5th Annual Quality & Safety SymposiumQuality & Safety Efforts Across the Mass General Brigham System

September 16, 2020

Quality & Patient Experience | Confidential—do not copy or distribute

2

Quality & Safety Efforts Across the System

Due to shifting the focus of the Quality & Safety Symposium to COVID related topics we were unable to accommodate the originally planned presentations highlighting the various quality and safety efforts taking place across the Mass General Brigham System. What follows are abstracts highlighting many of those efforts. We encourage you to review and connect with your colleagues to learn more about the amazing work taking place across our system. Abstracts are grouped by the following categories:

Quality & Patient Experience | Confidential—do not copy or distribute

Care Improvement Across the System Care Innovations Employing PI Concepts

Leveraging Analytics for Improvement Spreading Best Practices Utilizing the EHR for Care Improvement

Feel free to share this document internally as appropriate.

Please reach out to Victoria Carballo (vcarballo@partners.org) with any questions.

Care Improvement Across the System

Maureen Hemingway, DNP, RN,CNORMichael Farrell, MS, RN, CNOR

Active Shooter in the Perioperative Environment: A Study Assessing Perioperative Staff Knowledge

Massachusetts General Hospital

AIM: Participants will understand the results of a quality improvement education project focused on an active shooter event within the perioperative environment based on strategies developed by the US Department of Homeland Security.

TEAM:

MGH Perioperative NursingMGH Emergency Preparedness CommitteeMGH Center for Disaster MedicineMGH Police and Security

INTERVENTION:The education session consisted of didactics and the opportunity to record responses to scripted active shooter videos. IRB exempted study using quasi-experimental mixed methods with a pre-test/post-test design. Baseline data was collected before the education session and then again at the conclusion. The surveys were on a 5-point Likert scale and captured demographics regarding role group and work units.The sample was a non-random, convenience sample of all MGH perioperative clinicians and staff who work within perioperative services. There were 175 unique responses and this data was analyzed using McNemar’s test for differences in pre- and post-agreement using paired measurements for the same respondents.

IMPACT: Statistically significant differences in 4 of 5 questions specific to communication strategies, identifying active egresses, locating self-defense objects and finding safe hiding spots.Qualitative results: 51 out of 55 comments rated this experience as positive when analyzed by the planning teamComments: ranged from “thank you…great session” to “very detailed and very specific to the OR environment which was beneficial.”CONSIDERATIONS FOR SPREAD: Presented at the MGH 2019 Nurses’ Week Research Day SymposiumPublication in Perioperative Care and Operating Room Management (August 2019)Accepted For Podium Presentation AORN Conference April 2020

RESULTS: Statistical Analysis Highlighting Positive Learning

.

Insert graph

PROBLEM: Active shooter events have become more common in the United States (US) and healthcare facilities are especially vulnerable. The perioperative environment poses unique challenges in such a situation due to patient care considerations. Our clinicians were requesting education for actions to be taken in an active shooter event.

Chrissy Fitzgerald, MBA- Sr. Project ManagerStuart Hooton Director of Central Radiology Care Coordination

Brigham Health Unscheduled Radiology Orders Project

Brigham Health

AIM: 1. To reduce a radiology order backlog of 52,204 unscheduled orders by April 2019 while preventing any future backlogs. 2. The implementation of a future state workflow model with a high reliability through a single point of governance and

operations across BH, thus mitigating the likelihood of delays in patient care and improving favorable health outcomes.

TEAM:

INTERVENTION:

IMPACT: The cleanup efforts and streamlined scheduling processes ensure that imaging is scheduled within the intended timeframe to reduce the likelihood of delays in care.

CONSIDERATIONS FOR SPREAD: The team’s problem-solving methodologies can be applied across any other MGB site with the solution focused on order cleanup and streamlined scheduling processes in the practices and in a central radiology scheduling team.

RESULTS: The team reduced the number of unscheduled radiology orders from 52,204 orders in Oct 2018 to 229 orders by Dec 2019 (a 99% reduction).

PROBLEM: In October 2018, it was discovered that 52,000 radiology orders were left unscheduled throughout Brigham Health, resulting in a patient safety risk for those patients with unscheduled orders.

• A clean up effort was mapped out and executed for an extensive order cleanup effort for 52,204 unscheduled radiology orders, which included patient outreach by practice staff and managers, along with clinicians when clinical review was required.

• A “Future State” Operational Model was created, which outlined two streamlined scheduling models for departments to select from (the Central Radiology Scheduling Model and Local Scheduling Model) based on what was appropriate for their patient populations and practice operations. The model creates accountability through standards for ensuring that radiology orders are worked within 7 days of the initial order date.

• Progress is also tracked through Operational dashboards that have been created to report on performance and to hold practicesaccountable for working all radiology orders within a 7-day timeframe and to reduce any patient safety risk associated with a radiology order remaining unscheduled over time.

Elizabeth AudetteKori BerardinoBecca BrookeMark CunninghamRick CushingYara DavilaKelly FanningChrissy FitzgeraldRobert ForsbergCorey HansonKevin HartMike Healey ,M.D.Jillian HinckleyStuart HootonMichelle KennedyRamin Khorasani, M.D.,M.P.H.

Karen LeanDana MarchelloTyler MartinMarie MorissetJim O'ConnellSwathi ShettyDiane Taylor-VetreeElizabeth WengerJenna Zullo

Developing and Spreading a Nurse-Driven Protocol for the Management of Patients with Flu-Like Symptoms

Danielle LaPointe; Pam Cormier, MSN RN AHN-BC; Becca Brooke; John Rossi

Brigham & Women's Hospital / BWPO

Aim: Leverage the EHR to develop a standard process for nurses in Primary Care to triage inquiries from patients with flu-like symptoms to provide evidence based treatment and prevent the potential spread of influenza by managing them remotely.

Interventions:

• Engaged frontline staff for the design, pilot, modification and training aspects of workflow • Created Epic smartphrase for RN to identify patients for whom Tamiflu would be appropriate

and send a prescription to the PCP in Epic for signature • Tested and refined the intervention at 5 pilot locations, trained managers and frontline staff

through Webex, scaled to our 10 remaining practices • Refined and adapted aspects of our approach and used it to develop additional protocols for the

RN role (UTI, tick bite, and emergent calls) • Rolled out an updated version of the flu-like symptom smartphrases for the 2019-2020 flu

season based on the ongoing feedback we've received on the first protocol.

Summary of Results: Using the flu protocol, nurses manage patient's care independently, and Primary Care now has standard work processes for the management of several common patient illnesses using Epic Smart Tools

Description of Impact to Patients:

1) Timeliness of patient homecare advice and access to prescriptions and treatment 2) Avoid bringing infectious patients into the office and therefore preventing spread of influenza to

staff and other patients 3) Bringing care to the patient in a way that is more convenient for them 4) Standardizing the approach to caring for influenza patients across all BWH 15 Primary Care

locations, allowing for easier coverage within the care team and a more consistent patient experience

5) Use of virtual visits allows for increased access in the provider schedule for those who need in-office appointments

Consideration of Spread: We have used this methodology effectively to create 3 additional clinical workflows for triage protocols (UTI, Tick, Emergent calls). Each of the 4 protocols have been spread across all 15 primary care locations after designing and piloting with frontline staff from 3-5 practices. This design approach is adaptable to any multisite Ambulatory setting.

Aneesh Singhal, MD– Vice Chair of Quality, Dept. of NeurologySarah Dougherty- Sr Project Manager, Dept. of Neurology

"ED to Outpatient" Pathway to Reduce High-Cost Imaging and ED LOS for Transient Ischemic Attack (TIA)

Massachusetts General Hospital

AIM: To determine the feasibility, safety and efficacy of an “ED to Outpatient” pathway for TIA and minor stroke, and its impact on high-cost neuroimaging in the ED and ED LOS.

TEAM:

INTERVENTION: • Based on literature review, we created a guideline and smartphrase with I/E criteria

designed to optimize safe discharge, deferred imaging and prompt outpatient stroke F/U• Documents provide guidance on appropriate ED vs. deferred outpatient imaging, safety for

discharge, appropriate outpatient virtual follow-up timeframe, and patient ownership• Collaborated with ED, Imaging, and Cardiology (Echo Lab) for design and implementation • Created a database to capture and track key safety and feasibility outcomes IMPACT:

•Annual ED stroke volume is ~1,500 cases. •Of these, ~500 are TIA/minor stroke.•Based on pilot data analysis, ~30% of cases receive avoidable, duplicative imaging (CT/CTA, MRI/MRA).

•Many patients are clinically stable, yet admitted solely for echo and other lab tests.

•Our pathway changes practice by enabling safe ED discharges, eliminates or defers high-cost neuroimaging and echo from ED to outpatient setting, and enables prompt outpatient stroke virtual visit follow-up.

•Preliminary data suggests safety and feasibility•We anticipate significant impact on the volume of high-cost imaging and ED LOS.

CONSIDERATIONS FOR SPREAD: •Similar frameworks can be implemented for

other diagnoses which often receive high frequency of high-cost imaging

•Our approach is generalizable to other EDs

RESULTS:

PROBLEM: Our pilot data showed that patients presenting to the MGH ED with TIA or minor stroke undergo excessive or duplicative Neuroimaging in the ED, resulting in increased ED LOS Neurology:

Aneesh Singhal, MDSarah Dougherty Alexis Roy, MDA. Sreekrishnan, MDScott Silverman, MDErica Camargo, MDSherri Tramontozzi

ED:Kori Zachrison, MDJosh Goldstein, MDCardiology Echo Lab: Judy Hung, MDNeuroimaging:Pamela Schaefer, MDMichael Lev, MDAdmin Directors

Initiating SGLT-2 Inhibitors in Inpatient Cardiovascular Patients

Olivia Hulme, MD; Nadine Palermo, DO; Christopher Cannon, MD; Amy Bilodeau, PharmD; Lee-Shing Chang, MD; Melanie Goodberlet; Marie McDonnell, MD; Jorge Plutzsky, MD; Colleen Smith, NP

Brigham & Women's Hospital / BWPO

Aim: Recent cardiovascular studies have demonstrated that SGLT-2 inhibitors reduce the risk of cardiovascular (CV) events, including CV death, heart failure (HF) hospitalization and slow progression of kidney disease (CKD) in patients with and without recognized atherosclerotic disease, CKD, and/or a history of HF. Few studies are available, however, of initiating SGLT-2 inhibitors in the acute care setting. A multidisciplinary effort across Endocrinology, Cardiology, and Pharmacy at BWH has designed a pilot to demonstrate feasibility of initiation of SGLT-2 inhibitors in hospitalized patients.

Interventions: Over six months, patients admitted to Cardiology with diabetes on metformin monotherapy or newly diagnosed diabetes with the plan to prescribe metformin were considered for SGLT-2 inhibitors. Involvement of the Diabetes Management Service and inpatient pharmacy team was central to this effort, given the need for safe care transitions, prescription monitoring, and transition of medications upon discharge.

Summary of Results: Between May 1 and November 30, 2019, 33 patients were identified as appropriate candidates and have been initiated on SGLT-2 inhibitor therapy. Data collection continues to obtain information regarding interval labs, barriers to coverage, adverse events, and follow up with primary outpatient providers.

Description of Impact to Patients: With widespread prevalence of ASCVD, HF, and CKD, in whom SGLT-2 inhibitors have demonstrated potential to prevent CV events and CKD progression, there is a need to get this therapy to appropriate patients. Given challenges with initiating medications, educating patients, and ensuring insurance coverage, starting SGLT-2 inhibitors prior to discharge may lead to improved adherence to evidence-based therapies, and, ultimately, may contribute to prevention of CVD.

Consideration of Spread: This novel multidisciplinary program has been successful in identifying patients who would benefit from SGLT2 inhibitors, removing the barriers for therapy initiation, and helping to streamline care transitions. Should this pilot prove effective and scalable, it may provide the framework for implementation by other institutions.

Inpatient General Medicine Morning Discharge Project (Medicine Department)

Mass General Hospital

AIM: Increase the average percent of discharges that occur Pre-11AM from inpatient general medicine residency units from 10% to 25% by December 30, 2019.

TEAM: • Medicine Residents• Nurse Directors & Nursing Teams• Case Managers• Tasleem Spracklin (Pharmacy)• Nicole Johnson (PT)• Renee Reynolds (Nutrition)• Christina McCarthy (Social Work)• Ed Morris (DOM)• Joan Strauss & Rosy Gil (Process

Improvement)• Special Acknowledgement to our

pilot unit White 8

INTERVENTION: On May 15, 2019, one unit (White 8) piloted workflow changes to better identify and accomplish patient discharges by noon each weekday. These workflow changes were spread to the remaining 5 residency units on June 26, 2019 to coincide with the start of the residency academic year. • The team identifies potential AM discharges for the following day during afternoon interdisciplinary rounds.• Any action items needed for the discharges are confirmed, communicated and addressed the afternoon prior to

discharge.• The Case Manager updates the estimated date and estimated time of discharge in EPIC to help with

communication to other teams (e.g., Physical Therapy, Social Work, Nutrition)• On the day of discharge, the clinical team confirms the planned discharges and works to process the discharge

order / tasks in the early to mid-morning such that the patient can physically leave prior to noon.

