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Hospitalized patients experience a wide range of preventable harms despite
significant efforts to provide safe and effective healthcare. This project
seeks to identify and predict stressed clinical environments – or “risky
states” that predispose to preventable harms for patients – initially in
the intensive care unit, and then in the emergency department. This
approach goes beyond the clinical specifics of any individual patient and
any category of harm. It represents a departure from the historical “silo”
approach of hospitals addressing specific harm categories such as falls or
infections. This project is funded as a Career Development Award
by the Doris Duke Charitable Foundation.
Inpatient consultation is the primary mechanism by which specialists
provide care to hospitalized patients. For example, more than 90% of
Medicare patients have at least one consultation. Previous research has
demonstrated that the scope of variation in inpatient consultation use
across U.S. hospitals is substantial. This project seeks to advance
knowledge of inpatient consultation in three ways: by defining the
characteristics of beneficial consultations from multiple perspectives,
including those of patients and families; by investigating novel
non-clinical factors that drive consultation for reasons other than patient
or family need; and by quantifying the relationship between inpatient
consultations and patient outcomes and costs. This project is funded by the Agency for Healthcare Research and Quality. This work was
preceded by research focused on consult quality in the critical care
setting funded by the Gordon and Betty Moore Foundation.
Inter-hospital transfers (IHTs) are risky transitions of care and may be
associated with worse outcomes for patients. This project identified best
practices for IHTs nationally, assessed current practice within the Beth
Israel Deaconess network member hospitals (Boston, Milton, Needham, and
Plymouth), and then defined and implemented best practices for IHTs coming
to the Cardiology service at Beth Israel Deaconess Medical Center, Boston.
This work helped standardize the transition of care for IHTs during
off-work hours, and has provided valuable information for BIDMC’s Transfer
Center. This project is funded by the Risk Management Foundation.
Alcohol withdrawal syndrome (AWS) carries a significant risk of morbidity
and mortality. In the hospital setting, up to 40% of patients have
alcohol-use disorders that put them at risk for developing AWS.
Benzodiazepine administration remains the mainstay of current AWS care.
This project seeks to establish the prevalence and trends in inpatient
AWS-related admissions using data from the National Inpatient Sample (NIS),
while also identifying patient- and hospital-level determinants of outcome
and utilization. Building on this information, the project examines the
effectiveness of phenobarbital in treating AWS in the intensive care unit
(ICU) in a quasi-experimental intervention conducted in the Beth Israel
Deaconess Medical Center medical ICUs. This project is funded by the National Institute on Alcohol Abuse and Alcoholism.
Recent improvements in the acute care of critically ill patients have led
to new challenges in the management of patients who survive with
persistent, severe organ failure after critical illness. One such
intervention is the decision to place a gastrostomy tube to allow for
provision of long-term artificial nutrition in patients who are unable to
safely take in sufficient nutrition on their own due to new deficits in
functional status, mental status, and respiratory function. This project
seeks to quantify the incidence of gastrostomy tube placement across age
groups in critically ill patients in the United States from 1993-2012,
describe patient and hospital drivers of practice variation in the
placement of gastrostomy tubes, and describe the determinants of
patient-level outcomes after gastrostomy tube placement. The overall goal
of this project is to provide the necessary foundation for a future shared
decision-making tool for critically ill patients, their surrogate decision
makers, and clinicians to help decide whether the likely outcomes of a
gastrostomy tube are in line with the patient’s wishes and values. This
project is funded by the National Institute on Aging.
Despite the progress that hospitals have made in reducing harm in specific
areas, some preventable harm events still occur. These can result from
faulty decision-making, perceptions or situational awareness gaps,
communication deficiencies and other system failures. This project focuses
on how hospitals identify and respond to harms to patients, particularly
incidents resulting from complex system failures. Work included detailed
discussions with experts on risk – including a leading clinical safety
researcher from England and safety leaders at JetBlue airlines. The team is
currently using those discussions as a basis for implementing a small test
of change in the Beth Israel Deaconess Medical Center setting. This project
is funded by the Patrick and Catherine Weldon Donaghue Medical Research Foundation.
Procedure areas are high-volume, diverse, fast-paced units that are rapidly
growing due to advances in technology and the increased demand for
outpatient and non-surgical treatments. Traditionally these areas are
administered and managed by individual departments, with no central
coordination and limited multidisciplinary oversight in the hospital. This
can make review of unanticipated events, shared learning, and
implementation of improvement or corrective action extremely challenging.
This project is developing tools to standardize safety in interventional
procedure settings, such as cardiac catheterization labs, and GI and
radiology departments. Tools being developed include a root cause analysis
(RCA) focused specifically on interventional procedure settings,
recommending changes to online reporting systems to make the information
collected more accurate and comprehensive, and best practices around
specific interventional procedure-focused areas. The project is funded by The Risk Management Foundation.
