March Message from Steven L. Strongwater MD, CEO

The information below is an employee update of activities at Stony Brook University Medical Center prepared by Stony Brook University Hospital CEO, Steven L. Strongwater, MD.
Dr. Strongwater distributes a monthly update that is sent to all hospital faculty and staff to communicate initiatives and activities undertaken at the Medical Center to reach goals in the areas of patient satisfaction, patient safety, and community connections.

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March 2010

National Patient Safety Awareness Week is observed March 7 though 13. This is an opportunity to look back on past performance and celebrate our many improvements in patient outcomes. Over the past several years there has been increasing attention to the details of measuring patient outcomes, which has resulted in meaningful, reliable, reproducible, and comparative measures for academic medical centers across the nation. For many years, Stony Brook University Medical Center (SBUMC) has focused on improving systems that support care to improve patient outcomes. Under the able leadership of Dr. William Greene, Chief Quality Officer, and Carol Gomes, Associate Director of Quality Management, in collaboration with many faculty and staff, SBUMC has a great deal to celebrate. Following are just a few:

• Mortality rates have continued to be better than our risk-adjusted “expected” rate (despite an increasingly frail and sick patient population) and have dropped steadily from 2003 through 2008. In 2009, we remain in the top 30% of hospitals in the University HealthSystem Consortium (UHC).
• Central line infections (infections as a result of intravenous catheters) have dropped in most of our ICUs in 2009, most notably in the PICU, with a greater than 2/3 drop, and in the MICU, with an approximate 20% drop; the CICU continues to be central line-infection free.
• Ventilator-associated pneumonias have been markedly reduced in the MICU and in the NICU, and for the Hospital as a whole.
• Survival for myocardial infarctions (heart attack) and for patients with community-acquired pneumonia is among the best in the nation.
• Both the inpatient and outpatient electronic medical records are live and preventing medical errors every day.
• We continue to have outstanding survival for patients presenting with sepsis to the Emergency Department, at rates 30% to 35% below our historical baseline.
• We have been named once again as a Distinguished Hospital for Clinical Excellence, placing us among the top 5% of hospitals nationally.

Up until the November 1999 report from the Institute of Medicine (IOM), “To Err is Human: Building a Safer Health System,” the nation did not consider patient safety a priority. This year, which began as the year of healthcare reform, is different. Health reform upped the ante on value-based purchasing (VBP). VBP embodies the notion that hospitals should not be paid for mistakes, errors, readmissions, and the like. Policymakers like the idea of linking quality outcomes to payment. Quality has finally become a business priority—something that is long overdue. Now, care will improve in every hospital in the nation.

This month, SBUMC will launch an exciting patient safety initiative, which integrates several ongoing and new initiatives to even more aggressively improve patient safety. We will implement best practices throughout the Hospital with a goal of becoming error free. We will focus on five key areas: enhanced communication through crew resource management (CRM), a procedure and training system that healthcare adopted from the airline industry; enhanced detection through consistent use of better patient monitoring systems that are hard wired to require actions (e.g., medical early warning scores, pediatric early warning scores, obstetrical early warning scores, and emergency medicine early warning scores); enhanced staff and faculty feedback (e.g., dash boards); deployment of checklists in all high risk areas; and the broad implementation of and staff empowerment to use red rules (e.g., stop the work) when something in the chain of care appears “off.” This will complement ongoing exercises that seek to anticipate future problems and help prevent them through failure modes and effects analysis (FMEAs). In addition, in mid-March, we will greatly raise the involvement and visibility of management in patient safety through “Patient Safety Fridays.” Senior leadership at SBUMC has committed to adopt a strategy that has successfully changed the culture at New York Presbyterian (NYP) Hospital. SBUMC’s leadership team, from the level of manager on up, which includes more than a hundred people, will join together every Friday to look at safety and regulatory issues aimed at making improvements. Friday mornings will be dedicated to education and tracer activity, while the afternoon will be devoted to unit and service-based safety and quality activities. The team will engage in a united effort to rapidly resolve issues.