IMPACT: Patients to be discharged receive clear communication from all members of the team about expected timing. The patient care units report a better sense of organization in the mornings and a smoother flow with admissions spread more evenly throughout the afternoon. Earlier availability of discharge beds should help ease wait time for patients to be admitted from the ED.

CONSIDERATIONS FOR SPREAD: Work is underway to spread the morning discharge workflow to the Albright (hospitalist) units, as well as the Neurology/Neurosurgery units.

RESULTS: Average pre-noon patient discharges have increased from 10% to 18% across all residency units. Pre-11AM discharges increased but meeting the 25% target has been challenging.

PROBLEM: MGH continues to be challenged by capacity constraints which can result in long delays for patients waiting for a bed. Matching bed capacity (discharges) with bed requests early in the day will help ease congestion of patients waiting for beds.

William Hillmann, MD – Department of Medicine, AIPD for Quality and SafetyJoshua Ziperstein, MD – Department of Medicine, APD for Inpatient MedicineColleen E Gonzalez, RN – Nurse Director on White 8

Caitlin Sachs, ACNP-BC – Inpatient Plastic Surgery NPKari Thompson, PA-C – Inpatient Plastic Surgery PA

Standardizing Opioid Prescribing After Tissue Expander Breast Reconstruction

Brigham & Women’s Hospital

AIM: Decrease the percentage of patients who receive greater than the average amount of opioids upon discharge after tissue expander breast reconstruction to <25%. TEAM:

• Plastic surgery attending physicians

• Plastic surgery residents• Plastic surgery NPs/PAs• Plastic surgery nurses

INTERVENTION:• Review of opioids prescribed at discharge was collected via electronic medical record, online opioid prescription monitoring

tool, and patient self report. Opioids dispensed was converted to MME to account for variation in narcotic prescribed.• Patient survey was conducted with these patients with 47% response rate. More than 2/3 of patients felt they received enough

or too many opioid pills at discharge.• Decision was made to standardize opioids prescribed at discharge to the average (150MME or 20 tabs of 5mg Oxycodone).• Plastic surgery attendings, residents and PAs/NPs were notified of standardization protocol via email.• A nursing info sheet on standardization protocol was distributed to RN's primarily involved in discharging these patients.• A "smart phrase" was developed to be inserted into patients’ discharge instructions about safe opioid use, how to wean pain

medication, safe disposal of opioids, etc.

IMPACT: Over prescribing opioids by medical providers is contributing to the current opioid crisis in our country. Through standardization we have reduced the number of patients being over prescribed opioids which may contribute to decreased abuse, misuse, and overdose.

CONSIDERATIONS FOR SPREAD: • Standardize opioids prescribed for other

common plastic surgery procedures

• Share data with other institutions to influence standardization (work to be presented at American Society of Plastic Surgeons virtual conference)

RESULTS: Post intervention data was collected from November 20, 2018 through February 2020 revealing that only 11.1% of patients received greater 150MME of opioids on discharge. By month, we reached our goal of <25% for 15 out of 16 months.

Insert graph

PROBLEM: Between January-September 2018 33% of patients at BWH received greater than the average amount of opioids (150MME or 20 pills of 5mg Oxycodone) at discharge after tissue expander breast reconstruction.

Care Innovations

May Pian-Smith, MD, MS – Chief, Division of Quality and Safety, DACCPM Jeremi Mountjoy, MD, MSc, FRCPC – Assistant Director of Quality Assurance, DACCPM

A Perioperative Debriefing System Following Critical Events in the OR

AIM: The lack of such action can negatively impact patients and clinicians, but the addition of a debriefing exercise would contribute to optimal learning and positive system changes. To address these aspects, we are implementing a perioperative, multidisciplinary, timely, structured debriefing process, expected to begin by January 1, 2021.

STEERING TEAM: May Pian-Smith, MD, MSJeremi Mountjoy, MD, MSc, FRCPCJeffrey Cooper, PhD Haytham Kaafarani, MDTheresa Morris, RN, MS, CPPSWilton Levine, MDPatrice Osgood, RNMaureen Hemingway, RNMichael Farrell, RN Nancy Wu, MDAllison Doney, MHAKathy Kong, MPH

INTERVENTION:• Distributed a pre-intervention survey to all Anesthesia providers, collecting baseline data of clinicians’

experiences with OR critical events and debriefings• The multidisciplinary steering team created a debriefing tool for future debriefing facilitators• Initial pilot phase will be limited to unanticipated cardiac arrest or intraoperative death events• Debrief is designed to last ~15 min but will be situation-dependent • The objectives of the debrief are: 1) identify what is needed to care for the patient, 2) ensure all involved

in the event are okay, are aware that peer support is available, and are aware that clinical relief may be available should they need it, 3) identify equipment or supplies that need to be sequestered from the case, 4) discuss elements from the event that have affected individuals and identify follow-up actions needed to maximize the chances of learning from the event.

• Next steps include creating a teaching module and training debriefing facilitators

IMPACT: Debriefing critical events together as a perioperative team as soon as possible after an event occurs can help prevent harm to the next patient, similar adverse events and provide support to the providers who are in need of it.

CONSIDERATIONS FOR SPREAD: Critical event debriefing Is

applicable to other institutions; We are

exploring a collaboration

with BWH and the process can be spread

throughout the MGB network.

RESULTS:

PROBLEM: There is currently no process in place to debrief a perioperative critical event immediately after it occurs in order to assist the providers, gather critical information and ensure appropriate actions are taken for follow-up.

Commission7%

Dose32%

Formulation11%

Frequency16%

Omission28%

Substitution6%

TYPE OF MEDICATION ERROR PREVENTED

Carol Aboud, PharmD, RPh – Director of PharmacyVictoria Vargas, PharmD, BCPS, RPh – Pharmacy Supervisor

Better Rx with MedHx

AIM: To utilize a global source of outpatient medication history to identify and correct transition-of-care medication errors atpsychiatric hospital admission.

TEAM: McLean Hospital PharmacistsINTERVENTION: The DrFirst MedHx web-based platform for medication history data was made accessible to both McLean

Hospital admitting prescribers and pharmacists. After initial use by the admitting prescriber, pharmacists search for outpatientmedication history to identify inconsistencies in prior-to-admission medications and inpatient medication orders.Inconsistencies identified by pharmacists resulting in medication order change were manually recorded. Pharmacistinterventions were reviewed by a supervisory pharmacist for categorization and assignment of expected harm.

IMPACT: Eighty-five percent of pharmacist interventions reasonablyprevented harm to patients. Even after initial assessment by admittingprescriber, pharmacists were able to prevent medication errors in 2.1% ofadmissions upon review of outpatient medication fill history.

RESULTS: Even after initial review by a prescriber, over aperiod of six months, McLean pharmacists prevented 83admission medication errors of varying categories across 75unique patients by reviewing outpatient medication history.

PROBLEM: Establishing the correct medication list has the potential to improve patient outcomes1 and avoid adverse drugevents.2 However, admission medication reconciliation is time consuming1 and error prone.2-6 The process is complicated bythe acute condition at psychiatric admission,7 low health literacy,8-10 non-adherence,7 and incomplete records.10-12

83 Total Interventions

CONSIDERATIONS FOR SPREAD: MedHx would be a useful tool formedication reconciliation to improve efficiency and reduce transition-of-care medication errors at any institution. In addition, DrFirst offers Epicintegration, which, if pursued, would offer practitioners the benefit of acomprehensive medication fill history with the added efficiency ofaccessibility through Epic.REFERENCES: Available upon request to vvargas21@partners.org

Category E/F/G/H (Error, Harm)

Category B/C/D (Error, No Harm)

EXPECTED HARM PREVENTED

August 2020

Lisa Rotenstein, MD MBAChristin Price, MD

Development of a Transitions Primary Care Clinic in an Academic Medical Center

Brigham and Women’s Hospital

AIM: To develop a Primary Care Transitions Clinic that significantly reduces primary care wait times and reduces ED use/hospitalization by January 2020.

TEAM:

Lisa S. Rotenstein MD MBA, Caroline Melia RNPeter Gonzalez MDLipika Samal MDRebecca Cunningham MDStuart Pollack MDChristin Price MD

INTERVENTION:• The Primary Care Transitions Clinic (TC) was established within an existing primary care practice

and opened in January 2019. • It employs one RN Care Coordinator, one medical assistant, and is staffed by one primary care

physician each weekday afternoon.• While the clinic’s services were available only for Medicaid Accountable Care Organization

patients during the clinic’s first two months of operation, access has since been expanded to include patients with all insurance types accepted by Brigham Health.

IMPACT: • After one year, the TC had received 498 total referrals. 73.2% of TC referrals were

from the ED, 23.3% from inpatient, and 3.3% from outpatient clinics or home nursing.

• The TC interacted with 403 patients in some capacity (i.e. phone call with RN care coordinator, appointment scheduled but not attended). 208 patients were seen over one year, and 45% of patients were seen more than once.

• Average time to a TC visit was 5.0 (± 3.5) work-days. This contrasts to a mean 68.7 ±44.5 work-day wait to see a new PCP across Brigham Health in 2019. 45% of patients were seen in the clinic more than once.

• As compared to the 3 months pre-referral, patients seen in the TC had significantly fewer (p<0.01) ED visits and hospitalizations in the 3 months post-referral.

• They also had significantly fewer (p<0.01) ED visits in the 3 months post-referral than did a comparator cohort referred to Brigham Health Primary Care the year prior.

CONSIDERATIONS FOR SPREAD: • As the clinic expands, ensuring that robust resources are available for addressing

insurance issues and social determinants of health may enhance its impact.

RESULTS:

PROBLEM: Transitions of care, such as between the emergency department or hospital and home, are known to leave patients vulnerable to adverse outcomes.

Jennifer Decopain Michel, MPH – Project Coordinator Ashely Chukwu, MPH- Project Coordinator Anne M. McDonnell, PharmD, MBA, BCOP, CPPS Ambulatory Medication Safety PharmacistSonali Desai, MD, MPH- Director of Quality Dept of Medicine and Director of Ambulatory Safety

Diabetes Virtual Care Project

Mass General Brigham Department of Medicine Quality Program

AIM: To provide virtual outreach to high-risk patients with diabetes at Southern Jamaica Plain and Brookside community health center practices and reduce barriers to care, between the months of May 2020 through July 2020.

TEAM: • Department of Medicine

Quality Team• Primary Care Population

Health • Ambulatory Services Safety

Net Team • Southern Jamaica Plain

Health Center • Brookside Community

Health Center

INTERVENTION:This project included outreach calls to patients to ensure their ability to check blood glucose readings at home, confirmation of access to proper medications and to connect patients with providers virtually, for those presenting a need. Our team was composed of project managers, a pharmacist, medical doctors, nurses and medical interpreters. Patients were screened for social determinants of health (SODH) including food insecurity, health insurance needs and other support systems during the COVID-19 pandemic. Additionally, patient charts were routed to clinic staff members best capable of resolving issues identified during outreach calls with project coordinators.

IMPACT:

CONSIDERATIONS FOR SPREAD: • Outreach can occur via patient gateway, ahead

of virtual visit • Patients can be assigned to staff monthly via

Epic report

RESULTS:

Insert graph

PROBLEM: Patients with diabetes face a higher chance of experiencing serious complications from COVID-19.

86 8459

9270

44

178154

103

ELIGIBLE PATIENTS PATIENTS OUTREACHED PATIENTS REACHED

Site Wide Outreach

SJP Brookside Total

Total Charts Routed PCP 43Front Desk Pool 8Managed Care 9Pharmacist 6Nursing Staff 37Supply Requests Only 14

Lisa QuinnSr. Project Manager, Ambulatory Services

Direct Scheduling and Fast Pass Roll Out at Brigham Health

AIM: In FY19, implement DS & FP across applicable BH ambulatory practices to improve access. Measure the usage of these patient centered scheduling tools and plan for optimizing the functionality in the future.

TEAM: Liz AudetteYifan ZhangSarah WongPeC Cadence Team

INTERVENTION: Direct Scheduling (DS) offers patients established with a specific provider the ability to self-schedule their return appointments online. Fast Pass (FP) automatically works a practice’s waitlist by contacting patients when earlier appointments become available. • Leveraged Pool B (a financial incentive program) to work with practices to determine if DS & FP was

appropriate, and where appropriate, map out go-live dates. • Provided education and training to practice managers prior to go-live.• Ran usage reports for three months post go-live that were shared with practice managers, as well as

triaged any questions or issues that arose.• Maintained a high-level metrics dashboard to track the overall usage and benefits.