To date, the only protected process that exists for the exchange of outcome
data for individual providers across networks with separately licensed
facilities is a Patient Safety Organization (PSO). This project is
developing a process to exchange information under the protection that a
PSO provides to its members. This process can help facilities better
understand the service lines at multiple locations, provide accurate
quality information, and to drive effective improvement work. The team is
using the bariatric surgery service line as the basis for developing a
model for such exchange that could be transferred to other service lines.
This project is funded by The Risk Management Foundation.
The opioid epidemic has reached a new level of crisis that requires a
national approach to developing safe strategies to care for patients with
overdose in the intensive care unit (ICU). There is a national need to
provide coordinated outpatient addiction care resources for patients with
opioid use disorder and their families. This project devised a national
survey of institutions to assess the prevalence and agreement between ICU
opioid-related substance abuse disorder protocols. These findings provide
an opportunity for a new standard of care for this vulnerable population.
Nurses play a key role in the functioning of a hospital and its individual
departments, and their role is particularly critical in intensive care
units (ICUs). In Massachusetts, acute care hospitals are now generally
required to adhere to a 1:1 or 1:2 nurse to patient ratio in ICUs. To
achieve this, hospitals are required under state regulation to develop and
operationalize an acuity tool that measures the stability of ICU patients.
The goal of this project was to determine whether this regulatory
requirement has been associated with an improvement in patient outcome. The
team focused on mortality rates for patients in Massachusetts ICUs before
and after the mandate. The team then compared these findings to mortality
rates in out-of-state hospitals.
Neuromuscular blocking agents (NMB) are used in the intensive care unit
(ICU) for patients with severe acute respiratory distress syndrome (ARDS),
dyssynchrony during mechanical ventilation, open chest, and shivering post
cardiac arrest. Studies have found that the early use of NMB on patients
with severe ARDS decreased mortality, and this project identifies specific
ICU characteristics associated with a higher score of “perfect care” for
these complex patients.
Optimizing ICU Safety through Patient Engagement, System Science and
a Beth Israel Deaconess Medical Center (BIDMC) project funded by the Gordon and Betty Moore Foundation, addressed three fundamental,
interrelated barriers to the elimination of preventable patient harm on a
broader scale: (1) unreliable systems of care, coupled with a lack of
sophistication in healthcare as to how to improve those systems; (2)
failure to adequately engage patients and families in their own care; and
(3) failure to spread successful innovation into non-academic settings,
where the majority of healthcare is actually delivered in the United
States. Through the work described below, BIDMC leveraged health
information technology, system science and patient and family engagement to
improve quality and safety in the critical care environment.
Managing Risky States to Prevent Harm
“Risky states” refers to the environmental drivers in a unit that can put
that unit at risk for patient harm to occur. This project identified
correlations between states and harms to present a risk level for a unit,
and developed a model that calculates the risk levels of by unit.
Intensive care units (ICUs) use checklists of core quality measures during
clinical rounds to ensure evidence-based care is provided to all patients.
Typical checklists incorporate a range of quality measures but remain
agnostic to the patient. This project developed an electronic
decision-support tool, the Patient-Specific Checklist (PSC), to
individualize patient care by providing clinicians a patient-specific view
of pertinent data and daily care needs. This interface has assisted
clinicians in delivering high quality care while also improving workflow.
Being a patient or having a family member in a hospital intensive care unit
(ICU) can be a disorienting and confusing experience. This project
developed a mobile friendly application that promotes bi-directional
communication between the patient and family, and the ICU care team. The
application helps families learn more about the unit their family member is
in, learn about their family member’s daily plan, connect directly to
support services, and maintain a private journal of the ICU stay. In
bridging the gap between the family and the ICU care team, MyICU engages
patients and families in preventing physical and emotional harm in the ICU.
Stemming from the foundational work of MyICU, MyNICU was created to help
improve families’ experiences in the Neonatal Intensive Care Unit (NICU).
MyNICU is a mobile friendly application that further engages parents in
their infant’s care by providing them with information and resources that
extend beyond the NICU stay. Parents receive a CribNews update
each morning with information on the infant’s last 24 hours including
weight, feedings, medications, and times the infant was held. CribNews also includes members of the team who have provided care
to the infant in the last 24 hours. Family members can also request
services, track their infant’s progress in a private journal, and review
additional hospital resources.
During multidisciplinary rounds in the intensive care unit (ICU),
healthcare professionals work collaboratively towards providing
comprehensive patient care. This project designed a toolkit that
standardized, and structured daily rounds based on a unit’s culture.
