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Summer 2012 

In This Issue

Transitions and Continued Progress in 2012
Physician Satisfaction Results Now In
Epic's Problem List: A Win-Win for Everyone?
MRI Suite Upgrade Expands Capabilities
Patient Inhalers No Longer Going to Waste
Hospital Ethicist Hired Full Time
Massive Transfusion Protocol Set
Emergency Codes to be Decoded
Physician Spotlight: Gregory Love
Party of the Century!
Get Your FREE Centennial Book by June 29
New Faces on the Medical Staff
Honors and Recognitions

CME Grand Rounds

7-8 a.m., St. Mary's, Bay 1
August 2 “Acute Coronary Syndrome”
September 6 “Advancements/Updates in Oncology”

Physician Breakfast: June 28, 7-9 a.m. St. Mary’s PRC

Transitions and Continued Progress in 2012
In light of the new vacancy for the position of vice president for medical affairs, the seven medical directors share thoughts about the medical staff redesign and where to go from here.

We are one year into our medical staff redesign. Over the past year, we seven medical directors, in tandem with Vice President for Medical Affairs John Butler, have been working collaboratively to give a voice to all physicians within the hospital. Communication and physician input in the operation of the hospital have repeatedly been identified as needs on all Physician Satisfaction Surveys and we have taken that seriously, offering reliable communication through e-newsletters, the medical staff website and monthly breakfast discussions and other events.

In May, John Butler stepped down from his role as the Vice President for Medical Affairs. We are sad to see him leave, and we will continue the charge he led for integrating the voice of the entire medical staff into the workings of St. Mary’s Hospital. During this time of transition, Dr. Jeff Welch has stepped up to chair our medical director group to keep our momentum. In the past year alone, we were able to:

  • Redesign the peer review system with the creation of a multidisciplinary committee
  • Institute our medical staff quality committee
  • Create the new technology committee
  • Improve our core measures significantly
As we move forward, we invite each of you to participate in the process of continually improving our system and the care that we provide. Feel free to contact us through email, calling us directly or through the St. Mary’s Medical Staff office. We are here to represent all of you.

St. Mary’s Hospital Medical Directors:
Kay Barrett, Lee Carter, Timothy Crummy, James Goodsett, Anne-Marie Lozeau, Kyle Martin, Jeff Welch

2012 Goals
  1. Achieve 100% on all 5 core measures
  2. Continue to refine peer review system
  3. Engage medical staff in improving the quality and safety outcomes of our patients
  4. Improve the patient experience
  5. Improve physician satisfaction and engagement
  6. Increase physician input and participation in hospital decision-making

    Physician Satisfaction Results Now In
     A high rate of response among physicians surveyed—53%—outlines strengths and opportunities for improvement.

    The physician satisfaction survey, completed in March 2012, yielded 234 responses which was 53% of surveys sent – a great response rate and the highest ever! We thank all of you who participated in this survey, which marks the first time it was conducted by Press Ganey.

    Overall physician satisfaction with St Mary’s is in the 91st percentile. The strongest areas of satisfaction are in the care that is provided to patients at St Mary’s including nursing care, communications with you related to patient care, and overall quality of the facility.

    Results of this survey identified our greatest areas for improvement to be the visibility, communication and responsiveness of the hospital administration, emergency department services and radiology turn-around times. We have seen improvements in your perception of physician involvement in hospital decision-making and discharge planning—both of which had been identified as opportunities for improvement in surveys over the past several years.

    Below is a link to the full survey for your review. We will be incorporating the results into our planning for the year ahead as will most hospital departments and administration. Remember that it is only with your input that we can improve. We welcome your comments and feedback.

    The 2012 physician satisfaction survey results are now available on the medical staff website, Medical Connections.

    For users who are not on the Dean or St. Mary's network, or if you are prompted to log in you may access the site at any time using a generic account. Click here, and when prompted for a log in enter user name SMHdoc, and the password is Medcon1.

    Epic’s Problem List: A Win-Win for Everyone?

    Having an accurate and efficient way to review a patient’s medical history is a key to high-quality patient care. Within the EHR, the Problem List is Epic’s best way to present such a summary. A complete and accurate Hospital Problem List facilitates safe patient care, drives clinical decision support and improves reportable quality care metrics while improving physician efficiency in chart review and documentation. An accurate Problem List is a win-win situation for everyone.

    The upgrade to Epic version 2010 (specifically 2010 IU6) took place earlier this month. The new version has several changes that will support the use of the Hospital Problem List. After the upgrade to facilitate use of the Problem List, Epic offers a host of new features:

    • The Problem List becomes one of the numbered Med Rec navigator steps.
    • Whenever viewing the Problem List, editing activity is allowed.
    • When editing the Problem List, one click will:
      • convert any outpatient problem to the Hospital list
      • allow updating the problem to a more specific diagnosis
      • allow for resolving and removing the problem
      • open the Overview box to add diagnosis details
      • allow adding a new problem to the list
    The value of the Problem List is totally dependent on all providers contributing to its use. By adding and updating the Problem List as part of each patient encounter, it can become a win-win activity for our patients and us.