SBUMC can certainly celebrate our achievements in patient safety, but we believe we can do even more. We invite you to join us in making patient care better—every day, 24/7.

STONY BROOK PRIDE

Stony Brook University Hospital (SBUH) celebrates its 30th anniversary. On February 18, staff gathered in the HSC Galleria to celebrate the Hospital’s 30th anniversary. Led by Dr. Strongwater, a historical timeline was presented complete with video clips and photos illustrating the Hospital’s past. The presentation was followed by veteran staff sharing their stories of what it was like to be part of the Hospital’s growth in those 30 years, which has been nothing less than remarkable. Congratulations to all of you who played a part in the past 30 years. I look forward to continue working with you, and to a promising future for Stony Brook University Hospital.

 FDA approves drug discovered by SBUMC orthopedic researchers. Marie A. Badalamente, PhD, and Lawrence C. Hurst, MD, discovered and developed Xiaflex™ to treat Dupuytren’s contracture (or disease), a debilitating hand disorder that affects millions worldwide. It is the first FDA-approved non-surgical treatment for the condition. The Department of Orthopaedics at SBUMC will soon open the “Dupuytren’s Institute” to further support patient care, research, and education concerning the disease. Drs. Hurst and Badalamente will co-host a Dupuytren’s Disease Continuing Medical Education (CME) Symposium at Stony Brook University on April 17.

SBUMC leads the region in organ donor conversion rate. Donor hospitals are asked by the National Collaborative on Organ Donation to try to reach the national goal of a 75% conversion rate, meaning that of eligible potential donors, 3 out of 4 reach the stage of actual organ donation. During the last year, SBUMC achieved a 93.3% conversion rate—18% over the national goal. SBUMC also achieved 3.4 organs transplanted per donor from these donors, as compared to around 2.5 for the region. SBUMC remains a leader in our community helping those who need a lifesaving organ.

SBUMC receives approval to serve as a HLA-matched unrelated donors (MUD) transplant center. An essential component of allogeneic transplantation is to identify a human leukocyte antigens (HLA)-matched bone marrow donor. Ideally, a brother or sister can serve as the bone marrow donor. For those patients without a sibling donor, the National Marrow Donor Program (NMPD)-Be the Match Registry provides a service to locate HLA-matched unrelated donors (MUD transplantation). Currently, there are approximately five million volunteer bone marrow donors registered with the NMDP. An additional 40,000 new donors are added to the registry each month and the NMDP facilitates over 1,000 MUD transplants each year.

 SBUMC is granted re-accreditation for echocardiography and nuclear stress testing. The Echocardiography Laboratory was granted re-accreditation by the Intersocietal Accreditation Commission (IAC) in all components of adult echocardiography, including transthoracic, transesophageal, and stress. The outpatient sites at Islandia and Tech Park were granted re-accreditation in adult transthoracic echocardiography. Although echocardiogram is the most widely used cardiovascular imaging modality, we are one of only 25 laboratories in New York State accredited in all three components of adult echocardiography. The Medical Center and the outpatient sites were also recently granted re-accreditation in nuclear stress testing.

 SBUMC researcher is awarded a $62,000 grant. The Manhasset Women’s Coalition Against Breast Cancer funded Dr. Emily Chen’s study, “Cancer Stem Cells and Breast Cancer,” with the Mary Anita Conroy Memorial Breast Cancer Research Grant. The organization, formed in 1997, unites the women of Manhasset in the fight against breast cancer. Their mission is to fund innovative research, increase awareness through education, and provide support services to those with breast cancer and related diseases. Congratulations to Dr. Emily Chen for being SBUMC’s first recipient of this award.

Madagascar fossil exhibit is unveiled. On February 9, the fossil exhibit was unveiled in the Hospital lobby, in front of an enthralled audience that included young students from local schools. The permanent exhibit is a result of the generous support of the SBUMC Development Council, and the highly significant fossil finds made in Madagascar by Dr. David Krause and his team of researchers. The event was topped off by serving cakes, each decorated with the images of the fossils. To learn about the ongoing efforts in Madagascar by Dr. Krause and his team, and Stony Brook students and healthcare professionals, visit www.ankizy.org.

