Behavioral Health.doc - May 2012

• Banner Behavioral Health passes Joint Commission survey!
• Therapeutic Services Optimization
• Cherri D. Anderson named new chief nursing officer for Banner Behavioral Health Hospital
• Changes in Admission Histories and Physicals and Consultations
• Telepsych expands to Banner Desert and Cardon Children's
• Power Notes Star 2G Conversion Update
• Nutrition Matters: Non HDL-Cholesterol
• New Dictation Function
• Psychotropic Medication Consents

Banner Behavioral Health passes Joint Commission survey!

Banner Behavioral Health Hospital passed its inspection during a recent Joint Commission survey and received full accreditation for the next three years!

In the four days in early April that The Joint Commission was here, the four surveyors -- representing both the Hospital Accreditation Manual and Behavioral Health Accreditation Manual -- discovered only a handful of findings.

"This is something to crow about!" said CEO Cherie Martin. "There are still some things to fix and we will be working on these items. These are new ways to improve our processes, and measuring what we say we are doing."

Banner Behavioral Health Hospital was measured for compliance against 545 standards, which equates to a couple thousand elements of performance. The hospital was only cited for eight findings. Some of these findings are already corrected and hospital staff are in process of correcting the others.

The Joint Commission survey means Banner Behavioral Health Hospital has “technically” earned its deemed status from the Centers for Medicare and Medicaid.

“Thank you to so many of you for your hard work and effort during these recent visits," Martin added." I can’t tell you in enough words what a pleasure it has been to see you in action. This accomplishment could not and would not have occurred without our whole village."

Therapeutic Services Optimization
by Dr. Cliff Zeller

At Banner, we are committed to succeeding in the changing health care market and the new model of population health management. Our Corporate Services Optimization Project will ensure we are working as effectively and efficiently as possible. There has been extensive data-gathering involving hundreds of individuals throughout Banner resulting in recommendations for transformation during this challenging time.

Opportunities identified have fallen into four main themes:

1. Shared services frequently centrally-based for greater efficiency and effectiveness.
2. Service model improvement with tighter service strategy alignment.
3. Process redesign with more effective automation and leaner processes.
4. Alternate sourcing with rationalization of whether work is out-sourced or in-sourced.

In parallel to our Corporate Services Optimization, we have started an initiative that I would label Therapeutic Services Optimization. Our goal is to provide best practices for therapeutic interventions while looking for greater efficiency in allocation of resources. The challenge is to drive quality in a new cost-effective manner of accountability.

We’ve launched this project in one area that we feel can significantly benefit our patients. The use of staff-patient “one to ones” is a costly intervention both economically and in terms of staff availability to provide other therapeutic interventions that would benefit the milieu treatment process as a whole. We began by developing a system to keep track of the “one to ones” ordered in our facility. We gathered data for about two months. We noted the reason, the timing in the 24-hour work cycle, the diagnosis and other interventions attempted. After collecting the data, we were able to break this population down to subgroups. These groups are listed here in the order of frequency with the first three groups forming the majority and surprisingly the fourth group being a smaller percentage.

1. Patients with acute psychosis requiring direct structure.
2. Patients with self injurious behavior as a reaction to frustration and the need to self soothe.
3. Adolescent patients with aggressive behaviors.
4. Patients with suicidal ideation requiring intense monitoring.
5. Developmentally disabled or autistic spectrum patients.

The next step will be to develop a better system to help the physician track these patients using EMR reminders on a daily basis. This will alert the physician to actively decide if the patient continues to require this intervention.

After improving tracking and awareness, the subsequent step is more challenging. This will be to examine more precisely the specific need of each patient category. Our goal for this step is to actively engage in the thought process for designing the right treatment. For example the patients in Category 1 may be better treated with changes in pharmacologic intervention, as the literature teaches us that severity and duration correlates with recurring recidivism. The patients in Category 2 may respond to changes in programming including greater use of cognitive training or DBT, while reinforcement through the use of “one to ones” might have a negative effect. For Categories 3 and 5, new structured activities and staff training will be required. This will free up more resources for Category 4 which includes patients for whom the “one to one” engagement may be the best choice.