IMPACT: Allows patients the autonomy and flexibility to easily arrange their own appts on their own time. Direct Scheduling: • 12,703 total appointments made by patients

online • Patients ~40% less likely to no-show to DS apptsFast Pass:• 5,648 appointments moved up with FP• Total patient days saved = 259,403

CONSIDERATIONS FOR SPREAD: • Easily scalable• MyChart enrollment is current BH priority d/t

COVID-19• Functionality promoted by PHS and EDDH;

expanding and optimizing these tools will continue to be a priority.

RESULTS: End of FY19: 115 practices live on DS and 124 practices live on FP

PROBLEM: Enable the adoption of patient centered scheduling through change management with 180+ BH ambulatory practices.

Fast Pass

Twilight Cofield, CNP – Nurse Director Weiner Center for Preop EvaluationEunji Michelle Ko, PharmD – Senior Safety Program Manager

Integrating Telehealth and EHR Technologies with Pharmacy-led Anticoagulation Plan Services to Optimize Peri-Operative Care

AIM: 1) Reduction of unnecessary clinic visits increasing patient access, 2) decreased surgery delays/cancellations, and 3) increased AMS referrals by September 2020.

TEAM: Eunji Michelle Ko, PharmD Maryam Alobaidly, PharmD,

MSc David Hepner, MD, MPH Twilight Cofield, CNP Kimberly Wheeler, DNP, MSN,

RN, CNOR Kate Ulbricht, PharmD, MBA,

CPPS BWH Department of Quality

and Safety Interns

INTERVENTION: Pharmacists use Procedure Pass to communicate with surgeons/prescribers/pre-op staff before surgery

in order to determine an appropriate pre-procedure anticoagulation therapy management plan Patients that are managed by Brigham and Women’s Hospital (BWH) or Brigham and Women’s Hospital

Faulkner (BWFH) are then recommended for AMS referrals to further manage their anticoagulation.

IMPACT: A prior pharmacy-led medication reconciliation

support service reduced clinic visit length by >17% Obtaining pre-procedure anticoagulation plans in

advance and increasing medication reconciliations prior to surgery will reduce cancelled and rescheduled surgeries, improving patient safety

Clinic staff will be able to serve more patients efficiently, working towards improved experience and cost savings

Increasing number of patients managed by BWH AMS will meet TJC NPSG requirement

CONSIDERATIONS FOR SPREAD: Pharmacy-led medication/anticoagulation support

services, including trainees, can be expanded to other services and institutions as an efficient patient safety model

RESULTS:

PROBLEM: The Joint Commission (TJC) National Patient Safety Goals (NSPGs) require medication reconciliation and anticoagulation therapy management. A lack of comprehensive perioperative medication lists and anticoagulation dosing plans can contribute to rescheduled/cancelled procedures and increased risk of adverse events. Prior to intervention, BWH Anticoagulation Management Services (AMS) monitors only 350/4000 (8.75%) of DOAC patients, presenting a patient safety and compliance risk.

Brigham and Women’s Hospital

*(as of 3/31/20)

Total patients

completed:339*

Time per

patient (min)

Hourly rate ($)

NP time

saved (hr)

Savings per

patient ($)

Total hospital savings

($)

Return on investment

(ROI)

NP 15 86

85 14.44 4,895 204.7%RPh 8 53

Pharmacy Intern

15 0

Table 1. Time and cost savings of pharmacist anticoagulation management

Reducing ICU Utilization and LOS by Optimizing the Use of Continuous Monitoring Systems in the Hospital

Perry An, MD; Patricia Dykes, PhD, RN; Graham Lowenthal BA;Stuart Lipsitz SCD; Cathy Yoon MS; Jessie Munn MSN RN; Carolita Bourke MSN RN; NWH CMS Champions

Newton-Wellesley Hospital, Brigham & Women's Hospital / BWPO

Aim: We sought to demonstrate a significant reduction in ICU utilization, length of stay, and adverse events across all medical-surgical inpatients over a two-year period at NWH by optimizing the use of continuous monitoring systems (CMS).

Interventions:

• CMS automatically alert NWH clinicians to abnormal heart and respiratory rates in real time. • After it was determined that these alerts were not consistently attended to, key stakeholders

met monthly to address barriers to adoption and effective use. Managers and senior leadership provided strong support of such efforts.

• Response times to alerts serve as a proxy for technology implementation; median response times were reduced from 27 minutes in 2014 to 4.5 minutes in 2016.

Summary of Results:

• 16,781 med-surg admissions during the pre-optimization period (2013-2015); 20,320 during the post-optimization period (2016-2018); similar in age and gender distribution, but the post-optimization group had a higher Charlson Index (1.94 vs 1.71, p<0.0001).

• Our primary finding is that unplanned floor-to-ICU transfers were significantly reduced in the post-period (2.25% vs 1.73% p=0.026). The reduced odds (27%) of an ICU transfer corresponded to 350 avoided ICU days over a two-year period, representing $2.2 million in savings (using benchmark daily ICU cost of $6,343).

• Of patients who transfer to the ICU, hospital LOS was reduced by 13%, from 9.64 days to 8.37 days, p=0.006.

• Mortality and code blue event rates did not differ between the two cohorts.

Description of Impact to Patients: We demonstrate a striking correlation between improved response times to clinical alerts and the odds of needing ICU care, as well as hospital LOS. Our findings indicate that expedient bedside evaluation of deteriorating patients may decrease morbidity and help hospitalized patients recover more quickly, leading to significant ROI.

Consideration of Spread: Exchange ideas about current CMS practices across PHS institutions.Engage quality and safety leaders about lessons learned at NWH.

Virtual Chart Consultations in Inpatient Allergy/Immunology

Neelam Phadke, MD; Anna R. Wolfson, MD; Mark Matza, MD, MBA; Eli Miloslavsky, MD; Ohn Chow, MD PhD; Lacey Robinson, MD; Aidan Long, MD; Kimberly G. Blumenthal, MD MSc; Aleena Banerji, MD

Massachusetts General Hospital / MGPO

Aim: Complete fifty virtual chart consultations (VCCs) within 7 months of implementation

Interventions: Following a conversation with the requesting provider, allergists review the electronic health record to provide formally-documented guidance for a specific consult question through VCCs. As direct specialist/patient interaction does not occur, VCCs can be completed remotely. We implemented VCCs within Allergy/Immunology (A/I) for pre-screened indications through an internally-funded pilot at Massachusetts General Hospital (MGH). We reviewed A/I VCCs (April-October 2019) for indication, recommendations, and completion/turnaround time; a random subset of in-person A/I consults were reviewed for completion time.

Summary of Results: A/I VCCs were most frequently requested for adverse drug reactions (81%) followed by immunology evaluation (7%). Of 60 completed VCCs, 64% provided diagnostic and/or management guidance; only 15% recommended subsequent in-person A/I consult. Allergists required a median of 25 minutes [IQR 19, 33 min] to complete VCCs; chart-documented guidance was available a median of 53 minutes [36, 90 min] after request. A median of 1554 minutes elapsed between time of in-person A/I consult request and finalized chart documentation.

Description of Impact to Patients: Despite rising inpatient A/I consultation need, allergist access is limited; even hospitals with on-site allergists have insufficient resources to address all inpatient allergy questions. Allergists are reticent to be pulled from ambulatory duties, particularly for consults that prioritize documentation or medicolegal protection over need for in-person allergist evaluation. VCCs are an electronic health record-based solution with the potential to improve allergist access for hospitalized patients.

Consideration of Spread: A/I VCCs efficiently and rapidly deliver formally-documented allergist guidance for hospitalized patients and may be a useful form of inpatient telemedicine, particularly for drug allergy and immunodeficiency. Considering similar access issues in other specialties, this model can be adapted to increase inpatient specialist access across specialties, not only at MGH, but also across Partners community hospitals, and potentially beyond.

Employing PI Concepts

Improving the Effectiveness of Structured Interdisciplinary Bedside Rounds (SIBR)

Matthew DiFrancesco, MD; Allison Bernard, RN DNP, PhDc; Jeanne Hutchins, RN

Brigham & Women's Faulkner Hospital

Aim: The aim of this project is to increase the effectiveness of SIBR on a medical surgical unit. Aim (1) is to increase adherence to rounds structure by nurses and physicians from 21% and 58%, respectively, to above 75% for each group by 3/1/2020.

Aim (2) is to to increase the percentage of rounds performed at the bedside from an average of 19% to 40% by 3/1/2020. SIBR gathers physicians, nurses, case managers, social workers, and physical therapists to an interdisciplinary meeting with each patient to coordinate care and enhance communication with our patients. Through interviews and direct observation, we have identified inefficiencies in SIBR practice including a lack of adherence to the assigned structure and to including the patient in rounding. Additionally, there are currently no criteria for when to perform rounds at the patient's bedside.

Interventions: Nursing and physician staff will receive education on rounds structure via in-person modeling and role-playing demonstrations. A handout with clear instructions for the role of each staff member including a sample script will be distributed prior to rounds each day. Criteria for bedside rounding on at least 75% of eligible patients will be set and enforced by rounds leaders.

Summary of Results: Pre-intervention data reveal that adherence to rounds structure by nurses and physicians is 21% and 58%, respectively. Rounds are performed at the bedside for 19% of eligible patients. Pre and post-intervention data will be (and are being) collected using direct observation of rounds and surveys of participating staff members and analyzed using statistical process control charts.

Description of Impact to Patients: Evidence-based interdisciplinary rounding practice can improve the experience of patients, allow for team members to more effectively communicate, and to help the team avoid patient safety events like falls, DVT, and hospital acquired conditions.

Consideration of Spread: Consistent evidence-based interdisciplinary rounding practice can be applied to any inpatient unit in the health system.

Increasing the Utilization of Cyracom Video Interpreter iPad at Spaulding Peabody

Michelle Bradley, DPT

Spaulding Rehabilitation Network

Aim: Within six months, we hope to see an increase in the use of the interpreter iPad to by least 50% for evaluations, and 25% for follow-up treatment sessions. We will measure the data by use of therapist feedback and responses to surveys.

Interventions: Staff in-service, improving Wi-Fi connectivity, speaking with IT to improve speaker quality/volume, tip sheet for staff for problem solving.

Summary of Results: The intervention was successful in increasing the staff's familiarity and comfort with using the iPad for evaluations. Prior to this project, the iPad was used only 2% of the time for non-English speaking evaluations, and after the intervention, it was utilized 80% of the time. Staff feel more comfortable utilizing the iPad for evaluations and follow up sessions, which has improved overall patient care and quality.

Description of Impact to Patients: The video feature on the iPad improves overall patient quality and experience. Without ability to demonstrate and show exercises and interventions, our patient care is ineffective and less precise. The ability of the iPad to be mobile around the clinic allows clinicians to more effectively use the gym space and equipment with patients, thus improving their outcomes.

Consideration of Spread: Interpreter services and video interpretations are available and necessary throughout the entire network. Therefore, the initiatives we used to train staff to familiarize themselves to the iPad can be used across the network in all different settings, thus improving the overall quality of care across Partners.

Selina Osei, MD MPH MBA- Medicaid ACO Project CoordinatorSarah Matathia, MD MPH- Medicaid ACO, Assistant Medical Director

Internal Communication Strategies to Improve Workflow Processes of the Medicaid ACO Community Partners Program at MGH

MGH/MGPO

AIM: Improve timeliness of care plan return rates; Increase operational efficiency in overall workflow processes of LTSS assessment completion; Increase awareness of care team members about the Community Partners program.

TEAM: Selina Osei, MD MPH MBA1; Sarah Matathia, MD MPH1,2; Kristen Risley, PMP, MSW1; Erin Swanson, RN; Elizabeth T. Cafiero-Fonseca, SM1; Ann Erwin, MMHS2; Jacqueline Ngo1; Alexy Arauz Boudreau, MD1,3

1 Performance Analysis and Improvement Unit, Massachusetts General Hospital/Massachusetts General Physicians Organization, Boston, MA2Massachusetts General Physicians Organization, Boston, MA3Massachusetts General Hospital for Children, Boston, MA

INTERVENTION:

IMPACT:

CONSIDERATIONS FOR SPREAD: Identify key contacts at practice sites in care coordination role groups for patients. Follow established practice workflows for paperwork at practices Modify Epic Workflow to optimize EPIC foot print of the CP program by utilizing Patient Care Coordination note to document patient’s engagement with the CP program; adding a message to the cc’d chart to signal to the PCP that the message has an actionable item.CC existing care managers working with patient to loop them in on patient’s care plan and CP engagement. Escalate to Practice managers and/or Key contact to minimize over messaging of PCPs to minimize risk of burnout.

RESULTS:

PROBLEM: Operational inefficiency in the implementation of the Community Partners’ (CP) Program with key challenges identified in the late turnaround times for getting care plans approved and retuned to Community Partners, completing assessments for Long Term Support Services (LTSS) and lack of general awareness about the CP program among MGH care teams.