Carol A. Gomes becomes a 2009 American Society for Clinical Pathology (ASCP) Master. Carol, who serves on SBUH’s executive team, was recognized for her significant contributions to the field of pathology and laboratory medicine, and to ASCP. Carol has held leadership roles in a number of professional organizations, including the Program Committee of the Healthcare Leaders of New York chapter of the American College of Healthcare Executives, and as a member of the Clinical Laboratory Management Association Board of Directors. She has served on the Malcolm Baldrige Quality Program’s Board of Examiners since 1999, most recently as a senior examiner and alumni examiner.

Stony Brook University Hospital’s recycling rate places it in running for recognition. The Hospital reached a 25.03% recycling rate for 2009. Due to the efforts of many, SBUH can be considered for the Practice Greenhealth Environmental Leadership Award this year. 

PATIENT SAFETY

SBUMC celebrates Patient Safety Awareness Week. Patient Safety Awareness Week is a national education and awareness-building campaign for improving patient safety at the local level. Events have been planned beginning March 8 and running through March 12, including a patient safety cart that will visit hospital units on Monday, Tuesday, and Wednesday; lectures from 10:00 am to 5:00 pm at the HSC; the Patient Safety Fair on March 11, 10:00 am to 3:00 pm, in the Medical Center lobby; and the introduction of Patient Safety Fridays.

“Patient Safety Fridays” comes to Stony Brook. In our quest to achieve high reliability, SBUMC has committed to a new process called Patient Safety Fridays, which will kick off on March 12. SBUMC leadership staff members, both clinical and administrative, are firmly committed to this process, aimed at improving the quality, safety, and consistency of care. To help us improve our culture of patient safety, we’ll be providing continuing education and training. SBUMC department heads and clinical leadership will meet for Patient Safety Fridays each week, and then share what they have learned and make recommendations. Patient Safety Fridays will help establish a method of reaching out to our staff, providing them with the tools they need to be successful, and creating an opportunity to listen to staff and patients. On March 4, two representatives from New York Presbyterian (NYP) will be presenting the NYP experience with Patient Safety Fridays.

Failure Mode and Effect Analyses (FMEAs) lead to high reliability. As part of SBUH’s effort to strive for high reliability (failure-free processes over time), departments continue to focus on conducting FMEAs to implement risk reduction strategies for high-risk processes. The Department of Respiratory Therapy recently worked with other disciplines to focus on improving skin breakdown in the Neonatal Intensive Care Unit, with a focus on the use of nasal pharyngeal prongs. Best practices were implemented to enhance patient safety. In addition, the Department of Employee Health and Wellness conducted a FMEA that focused on improving annual assessment rates for non-medical staff. As a result, compliance improved considerably over time.

SBUMC poster is accepted by the United Network for Organ Sharing (UNOS). The poster, “Expediting the Kidney Referral to Waitlist Time,” submitted by the Kidney Transplant Service and CQI Department, was accepted for display at the UNOS Transplant Administrators Conference in April. The poster depicts a decrease in patient wait time from initial appointment to a place on the transplant wait list from 394 days (pre-implementation) to 90 days or less (post-implementation). This was accomplished by restructuring the roles of the Transplant Coordinators to allow them to facilitate timely appointments for medical testing required to clear the patients for transplant candidacy.

SBUMC poster will be presented at the Canadian Patient Safety Institute. The poster abstract, “Deep Diving for Patient Safety,” submitted by Ronnie McKinnon, Office of Counsel, was accepted by the Canadian Patient Safety Institute’s call for international abstracts for poster presentation. It will be presented at the annual conference in Toronto in April. Deep dives are multidisciplinary forums that provide an opportunity to discuss and improve processes relating to patient care and often focus on aspects relating to patient safety. 