We know the time spent with our patients is the most valuable resource we have to offer and through the Therapeutic Optimization Process we can develop the framework to spend this precious resource in a way that will most benefit our patient population. This is one of several initiatives we will embark on during this year. We will work together to drive our own destiny by identifying ways we can optimize outcomes in a more effective manner.

Cherri D. Anderson named new chief nursing officer for Banner Behavioral Health Hospital

Cherri D. Anderson, RN-C, MBA, HCM, has accepted the position of chief nursing officer (CNO) at Banner Behavioral Health Hospital. She officially starts in her new position on June 10.

Anderson, who has served as director of Adult Acute Care Services at Banner Desert Medical Center since 2006, takes over for former CNO Neena Mehta, who left Banner Health earlier this year.

“Cherri was the ideal choice for this position,” said Banner Behavioral Health CEO Monique “Cherie” Martin. “She is deeply committed to quality and safety, is a strong advocate for leadership and staff development, and is supportive of physician collegiality and collaboration to enhance physician-nurse communication and patient outcomes.

“Our patients, nursing staff and hospital will benefit now that Cherri has the responsibility and authority to share these strengths every day for every patient” Martin added.

Anderson, a nurse for 30 years at Banner Desert, received her nursing degree from Mesa (Ariz.) Community College and her MBA from University of Phoenix. She became the assistant director of the 32-bed general surgical unit in 1993 and the unit’s senior clinical manager in 2003.

As the director of Adult Acute Care Services, Anderson managed five adult acute care inpatient units consisting of 166 patient beds, 280 employees She recently served as interim CNO at Banner Desert for six weeks during a CNO transition, managing all clinical and administrative operations for the hospital’s Nursing department.

“I am proud to join Banner Behavioral Health Hospital and to have a role in guiding our excellent nurses through these changing times in health care, especially as there becomes a greater need for behavioral health services,” Anderson said. “I look forward to leading the nursing staff in continuing to make a difference in people’s lives through excellent patient care.”

Changes in Admission Histories and Physicals and Consultations

We have all been looking at ways to avoid unnecessary duplication of services and, working together, we realize that many of our patients have been seen either at another Banner facility or emergency room where they have received a history and physical examination. If this examination has been done within the 30 days prior to admission and is complete, there is no need to repeat the exam unless the patient’s condition warrants.

We have worked hard with our Health Information Management and Clinical Informatics departments to develop a system to efficiently inform the attending physician if this information is available in the electronic medical record (EMR). If, in the physician's judgment, there is no change in the patient’s condition, this can be documented to meet the H & P requirements. Kelli Abrahamson, our Clinical Informatics Coordinator, has been teaching us the proper way to check for this information and document findings accordingly. She is available for further consultation and assistance with how to use EMR in this regard. It is believed this will result in significant cost savings for our facility and conserve resources for services that are most beneficial to the patient.

Of course, if the situation warrants, the physician may order a new history and physical or consultation as necessary. Regarding consultation, it is most appropriate for the attending physician to make the decision regarding consultation rather than the on-call “after hours” physician. Unless it is emergent, after hour consultation requests will be processed by nursing the next day when the attending physician is present at the facility.

Telepsych expands to Banner Desert and Cardon Children's

Emergency physicians from Banner Desert's and Cardon Children's Emergency departments can now request a consult from a psychiatrist or psychiatric nurse practitioner at the Banner Psychiatric Center via a secured video link.

The Telepsych program allows patients in psychiatric crisis to receive a timely psychiatric evaluation and a treatment plan. This speeds treatment and eliminates transfer and secondary facility fees.

Telepsych is part of Banner Health's emerging tele-health strategy and has already been implemented at Banner Thunderbird and Banner Ironwood. The program will expand to other Banner hospitals in the Arizona regions, Page Hospital and the Banner Health Clinic in Payson.