March 2018- June 2019

Send Care Plans by Email-BHCP via BHSS/SW to PCP -LTSSCP—PCP directly-Email CRS names of patient to outreach to for LTSS Assessment

July 2019- Sept 2019 -Send care plans to PCPs via interdepartmental mailPreceded by in-basket message to PCP-Send reminders and Escalate to practice manager after 14, 21, & 28 days

October 2019 – February 2020-Adopt Interdepartmental mail & LTSS Outreach Tracker -Adapt Key Contact communications -Abandon EPIC in-basket messaging to PCPs

March 2020- June 2020 (Q2)COVID-19 disruption of program operations and decreased program capacity with staff redeployments

Volume of Care Plans Over Time period (July 2019-July 2020)

July 2020-presentAdapted EPIC workflow process developed by Partners (MGB) with modifications to smart phrases to make CC’d chart messaging actionable for care plan signing.

Timeline for key programmatic operational changes

Fig. 4. Tracking Referral type to assess Improvement of general awareness of CP program by MGH Care teams.

1 2Enhanced data capabilities

Fig. 5. Proactively obtaining list of opt-ins directly from CPs to build LTSS Outreach Tracker, improved # LTSS Assessments completed

Improved efficiency of operational workflow processes

Adam A. Dalia – MD,MBA, Department of Anesthesia, Critical Care, and Pain MedicineSheila Klassen - MD, Cardiac Ultrasound Laboratory, Division of CardiologyKrystina Miller – Admin, Department of Anesthesia, Critical Care, and Pain Medicine

AIM: Delay (time in minutes) between patient being brought to procedural area and start of procedure will be decreased by 40% (from 35 to 20 minutes) by March 1.

TEAM:• Department 1: A. Dalia, K. Miller, M. Fitzsimons, Department of Anesthesia• Department 2: S. Klassen, J. Hung, Cardiac Ultrasound laboratory

PROJECT SPONSORS: • M. Fitzsimons• J. Hung

INTERVENTION: • Designated specific days of the week to do TEE’s that require cardiac anesthesia care: Monday,

Thursday, Friday. Created central scheduling software Smartsheets.

• Echo fellows to screen each outpatient TEE order to determine if cardiac anesthesia is required prior to patient being scheduled/arrival

• Clearly identify who the daily cardiac anesthesiologists would be on a calendar sent out to the echo lab (in order to improve communication between the echo lab and the department of anesthesia)

CONCLUSIONS: • The delay in minutes for patients presenting to

the echo lab for outpatient TEE’s requiring cardiac anesthesia was reduced by 40%

• The average wait time from patient arrival to anesthesia start was 20 minutes, reduced from pre-intervention of 35 minutes

• Importantly 0 patients were rescheduled or cancelled after the intervention

NEXT STEPS: • Continued designation of days for TEE’s

requiring anesthesia• Developing a centralized “smart” calendar for

scheduling TEE cases with anesthesia

RESULTS:

Off‐Site Transesophageal Echocardiography requiring Cardiac Anesthesiology Care

After intervention, Average Wait Time (minutes) Reduced to 20 minutes

UCL 53.3

CL 20.2

LCL -12.9-20.0-10.0

0.010.020.030.040.050.060.0

12/1

7/20

1812

/26/

2018

12/2

7/20

1812

/28/

2018

12/2

8/20

1812

/31/

2018

1/2/

2019

1/3/

2019

1/7/

2019

1/8/

2019

1/14

/201

91/

16/2

019

1/18

/201

91/

22/2

019

1/24

/201

91/

25/2

019

1/29

/201

91/

31/2

019

1/31

/201

92/

1/20

192/

4/20

192/

6/20

192/

7/20

192/

11/2

019

2/19

/201

9

Wai

t Tim

e (M

inut

es)

12/17/2018 ‐ 2/19/2019

Patient Wait Time (Minutes)

Neil Martin, MD, MPH- Clinical DirectorMeghan Kearney, MS, RTT- Quality & Safety Program Manager

Operational Necessity Offers Opportunity to Redesign Care Model

Brigham & Women’s Hospital

AIM: Maintain average patient volume (63 sims per week) and access to Radiation Oncology during equipment replacement between February 28, 2019 and April 28, 2019.

TEAM: Alex Marques, RTTClinical Operations Leadership TeamRad Onc Programming groupNursesRadiation therapistsPhysiciansDosimetristsPhysicists

INTERVENTION:Identified opportunities to increase operational efficiency of simulation appointments • Designed & implemented physician coverage model to mitigate scheduling bottle necks• Targeted education and communication to reduce the number of same day consent and simulation

appointments (approximately 60% of patients required same-day consent on day of simulation)• Redesigned nursing education workflow to add pre-sim nursing visit to prepare patient prior to sim

IMPACT: • Access to care for patients and throughput

was maintained during an equipment upgrade that could have caused significant disruption

• Average number (and a record surge) of simulations per week were sustained safelyduring and after downtime

• Implemented new workflows and tools to enable safe transition to physician coverage model while maintaining quality care

CONSIDERATION FOR SPREAD:• The department has successfully adopted

coverage models for other procedures and will continue to apply similar structure when there are clear benefits to patients, operations and staff.

RESULTS:

PROBLEM: CT equipment replacement decreased departmental simulation capacity by 50% for 8 weeks

UCL 86.45

98.63

89.599

CL 62.69

73.00

65.348

LCL 38.94

47.37

41.096

20

30

40

50

60

70

80

90

100

2-Se

p-18

16-S

ep-1

830

-Sep

-18

14-O

ct-1

828

-Oct

-18

11-N

ov-1

825

-Nov

-18

9-De

c-18

23-D

ec-1

86-

Jan-

1920

-Jan-

193-

Feb-

1917

-Feb

-19

3-M

ar-1

917

-Mar

-19

31-M

ar-1

914

-Apr

-19

28-A

pr-1

912

-May

-19

26-M

ay-1

99-

Jun-

1923

-Jun-

197-

Jul-1

921

-Jul-1

94-

Aug-

1918

-Aug

-19

1-Se

p-19

15-S

ep-1

929

-Sep

-19

Aver

age

Num

ber o

f Sim

s per

Wee

k

Weekly Sim Volume

8 Weeks at 50% equipment capacity (1 CT scanner)

• Adaptation of this streamlined tool to other Partners ambulatory sites and ambulatory oncology clinics nationwide due to perceived variability in other practices as well

• Further integration of pharmacy services in the clinic setting

Pharmacists Respond to Severe Hypersensitivity (HSR) and Infusion Related Reactions (IRRs) at

MGH North Shore Cancer CenterBrenna Rowen, PharmD, BCOP, MGH NS Pharmacy Team and Infusion Nursing Team

Background

Aim

References

Results

Consideration for Spread

Interventions

Limitations

• The management of infusion reactions, hypersensitivity reactions for oncologic agents as well as monoclonal antibodies used for non-oncology indications varied from different treating providers within our clinic

• Care may be delayed due to obtaining appropriate medications based on patients reaction sequalae

Phase I: • Standardize the treatment of hypersensitivity and

infusion reactions to:• Reduce time to proper intervention for patients

with reactions• Increase staff comfort with this medical emergency

Phase II: • Pharmacists help the responding clinician and infusion

nurse with treatment options during “severe” reactions to: • Reduce time to proper intervention for patients and

reactions• Increase adherence to pathway• Help with appropriately re-starting infusion if

applicable

• Not all severe hypersensitivity and infusion reactions were documented at the beginning of data collection

• Single clinic experience and data

MASSACHUSETTSGENERAL HOSPITAL

DEPARTMENT OF PHARMACY

HARVARD MEDICAL SCHOOLTEACHING HOSPITAL

Problem

• Hypersensitivity and infusion reactions are a common occurrence in the oncology clinic due to various drug diluents and drug formulation (i.e. monoclonal antibodies that are not human derived)

• Hypersensitivity’ reaction (HSR) is defined as a disorder characterized by an adverse local or general response from exposure to an allergen

• Infusion related reaction (IRR) is defined as a disorder characterized by adverse reaction to the infusion of pharmacological or biological substances

• Clinical signs and symptoms associated with these reactions overlap

• We standardized the treatment of reactions based on drugs used and severity per NCI CTC v4 criteria for hypersensitivity

• Pharmacists help the responding clinician and infusion nurse with treatment options and have medications readily available for severe reactions

• A severe reaction is defined in our clinic as a significant drop in blood pressure (systolic < 90 mmHg and/or syncope) and/or oxygen saturation < 92%) or as otherwise clinically indicated

• Alternative pathway for anaphylaxis is also available and separate from this pathway

• National Cancer Institute Common Terminology Criteria for Adverse Events. v4.0 NCI, NIH, DHHS. May 29, 2009. NIH publication # 09 7473.• Jakel, Patricia, Cynthia Carsten, Melinda Braskett, and Arvie Carino. "Nursing Care of Patients Undergoing Chemotherapy Desensitization: Part I." Clinical Journal of Oncology Nursing 20.1 (2016): 29-32. Web. • Kingsley CD. In: M. C. Perry ed. The chemotherapy source book. 4th ed. Philadelphia: Lippincott Williams & Wilkins;2008:152-73.• Picard, Matthieu, and Violeta Racgnier Galvalo. "Current Knowledge and Management of Hypersensitivity Reactions to Monoclonal Antibodies." The Journal of Allergy and Clinical Immunology: In Practice 5.3 (2017): 600-09. Web.

Impact• Improved quality of care: 94% success rate in

restarting infusions with pharmacist assistance without future reactions

• Anonymous nursing survey showed 100% satisfaction with the reaction pathway

• Increased provider comfort with management of reactions

• Streamlined patient care

Pharmacist Response to “severe reactions”: January 2018- July 2020:

- Pharmacists responded to 26 “severe” reactions per RN request

- 9 (35%) reactions considered actually severe per definition- Only 1 patient re-started treatment with additional

pre-medications- 8 patients did not re-start treatment: 4 desensitized,

4 changed treatment- 17 (65%) reactions were not revere

- 94% success with re-starting infusion with pharmacist assistance

Re-education of Staff and Impact on Compliance Data

Giavanna Gaskin; Sharon Woo; Nacim Iranmanesh; Courtney Nolan; Casey McGrath

Brigham & Women's Hospital / BWPO

Aim: The aim of the re-education project is to improve the Enhanced Recovery After Surgery (ERAS) booking compliance amongst the BWH administrative staff.

The Clinical Pathways Team is working with the different administrative groups to educate them on placing "ERAS" in the procedure name of the eligible surgical patients. ERAS patients receive care that is based off evidence-based practice from the ERAS Society Guidelines and standard BWH protocols.

Interventions: Our team created educational tip-sheets for the administrative staff. The tip-sheets includes:

• Definition of ERAS • Specific population/ procedures that would need to be booked as ERAS • Importance of properly booking an ERAS patient and the downstream effect • Instructions on how to take the oral carbohydrate drink • Education patients receives in the Weiner Center

Summary of Results: The success of this intervention will be measured by two outcomes, how many patients have "ERAS" in the procedure name and the increase in overall compliance. Our goal is to have 90% of our eligible ERAS patients properly booked across our 11 developed ERAS pathways by March 2020.

Description of Impact to Patients: Placing "ERAS" in the procedure name is essential to our ERAS patients receiving the care outlined on our pathways. Without "ERAS" in the procedure name our staff does not know that a patient is ERAS. Therefore creates a domino effect from the Weiner Center to the postoperative floor resulting in patients not receiving the elements on their designated pathway.

Consideration of Spread: Our goal is to continually re-educate our staff to improve ERAS compliance. This intervention started with the administrative staff because they are the first step in assuring that our patients are properly identified as being on an ERAS pathway. This educational rollout plan and tip-sheet could be replicated by other institutions who are in the process of developing ERAS pathways.

Jack Donleavy – Project ManagerKali Kearns, MHA – Project Manager

Scheduling Optimization

Brigham and Women’s Hospital

AIM: Brigham Health’s Ambulatory Services team has launched a hospital wide initiative to optimize and standardize scheduling processes to ensure a high quality and consistent patient experience, increased access for patients, optimized sessions for providers, and enhanced reporting through Ambulatory Dashboard.

TEAM: Ambulatory Services Huron Consulting Group Department of Neurology Thoracic Surgery Pulmonary Division Partners eCare

INTERVENTION: • In collaboration with each Department/Division with a multi-disciplinary team of schedulers, administrators, and providers,

different interventions were designed and implemented to enable patients to be seen by the right provider, at the right location, at the right time.

