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Preventing System Failure is Focus of a “Just Culture”
SSM Health Care Transitions Sponsorship
From St. Mary’s President: Better Protocol Rolls Out After Wrong-Site Procedure
Epic Work Continues to Optimize, Streamline
Surgical Prophylaxis Guidelines Chart Now Available
Doctors Guide New Fund
Rooftop Tiles Honor Radiologists
Time for a Refresher on Medical Library Resources
Physician Spotlight: Mario Goessl
New Faces on the Medical Staff
In Memory: Dr. Gene Farley
Honors and Recognitions

Physician Breakfast: 7 a.m.
Dec. 19, Jan. 23, Feb. 27, March 27

Annual Medical Staff Meeting
Jan. 21, 7:00 a.m. Business Meeting
7:30-8:30 a.m.
CME Program: "So you thought all you had to do was provide medical care? Reducing obstacles to health literacy"
Presented by: Paul Smith, MS, Health Literacy Expert and UW Associate Director, WREN

CME Grand Rounds:
7-8 a.m., St. Mary's, Bay 1
Feb. 6 - Genomics in Medicine
Howard Jacobs, PhD, Chief of Genomics, MCW
March 6 - Inpatient Pain Management
Gregory Love, MD, and Addie Gaspar, APNP
April 3- Transitions in Care
Tonya Wetterneck, MD, and Phil Bain, MD

From the Medical Staff Directors:
Preventing System Failure is Focus of a “Just Culture”

The medical world’s ability to prevent errors is impeded by a traditional reaction to errors: punishment for making mistakes. “Just Culture” is a philosophy that emphasizes learning from previous mistakes to improve the system and minimize avoidable errors in the future.

We know that people make errors and errors can lead to accidents, and accidents can lead not only to higher incidences of morbidity and death, but also increased cost of care and litigation exposure. We also know that using blame and punishment does not solve the problem of errors occurring. The problem is often the fault of the system, not an individual.

We bring up the need for a “Just Culture” because we know that we need to adopt new approaches to make our organization a “learning organization” so that we can work on changing the system when errors occur rather than simply using blame and punishment. This means developing a culture where there is proactive learning, where events are looked at as opportunities to inform our risk model. It’s about looking for risk, reporting errors and hazards, helping to design safe systems and making safe choices.

Overall, a just culture takes the focus off of errors and outcomes and puts it on the quality of system design and the quality of behavioral choices. Ideally, staff can admit their mistakes and be held accountable for their behavioral choices, and there are clear lines between human error, at-risk behavior and reckless behavior. A just culture recognizes that competent professionals can make mistakes and, equally so, can develop unhealthy norms such as shortcuts. Read more.

We want to be able to share each other’s successes and errors so that we can all learn from one another. We need to avoid criticizing or taking action against any member of the St. Mary’s Hospital community for raising or reporting a safety concern.

We look forward to moving forward with all of us looking for risk, reporting errors and hazards and helping to design safe systems and making safe choices here at St. Mary’s Hospital.

St. Mary’s Hospital Medical Staff Directors

(front row) Greg Burnett, Kay Barrett, Lee Carter, Timothy Crummy, Jeff Welch
(back row) Tim Crummy, James Goodsett, Anne-Marie Lozeau, Kyle Martin

SSM Health Care Transitions Sponsorship
Sponsorship of SSM Health Care, the parent organization of St. Mary’s Hospital and Dean, has shifted to a new group that will carry on the legacy of the organization’s founding Franciscan Sisters of Mary.

On Nov. 16 – the 141st anniversary of the sisters’ arrival in the United States to begin their health ministry – the Franciscan Sisters of Mary officially transitioned sponsorship to a new sponsoring body, SSM Health Ministries.

The transition will not change the mission, values or identity of St. Mary’s Hospital or SSM Health Care. The establishment of SSM Health Ministries is necessary because the Franciscan Sisters of Mary are no longer able to continue sponsoring the ministries they founded.

SSM Health Ministries will assume ultimate responsibility for ensuring that SSM Health Care retains its Catholic identity. It has received official approval to serve as SSM’s liaison with the Vatican.

The Franciscan Sisters of Mary are active participants in the transition. SSM Health Ministries will include three Franciscan Sisters of Mary and three Catholic lay members. It will remain independent of SSM Health Care and will not include any members who are employees of the SSM health system.

From St. Mary’s President:
Better Protocol Rolls Out After Wrong-Site Procedure
A recent patient safety event at St. Mary’s provided opportunity to improve our SSM system-wide universal protocol. Piloted on Dec. 2 and rolling out fully in the next few months, the protocol is designed to enhance teamwork and collaboration and improve patient safety.

