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Quality of Care / Innovations in Healthcare

For over a decade, Division faculty have examined various topics relating to improving and measuring health care quality. Dr. Mark Aronson , Department of Medicine Vice Chair for Quality and Associate Chief of the Division of General Medicine and Primary Care, is leading quality improvement and patient safety studies in areas such as, examining the frequency and causality of ED visits following a GI procedure; evaluating the effect of an institution-wide policy of colonoscopy withdrawal time on polyp detection rates; and developing evidence based clinical guidelines for the peri-operative management of patients receiving anticoagulation therapy. 

Another recent initiative, led by Dr. Kenneth Sands , Senior Vice President, Chairman of the Department of Health Care Quality, and Dr. Mark Aronson, is the development of a web-based test results management system. Drs. Sands and Aronson led the development of an electronic system that provides workflow management and tracking of all outpatient radiology, pathology, cytology, and cardiology results ordered by our primary care practice. This system, designed for closing the loop on priority test results, was successfully implemented and was well accepted by the majority of our primary care physicians. Drs. Sands and Aronson now plan to build upon the already functioning result tracking system and create a mechanism for high-risk referrals management, which will close the loop on referrals as well.

Dr.   Russell Phillips leads the SUPPORT Project, funded by the Robert Wood Johnson Foundation.  This national multicenter study examined quality of care for patients hospitalized with serious illness, and evaluated an intervention intended to improve care.  He was one of the leaders at BIDMC of the Ambulatory Care Improvement project, a study funded by the Risk Management Foundation to evaluate and improve care at primary care practices affiliated with Harvard Medical School.  More recently, he assisted Dr. Gila Kriegel in her project, also funded by the Risk Management Foundation, designed to develop a computerized system to track follow-up of abnormal cancer screening tests.  He served as mentor to Dr. Saul Weingart  on this career development award in which he focused on using the patient perspective to identify quality problems.  His publications include studies that evaluate computerized alerts to assist in the care of hospitalized patients with acute renal failure, physician-patient communication at the end of life, and obesity as a barrier to the use of cancer screening tests.

Drs. Gila Kriegel and Hans Kim lead quality of care efforts within Healthcare Associates. With a grant from CRICO/RMF Dr Kriegel has implemented an electronic system that ensures that follow up of cancer screening tests is completed in a timely way on all patients.  Dr Kriegel is participating in revision of the CRICO RMF Breast cancer screening guidelines. She has also been involved with new department of medicine efforts to teach quality improvement principals and techniques to medical residents.
 
The HCA QI committee works to continously improve the quality of care provided in Healthcare Associates. The QI "Dashboard" created by the HCA QI committee is a powerful tool which provides regular updates and monitoring of  multiple areas including: access, record completeness, care of HIV patients, and care of pts on Anticoagulation. The committee investigates medical cases brought to the directors where questions about the quality of care have been raised. These cases are examined with the goal of improving the systems to prevent future errors Often, this has resulted in the formation of subcommittees. Subcommittees of the QI committee are working on issues such as, Narcotics Prescribing in HCA, Urgent care and access, Improving care of patients with Diabetes, and Regular review of all Medical and Psychiatric Code. Working with our pharmacist, Laura Bogdanski, RP, the committee investigates all medication errors. This year the committee is beginning new educational initiatives with BIDMC housestaff teaching QI techniques and applying them to several areas including Influenza immunization, Narcotics and Diabetes care. The QI committee also oversees guidelines development and has been working with nursing on phone triage protocols. Our nurses are doing regular chart review of colon cancer screening and we plan to review this and implement changes to improve our performance.

Dr. Richard Parker , in his role as Medical Director for the Beth Israel Deaconess Physician Organization, is in charge of the quality aspects of the Pay for Performance contracts with the major insurers.

Dr. Jennifer Potter has created / continues to develop on-line curricula dedicated to improving the sensitivity and skill with which clinicians communicate with patients.  One of these addresses how to communicate effectively with women who have disabilities; a second addresses how to talk with patients about sexual matters; currently she is designing a curriculum to teach health professions trainees how to develop productive partnerships with patients and their family members in order to facilitate truly participatory care.  A key feature of each of these projects is inclusion of patients as teachers, as well as incorporation of the perspectives of diverse clinicians, including nurses, social workers, physician assistants, and physicians. In addition to curriculum development, Dr. Potter recently published a seminal book, entitled The Fenway Guide to Lesbian, Gay, Bisexual and Transgender Health, and is leading a Division-wide initiative to improve the quality of cervical cancer screening in the practice.

Innovations in Education:

Continuous Quality Improvement Educational Programs

These programs seek to assure that all faculty members and trainees understand the rationale behind continuous quality improvement and have the skills to improve systematically the care they give.  Goals include: the development of continuous self-directed learning with respect to quality of care; satisfaction of the Accreditation Council on Graduate Medical Education (ACGME) core competencies in systems based practice, practice-based learning and improvement; demonstration of the importance of provider reporting of medical errors and near misses; and increased participation in Quality Improvement and Patient Safety (QI/PS) initiatives in the Department of Medicine.  The training efforts in QI/PS for residents form an important component of an Educational Innovation Project, which was awarded to the department by the Residency Review Committee (RRC) of the American Committee on Graduate Medical Education (ACGME).  Examples of QI/PS Education Programs include: 

  • "Medical Procedure Service" - Medical residents perform all procedures such as placement of central lines, paracentesis, lumbar puncture, and thoracentesis while they rotate on this inpatient service.  Certified faculty members and fellows from either the hospital medicine or critical care attending staff directly supervise all house-staff procedures. The rotation includes didactic sessions and simulator training. 
  • "Stoneman QI/PS Rotation" - In this required 3 week rotation, sponsored jointly by the department and the hospital, residents work through a Root Cause Analysis (RCA) of an adverse event or a near miss and develop a quality improvement plan under the mentorship of a faculty member. They also attend hospital-wide QI committee meetings and make a formal presentation of their RCA at the monthly meeting of the Medical Peer Review Committee.  Residents complete a portfolio of their QI/PS work at the end of their rotation and collectively help manage QI work on the hospital floors.  Core faculty members in patient safety, funded from the education budget, teach and mentor the residents in these activities.  
  • "Geographic Microsystems Initiative" - Ward residents are now organized into unit-based, geographically-integrated teams.  Clinical process and outcome measures are collected for each unit, and results are periodically reported back to the unit-based resident teams.  Such direct feedback on local clinical performance serves as the basis for engaging residents in analysis of their own systems-based practice and participation in unit-based quality improvement initiatives.