A Newsletter for the Medical Staffs of DeKalb Medical

MAY 2015

Send us your news…Published? Presenting? Need to announce a meeting that will be of interest to fellow physicians? Communique is a great venue to inform others about educational opportunities and achievements that demonstrate the expertise of DeKalb Medical’s medical staff. Send story ideas and information to sherylsjackson@bellsouth.net or call 404.501.5565.

It’s a Win: Complications Tactical Team Exceeds Quality GoalThe term “slam dunk” is not just a way of describing some exciting plays in the current NBA playoff season – it is an excellent way to describe the results of the Complications Tactical Team, one of the nine tactical teams in DeKalb Regional Health System’s performance improvement clinical leadership model.

A system wide goal to reduce the complication rate by eight percent by the end of fiscal year 2015 was set by the Quality Committee, under the direction and guidance of the board and with the support of physician members.

The actual reduction of observed to expected complications is 33 percent – bringing both the North Decatur and Hillandale hospitals close to the metrics that define the top 10 percent of large community hospitals by Truven Health Analytics, the data and reporting software used by DeKalb Medical.

“Public reporting of outcomes is here to stay and healthcare providers will forever be accountable for the data that is reported,” said John Kennedy, M.D. “It is, however, up to all of us to be sure the process of reporting data accurately reflects the quality of care we provide.”

The tactical team, which includes Adam Bressler, M.D., co-chair of the committee, Kennedy, Cyril Spann, M.D., Cathy Bonk, M.D. and Solomon Tafari, M.D., along with representatives of appropriate health system departments, identified a number of process improvements that ensure data reported to Truven is accurate.

The first step was to evaluate the most often reported complications, one of which was hemorrhage. Chart reviews revealed that reports of bleeding were interpreted as hemorrhage or other bleeding complication, when in fact, the bleeding was expected. Misinterpretation of the chart notes resulted in inaccurate codes that led to reports of higher complication rates than actually occurred.

“Coding criteria is not always quantifiable and physician notes require interpretation in some cases to be sure the case is coded appropriately,” Bonk said. “Members of the tactical team provide chart review to ensure information is interpreted correctly.”

The process developed by the tactical team now provides a high level of scrutiny for each valid complication case with review of charts by quality professionals, tactical team physicians and, if needed, peer review.

By creating a chart review process, guidelines for coding staff, improved communications with physicians and a collaborative approach that included physicians, medical records staff and other hospital representatives, the documentation and data reporting process now accurately reflects care provided.

“Improving the documentation and coding process for the top complication categories was an important first step to addressing clinical steps to improve complications,” said Kennedy.

By making sure the complications reported are true complications, the team can focus on issues that present opportunities for continued performance improvement.

“Our hospitals can be in the top 10 percent, but quality improvement requires a collaborative team approach.”

[Editor’s note: To see a larger version of these graphs, please open the digital version of this after it’s emailed to your inbox. Future issues of Communique will include updates on clinical quality improvements for specific complications.]

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SYSTEM

April 2015

CardiologySanjay M. Lall, M.D.

Colon & Rectal SurgeryAnthonia D. Adewole, M.D.

Family PracticeAbhay J. Deshmukh, M.D.

Internal MedicineEva I. Beaulieu, M.D.

Genetics Conference Attracts Statewide AudienceOver 30 physicians, genetics counselors, nurses, researchers and cancer center staff representing hospitals throughout the metro Atlanta area and other cities in Georgia, met to learn more about advancements in genetic testing and to share knowledge through real case presentations at the “Going Beyond BRCA” case conference on April 18.

Moderated by Jayanthi Srinivasiah, M.D., chairperson of the Cancer Committee at DeKalb Medical and chairperson of the Cancer Genetics Clinical Trials Subcommittee, and Claudia Tinkle, program manager for the DeKalb Medical Cancer Center, the case conference featured expert review by Tuya Pal, M.D., FAAP, FACMG, FCCMG, a board-certified geneticist based at the Moffitt Cancer Center. The interactive meeting enabled all attendees to present their own cases and offer advice on each other’s cases. Plans for more frequently scheduled genetics case conferences are in the works, including the possibility of taking a webinar approach to improve access to cancer professionals who cannot travel to Decatur.

Open House Celebrates New Hillandale Office On April 16, physicians, hospital administration and clinical staff gathered at the new DeKalb Medical at Hillandale office building, across the street from the main hospital building, to celebrate the grand opening of the center which houses Radiology Oncology Associates and DeKalb Medical Physicians Group Miller Grove Primary Care, which is the new practice of Eddie L. Whitehead, M.D.

The radiation oncology center located in the building is now part of the DeKalb Medical family of services. DeKalb Medical operates the center, which will continue to be open to private practice radiation oncologists. Patients in the local community who are battling cancer can receive radiation therapy close to home, while remaining in the DeKalb Medical system of care.

Welcome N E W PH YSIC I A NS

Aliya Saeed, M.D., joins DeKalb Medical Physicians Group, Montreal Internal Medicine Aliya Saeed, M.D., is joining DeKalb Medical Physicians Group Montreal Internal Medicine in June. Saeed earned her bachelor of medicine, bachelor of surgery (M.B.B.S.) from Rawalpindi Medical College in Pakistan in May 2003. She completed her internal medicine residency in June 2010 at Lincoln Medical and Mental Health Center/Weill Cornell Medical College and her fellowship in the department of nephrology at New York Hospital Queens in June 2013. Saeed is American Board of Internal Medicine certified in internal medicine and eligible in nephrology. She speaks four languages, including Urdu, Hindi and Punjabi.

