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Physician Focus Fall 2011 

In This Issue

From the Medical Directors: Collaboration Makes the World Go ’Round
New Delirium Order Set Debuts Sept. 13
New Chem Analyzer: Reference Ranges Will Change
Care Management: New 2011 InterQual Criteria Much More Stringent 
Tips for Efficient Review of Charts
Physician Spotlight: Benjamin Kleiber
Palliative Care Consult Service Now in Place
Physician Hand Hygiene Results are up, with Room for Improvement
Spotlight on Ronald McDonald Family Room and Physician Resource Center
Welcome New Residents!
Honors and Recognitions

CME Grand Rounds
Sept. 21
7:30 - 8:30 a.m. Bay 1
Special Guest: Diane Meier, MD, FACP
Director, Center to Advance Palliative Care (NY)
"Palliative Care 2011: Going to Scale"

8:45-9:30 a.m.
"Dilemmas in Prognosis – Palliative Care”
(Follows Grand Rounds)
Diane Meier, MD, FACP, Lu Marchand, MD, Kris Catrine, MD, Michael Panicola, PhD, Bill Rock, MD

Save the Dates - Upcoming Grand Rounds:
Nov. 3, 7 a.m. “Total Joints Arthroscopy” Hosted by Orthopedics
Feb. 2, 2012 7 a.m. “Ethical Dilemmas in Practice” Michael Panicola, PhD, Facilitator

Watch the Sept. 1 Grand Rounds "Pituitary Adenomas" Contact Gale Garvey, CME program with questions.

News From...
2010 Progress Report
UW Family Medicine


From the Medical Directors:
Collaboration Makes the World Go ’Round

With a new structure in place for St. Mary’s medical staff, progress toward goals and other improvements are moving like clockwork.

With the implementation of the medical staff redesign, we now have a group of medical directors who represent all physicians within the hospital. In early May, the seven of us rolled up our sleeves and began our new roles. We’re working to implement system changes that will have positive effects on the way we work and on patient outcomes. Specifically, we’ve set the following goals, listed along with the primary contact person:
  • Meeting Core Measures at 100% (Jim Goodsett and Jeff Welch)
  • Revision of the physician peer review system (Kyle Martin and Anne-Marie Lozeau)
  • Improving patient satisfaction (Kay Barrett)
  • Improving physician satisfaction with
    • improved quality and safety (Jim Goodsett and Jeff Welch)
    • improved communication with physicians (Anne-Marie Lozeau)
  • New Technology evaluation and integration (Jeff Welch and Tim Crummy)
Working together—across disciplines and with the same end goal in sight—we will continue to strengthen our hospital and provide a workplace that is truly satisfying, both personally and professionally.

Physician Resource Center’s Role
The new Physician Resource Center has proven to be a boon to collegiality. It is a welcoming gathering place for colleagues to meet, work and network with other physicians. With the Medical Staff Office next door and the addition of Dragon dictation to three computers in the PRC work space, it increases productivity, too.

To improve access to the seven medical directors, we’ll be establishing office hours so that at least one of them is available during routine times to discuss ideas and concerns. Regardless of the schedule, feel free to talk with any one of us at any time. After all, the medical staff redesign is all about communication and collaboration.

New Delirium Order Set Debuts Sept. 13
A collaborative effort with physicians, nursing, and pharmacy, the new order set includes IV haloperidol monitoring parameters, dosing recommendations, and alternative therapies. Read more.


New Chem Analyzer: Reference Ranges Will Change
Reference ranges on chemistry and immunoassay testing will soon be standardized among all facilities in the Dean and St. Mary’s laboratory network, resulting in benefits and changes that should be noted.

St. Mary’s new Abbott chemistry analyzers will be brought into service over the next few months. Both general chemistry and immunoassay testing will be migrated from several older instruments to this integrated system. Benefits will include less patient sample needed and faster results, with more tests using plasma and less batching.