SBUH earns best Strategic Surveillance System (S3) score ever. The S3 quarterly assessment and comparative report by The Joint Commission provides a series of risk assessments. Risks are given points and the lower the point total, the better the risk score for the hospital. The fourth quarter 2009 report attributes to SBUH a risk score of 118, down from 129 last quarter. This S3 risk score is at the lowest level since the Hospital first received these reports in 2007. The improvement is attributed to a well-received Joint Commission Survey last June, and successfully meeting our Plan of Correction goals for that survey. This score places SBUMC below the national, state, and UHC average, and is lower than the average for the U.S.News & World Report, “America’s Top Hospital” scores.

Comprehensive unit-based safety program is coming to the Pediatric Intensive Care Unit (PICU). The PICU is scheduled to roll out the Comprehensive Unit-Based Safety Program (CUSP) beginning in March. CUSP is a five-step program designed to impact the safety climate by empowering staff to assume responsibility for safety in their environment. This is achieved through education, awareness, access to organizational resources, and a toolkit of interventions. In addition to empowering their front-line staff, the PICU is engaging parents of patients in the project.

Using electronic solutions to improve patient care. Early detection and the treatment of sepsis are key to a patient’s survival. Electronic solutions are being explored to trigger the screening of patients on the medicine and surgical floors who meet the criteria for severe sepsis. Among these are the creation of the fever panel for the medicine and surgical floors, which include the testing of serum lactate, and firing a task to the bedside nurse in Cerner to evaluate high risk patients for severe sepsis, in efforts to help ensure early recognition.

First Employee Patient Safety Breakfast is held. Patient Safety Breakfasts are geared for staff members who have experienced SBUMC’s healthcare system as patients or family members. They are designed to give staff members a voice and recognize that the richest information we can ask for comes from our own employees. On February 8, as staff members shared stories about their experiences, some themes evolved, such as a need to streamline the admission process, ensuring all issues are resolved prior to discharge, making the experience of bereavement more humanistic, and improving processes surrounding pain management. These are being viewed as opportunities to make our processes support an excellent clinical and interpersonal experience for all our patients. Future sessions will be held.

Core Measure Improvements meet with success. SBUMC has achieved 100% compliance for both acute myocardial infarction core measure aspirin indicators (aspirin within 24 hours of arrival and aspirin at discharge) in the 3rd quarter of 2009, the most recent quarter for which results are available. Surgical Care Improvement Program (SCIP) antibiotic indicators have also shown improvement, with greater than 95% of patients (97.5% in the most recent quarter) receiving antibiotics within one hour prior to surgical incision time, and discontinuation of prophylactic antibiotics within 24 hours of surgery end (48 hours for cardiac surgeries), greater than 90% for the past three quarters. The higher rates for these SCIP measures follow efforts by Nursing, Anesthesiology, Surgery, and Quality Management Departments to follow up on detailed drill-downs targeted to their area of influence. The Surgical Safety Checklist and the dedication by Anesthesiology to update documentation practices played a significant role in these improvements. Finally, assessment for pneumococcal vaccination improved from 53.8% in the 2nd quarter of 2009 to 84.6% in the 3rd quarter. This follows the implementation of pneumococcal vaccination screening in Cerner, which automatically fires a power order, which appears on the eMAR (electronic medication administration record.

Decision Support Services to present at prestigious MIT symposium. Elisa Horbatuk will present on “Electronic Patient Records (EPR) and Public Reporting: Benefits and Challenges to Data Quality” at the MIT Information Quality Industry Symposium, an international, multi-industry conference scheduled for July 2010. This presentation will describe ways EPR facilitates data capture as well as steps taken to meet reporting specifications.

PATIENT SATISFACTION 

Patient satisfaction reports for the 4th quarter and for all of 2009 are in. Scores show that the overall score increased slightly in the 4th quarter and for the calendar year 2009. Scores also indicate that the Ambulatory Surgery Center continues to shine for patients, and it once again ranks highest in the UHC database. Fourth quarter scores improved slightly in five of the six areas where Press Ganey surveys were conducted: inpatient units, NICU, ED, Ancillary Outpatient, and Ambulatory Surgery Center.