(From left) Claudia Tinkle, Al Soltan, M.D., Jayanthi Srinivasiah, M.D., Tuya Pal, M.D., Michael Quinones, M.D., David Holladay, M.D., Bill McNeill, M.D. and George Miranda, director of DeKalb Medical Cancer Center at the “Going Beyond BRCA” case conference on April 18.

Marjorie Alston, director of operations for DeKalb Medical Physicians Group, Jim Forstner, senior vice president and chief strategy officer, and Takki Momin, M.D.

Dominque Smith, M.D., and Laurey Bryant, Imaging liaison, Radiology Associates of DeKalb

NEED-TO-KNOW NUMBERS DeKalb Medical services that can help you help your patients:

Audiology, Driving Solutions 404.501.5155

Cardiac Rehabilitation 404.501.7155

CT Calcium Scoring screening 404.501.2660

Heartburn Solutions Center 404.501.4844

Lung Cancer Screening 404.501.5864

Nutrition and Diabetes Education Center 404.501.1790

Outpatient Rehabilitation 404.501.5140(Lymphedema, Hand, Speech, Aquatic)

Sleep Disorders Center 404.501.5927

Wound Care Center 404.501.7455

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FOUNDATION

SERVICES

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Rockbridge Family Medicine Physician Joins Founders’ Circle

Giving back to her community is a philosophy that Tina-Ann Kerr Thompson, M.D. (pictured), was raised with almost as soon as she could walk.

“My grandmother used to tell me that to whom much is given, much is required,” said Thompson, who has joined the DeKalb Medical Foundation’s Founders’ Circle Physicians in Philanthropy giving club.

Thompson’s love of medicine and philanthropy began more than 20 years ago as a volunteer in a pediatric unit in a hospital in Connecticut.

“Being a doctor is a gift and a privilege, and I am extending that gift to as many patients as possible so they can access good care at DeKalb Medical.”

For more information about Physicians in Philanthropy, please contact Leigh Minter, executive director of the DeKalb Medical Foundation at 404.501.5764 or leigh.minter@dekalbmedical.org.

UFE improves quality of life for fibroid patientsNew referral process streamlines road to treatmentMost American women will develop uterine fibroids at some point in their lives. According to the National Institutes of Health, studies have shown that by age 50, 70 percent of Caucasians and 80 percent of African Americans have fibroids. In many cases, fibroids are believed not to cause symptoms so women may not know they have them.

In other cases, fibroids cause many symptoms ranging from heavy bleeding during one’s period, anemia, abdominal pain or pressure, incontinence, constipation, painful periods, bleeding between periods, a feeling of “fullness” in the lower abdomen, frequent urination, pain during intercourse, and lower back pain.

Interventional radiologists at DeKalb Medical has been successfully treating fibroids with uterine fibroid embolization (UFE), a minimally invasive treatment that block blood flow to the arteries supplying blood to all fibroids, causing them to shrink and die.

Because uterine fibroid symptoms affect the quality of a woman’s life, many women want to address symptoms in the spring so they can eliminate their symptoms during the summer and enjoy family, friends and vacation.

Physicians should note that the process to refer patients for UFE has changed. Physician offices or patients should now call radiology scheduling at 404.501.2660 to schedule a UFE consult. The physician will need to provide clinical notes that support a diagnosis of symptomatic fibroids. The clinical notes can be faxed to 404.501.1743. The patient will be scheduled for a pelvis MRI scan with and without contrast with a consult to follow. DeKalb Medical will obtain the MRI pre-certification using the clinical notes from the referring physician.

AWARDS & RECOGNITION

Nurse Navigator Earns National CertificationDoris Jones, R.N., BS, OCN, earned the national certification from the National Consortium of Breast Centers (NCBC) in March. Jones passed a national certification exam that validated her professional knowledge and skills in navigating breast patients through their cancer/care continuum, beginning with breast

imaging and through survivorship. You can reach the Cancer Center specialized breast care services at 404.501.PINK.

Hillandale ED Nurse Recognized for Nursing ExcellenceRonnie Gilbert, R.N., an emergency department nurse at DeKalb Medical at Hillandale, was recognized as an award recipient in the 10th Annual Nursing Excellence Awards. Sponsored by the Atlanta Journal Constitution and AJCJobs,

the program honors 10 nurses for their commitment and effect on patients’ and families’ lives. An emergency department nurse since 1979, Gilbert explained that everything he does is just part of his job, “I get to see the difference I make in people’s lives and that is why I get up and go to work each day.”

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2701 North Decatur RoadDecatur, GA 30033

Share your time and skill this summerAs summer approaches, thoughts of vacation and lazy weekends are top of mind, but DeKalb Medical employees, volunteers and physicians are needed to show support for two big events:

July 18 - Sisters By Choice 5K at Piedmont Park

September 4, 5 & 6 - Decatur Book Festival in downtown Decatur (DeKalb Medical is a major sponsor of this event and has a large presence.)

If you are available, please contact Community Outreach Manager Beth Jansa at beth.jansa@dekalbmedical.org or 404.501.7481.

Community Physician Talks Cover Range of Topics

The “Puberty Rocks” doctor talks offered separately for boys and girls at the North Decatur and Hillandale campuses were a success with over 85 boys and 75 girls attending. Thanks to Caryn Johnson, M.D. (pictured), for leading the girls’ talks and Stuart Pancer, M.D., and Kenneth Harper, M.D., for leadind the boys’ talks.

Nathan Jove, M.D. presents information on orthopedic conditions at a community talk in February.

(From Left) Scott Steinberg, M.D., Dietician Ashley Stewart, Mark Stern, M.D., and Nurse Navigator Pam Briggs, R.N. serve on community talk panel on heartburn and the latest treatments.

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