THE REALITY: First, we need to share some information about a recent patient safety event at St. Mary’s. A few weeks ago, a wrong-site procedure was conducted at our hospital. While this patient experienced no permanent harm, we know that the root causes of this event could easily lead to a devastating outcome for another patient if we don’t raise the alarm across the hospital and take action.

St. Mary’s has a policy that requires a “time-out” where correct patient, correct site and correct procedure are verified before the start of a surgery or other invasive procedure. Every hospital in the country has adopted this standardized approach to avoiding a wrong-site procedure. Despite the existence of defined policies and procedures, wrong-site surgeries continue to happen. It may surprise you to learn that, since 2007, at least 36 wrong-site procedures have occurred in SSM facilities, including nine in 2013 to date. The most frequent failure modes of these events relate to: 1) failure to follow the established policy; 2) inadequacies in the established policy; and 3) failure of a team member to speak up when a problem was noticed or suspected.

PLAN OF ACTION: With these identified failure modes in mind, Dr. Jeff Welch, St. Mary's Chief of Surgery and Medical Staff Director, is leading a corporate team that developed a SSM System-Wide Universal Protocol Policy that applies to all invasive procedures. This new policy makes it clear that correct patient, correct site and correct procedure will be verified at every point in the system, from the scheduling process right up to immediate pre-procedural verification. This same policy also addresses site marking, requirements for additional time-outs in certain circumstances, and that as the surgeon calls for the time-out, he or she is the last to speak up in order to avoid biasing the procedure team.

Specially designed slider boards will serve as a visual reference to team members that all elements of the Universal Protocol have been addressed. The policy also includes a provision for routine monitoring for adherence to the policy via direct observation. As part of the action plan for our recent safety event, St. Mary’s will began piloting the System-Wide Universal Protocol on Dec. 2, 2013. It will be rolled out in other procedural areas over the next few months. You will receive further information and education about this protocol in the next few weeks.

ENHANCED PROTOCOL: The new System-Wide Universal Protocol policy also requires any member of the team with a question or concern about the accuracy and completeness of the time-out elements to stop the line. Stopping the line is a concept borrowed from the Toyota production model in which every employee is empowered to stop the process when a problem or concern is identified. TeamSTEPPS, an evidence-based teamwork system for health care, recommends that employees keep the acronym CUS in mind when they recognize the need to stop the line. CUS is a way to advocate for patient safety by using key words that communicate an escalating level of discomfort about a potential patient safety issue. “C” stands for concern – “I’m concerned that we might have a problem.” “U” stands for uncomfortable – “I’m uncomfortable with proceeding.” And “S” stands for safety – “We have a safety issue and need to stop now.” By integrating the use of “CUS words” into our daily work, we can signal the need to stop, address real or potential risks and avoid patient safety events.

In the unlikely event that attempts to stop the line aren’t successful, your administrative team wants you to know how to activate the chain of command in the interests of patient safety. Activating the chain of command means that the individual moves up the organizational hierarchy through successive levels of authority in order to get needed support. For example, a staff nurse with a concern about patient safety would go first to his or her charge nurse, then the director or nursing administrative supervisor, the AC member on call, and then to the hospital president. At St. Mary’s there is always someone available with the authority to step into the situation and stop the process. It is important for each member of the organization to know that you will be supported at every level of the organization for activating the chain of command. If you do have to activate the chain of command, you should expect to be told “thank you for putting the safety of our patients as your first priority.”

EXCEPTIONAL CARE AND SAFETY: A core element of a culture of patient safety is an environment where staff are encouraged to speak up when a real or potential risk is identified, regardless of their position in the organization or role on the team. The new SSM System-Wide Universal Protocol policy, coupled with the CUS words and your knowledge about how to activate the chain of command, represents our collective desire to stand up and speak up for patient safety.

Epic Work Continues to Optimize, Streamline

Physician news worth knowing: inpatient newsletter for Epic info, change in partial code status orders and addition of Platteville hospital to our Epic network.

MONTHLY INPATIENT NEWSLETTER: In an effort to optimize the use of the inpatient Epic module and to inform users of new functionality, the WIITTS Medical Informatics Directors began publishing a monthly newsletter for physicians this fall. Topics range from changes to expect in the Epic build as well as changes to workflows, shortcuts and other optimization techniques. The newsletter can be found on the Medical Connections website or this link.

CODE STATUS ORDERS: SSM Health Care is working to standardize patient care by having consistent Epic verbiage and orders throughout all of SSM, which operates in four states. The largest change for St. Mary’s Hospital in Madison will be a name change in the partial code status orders. What used to be called “PARTIAL CODE” will now be called “LIMITED CODE.

PLATTEVILLE HOSPITAL: On Nov. 1, SouthWest Health Center in Platteville, Wis., went live on our instance of Epic. Users are now able to see all hospital encounters for their patients, which should help make transfers of care significantly easier.