    Dr. Jim Porter and Dr. Robert Gilbert

    MRI Suite Upgrade Expands Capabilities
    The MRI suite at St. Mary’s Hospital is getting a new 3T magnet and complete facelift. The Turville Bay MRI announces its new Siemens 3T Skyra magnet will be an addition to the existing 1.5T scanner in the MRI suite. Construction of a new control room, dressing room for outpatients, and waiting area is under way.

    The Skyra, part of a new generation of MRI magnets, will give physicians an additional option when ordering images. New coil technology supplies higher resolution capability than current 3T magnets. And, Siemens’ new "True Form" Design delivers 50 x 50 x 45 cm FOV (Field of View) images that are clear to the edges with no signal drop off. The 70 cm Open Bore and 173 cm Ultra Short Bore provide an easier imaging experience for larger patients and those dependent on medical equipment.

    The 3T magnet will be fully operational as of July 16. Construction will be completed within the suite by September 26. For more information regarding this new technology, please contact Mike Graffin, MRI Manager, at 258-7820.

    Patient Inhalers No Longer Going to Waste
    Wish your patients could take home their hospital inhalers? The Pharmacy Department’s CQI project will help make that a reality. Read more.

    Hospital Ethicist Hired Full Time
    Father Patrick Norris, O.P., will join our Pastoral Care team as our new priest chaplain/medical ethicist starting in mid-August. Fr. Pat is very familiar with St. Mary’s, serving as a member of our Ethics Committee and as a regular advisor to the hospital on ethics issues.

    In his chaplaincy role, he will be ministering directly to the spiritual needs of our patients, families and staff. As a medical ethicist, he will be working with patients, families, staff, physicians and other SSM Health Care of Wisconsin hospitals to handle medical ethics dilemmas. Additionally, he will be available to help physicians and nurses explain to patients' families the reasons for certain decisions or policies.

    Previously pastor of Blessed Sacrament Parish in Madison, Fr. Pat also has been serving as the Bishop’s Coordinator for Health Care in the Diocese of Madison. He has served as the associate director of the Center for Health Care Ethics at Saint Louis University and an assistant professor on the faculty of the Department of Internal Medicine at the Saint Louis University Health Sciences Center.

    We have been fortunate to have exceptional ethics support available through SSM Health Care Senior Vice President Michael Panicola, and for the first time we now will also have a hospital ethicist available here at St. Mary’s full-time. As the Federal Government, accrediting agencies and other outside organizations pay closer attention to hospitals' handling of ethical issues, the need has increased for trained medical ethicists.

    Massive Transfusion Protocol Set

    Initiated by our Trauma Committee leadership, the need for a massive transfusion protocol was identified. A massive transfusion is defined as a patient requiring 4 to 5 units of pRBCs in 1 hour or 8 to 10 pRBC units in a 24-hour period. Obviously this is a rare event, but it is imperative that our patients have these transfusions in a timely fashion, and that the accompanying coagulopathy and thrombocytopenia be corrected appropriately. A massive transfusion protocol has been created to address this. This has been examined by Pathology as well as all of the specialties that care for patients that could require such a transfusion. Additionally, there has been an order set created called massive transfusion protocol [4215].

    The lab is finalizing the training required for this, and it will be available and active starting June 25. An additional medical staff email from us will serve as a final reminder, also including instructions on how to add this order set to your favorites to facilitate finding it in the rare circumstance you need it. Read the protocol.


    Emergency Codes to be Decoded
    Effective Sept. 1, the emergency codes will change to “clear text” – meaning the use of words to clearly indicate the emergency. The move aligns with practice at St. Clare Hospital, St. Mary’s Janesville Hospital and the vast majority of other hospitals in Wisconsin. To aid in the transition to “clear text,” the new code and the old code will be paged together through Dec. 31. Click here to see the new codes.


    Physician Spotlight: Gregory Love
    Dr. Greg Love is a new member of Dean Clinic's Pain Medicine Department. He attended the University of Missouri at Columbia School of Medicine, graduating in 1980. He also completed his residency there in 1983. Dr. Love’s primary location is the Dean & St. Mary’s Outpatient Center with affiliations at St. Mary’s Hospital in Madison, St. Mary’s Janesville Hospital and Mercy Hospital in Janesville. He is board certified in anesthesiology and pain medicine. Below, Dr. Love offers a look at his personal life.

    I love the water. I began swimming when I was 18 months old. I began swimming in competition at age 5. I began waterskiing at age 5. I began sailing at age 14. As an adult, I learned how to wind surf while living in Milwaukee. I lived five blocks from Lake Michigan at that time, and once I was proficient at windsurfing, I could put my gear on a small two-wheeled cart and walk down to the Lake and launch from the beach. I have wind surfed in the Waters of the Atlantic, the Pacific, the Gulf of Mexico, and the Caribbean in addition to Lake Michigan.