• Developed a Diagnosis Matrix, consisting of conditions and symptoms reported by patients/clinicians that indicates which clinicians are appropriate to see those specific conditions/symptoms

• Optimized templates by working with clinicians to build templates that have appropriate start/end times, durations, visit type blocks, and sequencing of appointment types

• Implemented Decision Tree that uses guided scheduling functionality to ensure each patient is appropriately scheduled, transferred to APP for triage, or re-directed to appropriate specialty

• Developed Tableau dashboard to evaluate and monitor effect of scheduling on Patient Access, Volume, Utilization, Session duration, and many other Ambulatory key performance indicators

IMPACT: • Quality Experience

• Enhance access experience to attract/retain patients

• Improve provider and staff experience by automating scheduling functionality and effectively utilizing provider’s sessions

• Ease scheduling experience for patients at all entry points

• Operational Optimization• Automate & streamline scheduling workflows• Leverage tools consistently for accurate scheduling

and reporting• Establish foundation for leveraging new digital

health tools and applications• Empower staff to resolve patient requests at point

of service/appointment request• Organizational Alignment

• Support providers, operations, and system goals• Enhance scheduling staff training and education

• Ensure flexibility of design to address changing environment

RESULTS:

1. Please note, holidays and COVID may have effected Average New Patient Lag data in chart above2. Department of Neurology is used as an example of the impact of Scheduling Optimization above.

This work was also implemented in Thoracic Surgery and Pulmonary Division during the first phase of this work

Dana Pagliuco M.S., CCC-SLP – Speech Language PathologistKerry Davis Ed.D., CCC-SLP – Speech Language Pathologist

SLP Knowledge of Onsite VFSS Referral Process

SRH Outpatient Lexington

AIM: By February, 2020 outpatient SLPs who can identify referral sources and related processes for VFSS referral will increase by 50%

TEAM: Team Leaders: Kerry Davis, SLP, Dana Pagliuco, SLP Team Members: Dana Pagliuco, SLP, Kerry Davis SLP, Susan Summers SLPPI Committee Liaison: Kerry Davis, SLPExecutive Sponsor: Rob Welch

INTERVENTION: Surveyed all outpatient pediatric SLPs regarding knowledge and process for VFSS referral Created printable document and EPIC Smartphrase template outlining a consistent process for referrals Document included all hospital sites currently providing pediatric VFSS organized by geographical region Distributed document and EPIC Smartphrase to all pediatric SRH sites Sent out post-intervention surveys to re-assess clinician knowledge for referral process

IMPACT: Ensures efficient and effective care for patients who have been identified as at risk for aspiration Streamlined process reduces clinician workloadReduces caregiver burden to locate services in their area or travel out of their areaPromotes greater follow through from families to schedule recommended VFSS appointments

CONSIDERATIONS FOR SPREAD: SRH outpatient programs may continue to assess processes to ensure in-network referrals in the future to meet patient’s access to VFSS

RESULTS: 100% of pediatric SLPs across the network reported increased understanding of how to refer patients for VFSS, as well as where to refer them to based on the patient’s geographical location within New England. This reflects an increase of 72% over baseline.

PROBLEM: No consistent process or resources in place to refer patients who require a VFSS. This results in potential inconsistencies in care, and an increase in workload for clinicians.

When my patient requires a VFSS, I know how to refer them to the appropriate provider or hospital.

Pre-Intervention Post-Intervention

Leveraging Analytics for Improvement

Anne M. McDonnell, PharmD, MBA, BCOP, CPPS – Ambulatory Medication Safety PharmacistSonali P. Desai, MD, MPH – Medical Director of Ambulatory Quality and Safety

Building a High-Risk Ambulatory Medication Safety Registry to Reduce Medication Errors

Mass General Brigham Hospital

AIM: Develop an electronic registry to identify high-risk ambulatory patients in primary care, who may benefit from a pharmacist intervention to reduce likelihood of medication error

TEAM:

Hojjat Salmasian, MD, PhD

INTERVENTION: We developed an electronic registry to identify high-risk ambulatory patients within primary care The registry captures patients who meet the following criteria:

BWH primary care provider & BWH specialist with at least one visit each in the past year Currently prescribed ≥ 5 medicationsAge ≥ 50

The pharmacist uses the registry to identify diabetic and non-diabetic patients for medication reconciliation and disease management

IMPACT: The weekly-generated registry captures more than 19,000 patients that meet criteria The registry is sorted by date, location and patient specific factors to identify patients for pharmacist visits and encountersDuring two to four half-day clinic sessions per week, the pharmacist meets with approximately twenty patients per week

CONSIDERATIONS FOR SPREAD: This registry will help identify patients that would benefit from a pharmacist visit in primary care It will be leveraged and utilized across the system to target high-risk patients, based on existing infrastructure and staffing within each practice

RESULTS:

PROBLEM: Reliably identifying patients in the ambulatory setting at high-risk for adverse events is challenging

Impact of Medication Reconciliation in Primary Care Pharmacist Visits in 4 Months

Metric Value (Number)

Patients with completed pharmacist visits 67

Patients referred from registry 39

Age, years (Mean, range) 70 (48, 87)

Patients requiring interpreter 49

Medications per patient (Mean, range) 18 (4, 47)

Time per patient, minutes (Mean, range) 38 (15, 90)

Changes per patient (Mean, range) 5 (0, 17)

Total number of changes for all patients 348

Number of patients with teaching or education provided

35

Does the Emergency Surgery Score (ESS) Predict Failure to Discharge the Patient Home? A Nationwide Analysis

Reem AlSowaiegh, MD, MSc; Leon Naar, MD; Ava Mokhtari, MSc; Jonathan J. Parks, MD; Jason Fawley, MD; April E. Mendoza, MD, MPH; Noelle N. Saillant, MD; George C. Velmahos, MD, PhD; Haytham M.A. Kaafarani, MD, MPH Massachusetts General Hospital Background: The Emergency Surgery Score (ESS) is a point-based scoring system validated to predict mortality and morbidity in Emergency General Surgery (EGS). In addition to demographics and comorbidities, ESS accounts for the acuity of disease at presentation. We sought to examine whether ESS can predict the destination of discharge of EGS patients, as a proxy for quality of life at discharge. Methods: Using the 2007-2017 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified all EGS patients. EGS cases were defined as per ACS-NSQIP as those performed by a general surgeon within a short interval from diagnosis or the onset of related symptomatology, when the patient’s well-being and outcome may be threatened by unnecessary delay and patient’s status could deteriorate unpredictably or rapidly. EGS patients were then categorized by their discharge disposition to: home vs. rehabilitation or nursing facilities. All patients with missing ESS or discharge disposition and those discharged to hospice, senior communities, or separate acute care facilities were excluded. ESS was calculated for each patient. C-statistics were used to study the correlation between ESS and the destination of discharge. Results: Out of 6,485,915 patients, 84,694 were included. The mean age was 57 years, 51% were female, and 79.6% were discharged home. The mean ESS was 5. ESS accurately and reliably predicted the discharge destination with a c-statistic of 0.83. For example, ESS of 1, 10 and 20 were associated with 0.9%, 56.5%, and 100% rates of discharge to a rehabilitation or nursing facility instead of home. Conclusions: ESS accurately predicts which EGS patients require discharge to rehabilitation or nursing facilities and can thus be used for preoperatively counseling patients and families, and for improving early discharge preparations, when appropriate.

Enhanced Recovery After Surgery (ERAS) Nursing SmartPhrase and Impact on Surgical Outcomes Compliance Data

Courtney Nolan, MPH; Nacim Iranmanesh, MPH; Sharon Woo, MS, MBA; Giavanna Gaskin

Brigham & Women's Hospital / BWPO

Aim: Improve the effectiveness and efficiency of nursing documentation of Enhanced Recovery After Surgery compliance items such as mobilization and energy intake; and overall standard of care for all ERAS patients. SmartPhrase usage can be manually abstracted.

Interventions: The Department of Quality and Safety's Clinical Pathways team created a new nursing SmartPhrase with assistance from nursing and IS/IT. The SmartPhrase encompasses key compliance metrics from Enhanced Recovery After Surgery (ERAS) Society Guidelines including mobilization, energy intake, and Ensure Clear consumption up to post-operative day 3.

Summary of Results: The Nursing SmartPhrase initially rolled out in April 2019 with an upgrade in September 2019. Over the course of several months of data collection, Nursing SmartPhrase usage for ERAS Colorectal Surgeries is roughly 70%. Utilizing the SmartPhrase allows our frontline staff to efficiently document numerous variables in the Plan of Care note or Progress note.

Description of Impact to Patients: The goals of the SmartPhrase are to increase overall compliance of Enhanced Recovery After Surgery variables, efficiently document, and improve overall standard of care for surgical patients. Using the SmartPhrase encourages frontline staff to engage with their patients; to assure they are out of bed for meals and consuming the right number of calories based on individual needs. Mobilization and energy intake are strongly associated with a decreased length of hospital stays according to the ERAS Guidelines.

Consideration of Spread: In general, Nursing SmartPhrases are a common practice across all Partner's enterprise. Frontline staff who have access to create and addend notes can utilize the SmartPhrase.

ERAS Interactive Audit System (EIAS) Data Collection Methods and Dissemination Practices to Monitor Compliance and

Improved Outcomes

Sharon Woo, MS, MBA; Courtney Nolan, MPH; Giavanna Gaskin, BSPH; Nacim Iranmanesh, MPH, CPPS; Casey McGrath, RN, MSN

Brigham & Women's Hospital / BWPO

Aim: Ensure accurate collection and dissemination of Enhanced Recovery After Surgery (ERAS) data through the use of EIAS in identifying areas of improvement and correlating process change to outcome.

Interventions: In June 2018, the Clinical Pathways Program adopted EIAS to assess adherence of eight ERAS pathways. Since then, an infrastructure of a continouous cycle of collecting and managing data, reporting and visualization, and dissemination was established. In order to standardize methods for data collection and analysis, a data dictionary of EIAS data fields was created, which includes location of data found in Epic and definition of variables. Then process and outcome measures were identified according to ERAS evidence-based guidelines and agreed upon by a multidisclinary surgical team that consists of champions from surgery, anesthesiology and nursing. For effective visualization of ERAS compliance data, heat maps of horizontal compliance were created for stakeholders to quickly identify areas of opportunity and variability throughout all phases of care. ERAS compliance data were disseminated to various stakeholders within the institution through multiple forums.

Summary of Results: Sustained improvements in ERAS compliance throughout the past six months show success of implementation and refinement of EIAS data collection and reporting system. For colorectal and gynecologic oncology pathways, overall compliance has been stable in the past six months, ranging from 77% to 81% and 83% to 87% respectively.

Description of Impact to Patients: As of December 2019, eleven services have adopted ERAS and the additional four ERAS pathways are in development. Since January 2019, there have been approximately 2500 procedures in which patients were on an ERAS pathway.

Consideration of Spread: Given the resources of EIAS and data coordinators and engagement of a multidisciplinary clinical care team, this system can be applied to other institutions with surgical departments.

Improving Allergy Documentation: A healthcare system-wide patient safety initiative

Dinah Foer, MD; Lily Li, MD; Main project mentors/senior leadership: Kimberly G. Blumenthal, MD, MSc (MGH) Paige G. Wickner, MD, MPH (BWH)

Brigham & Women's Hospital / BWPO

Aim: The goal of this initiative was to systematically reduce free-text allergen entries in the EHR allergy module.

Interventions: We assessed free-text allergy entries in a commercial EHR used at a multi-hospital integrated healthcare system in the greater Boston area. Using both manual and automated methods, a multidisciplinary consensus group prioritized high risk and frequently used free-text allergens for conversion to coded entries, added new allergen entries, and deleted duplicate allergen entries. Environmental allergies were moved to the patient problem list.

Summary of Results: We identified 242,330 free-text entries, which included a variety of environmental allergies (42%), food allergens (18%), contrast media allergies (13%), "no known allergy" (12%), drug allergies (2%), and "no contrast allergy" (2%). The majority of free-text entries were entered by medical assistants in ambulatory settings (34%) and registered nurses in peri-operative settings (20%). We remediated a total of 52,206 free-text entries with automated methods, and 79,578 free-text entries with manual methods.

Description of Impact to Patients: Through this multidisciplinary intervention, we identified and remediated 131,784 free-text entries in our EHR to improve clinical decision support and patient safety.

Consideration of Spread: Free-texted allergies fundamentally undermine quality and safety goals due to diverse terminology, misspellings, and abbreviations that do not reliably protect patients across healthcare settings. Our iterative process with both automated and manual remediation methods reduced the allergy free-text considered most likely to result in adverse patient consequences. This approach is applicable to other institutions and replicable. Our process was informed by a wide range of stakeholders including safety experts, senior pharmacists, hospitalists, allergists and contracted information technology support. Finally, in the absence of educational interventions in this area, we also created an education tip sheet for allergy entry which can be adapted for use by others.

