chair Emergency Medicine Robert Kezirian, MD, Chair Henry Pollack, MD, Vice Chair Medical Imaging Fred Laningham, MD, Chair Michael Myracle, MD, Vice Chair Medicine John Kinnison, MD, Chair Wendy Tcheng, MD, Vice Chair Pathology & Laboratory Medicine Stephen Kassel, MD, Chair Aleli Siongco, MD, Vice Chair Surgery 2 Michael Dunham, MD, Chair Mimi Chao, MD, Vice Chair Committee Chairs Medical Executive Committee Timothy Hansen, MD Committee on Interdisciplinary Practices Peter Nakaguchi, MD Credentials Committee Carl Owada, MD Health Information Management Committee Joel Brownell, MD Human Subjects Committee (IRB) Stephen Kassel, MD Institutional Ethics Committee Armando Fuentes, MD Joint Performance Improvement Committee Sahar Barayan, MD, Chair J. Charles Smith, MD Medical Staff Education Committee Co-Chairs Ana Lia Graciano, MD Robert Kezirian, MD Medical Staff Well-Being John Sanchez, MD Patient Safety Committee Samuel Lehman, MD Pharmacy, Therapeutics & Utilization Stephen Kassel, MD Professional Review Committee Timothy Hansen, MD Quality Council Stephen Kassel, MD Committee Reporting to the Department of Surgery: Trauma Committee Michael Allshouse, DO, Chair Improving Patient Care A Continuous Process This publication is known as Progress Notes. At some point in our medical education we started writing progress notes as we rotated through the various services as medical students. I wrote my first progress note while on the general surgery service. I recall those notes being about a quarter to half-page in length. My next month was with the orthopaedic service at the VA, and one of the comments I received about those notes was that they were much too long. My supervising resident said to me with his Tennessee accent, “I ain’t no medical doctor! So don’t put all that extra junk in there.” When I began my internal medicine rotation my supervising intern told me that I needed to add “much more information” in my progress notes. Needless to say, as a medical student, I was quite confused as to what constituted proper documentation of the care I provided. That was before I had any exposure to peer review, quality of care or the concept of performance improvement. Evaluation of the care physicians provide has gone through many different stages. What used to be considered “acceptable outcomes,” “acceptable complication rates,” or “That’s just the way it is,” is now being looked at very carefully and questioned. “How can we improve care?” “How are others finding ways to improve care?” The medical staff is in the process of reorganizing the way we perform peer review. We are preparing a system that has multispecialty representation, and is consistent, timely, educational and positive. We believe that physicians are inherently interested in learning how to continually improve the care we provide our patients. Our goal is to develop a process that emphasizes self-improvement, learning from our collective experiences and working to advance systems. You will notice in this edition of Progress Notes that we continually work to improve patient care here. Todd Suntrapak describes the role of the new quality officer, Sam Lehman describes the success of our Executive Patient Safety Rounds and Joel Brownell writes about the goal of enhanced patient care through electronic tools and processes. Our Willson Heart Center broke new ground with the Melody Valve. We also welcome the new housestaff who will be writing their own “Progress Notes.” Samuel Lehman, MD Medical Director, Patient Safety Pediatric Intensivist Executive Patient Safety Rounds We have many improvement projects in our patient safety program. Some of these programs target reducing a specific type of harm such as our CLABSI program. Other initiatives focus on improving our patient safety culture. This culture is an attribute that is hard to define in a healthcare organization. I like to think of it as how we, both individually and collectively, prioritize the safety of our patients. While most people and regulatory bodies think of harm-specific initiatives, perhaps the most important work our organization can do is develop a culture of safety. Having an environment where people put patient safety above all else makes the rest of the work easy. Six years ago when I assumed the role of patient safety officer at Children’s, I brought a program entitled the Executive Patient Safety Walk Rounds from the Institute of Healthcare Improvement. The primary goal of this initiative is to improve our patient safety at all