When other labs, including Dean Clinic, St. Mary’s Janesville and St. Clare, also change to the Abbott platform in the coming months, there will be standardized reference ranges across the network. Reference ranges for several tests will be changing.

Beginning in early August, the first group of tests will be migrated to the new analyzer at St. Mary’s, resulting in minor changes to some reference ranges, and no change to others. Slight changes for immunoglobulins, C3, C4 and haptoglobin will be seen in this first group, with reports in Epic stating "Note: Change in Reference Range."

Other tests will be moved over to the new analyzer in groups over several weeks, into autumn. Laboratory staff and pathologists are working with the medical directors to assure that timely appropriate communications are given about these changes. Stay tuned!


    Care Management: New 2011 InterQual Criteria Much More Stringent
    St. Mary’s Ethics Committee provides guidance on ethical issues at the request of any staff member for a patient or ethical matter within our hospital.

    Inpatient versus observation…these words have been a source of frustration for many (if not most) providers. Many providers still feel that that they do not understand the different between the two. This communication will (1) review the basic differences between inpatient and observation status, (2) put into perspective why getting the right status designation is extremely important, (3) outline what Care Management’s plans are to provide continued assistance to getting the most accurate status determination, and (4) lay out what we need from all of you, the physicians and advanced practitioners, to make this all work.

    The status designation for hospitalized patients falls into 3 categories: (1) hospitalizations that are clearly observation (i.e. “soft admits”, “social admits”, etc.) (2) hospitalizations that are clearly inpatient (acute, life-threatening illness such as acute respiratory failure, bowel perforation, severe sepsis, etc.), and (3) hospitalizations that could be either inpatient or observation depending on the sequence of events and outcomes during the course of the patient’s hospital stay.

    Thus, status designations are really distributed along a bell shaped curve with the third category, in the middle of the curve, presenting the most challenges. The table below outlines the basic differences between observation and inpatient status. Whether a patient is observation or inpatient status is really a judgment that we make all the time as providers: Is this patient really sick enough to need to be in the hospital or can I manage his/her problems on an outpatient basis? Medicare and other payers are now expecting to us explicitly state why we think a patient needs inpatient care /admission (more on documentation later).

    CMS (Centers for Medicare and Medicaid Services, i.e. the federal government) started the RAC (recovery audit contractor) program in July 2010. RAC auditors are private contractors who have been hired by CMS to audit the charts of every hospital in America to ensure that we are all getting the observation and inpatient status designation correct. Hospitals are reimbursed significantly higher for inpatient care compared to observation care and if any given hospital has billed for inpatient care when the hospitalization did not meet inpatient criteria, the hospital will need to repay Medicare. The auditors are allowed to review admissions from as far back a 2007. As you see, getting the status determination wrong over time can quickly mount up to millions of dollars of payment due back to CMS.

    The RAC process for St. Mary’s Hospital is now entering a more accelerated phase in which auditors are scrutinizing charts more closely and denial rates are increasing. The entire administrative team is working hard to recoup as much of this revenue as possible. Going forward, it is important that we all work together to continually improve the accuracy of status designations for hospitalizations. One of the many important tasks that our Care Management Department (formerly PFS) performs is assisting care teams with getting the most accurate status determination. One their most important tools is InterQual. InterQual is a set of national evidence-based criteria that help determine if a hospitalization is consistent with inpatient or observation care. In order to keep up with ever more complex and strict CMS rules around status determination, the latest version of InterQual (2011) is more stringent than ever.

    How will this affect you? The Care Managers will likely be calling you more regarding status designation. They will also be asking you more about why you feel a particular status is appropriate. Our Care Management team is entrusted with the challenging and vitally important task of ensuring that we all stay in compliance with Medicare guidelines. These calls and inquiries are not meant to question your judgment in any way; they are a necessary part of making sure that we work together to get the status right.