Amie Samuylov, RTR(CT)(OPN-CG) Pulmonary Nodule NavigatorMiriam Neuman, MD Chair of Radiology

Incidental Pulmonary Nodule Tracking

North Shore Medical Center-Salem Hospital

AIM: Capture 100% of patients with incidental pulmonary nodules requiring f/u into navigator’s database within 7 days

TEAM: • Amie Samuylov, PNN Miriam Neuman, MD• Margaret Houghton, Director

Radiology• Christian Semine, MD• Adrienne Allen, MD• Joseph Salem, Sr. Improvement

Specialist• John Murray, MD• CMIO, CMO, ER MD’s,

Hospitalists, PCP’s

INTERVENTION: A macro was created for the radiologist to deploy at the time of dictation. This macro embeds a phrase that is captured into an Epic report that can be exported into the Pulmonary Nodule Navigator’s Excel database for follow-up, which eliminated manual data entry. A back up report was also designed to ensure capturing reports where the macro was not used. This report relied on a comprehensive logic that scanned studies with key phrases that are often used when nodules require f/u. Radiologist compliance was tracked and specific feedback was given

IMPACT: Nearly 58% of Lung Cancers Identified through the IPN program were found at Stage 1. This dramatically reduces mortality and makes treatment easiest. Prior to an IPN program the national average of Stage 1 lung cancer identification was a dismal 15%

CONSIDERATIONS FOR SPREAD: Important safety net for all patient populations. Process that could be operationalized at other institutions. With the integration of machine learning/robust software solutions could be spreadable to larger organizations with higher volume

RESULTS:

PROBLEM: Mitigate missed and delayed diagnosis of lung cancer due to lack of f/u of IPN’s

33%

46% 43%

64%

55%

41%

50%

52%

44%

69%

86%

75%67%

79%72%

69%

72%

70%

78%

75%

0%10%20%30%40%50%60%70%80%90%

100%% studies directly channeled to PNN

Linda Irwin, RN, MA, ANP, CCTCJay Fishman, MD

Leveraging the Electronic Health Record to Enhance Patient Safety in Organ Transplantation

MGH Transplant Center

AIM: Our Transplant Center sought to offer life-saving transplantation to patients and ensure that they received appropriate follow-up testing at 1-3 months and 6-12 months after transplant.

TEAM: Transplant ComplianceTransplant CoordinatorsTransplant PhysiciansTransplant Nurse PractitionersTransplant Physician AssistantsDatabase Specialists

INTERVENTION: Through multidisciplinary collaboration the following interventions were implemented: the Transplant Center’s Infectious Disease Program created a clinical protocol for the management and post-transplant monitoring for recipients of PHS donor organs; staff education including Grand Rounds; the informed consent discussion/documentation was modified including the surgical consent; the electronic medical record (EMR) was modified to include if the recipient received a PHS donor organ; order sets were created in the EMR for serological testing at admission and follow-up intervals; a report was created in the EMR of recipients of PHS donor organs along with their follow-up testing; the Center collaborated with the New England Donor Services Organ Procurement Organization regarding potential disease transmission; and the tracking of recipients, including ensuring that the informed consent for surgery was documented was incorporated in the Transplant Center’s QAPI Program.

IMPACT: Many lives have been saved by the utilization of PHS increased risk for disease transmission organ donors. Ensuring that patients understand the risks and benefits of receiving or rejecting the organ offer is crucial. By implementing a robust tracking system potential disease transmission can be detected earlier with treatment initiated if needed.

CONSIDERATIONS FOR SPREAD: Health care programs that need to track specific clinical elements may benefit by creating similar monitoring programs in their EMR by partnering with database specialists.

RESULTS:

PROBLEM: In New England over 40% of deceased donors are defined as Public Health Service (PHS) increased risk for disease transmission. Because of the risk of transmission of donor infections (HIV, HBV, HCV) programs are federally mandated to obtain informed consent from recipients prior to transplant and to offer follow-up testing.

There have been 641 donor organs transplanted from January 2013 to August 2020 that met the definition of PHS increased risk for infection. Follow-up tracking revealed:

• 1 heart transplant recipient was found to be HCV viral load positive (believed not to be related to donor organ)

• 17 lung transplant recipients converted their HBV core antibody from negative to positive after transplant (did not persist and believed to be related to CMV immunoglobulin infusions)

• 8 liver recipients were HBV DNA positive after transplant (4 were believed to be false positive; 3 donor derived, 1 was HBV core positive pre-transplant)

• 2 patients had HIV false positive testing (1 lung, 1 kidney) with negative evaluations.

The creation of a robust tracking system in the EMR has enabled the Transplant Center to manage the ever-growing list of recipients of increased risk for infection organ donors for potential disease transmission.

Juan Diego Paredes, Project Coordinator

Maximizing Patient Satisfaction: Surveying

AIM: To maximize the volume of actionable patient satisfaction data by optimizing the quantity of ambulatory visits that are surveyed through a clean and sustainable process that ensures all providers and practices are eligible for surveying

TEAM: Yara Davila Ben TocciTara Dana Juan Diego Paredes

INTERVENTION: Brigham Health standardized eligibility criteria to identify the appropriate providers and practices to survey. In turn, data is accessible in a Brigham Health Patient Satisfaction dashboard that empowered Ambulatory leaders and practice management to properly interpret survey results and identify improvement opportunities.

CONSIDERATIONS FOR SPREAD: Can easily be spread across other institutions due to the various benefits involved. Furthermore, this experience with patient satisfaction surveying can inform ongoing network-wide discussions around future survey vendors.

RESULTS: By November 2019, we had set up 74 new DEPs for surveying which expanded surveying to 1,200 physicians, 477 Advanced Practice Providers, 462 visit types, and over 50,000 visits. As a result, engagement with our patient satisfaction dashboard increased by nearly 50% over the last 12 months.

PROBLEM: Not all potentially eligible patients are surveyed for patient satisfaction due to gaps in the inclusion of ambulatory visits in the survey process

IMPACT: We receive approximately 4,000 patient responses a month; the culmination of which is critical in issuing patient-centric care. Moreover, these responses will ensure that patient’s experiences are used to create targeted and meaningful process improvement projects across Brigham Health.

Spreading Best Practices

Adrenaline Rush - Racing to the Right Dose

Tanya J. Aray, PharmD; Iman Moawad; Laura Meleis; Katherine Sencion; Ben Pennell; Bryan Hayes; Felicia Britt; Aaron Sacco

Massachusetts General Hospital / MGPO

Aim: To implement safety strategies aimed at safer ordering and administering of epinephrine in adult/pediatric patients for cardiac and anaphylactic indications.

Interventions: Based on several safety events at MGH, a workgroup brainstormed effective strategies to prevent epinephrine dose, route, & concentration errors. ISMP best practice recommendations for hospitals were consulted. We reviewed how the provider interfaced with the system to streamline ordering choices, remove inappropriate dosing buttons, and differentiate indications. We incorporated ISMP recommendations for epinephrine in our anaphylaxis kits to highlight the intramuscular (IM) route and provide clear dosing information at the point of care.

Summary of Results: There were 36 instances (n=2,187 patients) with the incorrect epinephrine dose ordered for anaphylaxis (1 mg instead of 0.3mg); in 4 patients the incorrect dose was administered. A three-month review of orders will be conducted following implementation of the Epic changes.

Six ordering improvements were made: streamlined epinephrine choices, removal of 1 mg dose button for anaphylaxis/pediatrics, adding "cardiac" to the 0.1 mg/mL description.

For the anaphylaxis kit, the epinephrine vial, now with IM needle and syringe, will be packaged within the kit in another bag, with a bright sticker denoting appropriate dosing and a reminder for IM administration only.

Description of Impact to Patients: Epinephrine is a life-sustaining treatment for cardiac and anaphylaxis indications that can be confused in an emergency due to multiple concentrations, doses, and routes of administration. Reports to ISMP describe serious harm and fatalities due to errors or delays in the administration of the appropriate antidote or rescue agent (e.g. anaphylaxis). By decreasing potential areas of error for patients in ordering, preparation, and administration, we can create a safer environment for patients.

Consideration of Spread: The ordering improvements in EPIC were approved by Partners in both adult and pediatric patients, with plans for further enhancements. Providing epinephrine in a more ready-to-use way in the anaphylaxis kit is a significant enhancement for patient safety and requires minimal resources.

Advanced Practice Provider Orientation- a focus on quality, safety, and APP engagement

Johanna Baldassari, NP; Peggy Duggan, MD; Christi Barney; Allyson Hammerstedt; Alana Gruszecki; Vonette Anglin; Katie Killinger; Krista Klopfenstein; Nickisha Hurlock; Julie Steller

Brigham & Women's Faulkner Hospital

Aim: Our safety reporting identified a gap in our APP base knowledge and onbaording processes. Presently, there is no dedicated central APP hospital orientation as APPs are oriented by their departments. The purpose of this project is to implement an ongoing APP orientation to educate our APPs on core competencies around patient safety, quality metrics, and professional development. By the end of orientation, 80% of newly hired APPs will be able to identify hospital safety goals, medication safety best practices, hospital safety resources, and understand the APP role in hospital structure and escalation pathways

Interventions: Implement a 4 hour multi-disciplinary formal orientation for newly hired APPs taught by the Chief APP, Directors or Quality & Safety and risk, pharmacy leadership, and departmental chief APPs.

Summary of Results: The first orientation will occur Dec 18, 2019. Pre-testing and post- test data has not yet been obtained. Data will look at APPs knowledge of how to access and use IT resources, best practice for medication reconciliation and allergy review, medication safety practices, their role and knowledge in hospital quality initiatives.

Description of Impact to Patients: None yet. Can track # of rLs related to medication safety, allergy, and HACs.

Consideration of Spread: It is possible for this orientation can be rolled out to all current APPs to level set APPs knowledge of best safety practices and their role within the larger hospital structure. In addition, it can be applied to other clinicians that work at our hospital including attending hospitalist and residents.

Yifan Zhang, MPH – Project ManagerJuan Diego Paredes – Project Coordinator

Ambulatory IS Downtime

AIM: To increase the preparedness of our Ambulatory Clinics during unplanned downtimes and maintain preparedness moving forward by through educational outreach

TEAM: Juan Diego ParedesLaura MacleanRick CushingYara DavilaYifan Zhang

INTERVENTION: We provided standardized downtime forms, a process guide that details standard operating procedures for services offered at our practices, instructional guides for BCA, SRO, Printing ADT Labels, how-to videos for operating downtime tools, educational outreach in the form of workshops, and will be implementing downtime drills to help maintain readiness. We also provided a physical downtime binder for all our practices with the aforementioned resources.

CONSIDERATIONS FOR SPREAD: Our resources could easily be adapted and shared amongst other institutions. The framework of this project and its deliverables could be used as a reference for other institutions to create their own downtime resource. Entities themselves could then edit the contents to fit the different workflows and expectations of each site. Our existing downtime documents and training materials are already being used as a basis for MGB-wide HealthStreams and forms.

RESULTS: Workshops started in December and were completed in January. We reached active education of over 85% of ambulatory practices. We handed out over 150 downtime binders to our practices. In addition to the mandatory attendees, many support staff also attended the workshops to ensure their preparedness for unplanned downtime events. The project forms and training videos are also currently being used to create other MGB forms and a HealthStream to further increase downtime readiness across the system.

IMPACT: This project will help ensure safe, high quality care can be continued as smoothly as possible in the case of downtime. Our goal is to help our practices have clear expectations of workflows during downtime and to provide the knowledge for a smoother transition during unplanned downtime and recovery. This will in turn help improve the patient experience and decrease mistakes during unplanned downtimes.

PROBLEM: Ambulatory Clinics are not all equally prepared in the event of an unplanned downtime.

Benefits of Improving Vaccination Rates in Patients on Disease-modifying Antirheumatic Drugs (DMARDs)

Maryam Alobaidly, MSc, PharmD; Sonali Parekh Desai, MD

Brigham & Women's Hospital / BWPO

Aim: We aim to increase vaccination rates in patients on DMARDs as recommended by the American College of Rheumatology (ACR) in Rheumatoid Arthritis (RA) patient s by 2020, focusing on influenza, pneumococcal and zoster vaccines.

Interventions: The BWH ambulatory patient safety team and the Department of Quality and Safety Pharmacy Fellow/interns are conducting rheumatology patient chart reviews on approximately 500 patients for existing immunization/ DMARD status, capitalizing on an existing Epic report and collaborating on a process improvement (PI) plan for ensuring appropriate vaccinations are administered at the point-of-care for at-risk rheumatology patients.

The PI plan entails:

1) leveraging an existing Epic report to conduct patient chart reviews for existing immunization/DMARD status and

2) prompting staff to give additional recommended vaccines at the point of care, supported by Certified Pharmacy Immunizers. Charts will be reviewed during the post-intervention period to re-assess vaccination rates.

Summary of Results: We expect increased vaccination rates, workflow efficiency, patient and staff satisfaction.

Description of Impact to Patients: Increased vaccination rates will positively impact morbidity/mortality rates, quality of life, workflow efficiency, patient/staff satisfaction, and compliance with ACR recommendations.

Consideration of Spread: A long-term goal is spreading this cost-effective patient safety model across Mass General Brigham entities.