levels. We bring our most senior executives face to face in small groups with our frontline staff to identify patient safety issues. Each month we visit an inpatient or outpatient area at Children’s. We meet with nurses, doctors, respiratory care practitioners, therapists, health unit coordinators, etc., and ask them their concerns. • Have they seen an error or a near miss? • Have they seen a patient harmed? • What about our systems – do they help us prevent mistakes? At the end of our discussion we meet with the manager or director of that area and develop action plans for the items we identified. Since launching our Executive Patient Safety Walk Rounds in 2007, we have logged over 800 safety concerns in our database and implemented over 600 action plans related to these items. Key accomplishments range from the pharmacy and patient care division collaborating to adjust standardized scheduled medication administration times to ensure enough time for patient assessment and on-time medication administration, to surgeons and patient care administration working together to open additional postoperative beds on Voyager to provide postsurgical nursing care. The real benefit, however, is the opportunity for the Hospital’s most senior leadership to interact with the frontline staff taking care of patients. This allows leadership to learn about patient safety concerns firsthand and brings focus to the patient safety program. Equally important is that our frontline clinical staff also have the opportunity to witness firsthand the significant value that our senior leadership places on keeping patients safe from medical error. Get Involved Have you seen a patient safety concern? Does something keep you up at night worrying about how harm might come to one of your patients by medical error? You don’t have to wait until the Executive Patient Safety Rounds. You can email your concern and we will add it to our register: Dr. Lehman, Medical Director, Patient Safety: [email protected] or Melissa Rhoads, Patient Safety Program Manager: [email protected] New Medical Staff Members include: Pediatric Cardiology David Rosenthal, MD Dr. Rosenthal practices at Lucile Packard Children’s Hospital as a pediatric cardiologist and sees patients in our pediatric cardiology clinic Education & Training: Albert Einstein College of Medicine at Yeshiva University in New York Residency: Columbia University College of Physicians and Surgeons Dr. Rosenthal completed a fellowship at Yale-New Haven Hospital in Connecticut in pediatric cardiology. Pediatric Critical Care Azadeh Fayazi, MD Dr. Fayazi is a new member of Pediatric Anesthesia Associates Medical Group (PAAMG) practicing as a pediatric intensivist Education & Training: Wright State University School of Medicine in Ohio Residency: Virginia Commonwealth University Dr. Fayazi completed a fellowship at Virginia Commonwealth University in pediatric critical care. 4 Family Practice Michael Bohlman, MD Dr. Bohlman practices at Madera Family and Pediatrics Medical Group as a family practice physician Education & Training: Loma Linda University Medical Center Residency: Mercy Medical Center Maternal Fetal Medicine Elizabeth Platz, MD Dr. Platz is a new member of Specialty Medical Group practicing as a perinatologist Education & Training: Medical University of South Carolina Residency: Medical University of South Carolina Dr. Platz completed a fellowship at Medical University of South Carolina in maternal fetal medicine. Pediatric Otolaryngology (ENT) James Barrese, MD Dr. Barrese is a new member of Specialty Medical Group practicing as a pediatric otolaryngologist Education & Training: University of Illinois College of Medicine Residency: Los Angeles County+USC Medical Center Dr. Barrese completed a fellowship at Boston Children’s Hospital in pediatric otolaryngology. Pediatrics Lisa Hills, MD Dr. Hills is a new pediatrician practicing at Fresno Children’s Medical Group Education & Training: American University of the Caribbean Residency: Florida State University Joel Brownell, MD Chief Medical Information Officer Half-Time Over the past few years we implemented a significant upgrade to our electronic medical record and transitioned some of our most basic activities away from paper, including electronic prescriptions, physician orders, physician documentation, nursing documentation, ancillary staff documentation, etc. In the fall we will implement Athena in the ambulatory space – one of the last major steps toward transitioning from a paperbased practice