    I have enjoyed the outdoors all my life. I learned orienteering and camping as a boy. I have hiked many of the outdoor areas in Northern Wisconsin since I moved here. I have also enjoyed desert hiking in the Southwest, particularly the mountains surrounding and to the north of Tucson, Arizona. My wife enjoys these things as much as I do, so we spend a good part of our leisure time hiking together.

    As I have hiked in Northern Wisconsin, I have seen many many wildflowers that I could not identify. Over the last few years, I have packed a wildflower book when I go hiking. The flowers that I cannot identify with the help of a book, I photograph with my phone so that I can continue to try to identify them after I get home.

    Make no mistake, the indoors has its appeal as well. Going to college in Chicago I was exposed to all of the cultural life of the city with opera, symphony, chamber orchestra as well as jazz and blues. Since moving to this area I have really enjoyed the rich cultural life of Madison with music, theater, Concerts on the Square in the summertime, as well as the many fine restaurants in the area.

    Like many in Wisconsin, I grew up with hunting and fishing. My father was a veterinarian and looked at hunting as a harvest. He believed in responsible hunting and taught that to me and to my brothers. I also have many fond memories of fishing as a boy. Now, I am too busy to fish as much as I would like, but I like to wave a rod and reel when I get the chance. I have had some success as a hunter, and now I am focused more on bow hunting during fall deer season.

    Medical Library Unveils New Physical and Virtual Digs
    Along with the move just off the hospital’s main lobby, St. Mary’s Medical Library has a new homepage that makes finding what you need online a breeze. Read more.

    Party of the Century!
    Dr. Joe Dean made a $100 gift to support construction of St. Mary’s in 1911 (nearly $2,500 in today’s money) but he never got to party like this! Read more.

    Get Your FREE Centennial Book by June 29
    Every member of St. Mary’s medical staff is eligible to receive a FREE book that commemorates the spirit of care provided at our hospital. This beautifully illustrated book is called “Life Happens Here: A Scrapbook Celebrating 100 Years of Spirited Care” and gets to the heart of St. Mary’s and Dean Clinic through a series of stories from the decades, accompanied by timelines that illustrate the hospital’s growth in facilities, services, educational opportunities, community outreach and innovative ideas. To get your free book, simply stop in the Medical Staff Services Office in the Physician Resource Center by June 29. Hard-bound and soft-bound copies will continue to be available for sale in the hospital Gift Shop.

    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. 

    High-Value Health Care: St. Mary’s Hospital is one of just nine hospitals in the country to be recognized for its efforts in reducing mortality, readmissions and costs, while improving the overall patient experience. St. Mary’s is finalist for the QUEST Award for High-value Healthcare from Premier, a hospital-owned performance improvement alliance of 2,600 hospitals and 84,000 other care sites. During the first three quarters of 2011, St. Mary’s reached top performance thresholds based on the following measures:
    • Mortality: Eliminated 89 avoidable hospital deaths with a mortality rate of 1.18%.
    • Cost of care: Safely lowered costs by an average of $250 per patient.
    • Patient experience: Increased patient satisfaction scores by 0.4 percent.
    • Readmissions: Reduced readmissions by 2.06 percent.

    Chest Pain Center: St. Mary’s received Chest Pain Center Accreditation from the Society of Chest Pain Centers (SCPC), indicating a high level of expertise in dealing with patients who arrive with symptoms of a heart attack. The three-year accreditation means that processes are in place for:

    • Reducing the time from onset of symptoms to diagnosis and treatment.
    • Treating patients more quickly during the critical window of time when the integrity of the heart muscle can be preserved.
    • Monitoring patients when it is not certain that they are having a heart attack to ensure that they are not sent home too quickly or needlessly admitted to the hospital.

    Orthopedics Program: St. Mary’s, along with physician partners at Dean Clinic, has earned The Joint Commission’s Gold Seal of Approval™ for Hip and Knee Joint Replacement. This designation means St. Mary’s and Dean have gone beyond expected requirements and have fully implemented a continuum of care based on established best practices to ensure the very best in patient care. Measures include infection prevention and control, leadership, and medication management. More than 400 hip replacements and more than 600 knee replacement surgeries are performed by Dean physicians at St. Mary’s annually, making it the largest such program in Dane County.

    Guardian Angels: Thirteen physicians were among those honored as Guardian Angels between January 1 and March 31, 2012. 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.

    James Andersen

    C.K. Chang

    Susan Charboneau

    James Couser (pulmonology)

    Jean Demopoulos

    Mary Dominski

    Scott Gibson

    Jonathan Gombola (anesthesiology)

    Neil Kennedy

    Ken Levin

    Sally McKinnon

    John Phelan

    Ronald Wenger





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