Cayla O’Hair, BA – Program Coordinator, Depression Clinical and Research Program Nhi-Ha Trinh, MD – Director of Clinical Services, Depression Clinical and Research Program

Cultural Sensitivity 101: A novel online training program to promote diversity, equity, and inclusion in an academic psychiatry department

AIM: Develop and implement a brief, novel, web-based cultural sensitivity training as a tool for 1) raising awareness of the importance of diversity issues and 2) providing clinicians practial tools to gather a cultural and ethnic history and assessment.

TEAM: Taquesha Dean, BA, Anne Emmerich, MD, David Rubin, MD, & Janet Wozniak, MD

INTERVENTION: In 2018-2019, three trainings were released: 1: Introduction to Cultural and Ethnic Assessment§Defined concepts of culture, race, & ethnicity§Reviewed DSM-5 Outline for Cultural Formulation

and Cultural Formulation Interview

IMPACT: • The Department of Psychiatry at

MGH has nearly 700 clinicians who see approximately 180,000 outpatient visits.

• This training provided clinicians with tools to better gather cultural and ethnic history assessments to include in their treatment plans, therefore improving patient care.

CONSIDERATIONS FOR SPREAD:• Given the ease of implementation

using a virtual format, this training could be implemented across institutions.

RESULTS:

PROBLEM: In order to provide safe, quality medical care to the growing minority population, increasing emphasis is needed on patients’ cultural and personal values, beliefs, and preferences. The challenge: designing educational programs focusing on diversity in the healthcare setting that are effective, efficient, equitable, patient-centered, and scalable.

3: Cultural Assessment & Clinical Considerations• Provided two examples of taking a cultural

history and formulating a cultural assessment

2: Cultural Sensitivity 101• Introduced the concepts of implicit

biases and microaggressions• Featured clinical vignette examples

89%

11%

Impact of training on participants’ practices

Will change practice

Will not change practice

4.16 4.29

1

2

3

4

5

Technology &Website Usability

Quality of Conent

Participants’ Assessmentof Training*

*Based on 5-point Likert Scale (1=Poor, 5=Excellent)

Anne M. McDonnell, PharmD, MBA, BCOP, CPPS - Ambulatory Medication Safety PharmacistSonali P. Desai, MD, MPH – Medical Director of Ambulatory Quality and Safety

Development of a Pharmacist-Led Ambulatory Medication Safety Program

Mass General Brigham Hospital

AIM: Reduce ambulatory medication errors and improve medication use at a large academic medical center

TEAM:

Caryn Belisle, RPh, MBA Heather Dell’Orfano,

PharmD, BCPS, CPPS John Fanikos, RPh, MBA Hojjat Salmasian, MD, PhD Kreager Taber, BA

INTERVENTION: The pharmacist provides intensive medication list management and diabetes management for primary

care patients, through provider-referral and a high-risk registry Using electronic health record tools, we will work to improve laboratory screening and vaccination rates

for patients on immune modifying agents Pharmacist reviews and responds to all ambulatory medication safety reports in collaboration with the

BWH safety team

IMPACT: We have identified over 7,100 patients per year who may benefit from the ambulatory safety pharmacist: 1,000 primary care patients, including diabetics as well as 6,000 immunosuppressed patients. Within two primary care clinics, a pharmacist-led model of care can decrease risk of medication errors through intensive medication management with the care team. CONSIDERATIONS FOR SPREAD: This novel program can decrease medication errors in the ambulatory setting leveraging an electronic patient registry of high-risk patients coupled with a pharmacist-led intensive medication management program in primary care and specialty practices. The pharmacist role has broad applicability at the health system level and can be spread through MGB Healthcare System.

RESULTS:

PROBLEM: Based on CRICO benchmarking data, approximately 50% of ambulatory medication events occur in the ambulatory setting

Metric

Total NumberAll Sites During Pilot

(11/19 to 2/20)Patients seen by

Pharmacist 45No-show patients 19Provider referrals 21

Pharmacist interventions 192

Translator needed 21

Define need & role for ambulatory safety pharmacist (ASP)

Collaborate across PHS enterprise and safety

leaders

Identify key areas of improvement opportunity

Begin establishing ASP initiatives

AIM: • To develop patient engagement tools that foster self- and team- initiative for enhanced recovery after surgery. • To collaborate with frontline staff members to generate resources that will set precedence as best practices

across the organization and disseminate shared learnings.

Enhanced Recovery After Surgery (ERAS): The Era of Patient EngagementNacim Iranmanesh, MPH, CPPS, DHSc(c) – Clinical Pathways Program Manager

TEAM: o Surgeonso Anesthesiologistso Nurseso Nutritionistso Clinical Pathways Team Members

INTERVENTION: • Frontline staff members in collaboration with the Department of Quality and Safety, Clinical Pathways team

members used hospital practices and ERAS guidelines to develop laminated placemats and self-paced surveys to empower the patient in their rehabilitation.

• These tools are introduced in the pre-operative stage of the patient’s journey and re-introduced during the post-operative phase on the inpatient floors when their Nurse reviews the items and inquires for their responses in completion of tasks.

• By creating these tools, patients had a resource at hand that clearly defined their discharge expectations and what their providers were looking for in their recovery as well.

IMPACT: Increased preoperative carbo-loading treatment Reduced length of stay Informed patients throughout the whole process Anecdotally happier patients due to improved quality of

life

CONSIDERATIONS FOR SPREAD: These patient engagement tools are easily reproducible and can be shared with other institutions through appropriate intellectual property channels.

Within our network, current inpatient floors with ERAS Pathways have received the patient engagement tools and all new Pathways and inpatient floors will be receiving a packet with this information.

RESULTS:

PROBLEM: The ERAS pathway is dependent on collaboration and engagement of all stakeholders – specifically the patient. The memorization of ERAS pathway care can be overwhelming for some so providing materials in a patient’s preferred learning methodology can impact the patient’s overall healing process post-operatively.

40%

50%

60%

70%

80%

90%

100%

Feb-20n=62

Mar-20n=64

Apr-20n=9

May-20n=38

Jun-20n=20

Jul-20n=21

Impact of Preadmission Patient Education on Preoperative Oral Carbohydrate TreatmentColorectal Service Line Only

Preadmission patient education Preoperative oral carbohydrate treatment

*Post-June 2020 data reflects a 30% sampling volume.

Kristin Tuiskula, PharmD, RPh – Clinical Coordinator, Medication SafetyParita Chowatia, PharmD, RPh – Attending Clinical Perioperative Pharmacist

Evaluation of promethazine injection use to meet a Targeted Medication Safety Best Practice from the Institute for Safe Medication Practices (ISMP)

AIM: By December 2018, comply with the ISMP Targeted Medication Safety Best Practice 13: Remove injectable promethazine from all computerized medication order screens, and from all order sets and protocols.

TEAM: Anesthesia Providers PACU Nurses Perioperative Pharmacists Jacqueline MacCormack-Gagnon, PharmD, BCPSJevon Oliver, PharmD, MSCPO Quality, Safety and Regulatory Committee

INTERVENTION: Initial medication use evaluation conducted and identified perioperative area as a high usage area for

injectable promethazine via preliminary review of inpatient medication orders Injectable promethazine removed from all post-operative computerized medication order sets Promethazine order entry functions modified to force Intravenous (IV) doses to be mixed in 50 mL

normal saline Targeted education provided to all Post Anesthesia Care Unit (PACU) staff about the ISMP

Targeted Medication Safety Best Practice and risks associated with injectable promethazineMedication guidelines updated to reflect risks associated with injectable promethazine

IMPACT: In a survey from ISMP, 1 in 5 respondents (out of a total of almost 1,000) reported awareness of an adverse event related to injectable promethazine within the prior 5 years at their institution Removing promethazine injection from post-operative order sets decreased use by ~90%

CONSIDERATIONS FOR SPREAD: Promethazine injection removed from post-operative computerized medication order sets at all institutions Other sites may benefit from evaluating their medication guidelines, providing targeted staff education, and conducting a drug use evaluation Another evaluation will be conducted 2 years post implementation to evaluate trends and identify further opportunity to reduce use

RESULTS:

PROBLEM: Medication safety coordinators identified non-compliance with a newly introduced ISMP Targeted Medication Safety Best Practice.

60

7

0

10

20

30

40

50

60

70

Pre Removal from Order Set Post Removal from Order Set

Num

ber o

f Adm

inis

trat

ions

Injectable Promethazine Administrations in PACU

Implementation of a Pharmacist-Led Inpatient Warfarin Management Service

Purpose: Warfarin therapy is used in the treatment of atrial fibrillation, venous thromboembolism, mechanical heart valve implantation, and other hypercoagulable conditions. Warfarin has a narrow therapeutic index and is associated with complex medication dosing, the need for close monitoring, numerous drug-drug and drug-food interactions. Pharmacist-driven warfarin management has been shown to decrease the time international normalized ratio (INR) is out of range, which results in better quality and safety outcomes. The purpose of this study is to assess the effect of implementation of a new pharmacist-driven warfarin management service on two inpatient medical units. This novel service provides a safe and effective method for initiating and maintaining desired anticoagulation response with warfarin compared to the standard of care (physician driven anticoagulation management). Dosing, time in therapeutic INR, percent of patients with therapeutic INR on discharge, bleeding/thrombosis events, and counseling on new warfarin therapy over the 8-month pilot period were measured. Interventions: Adult general medicine patients on two units Ellison 12 and Bigelow 9 were enrolled. Once a patient is enrolled in this polit, the pharmacist will immediately assume the responsibility for assessing and providing dosing for warfarin based on information given by the provider and/or obtained from the patient’s chart (i.e. indication, age, albumin, baseline INR, interacting medications, renal function, previous warfarin history etc.), and the pharmacist will enter warfarin orders and write daily progress notes in EPIC with dosing recommendations. The pilot units will be compared to control units with similar patient populations on warfarin therapy that was solely managed by the providers.

Results: Preliminary results are n=34 (control) and n=45 (study) with time in therapeutic range 40.68% (control) vs. 53.42% (study), and therapeutic INR at discharge 44.12% (control) vs. 60% (study) with no differences in the bleeding or thrombosis events, with 0% patients on new start warfarin received medication counseling (control) vs. 35% patients received counseling (study). Further analysis will be done looking at the drug-drug interactions and appropriate dose adjustments made by pharmacists.

Impact to Patients: Increased time in therapeutic range 12.74% with no increased risk of thrombosis or bleeding in study group with additional benefits on patient counseling by the pharmacist prior to their discharge

Considerations for Spread: Yes – it is applicable to other institutions as a part of best practice to optimize anticoagulation in patient populations for better safety and efficacy outcomes as well as improved patient satisfaction and education.

Sandra Silvestri, MS, RN , CNOR Nursing Practice SpecialistMaureen Hemingway, DNP, RN, CNOR Nursing Practice Specialist

Implementing a Hazardous Drug Protocol in the Perioperative Environment

Massachusetts General HospitalPerioperative Services

AIM: Ultimate Goal: Protect our employees from unnecessary exposure to hazardous drugs that may cause health issuesWith proper protective equipment and safe work practices, employees should be minimally exposed to hazardous drugsFuture state: Once fully implemented, will determine if the hazardous drug safety program is effective by testing for surface contamination, both within the pharmacy and around the hospital

TEAM: Laura Meleis Pharm D, MS BCPSJevon Oliver PharmD, MSStaff NursesSurgical Technologists

INTERVENTION: Perioperative Specific ProceduresWhen hazardous medications are brought from the pharmacy to the operating room area, they must be placed in a segregated area that denotes it is a hazardous medication until the medication is ready for administration in the operating room suite.

Hazardous medications must not be comingled with non-hazardous medications and must not be placed around the nursing stations and other areas outside of a designated area where potential surface contamination can spread.

Place a “Caution – Chemotherapy in Use” sign on the door of the OR when administering antineoplastic chemotherapy.All antineoplastic chemotherapy drug waste and supplies must be disposed of in a yellow waste bucket.All PPE worn while handling hazardous drugs and hazardous drug waste must be removed and discarded prior to leaving the OR to reduce exposure and contamination in other parts of the operating room suite.Instrumentation flagged at end of case

RESULTS: Use of hazardous drug carts with required PPE for all staff

PROBLEM: The U.S. Pharmacopeia (USP) is implementing new standards to address safe handling and administration of hazardous drugs for healthcare workers. As an academic medical center, our cancer patients are increasingly treated with chemotherapeutic agents as part of their surgical procedure with unique ways of delivering the medications. These factors have implications to the Perioperative team. In response to the new USP regulations, a detailed plan was developed and implemented to comply with regulations to effectively care for our patients and assure staff safety in the perioperative areas.