to a contemporary EMR both in the hospital and clinic settings. From that perspective, the game is nearly over! The reality is that we are much closer to half-time than the seventh-inning stretch as it relates to patient care. These electronic tools and processes were never really the goal in and of themselves. The goal, of course, is improved and more cost-effective patient care. It’s not difficult to understand that a paper-based world would never provide us the tools we need to reach our goal, but simply implementing electronic tools is not enough. The roadmap that makes up Meaningful Use calls out this transition clearly. We recently completed our 90-day period attesting for Stage 1 Meaningful Use by demonstrating our use of some basic electronic tools and doing minimal testing of data exchange. Nationwide, the healthcare industry will be pushed toward meeting objectives associated with Stage 2 Meaningful Use, which focuses more on improved use of these basic tools as well as a much more robust exchange of information between healthcare organizations and the patients we serve. The real goal of being able to demonstrate improved outcomes and cost-effectiveness is part of Stage 3, which we anticipate achieving in several years. A long process indeed… So, as we gear up for another round of disruptive innovation transitioning to our ambulatory EMR, let’s try to pace ourselves in meeting our short- and long-term priorities. It’s important that we balance caring for our patients – as well as taking care of ourselves – with investing the time and energy necessary to progress toward the long-term transformational changes in healthcare so desperately needed. Keep up the good work! Radiation Reduction Children’s Hospital offers new computed tomography (CT) technology that cuts patients’ radiation exposure by half. Children’s 64-slice CT scanner with the new adaptive statistical iterative reconstruction (ASIR) software-based technology delivers high-speed, high-quality images with 25 percent to 50 percent less radiation. The decrease is based on the type of procedure the child undergoes. The Hospital’s 16-slice CT scanner already utilizes the dose-reduction software. “This technology enables us to significantly reduce radiation levels on our fastest CT scanner and administer just the dose required to achieve quality images,” said Elsa Ozuna-Richards, director, diagnostic imaging services, Children’s Hospital. “This is especially important for our kids who may need multiple imaging tests, such as cancer patients.” Monica Prinzing Senior Writer, Communications and Marketing Children’s Hospital Central California Melody Valve Comes to the Valley Pioneering new ground, Children’s Hospital successfully performed the first heart valve replacements in the Valley without cracking open the chest. Dr. Paolo Aquino, a pediatric cardiac interventionist, led the Children’s team that implanted Melody Transcatheter Pulmonary Valves in two teenage boys on July 1. Both went home the next day after undergoing a four-hour procedure. “I’m looking forward to having more energy!” said Devon Robinson, 13, of Fresno excitedly while preparing for discharge. The other Melody valve patient is 17 years old from Porterville. Many children with congenital heart disease are born with a dysfunctional or nonexistent pulmonary valve. Surgery may be necessary to insert a conduit or tube to substitute the faulty pulmonary valve. As the child grows these artificial conduits need to be replaced over time, resulting in multiple open-heart surgeries. The new Melody transcatheter pulmonary valve is used to repair a blocked or leaky artificial pulmonary valve previously inserted to correct the patient’s congenital heart defects. The Melody valve is implanted into the heart through a catheter inserted inside a vein in the patient’s leg during a heart catheterization. Composed of processed tissue, the Melody valve is sewn inside a wire stent and crimped onto an angioplasty balloon on the end of the catheter. Using X-ray, the valve, wire stent and balloon assembly is directed into the heart. The balloon is inflated to deploy the valve. After the assembly is removed, a Band-Aid is placed over the entry site. “Replacing a heart valve without major surgery is an important breakthrough in preserving our patients’ health and ensuring the best quality of life,” said Dr. Aquino. The Melody valve may delay the time until patients require surgery, hopefully decreasing the number of open-heart surgeries over a lifetime. “This