    What do we need from you? Complete documentation that explicitly states why you feel that inpatient care is needed is essential to getting the most accurate and appropriate status designation. Ultimately, you are the final judge of whether a patient’s hospital care is consistent with inpatient or observation. Therefore, it is important to document clearly how much risk the medical condition(s) poses to your patient and, based on your medical judgment, why the care cannot be safely delivered on an outpatient basis. Doing so will help identify the most accurate status designation. Thank you for support.

    James Goodsett, M.D.
    Dean Internal Medicine Hospitalist
    SMH Medical Staff Director
    Physician Advisor for Care Management

    Tips for Efficient Review of Charts

    Efficiently reviewing notes during a hospital stay is important to quality patient care. Here are some tips to help you navigate the charts and make the most use of your time and data.

    The NOTES activity tab found in the left side column will list all the notes written since admission by any provider (physicians, social workers, therapist, nurses, etc). There are many options to organize the list to make review more efficient.

    Across the top are two rows of tabs. The category row tabs sort by note type (progress note, consult, H&P, operative, etc) and the row below lists notes filed by author (who wrote the note), author type (RN, physician, OT, etc), time the note was written, and recently added is a column for service which lists the department of the author. This allows one to review all notes from one department (family medicine, cardiology, orthopedics, etc).

    One caveat needs to be kept in mind by providers who work and log into multiple different departments. The note will file based on the department logged into. Therefore FP residents need to sign into the department of the attending who is co-managing the patient. When the attending co-signs the note, it will file into the department that the FP resident was logged into when the note was written.

    Spending a few minutes reviewing these options should help make chart review more efficient.

    Jim Porter, MD
    Medical Informatics Director

    Physician Spotlight: Benjamin Kleiber
    In the three years since he joined Dean and St. Mary’s, Dr. Ben Kleiber has shown himself to be a valuable force in providing and advocating for great heart care.>

    Dr. Kleiber, a Fellow of the American College of Cardiology, has a special interest in cardiac imaging and valvular heart disease. "This is a very exciting time in cardiology," he says. "Valvular heart disease treatments are rapidly evolving, particularly new imaging techniques, surgical valve repair and percutanous valve replacement, which we hope to bring to St. Mary’s in the near future."

    St. Mary's Chest Pain Center in Emergency Services is working toward accreditation with the help of Dr. Kleiber as the cardiology advisor. Other things you might like to know:

    Previous positions
    University of Michigan Medical School, 1999
    Georgetown University, Internship, Residency, Cardiology Fellowship, Chief Cardiology Fellow, 2006
    Staff Cardiologist, Aurora Denver Cardiology, Denver, Colorado, 2006-2008

    Professional Recognitions
    Director, UW Family Medicine Residency Cardiology Rotation (a new rotation that will begin this year that will combine inpatient and outpatient cardiology learning experience)
    Co-Director, Valvular Heart Disease Clinic, Dean Clinic
    Cardiology Advisor, Chest Pain Committee

    Personal Interests
    My family (with two young daughters), cycling, sailing, skiing, travel
    I’m most proud of my association with St. Mary's because of dedicated staff who go the extra mile in treating patients with respect and providing the best possible care.

    I’d like to recognize the following for enhancing my work: Echocardiography technicians, cath lab staff, 4E nurses, nuclear technicians, Dean cardiology outpatient clinic staff, Dean cardiologists and cardiovascular surgeons.

    If I could change one thing about health care for the good of our community, it would be the early inclusion of heart-healthy lifestyles in children’s education.

    Palliative Care Consult Service Now in Place
    St. Mary’s began a pilot program in July on 5SW and 8SW to effectively meet the needs of patients with advanced chronic illness while also focusing on quality of life.

    Palliative care encompasses the control of physical symptoms in the context of a patient’s emotional and spiritual needs, goals and well-being, and assists patients and families in making complex decisions about the goals of their care. Palliative care can include hospice care but is also appropriate earlier in the course and throughout treatment of advanced chronic illness.