Surgical Prophylaxis Guidelines Chart Now Available
Using appropriate antibiotic prophylaxis in surgery is a key part of helping to reduce the risk of surgical site infections. American Society of Health-System Pharmacists (ASHP), along with the Infectious Diseases Society of America (IDSA), published “Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery”1 last February. The core of these long-awaited guidelines is the evidence-based grading of the surgical literature.

Updating the 2010 chart was an interdisciplinary process. It began in May with comparing our current practice with SCIP 2013 /2014 Quality Measures to the new guidelines. In some cases, specialty organization guidelines were considered. Surgical specialty involvement was integral in this change process. Discussions were conducted either by mail, email, and phone or section meetings.

What are the key considerations in this 2013/2014 Surgical Prophylaxis chart?
  • Formatting follows the published guidelines.
  • Maintain the recommendation of starting antibiotic administration within 60 minutes before surgical incision. Vancomycin and ciprofloxacin should begin within 120 minutes due to their prolonged infusion times.
  • When to re-dose during longer surgeries is simplified.
  • In SCIP procedures, antibiotics and duration are identified. For many procedures, a single dose or a maximum of 24 hours is recommended. Note: if antibiotic therapy is continued beyond 24 hours, a reason for continuation of therapy should be documented in the progress note.
  • New focus on dosing in obese patients. Several studies showed that increasing the dose of cefazolin in obese patients can reduce the risk of surgical site infections compared with lower doses. We adopted cefazolin2 gram as our standard dose several years ago. Now, for patients who weigh more than 120 Kg (260 pounds), cefazolin 3 gram is recommended.
  • Vancomycin is an alternative to cefazolin (as is clindamycin) for gram-positive organisms in patients who have had serious reactions to beta-lactams (eg. anaphylaxis, bronchospasm, urticarial). Previously, only clindamycin was an alternative choice.
  • Laminated charts will be distributed in December to clinical areas. E-copies are available by clicking here. Epic changes to the order sets will be done during early January 2014.
-- Geri Naymick, PharmD -- Antibiotic Stewardship Pharmacist
1 Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013;70:195-283. Also available www.idsociety.org

Doctors Guide New Fund
Physicians have a new opportunity to advance patient care through the Physician Resource Fund newly established by St. Mary’s Foundation. The new fund, which will be guided by a physician advisory committee, will direct gifts toward projects and programs that are most meaningful to our medical staff. Those needs will be identified by physicians to advance patient care at St. Mary’s Hospital and St. Mary’s Care Center. If you wish to contribute to this fund, please submit an online gift on stmarysmadison.com and indicate the fund for designation or send a check to St. Mary’s Foundation. For questions please contact St. Mary’s Foundation at 608.258.5600 or email stmarysfoundation@ssmhc.com.

Rooftop Tiles Honor Radiologists
Since the group’s founding in 1966, Madison Radiologists have made their mark on St. Mary’s in many ways – the latest of which are commemorative tiles in St. Mary’s Auxiliary Tranquility Garden on the hospital rooftop.

A tile dedication ceremony this fall acknowledged a generous gift to St. Mary’s Foundation in honor of the original five founding members and eight retired members of Madison Radiologists, S.C. The engraved tiles were made possible by active Madison Radiologists who are grateful for the legacy entrusted to them. Special thanks goes to Dr. Timothy Crummy, Madison Radiologist and Foundation Board member. The five founding physicians are Tamnit Ansusinha, Stephen Dudiak, , Ivan Knezevic, Richard Lindgren and George Roggensack. The retired physicians being honored are David Atwell, R. Marshall Colburn, Michael Curtin, John B. Davis, Robert Durnin, Anthony Merlis, Julie Mitby and Michael Stieghorst.

Front Row: Sandy Lampman, Karen Miller, Jim Hook, Dr. Harold Bennett, Dr. Richard Baker, Jr., Dr. Michael Stieghorst, Dr. George Roggensack, Chirawan Ansusinha, Dr. Ivan Knezevic, Dr. Michael Curtin. Back Row: St. Mary’s President Dr. Frank Byrne, Dr. Douglas Andrews, Dr. Daniel Hoefer, Dr. Eric Monat, Dr. Richard Lindgren, Dr. James Andersen, Dr. Todd Denholm, Dr. Michael Cullenward, Dr. Mark Rich, Dr. Tim Crummy.

Time for a Refresher on Medical Library Resources

Check out this easy-to-read review of St. Mary’s Medical Library resources. It’s helpful to know! Read more.