should last Devon for many years,” said Dr. Aquino. That’s good news to Devon who has had many heart procedures since he was a baby. Diagnosed with tetralogy of Fallot, pulmonary atresia, and multiple aortopulmonary collaterals, Devon underwent his first open-heart valve surgery at 5 months old, and again at 2 and 6 years old to replace it. When Devon’s valve recently became narrowed and leaky, Children’s cardiac specialists offered the new Melody valve as an alternative to surgery. The U.S. Food and Drug Administration approved the Melody valve in 2010. Children’s is the first hospital in the region authorized to use it in patients. Children’s pediatric cardiac team has long been known for its expertise. A decade after conducting its first pediatric open-heart surgery in 1958 on a 9-year-old girl, Children’s reportedly performed the first open-heart surgery with an artificial valve on the youngest person in the world, a 5-month-old girl. Today, the Willson Heart Center at Children’s actively follows over 200 patients who eventually will need their pulmonary valves replaced. “The Melody valve is very promising for many of our patients but it’s not for every patient,” said Dr. Carl Owada, medical director, catheterization lab. “This is a game-changer in the management of congenital heart disease.” “Dr. Aquino is my favorite doctor!” exclaims Devon Robinson, 13, the day after undergoing the Melody Valve procedure. 5 Robert Kezirian, MD Pediatric Emergency Medicine UCSF-Fresno Pediatric Program Director A Lifelong Journey of Learning Education is the great equalizer of the conditions of mankind, the balance-wheel of nature’s abuses and barriers for health and functional wellbeing. Every medical student, resident and subspecialist in training or physician in practice must be encouraged to get as much education as they have the ability to take. We want this not only for the patient’s sake, but also for the practitioner’s sake. What can be more edifying or more seasonable than learning and the healthcare of children, each leaning on the other for their mutual and surest support! Medicine and education are devoted companions. This summer, our new pediatric housestaff continues in their lifelong journey of learning. Please welcome them and support their educational quest in being the best pediatricians. 6 Janae Barker, DO Touro University Dr. Barker completed her medical training at Touro University College of Osteopathic Medicine at Vallejo, Calif., in June. While at Touro, she received the Pediatric Distinguished Student Award and Student Doctor of the Year Nominee. She received her B.A. degree in biology from UC Santa Barbara. Dr. Barker has volunteered for many programs, including Doctors Without Walls and Women’s Free Shelter Clinic. Anita Chadha, MD Ross University Dr. Chadha graduated in March with her medical degree from Ross University. She received her B.A. degree in molecular and cellular biology from UC Berkeley. Dr. Chadha was a volunteer for Physicians for Human Rights in Portsmouth, Dominica, where she provided information and awareness on women’s healthcare. Albert Chow, MD Medical College of Wisconsin Dr. Chow received his medical degree in May from the Medical College of Wisconsin. He received his B.S. degree in biology at University of Michigan Ann Arbor. While in medical school, Dr. Chow was a member of the Asian Pacific American Medical Student Association, which organized activities such as the Hmong Health Education Program and the first medical student-driven Community Health Fair. Anna Ekstrom, DO Touro University Dr. Ekstrom received her medical degree from Touro University College of Osteopathic Medicine in Vallejo, Calif. She received her B.S. degree in biochemistry from UC Davis, and her MPH from Touro University. Anna was a volunteer for the Suitcase Clinic at Berkeley, which offered free health and social services to the homeless and to a women’s shelter. She also taught science to elementary school children. Erica Gastelum, MD University of California, San Francisco Dr. Gastelum received her medical degree from the University of California San Francisco in June. She completed her B.S. degree in neuroscience from University of California Los Angeles. Dr. Gastelum has been involved in many activities, including being the founding chair of INTERAXON, a program geared toward underserved inner-city schools in the Los Angeles area, to foster interest, excitement and curiosity about the brain among K-12 students. Jessica Lee, MD Ross