• In 2009, inpatient units that scored above the Hospital average of 83.8 were 04L2 (Burn), 05&6ENEP (Mother/Baby), 05CH (Cath Holding), 17N, and 19S2. 
• In 2009 outpatient units that scored above the Hospital average are Phlebotomy at Tech Park, CT scanning and other radiological services at the Imaging Center, and EEG. 
• In 2009, patient satisfaction improved on the Mother/Baby unit where the overall score increased from 84.2 in 2008 to 86.7 in 2009. Ratings of items in the room section of the survey improved most in the Mother/Baby Unit and was most likely a result of the opening of the new Unit in late 2008. 
• In 2009, patients who say they received a call from the Hospital following discharge rated the Hospital 3.5 points higher than those who say they did not get a post-discharge call. The Hospital is launching an effort to contact every discharged patient within 48 hours of discharge. In late December, the NICU began making discharge phone calls, and results to date are very encouraging.

COMMUNITY CONNECTIONS 

A vigil for the people of Haiti. Students from the Student National Medical Association in conjunction with Stony Brook University Medical Center and the Health Sciences Center organized a Memorial Vigil for Haiti, which was held on February 12 in the HSC Galleria. The vigil included comments by Hospital CEO Steven Strongwater, a poetry reading, a slideshow, the sharing of personal experience, candle lighting, and prayer.

Stony Brook University School of Dental Medicine participates in “Give Kids a Smile Day.” The event is the centerpiece of the American Dental Association’s National Children’s Dental Health Month. The School of Dental Medicine performed free dental screenings, exams, and cleanings for hundreds of children at the School’s Dental Care Center on February 5, in addition to providing dental health education.

March is National Nutrition Month. Nutrition Month focuses attention on the importance of making informed food choices and developing sound eating and physical activity habits. SBUMC is offering the following activities: Monday, March 1, 7:00 pm to 9:00 pm, Long Island State Veterans Home, the showing of documentary Food, Inc., followed by a question and answer period and facilitated by Suzette C. Smookler, RD; Wednesday March 17, 11:00 am to 3:00 pm, Hospital Lobby, a Nutrition Exhibit and Food Drive (donations of nonperishable food items will be greatly appreciated), presented by SBUMC Clinical Nutritionists; Wednesday, March 24, 7:00 pm to 9:00 pm, Long Island State Veterans Home, a lecture titled, “FOOD ALLERGY: No peanuts for you!” covering general aspects of food allergy, including peanut allergy, presented by Anthony M. Szema, MD, Adult Allergist, and Kalpana Patel, MD, Pediatric Allergist.

Multiple Sclerosis Awareness Day Information Fair is planned. On March 10, from 7:00 am to 7:00 pm, in the Hospital lobby, the Department of Neurology, the MS Comprehensive Care Center, and the National Pediatric MS Center is hosting an information fair that will include an update on the progress being made in MS research, posters, exhibits, videos, educational materials, and an opportunity to speak with SBUMC’s MS experts. 

SBUMC Blood Bank honors “frequent donor.” The Blood Bank presented George Wybenga, 73, of Center Moriches with a watch in honor of his 200th blood platelet donation, a rare feat. Mr. Wybenga, a retired professor and a talented artist renowned for his watercolor paintings of railroad cabooses, said, “I love going to the Stony Brook Blood Bank because the nurses there are fantastic; they really make you feel at home and a part of the family.” Dr. Dennis K. Galanakis, the Director of the Stony Brook University Medical Center Blood Bank, applauds Wybenga’s devotion to blood platelet donation. To learn how to become a donor at SBUMC’s Blood Bank, call (631) 444-DONATE (444-3662).

Mind/Brain Lecture Series hosts “Waking from the Dark.” The talk, by Dr. Nicholas Schiff, Director of Laboratory of Cognitive Neuromodulation at Weill Cornell Medical College, will focus on understanding the recovery of consciousness after brain injury. The free presentation takes place on Monday, March 15, at 4:30 pm at the Staller Center for the Arts and is intended for a general audience. The Mind/Brain Lecture Series is sponsored by the Swartz Foundation in cooperation with the Department of Neurobiology and Behavior and Stony Brook University.