Working with clinicians and refining the toolkit, the project has increased
nursing participation in team discussions and decreased miscommunication
among team members. This project demonstrates that implementation of a
simple toolkit, incorporated into existing workflow and rounding culture in
different types of ICUs, can improve engagement of nursing staff and
Being a patient in the intensive care unit can be disorienting and
unsettling, with a number of clinical team members entering and exiting the
patient’s room to provide care. The aim of this project was to improve
patient and family satisfaction, and create an environment that drives
correct workflow. The team recognized that hand hygiene is a single step in
a substantially more complicated process of room entry. They applied Lean
engineering techniques to develop a standard process that included both
physical steps and standard communication elements from provider to
patients and families.
Improving the Usability and Quality of Critical Care Policies,
Procedures and Guidelines
Nursing policies and procedures are designed to guide and inform
standardized care based on evidence-based best practice, consistent with
regulatory and accreditation standards. At BIDMC, policies, procedures and
guidelines are maintained in the Critical Care Practice Manual; a resource
for all critical care clinicians in the intensive care units (ICUs). Based
on concerns about the quality and usability of the existing policies and
procedures, the project team created a new electronic format that
incorporated the best evidence-based research available and standardized
the presentation of all policies and procedures. Not only did this work
ensure that clinical practice was aligned with the best evidence but it
incorporated a process for systematic review and updating of policies,
procedures, guidelines and directives over time. In addition, the
electronic format facilitates the sharing of this material with critical
care clinicians with community hospital partners, BID-Milton, BID-Plymouth
Communication, Apology, and Resolution (CARe) is BIDMC's transparent and
honest approach to unanticipated clinical outcomes and adverse events.
Prompt recognition of and response to medical injury, along with
appropriate compensation to the patient or family if the harm was
preventable, has demonstrated the potential to improve patient safety,
reduce medical costs, and enhance fairness and transparency in health care.
It is, simply, the right thing to do. The CARe program was piloted in 2012
through the Center for Healthcare Delivery Science. Grant funding helped
launch the program at BIDMC, BID-Needham, BID-Milton, and several hospitals
in the Baystate Health network, and supported the development of a
statewide alliance to assist in implementation of CARe across Massachusetts
through education, resources, and training called the Massachusetts
Alliance for Communication and Resolution following Medical Injury ( MACRMI). The pilot study demonstrated
that after three years using CARe to resolve adverse events, there was no
increase in the number of claims, and providers were satisfied with the
Respect is a critical element of safety, patient-centered care, and
fostering a trusting patient-provider relationship. Most healthcare
organizations’ efforts to reduce harm focus on physical harm, but other
forms of harm are both prevalent and important. These “non-physical” harms
can be framed using the concepts of respect and dignity. In healthcare,
these concepts can be defined as follows: dignity is the intrinsic,
unconditional value of all persons, and respect is the sum of the actions
that honor or acknowledge a person’s dignity. Disrespect is an affront to
dignity and can cause harm, and organizations and providers should strive
to eliminate disrespect. Due to its importance, our team has dedicated
various projects to improving this aspect of healthcare delivery.
A Roadmap for Advancing the Practice of Respect in Healthcare
In 2016, leaders at Beth Israel Deaconess Medical Center convened a group
of experts from around the world to strategize about expanding the
definition of preventable harm to include non-physical harm, and to develop
a more reliable approach to the “practice of respect.” These discussions,
funded by the Gordon and Betty Moore Foundation, were the starting
points for the development of a consensus statement to serve as a model for
institutions implementing this work. A team at BIDMC then developed a
consensus statement and invited all convening attendees to participate in a
modified Delphi process to finalize its language. This process included
five rounds of surveys, by which participants identified key strategies.
These included hospital leadership championing a culture of respect and
dignity; promoting accountability in this area; engaging and supporting the
healthcare workforce; partnering with patients and families; establishing
systems to learn about and improve the practice of respect; and expanding
the research agenda and measurement tools, and disseminating what is
Development of a Framework for Health Care Organizations to
Describe Patient and Family Harm form Disrespect and Promote
Improvement: A Scoping Review
This project used the current literature to develop a practical,
improvement-oriented framework to recognize, describe, and prevent
non-physical harm events that result from disrespectful interactions with
the healthcare system. The team described a framework designed to expand
organizations’ ability to recognize, describe and understand non-physical
harm events using the concept of disrespect. The components of this
framework include care processes, contributing factors,
professional/organizational behaviors, modifying factors and consequences,
including consequences affecting patients and families, professionals,
organizations and society. This project was funded by the Arnold P. Gold Foundation.
is a pioneering Brookline Community Mental Health Center program that
treats adults with serious chronic medical conditions and a behavioral
health comorbidity. The Program was first piloted in Health Care Associates
at Beth Israel Deaconess Medical Center and later spread to Bowdoin
Community Health Center. The Healthy Lives team received a Massachusetts
Health Policy Commission Investment Award to implement their approach
within the BIDCO care management structure integrating behavioral health,
primary care and community services.