University Dr. Lee graduated in May with her medical degree from Ross University. She received her B.A. degree in public health and her M.H.S in environmental health sciences from Johns Hopkins University. She has many interests, including being a volunteer in Dominica for the Salybia Mission Project, where she directed and organized three health clinics per year. Mitul Patel, MD Ross University Dr. Patel received his medical degree from Ross University. He received his B.S. degree in human biology from UC San Diego. Dr. Patel has been involved in many volunteer activities and is the creator/director of the first Asha for Education Fashion Show (San Diego California Chapter), which has now become an annual charity event that creates awareness and raises funds for education of children in India. Elaine Peterson, DO Pacific Northwestern University of Health Sciences College of Osteopathic Medicine Dr. Peterson received her medical degree in May from Pacific Northwestern University of Health Sciences College of Osteopathic Medicine. She received her B.S. degree in biochemistry from Western Washington University. Dr. Peterson has volunteered with Humanity For Children, Nick of Time Foundation, and Child and Family International. Sonia Solomon, DO Philadelphia College of Osteopathic Medicine Dr. Solomon graduated in June with her medical degree from Philadelphia College of Osteopathic Medicine. She received her B.S. degree in biology from the Widener University in Philadelphia. Dr. Solomon was a volunteer for Maximo Nivel in Costa Rica, where she volunteered at an AIDS/HIV clinic and conducted physical examinations and assisted in organizing preventative medicine seminars. Jasmine Turner, MD Loma Linda University Dr. Turner received her medical degree from Loma Linda University in May. She received her B.S. degree in biomedical sciences from Oakwood University in Huntsville, Ala. Dr. Turner has volunteered in many areas, including as community service coordinator for an OB-GYN interest group that promoted women’s health. Alicia Walker, DO Touro University Dr. Walker received her medical degree from Touro University in Vallejo, Calif. She received her B.A. degree in chemistry from California State University, Fresno. Dr. Walker was a volunteer at Valley Children’s Hospital in Fresno before going to medical school. She was also an academic research associate at University Medical Center. Monica Zlotnicki, MD St. George’s University Dr. Zlotnicki completed her medical training in May at St. George’s University in Grenada. She received her B.S. degree in microbial biology at UC Berkeley. Dr. Zlotnicki was a student volunteer researcher for the United States Department of Agriculture in Alameda and assisted in the research of analyzing the molecular regulation of the milkweed pod 1 gene in maize and its subsequent effects on organ morphology. 7 9300 Valley Children’s Place Madera, CA 93636-8762 RETURN SERVICE REQUESTED Announcements Save the Date - Medical Staff Dinner The Medical Staff of Children’s Hospital invites you and a guest to join your colleagues for an evening of socializing and recognition of Children’s many dedicated physicians: Tuesday, Sept. 24, 2013, 6:30 p.m. - 9 p.m. Copper River Country Club, 11500 N. Friant Road, Fresno Hors d’oeuvres will be provided. Two drink tickets provided per person. Please RSVP to (559) 353-6115 Dr. Watts Receives ‘Heroes’ Award Dr. Gregory Watts, a pediatric emergency medicine physician, was nominated and selected for one of the 2012 “Heroes in HealthCare” awards by Business Street Online. Dr. Watts was awarded in the physician category for his tireless work to improve healthcare in our community. Dr. Watts, congratulations on your honor! PICU Wins the Gold The Pediatric Intensive Care Unit (PICU) at Children’s Hospital Central California earned the Beacon Award for Excellence from the American Association of CriticalCare Nurses (AACN). Less than a dozen PICUs nationwide and only three PICUs in California have received this designation. Children’s received gold – the highest level of success – demonstrating sustained excellence in unit performance and patient outcomes. Children’s was first recognized with the honor in 2010. Medical Staff Services (559) 353-6115 Children’s Hospital Medical Staff Services solicits articles for Progress Notes several times a year. It’s a great place to distribute news, share accomplishments, and communicate with all members of our medical staff. Contact us for information or to make a submission.