    The pilot phase of the Palliative Care Consultation Service is planned to expand rapidly and transition across the care continuum at St. Mary’s and around the SSM Health Care of Wisconsin system in 2012. As a growing field, this new medical specialty has been shown to improve the quality of life for patients, improve their satisfaction with their care and reduce costs by eliminating unwanted or ineffective treatments.

    St. Mary’s palliative care team currently includes medical director Dr. Lucille Marchand, who is board-certified in palliative medicine, nurse-practitioner Adrianne Gasper and social worker Rosanne Derdula. The Palliative Care Consultation Service is available weekdays from 8:30 a.m. to 5 p.m. by calling 608-446-6920.

    Physician Hand Hygiene Results are up, with Room for Improvement
    June - Before Patient Contact - 84%
    After Patient Contact - 87%

    July - Before Patient Contact - 83%
    After Patient Contact - 86%

    The hand hygiene chart along with additional data on quality, patient & physician satisfaction can be found on the Medical Connection website


    Spotlight on Ronald McDonald Family Room and Physician Resource Center: St. Mary’s Foundation Donors Turn Project Dreams into Reality
    St. Mary’s families will soon benefit from Wisconsin’s first Ronald McDonald Family Room (RMFR). Physician and staff support will play a key role in building this much-needed respite space for the families of critically ill pediatric patients. Construction will begin in 2012 when the $1 million fund-raising goal is met. In the coming months, orthopedist Dave Wolff, MD, and Sandy Lampman, St. Mary’s Foundation executive director, will visit various physician group meetings to present information about RMFR. If you and/or your physician group would like to learn more about this project, please contact Sandy Lampman at 258.5601 or sandy_lampman@ssmhc.com.

    St. Mary’s Foundation partners with donors on opportunities and develops support for improvements that benefit patients, both directly and indirectly. Recently, gifts to the Foundation have funded The Gardens of St. Mary’s and the Physician Resource Center (shown above), both of which enhance our environment of quality care. Click here to see photos of the PRC and the dedication event.

    Welcome New Residents!
    The UW Family Medicine Residency class of 2014 arrived at St. Mary’s in July. Standing (from left) are Thomas Hahn, Elizabeth Matera, James Conniff, Kevin Thao, Joseph Wolfe, Mischa Ronnick, Nathan Vakharia, Andrew Schmitt, Sean Trafficante, Matthew Swedlund and Karina Sater. Kneeling (from left) are Ann Barry, Taryn Lawler, Elizabeth Fleming, Lisa Go and Jennifer Mastrocola.

    New Faces on the Medical Staff – Click here

    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. 

    Department of Family Medicine Awards: Residents from the University of Wisconsin Department of Family Medicine honored Dr. Thomas Gehlbach (pulmonology) and the UW Pediatric Hospitalists who serve St. Mary’s Pediatrics Unit with Clinical Teacher Awards. (They include Drs. Katherine Baker, Margaret Bartholomew, Kristina Catrine, Shannon Dean, Jonathan Fliegel, Michelle Kelly, Ndidiamaka Musa, Kristin Shadman, Angela Veesenmeyer, Sabrina Wagner and Jeffrey Yaeger.) This year’s Faculty Teaching Award went to Dr. Andrew Slattengren, who is a recent graduate of the Family Medicine Residency Program, and the Resident Teaching Award went to Dr. Ronni Hayon, who graduated in the spring.

    Dr. Thomas Gehlbach

    Dr. Andrew Slattengren

    Guardian Angels: Four physicians were among those honored as Guardian Angels between April and June 2011. The program, sponsored by St. Mary’s Foundation, invites patients and families to make a gift in honor of someone who provided them with exceptional care.

    Julie Hildebrand, MD

    John Phelan, MD 
    Gary Waters, MD

    Ron Wenger, MD





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