Physician Spotlight: Mario Goessl
When Dr. Mario Goessl joined Dean & St. Mary’s Cardiac Center earlier this year, he didn’t know St. Mary’s would be named a 2014 Top 50 Hospital for Cardiovascular Services (see Honors and Recognitions, below). But such a place is perfect for his own expertise in interventional cardiology and simulation training.

Dr. Goessl (spelled Gössl in his native German) is perhaps the only Dean & St. Mary’s physician who is trained to provide specialized education to other staff through simulation exercises, and he is part of a highly specialized structural interventional team consisting of cardiothoracic surgeons and interventional cardiologists able to perform the recent FDA-approved transcatheter aortic valve replacement (TAVR) procedure. In addition, in the beginning of November, Dr. Goessl and his team performed the first paravalvular leak closure at St. Mary’s hybrid room.

“I am proud to be part of a system that puts the needs of the patients first and provides the highest quality of care every single day,” he says. Dr. Goessl grew up in Liebenscheid, Germany, in the Rheinland-Pfalz region, graduated from medical school at the University of Cologne in 1999 and did internships at University Clinic in Essen-Duisburg and the Centre for Internal Medicine at the West German Heart Centre. In 2006, he began his residency in Rochester, Minn., at Mayo Clinic, where he continued for three consecutive fellowships over five years (in cardiology, interventional cardiology and advanced structural interventional cardiology).

In Germany, he taught proper cardiac exam techniques using a mannequin, and Mayo had a fully equipped simulation center for the training of central line placements, CPR and intensive care unit scenarios. “Simulation cannot replace hands-on experience but it a great way to practice automatisms that are necessary to succeed in such scenarios without harming a patient,” says Dr. Goessl, who is a fellow of the American College of Cardiology, American Heart Association and the European Society of Cardiology. Simulation training is expected to increase within St. Mary’s continuing professional development in 2014.

While Dr. Goessl takes his work seriously, he also loves to play. “Like every German kid, I love soccer,” he says. He also enjoys pheasant hunting, fishing, cycling, movies, theater, opera, cooking and traveling with his wife, Alissa, and his German Shorthair Pointer, Ares. This year was one of great life change. Not only did he make his home in Madison with Dean & St. Mary’s, he and Alissa were just married in October.

New Faces on the Medical Staff
Click here to download the list of new medical staff.

In Memory: Dr. Gene Farley
Dr. Gene Farley, 86, emeritus professor at the University of Wisconsin School of Medicine, died Nov. 8. He was based at, and a supporter of, St. Mary's Hospital and a strong collaborator with Dean. He was one of the founders of the concept of family medicine, a champion for the cause of universal health care and the creator of the Farley Center for Peace, Justice and Sustainability in Verona. Farley served as chair of the Department of Family Medicine from 1982 until 1992.

Honors and Recognitions
Congratulations are in order for institutional successes and for our colleagues who go above and beyond the duty of their day (or night) jobs. 

Cardiovascular Kudos:
St. Mary’s has been named one of the Top 50 Hospitals for Cardiovascular Services for 2014 by Truven Health Analytics and is the only recipient in Wisconsin. These hospitals spent roughly $2,000 less per bypass surgery, about $1,000 less per heart attack patient admitted and were quicker to release their patients: a half day better than their peers for heart attack, heart failure and angioplasty cases, and a full day sooner for bypass patients. In its 15th year, the study evaluated general and specialty, short-term, acute care, non-federal U.S. hospitals treating a broad spectrum of cardiology patients. Truven uses independent and objective research in its work, including metrics for mortality, complications, LOS, core measures, readmissions and cost per case. The date range for the data varies for each metric, but the overall range is from January 1, 2009 to September 30, 2012. Organizations do not apply or pay for this honor, or pay to promote their award.

Dean Health Plan is one of only 11 plans nationwide to receive the Centers for Medicare & Medicaid Services' (CMS) five-star rating—the highest possible quality ranking—for private Medicare insurance plans and Medicare Advantage plans. Medicare ranks how well health plans perform on more than 50 measures, which are grouped into different categories:
  • Staying Healthy: Screenings, Tests and Vaccines
  • Managing Chronic (Long-Term) Conditions
  • Plan Responsiveness and Care
  • Member Complaints, Problems Getting Services and Choosing to Leave the Plan
  • Health Plan Customer Service

deancare.com won an award of distinction for the Best Internet Site in the Health Care System category in the 14th Annual eHealthcare Leadership Awards.

Guardian Angels: Five physicians have been honored as Guardian Angels August 1 to October 31 for their exceptional care. Patients and families have made a gift to St. Mary’s Foundation to honor the following physicians:

Dr. Brian Bachhuber

Dr. Anthony Callisto
(Emergency Services)

Dr. Christoph Eggert

Dr. Vijay Kantamneni
(Cardiovascular Surgery)

Robert Leschke
(Emergency Services)





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