My Last Touch

Do you ever feel caught up in waves of inertia related to things that frame your life, like fashion, behavioral mores, work style, and who knows what else? Who sets these rules? The rules are sometimes hard to interpret. Do we have input into them? They even differ within our own country. Simply traveling from one part of the country to another, we can notice different mannerisms in people. Even local expressions differ. In the Midwest “pop” is soda, whereas it is “fizzy” elsewhere.  “Forgetaboutit” is a New York-ism. A Brooklyn accent is not the same as a Long Island accent. Driving habits differ too. It is fun to learn and compare these differences, which help us to understand how people behave and sometimes how they think. Even though each of us contributes only a small part to the larger whole, the question is, can we make a big difference?

When you ask why most people choose a career in healthcare, my experience is the majority will tell you it is to make a difference. Indeed, it is hard to imagine any field where you can make more of a difference. Individuals change the lives of patients, families, and generations to come. Sometimes it is frustrating to work in a large place with many rules, policies, and procedures. Do you wonder if it is possible to make changes on a larger scale, perhaps influencing the way the whole hospital works? Most can find things that need to and could be improved based upon keen observations. But, trying to change the “system” is energy dependent, sometimes daunting, and perhaps just too complicated to take on. But there is a way.

Think of the Queen Mary—the whole ship goes by and then comes the rudder. And there’s a tiny thing on the edge of the rudder, which is call the trim-tab. It’s a miniature rudder. Just moving that little trim-tab builds a low pressure that pulls the rudder around. It takes almost no effort at all. So I said that the little individual can be a trim-tab. Society thinks it’s going right by you, that it’s left you altogether. But if you’re doing dynamic things mentally, the fact is that you can just put your foot out like that and the whole big ship of state is going to go.(R. Buckminster Fuller, in a 1972 interview with Barry Farrell)

There are trim-tabs in our lives. The key leverage points have been described by the Center for Applied Research (CFAR) as “small wins.” CFAR describes two kinds of small wins. One is a quick hit, an easy victory. By way of example, over a long period of time two divisions within a department have developed engrained behaviors leading to ongoing mistrust. The department head knows that work and morale would improve if the relationships between these divisions improved. To nip away at the “bunker mentality” she finds a non-controversial task to engage both divisions. They have to acquire new software, which everyone in the department will ultimately adopt. The two groups come together and do a great job selecting the software.  Progress. A small win. When the next project comes along, the hope is that things will be easier.

Another kind of small win has been described by American organizational theorist, Karl Weick, as the continuous application of small advantage. “For example, a baseball team can win the pennant not necessarily because its players hit home runs, but because the team consistently gets one more hit per inning than its competitors. The extra hit represents the continuous application of a small advantage. The small advantage steadily applied where it can have the greatest impact improves the odds.”

Channeling energies into performance improvement is the translation of the trim-tab concept into our workplace lives. The hope is the continuous application of small advantages over a long period of time will lead to near perfect outcomes in an error-free environment. To do this, and to engage as many people as possible, small groups of people come together to tackle problems. Typically, these are problems that have been identified by the staff. Special techniques have been developed over many years to ensure that the process is focused and does not waste time. Nearly always there are quick wins. This is why we have embraced quality improvement so broadly as a systematic process to ensure the continuous application of small advantage leading to big differences at Stony Brook University Medical Center. Thank you for participating. Perhaps you are our next trim tab.

Changing a culture requires pull rather than push. 
—Anonymous

The desire to do something because you find it deeply satisfying and personally challenging inspires the highest levels of creativity, whether it’s in the arts, sciences or business.
—Teresa Amabile

As quoted in the chapter on “Mastery” in Dan Pink's book, Drive
You need not see what someone is doing
to know if it his vocation,
you have only to watch his eyes:
 a cook mixing a sauce, a surgeon making a primary incision, a clerk completing a bill of lading,
wear the same rapt expression,
forgetting themselves in a function.
How beautiful it is, that eye-on-the-object look.            
—W.H. Auden 

Enjoy your journey.

Steven L. Strongwater, MD
Chief Executive Officer
Stony Brook University Hospital 

Patients First—World-Class Processes—Teamwork—Growth—Use Resources Wisely