Banner's iCare program, includes an electronic intensive care unit (eICU) that uses specially-trained physicians and nurses to back up the bedside ICU team and monitor ICU patient information 24/7. The remote team responds to requests for help from the bedside care team, monitors for adverse trends and interrupts before adverse trends become adverse outcomes and monitors and supports "Best Practice” compliance. The iCare program currently has the ability to monitor over 430 ICU beds in three states (Arizona, Colorado, Nebraska) and will be adding two more (Nevada, Wyoming) in 2012.

“As with our iCare program that connects expert physicians and nurses to our hospitalized patients in our ICUs and selected telemetry and medical-surgical units, the extension of our ‘remote presence’ that connects these specialists to patients in the ED is yet another innovative way we can serve our Banner patients and their families,” said Julie Reisetter, RN, MS, chief nursing officer, Banner Health iCare.

Power Notes Star 2G Conversion Update

May 2012

In preparation for the 2012 Cerner Upgrade,  Banner Health is in the process  of replacing PN2G and PNED with  PN*2G.

• The conversion for ED and NNP’s will begin on 5/16/12 through 6/24/12.
• The conversion periods for Medicine, PA’s and NP’s (not ED or NNP’s) has completed. If you require assistance please contact your local Clinical Informatics team.

During this time Clinical Informatics staff will be available to guide providers  in converting existing pre-completed notes and macros to PN*2G.

As a reminder, PN2G and PNED will be turned off on October 31, 2012. 
Information regarding this project is available for providers on the Power Note *2G Share Point.

Existing pre-completed notes and macros are stored for you on the Power Notes *2G Share Point.

If you are a provider with a large number of pre-completed notes and macros please be sure to contact the Clinical Informatics staff at your facility as they will provide detailed conversion information.  Please feel free to contact your local Clinical Informatics Team with questions.

Nutrition Matters: Non HDL-Cholesterol
By Bonny Tabah, MS, RD; Food Nutrition & EVS Senior Manager

You may notice a new parameter laboratories are adding to lipid profiles, the NonHDL-C.

The calculation of LDLC=TotalC-HDLC-Triglycerides/5, often underestimates the true LDL-C value as a patient’s triglyceride level increases (this is why LDL cholesterol is not reported when Triglyceride levels are over 400mg/dl). This formula is actually affected by all Triglycerides levels above 100mg/dl resulting in low levels of LDL-C which may be interpreted as lower risk category then is the case.

Patients with metabolic syndrome, diabetic dyslipidemia, and central obesity are typically seen to have elevated triglycerides, low HDL, and relatively normal calculated LDL targets.

Non HDL-Cholesterol provides a single index of all apolipoprotein ß –containing lipoproteins.

Non HDL-Cholesterol maybe considered the more accurate predictor of atherogenic risk then LDL or triglycerides in certain patient populations.

A Non-HDL-Cholesterol calculation is not affected by triglyceride level s and does not require a fasting sample.

NECP ATP III guidelines recommend lowering non-HDL cholesterol as a secondary goal when triglycerides are >200mg/dl.

Reference:  JAMA. 2012; 307:1302-1309

New Dictation Function
Kim Shoults, RHIT, HIMS Senior Manager

This is a new dictation function that allows the providers to record over dictation.

ESCRIPTION INSTRUCTIONS ON HOW TO RECORD OVER DICTATION
When dictating and you realize you have made a mistake or want to change something:

• #3—rewind to the location in the dictation where you wish to make the correction
• #1—to start dictating the correction
• If you are already at the end of your dictation and wish to continue with the dictation just continue dictating normally.

If you have done a rewind back to the middle of a paragraph and made a correction and now wish to return to the end of your dictation to continue:

• #6—to forward to the end of the dictation
• Proceed with your dictation as per the normal functions.

Psychotropic Medication Consents

The State of Arizona requires signed informed consent be obtained for the use of psychotropic medications. The informed consent process must occur between the patient and the provider. Consent must be obtained prior to initiating a new medication but is not required for changes in dosage.

In after-hours situations, the physician can complete the informed consent process via telephone. The nurse can verify with the patient that informed consent was provided so the patient can sign the appropriate form. The provider can then sign the form the next business day.

In emergent situations, a one-time order can be given without consent. If additional orders are needed beyond this, the patient will need to be evaluated by a provider prior to new orders being given.