Improving CAUTI/CLABSI Awareness and Prevention through Multidisciplinary Engagement

Casey McGrath, RN, MSN; Kristen Diblasi; Amy Bulger, RN Marc Pimentel, MD Maria Bentain Melanson, RN Meghan Baker, MD Leena Bower, RN

Brigham & Women's Hospital / BWPO

Aim: Ensure all levels of the organization are made aware in a timely manner when a CAUTI/CLABSI occurs on their unit; Ensure timely local huddle to review cases and develop lessons learned/action plan for future prevention; Share lessons learned across organization

Interventions: Developed a Safety Huddle Program; CAUTI/CLABSI when identified to ID are reported to local leadership; reported out at hospital-wide Safety Huddle with call for local huddle; Local huddle conducted and results shared at next Safety Huddle; lesson learned compiled and QI efforts scoped

Summary of Results: Pilot transitioned to hospital-wide efforts in November; 25+ local huddles conducted improving awareness and identifying improvement opportunities

Description of Impact to Patients: All patients with an indwelling line have the potential to benefit from this project

Consideration of Spread: Process can easily be spread to other organization.

Maryam Alobaidly, PharmD, MSc - Department of Quality and Safety FellowSonali Desai, MD, MPH - Medical Director of Ambulatory Quality and Safety

Improving Vaccination Rates in Rheumatology Patients on Immunomodulators

AIM: Identify rheumatology patients on Disease-modifying antirheumatic drugs (DMARDs) in order to improve vaccination rates in the future using a nurse driven protocol.INTERVENTION:

RESULTS: The three most common diagnoses were inflammatory arthritis (including all subtypes), lupus, and ankylosing spondylitis. Median age was 58 years and 76% were female.

PROBLEM: Rheumatology patients on immunomodulatory therapies have increased risk of vaccine-preventable diseases.

Vaccinations Number (%) of Patients Vaccinated Additional Patients to be Vaccinated per Month

Influenza (n=386) 202 (52.3%) 184 (47.7%)

One dose of Pneumococcal (n=386) 308 (79.8%) 78 (20.2%)

Both doses of Pneumococcal (n=386) 265 (68.7%) 121 (31.3%)

One dose of Zoster (n=271) 122 (45%) 149 (55%)

Both doses of Zoster (n=271) 38 (14%) 233 (86%)

Total for all three vaccinations: 765

Total without influenza: 581

TEAM: Anne McDonnell, PharmD, MBA, BCOP, CPPS

Mary Amato, PharmD, MPH, FCCP, BCPS

Kate Ulbricht, PharmD, MBA, CPPS

Department of Quality and Safety (DQS) pharmacy interns

IMPACT: Using this interdisciplinary model, we expect increased vaccination rates, workflow efficiency, patient and staff satisfaction. Increased vaccination rates can positively impact quality of life, morbidity and mortality rates, in compliance with American College of Rheumatology ACR recommendations.

SPREAD:The long-term goal is to spread this cost-effective patient safety model across additional Mass General Brigham entities.

EHR reports identified patients on

immunomodulatory agents in BWH

rheumatology clinics during April 2019

Identify Patients

DQS Fellow and interns conducted chart reviews to

establish baseline vaccination rates

Chart Review

Goal to implement nurse driven protocol

to improve vaccination rates

Nursing Collaboration

Bridgit Holemo, BSN, RN- Director, Clinical ComplianceJohn Belknap, MPA- Chief Compliance OfficerPatrick Adams, BSN, RN

Victoria Carrabino, MBAYordanos Girmai BSN, RN, MBA

MGH Excellence Every Day Tracer Program

Massachusetts General Hospital

AIM: Tracer visits are designed to observe, educate, and reinforce best practices in real-time with caregivers. In 2018, the Excellence Every Day (EED), Everywhere Tracer Program expanded to include Massachusetts General Physicians Organization private practices to provide a unified MGH-MGPO approach to clinical and environmental surveillance and to ensure a single standard for quality and safety in our clinical practices.

TEAM: Infection Control, Central Sterile Processing, Pharmacy, Information Systems, Materials Management, Buildings and Grounds, Biomedical Engineering, Clinical Compliance, Environmental Health and Safety, Police and Security, Lab, MGH eCare, Patient Care Services, Physicians.

INTERVENTION: Due to this expansion in areas visited and diversification of tracer team members, the data collection has grown exponentially. To track and prioritize data to better meet the needs of the institution we have collaborated with the MGH Laboratory of Computer Science (LCS) to build a homegrown data management application. Through this system, all information collected by tracer teams throughout the hospital, including smaller focused task force groups, will be maintained in a central location. This collaboration will facilitate automated reports that will be distributed to leadership and will promote sustainability of the program. The data extracted from this program drives process improvement initiatives to promote continuous enhancements at MGH.

IMPACT: The MGH EED tracer program strives to improve quality and safety for patients at MGH. The tracer program results also provides the institution with focused areas for quality and safety performance improvement targets. This strategy for performance improvement has been a key success factor during our triennial Joint Commission surveys.

CONSIDERATIONS FOR SPREAD: We would like to share this application across Mass General Brigham with other institutions that are interested.

RESULTS: In 2018, we completed 148 tracers across MGH, in 2019 we had 193 tracers completed.

Insert graph

PROBLEM: The tracer program has grown by over 250 percent over the past 3 years. With growth came a significant influx of data. Managing the data for the nearly two hundred tracer visits has proven challenging.

John Phillips, MD – Radiation OncologistTara Kosak MEd, RTT(CT) – Quality & Safety Program Manager

Prospective Peer Review for Stereotactic Radiation Therapy Treatment

Dana Farber/Brigham & Women’s Cancer Center

AIM: To provide prospective peer review for all stereotactic radiation therapy contours and treatmentplans in advance of treatment delivery

TEAM: Peter Orio, DO Daniel Cail, MSKevin Beaudette, MSClay Houghton Holdsworth, PhD Candy Zanelli, CMD

INTERVENTION: Patients receiving stereotactic radiation therapy treatment were identified in advance oftreatment and presented for prospective peer review in a weekly meeting with radiation oncologists,physicists, dosimetrists and radiation therapists. A standardized approach for presentation was utilized toensure that each case had a uniform and thorough review. Physicians treating these cases were requiredto attend and present their cases to the group as well as peer-review other physician cases. No case wasallowed to be treated without peer review approval from another physician.

IMPACT: Prospective Peer Review for Stereotactic RadiationTherapy was implemented in March 2019. As of August2020, 405 cases have been presented and peer reviewed.As a result, 74 cases have been revised resulting in animproved treatment plan, potentially reducing morbidityand improving overall quality of treatment. In addition topatient impact, these rounds have served as aneducational platform to physicians and treatmentplanners that are less experienced with this modality oftreatment. Several innovations in our stereotacticprogram have stemmed from peer discussions at thisweekly meeting.CONSIDERATIONS FOR SPREAD:Prospective Peer Review for Stereotactic RadiationTherapy treatment is currently conducted at all networkdepartments. This forum could be expanded to includemain campus sites in Boston. Additionally, prospectivepeer review could be extended to all disease sites andmodalities of treatment.

RESULTS:

PROBLEM: Stereotactic radiation is a high stakes treatment with the need for tight quality control. Thesetreatments are typically peer reviewed after one or more treatments are delivered which prohibits theability to make revisions in advance of dose delivery.

CL 0.1827

UCL0.4820

0.000

0.100

0.200

0.300

0.400

0.500

0.600

Revi

sion

s -

% C

hang

e

Mar-19 - Aug-20

Revisions -% Change p Chart

Kathy Armando, BSN, RN, Clinical Leader karmando@bwh.harvard.eduAmie Kandalaft, RN, Clinical Nurse

Reducing Cancellations in Outpatient Spinal Cord Stimulator (SCS) Trials through Patient Education

AIM: Reduce the number of outpatient cancellations for patients scheduled for a SCS trial through patient education.

TEAM:

Kathy Armando, BSN, RN

Michelle Dixon, BSN, RN

Laurie Flahive, BSN, RN

Mohammed Issa, MD

Amie Kandalaft, RN

Kathy Merrigan, MSN, RN

INTERVENTION: Nurses developed a patient self-report questionnaire to evaluate knowledge level regarding SCS trial process.Patients were scheduled for a pre-procedure appointment. During this appointment:• Patient completes the questionnaire to establish baseline knowledge about the SCS trial• Nurse educates patient, including review of pre-procedure instructions, frequently asked questions, how to

complete a pain diary, how to access device educational video website• Vendor and physician meet with patient to support any further education On the day of trial, patient completes the self-report questionnaire prior to the SCS trial to evaluate knowledge level

IMPACT • Zero SCS Trial patient cancellations

March 2017-July 2020 (n=75)IMPLICATIONS FOR PRACTICE• Standardized pre-procedure

education is effective in increasing patient knowledge thereby decreasing procedural cancellations

• Nurses in all ambulatory practice settings have a responsibility to ensure that patients receive appropriate, evidence-based, pre-procedure education

• Pre-procedure education for patients undergoing SCS trial is now an established practice and component of the SCS Trial Protocol

• Program disseminated to the BWH Pain Management Department

RESULTS: Results demonstrate that patient education prior to the SCS trial was successful in improving knowledge regarding the SCS trial process resulting in zero procedural cancellations.

PROBLEM: Over 3 months, 100% of SCS trial procedures (n=5) had been cancelled due to a lack of patient knowledge regarding pre and post SCS trial process. Cancellations resulted in decreased patient satisfaction and loss of revenue.

Revisiting Neuromuscular Blocker (NMB) Safety: using updated best practices after a serious, published Vecuronium error at an

outside institution

Tanya J. Aray, PharmD; Kristin Tuiskula; Laura Meleis; Jevon Oliver; Bryan Hayes; Russ Roberts; Ben Pennell

Massachusetts General Hospital / MGPO

Aim: To reduce the risk of NMB errors by reevaluating & expanding our compliance with updated best practices by December 31, 2019.

Interventions: After the 2019 report of a fatal medication error when vecuronium was mistakenly administered instead of Versed (midazolam) at a prominent medical center, a multidisciplinary NMB workgroup reevaluated our compliance with updated best practice recommendations. Institute for Safe Medication Practice's (ISMP) high alert medication self-assessment & 2018-2019 Targeted Best Practice # 7, Segregate, sequester, and differentiate all neuromuscular blocking agents (NMBs) from other medications, wherever they are stored in the organization were assessed .

Summary of Results: Eight new strategies & best practices were implemented:

• To reduce the chance of mix-ups and standardize practice, ten (13%) NMB storage locations were eliminated in our critical care, emergency department (ED), and neonatal/pediatric units. Additionally, all pediatric units standardized practice to use rocuronium as a first line agent. Three medication automated dispensing cabinet (ADC) override list changes were made with rocuronium replacing vecuronium.

• This drug class was added to our high alert medication policy to describe risk reduction strategies and alert staff of the increased risk of patient harm when used in error.

• A new comprehensive, medication guide was created to provide monitoring parameters, precautions in special populations, & to emphasize safe practices for this high alert medication.

• Lidded "High Alert" bins were set up in refrigerated storage locations to prevent inadvertent mix-ups.

• Interruptive electronic ADC alerts, "Warning: Paralyzing agent...Patient must be intubated" were added.

• A more descriptive auxiliary sticker is being affixed to all NMB vials. • Targeted strategies for the perioperative area, including segregated storage with high alert

medication labeling in the OR pharmacy and NMB warning labeling on medication kits.

Description of Impact to Patients: ISMP has received over 100 reports of accidental administration of NMBs over more than a decade of safety publications, with serious adverse effects including fatalities. By employing multiple safety strategies, we can reduce the risk for error to providers, and create a safer environment for patients.

Consideration of Spread: Safety strategies and best practices were shared and applied to offsite MGH locations. Partners sites have expressed interest in collaborating on high alert medication strategies, and are moving towards a shared high alert med list that could lead to additional safety strategies within information systems.

Allison Doney, MHA – Sr. Q&S Administrative Manager Jeremi Mountjoy, MD – Associate QA Director

Streamline Perioperative Transfusion Systems (SPOT)

MGH

AIM: Improve understanding of the blood product request process by 40%.

TEAM: Adam Dalia, MDSusan Maher, CRNANancy Wyman, RNKathy Kong, MPHMaureen Hemingway, RNChristina Shin, MD

INTERVENTION: A pre-intervention survey was sent to the Anesthesia department to collect baseline data of clinician’s understanding of the process in the blood bank after requesting blood or blood products, what to do if you need blood emergently, what to do during downtime, and what to do with unused products. The Quality and Safety Improvement Committee then put together a frequently asked questions document to live in our departments electronic site (Ether Wiki) as well as an emergency blood product packet to be placed in each of the OR’s. The packet contains a process map on obtaining blood product in the OR, the emergency blood order and pick up slip, the specimen tube required to collect and send a blood bank sample and downtime forms when the Electronic ordering system is down.

IMPACT:

Understanding the correct process in the bloodbank after requesting blood or blood products reduces confusion during critical events andfacilitates timeliness of obtaining blood andblood products.

CONSIDERATIONS FOR SPREAD: An institution specific packet and AQ document could be rolled out.

RESULTS:

Problem: Clinicians are not familiar with emergency blood procedures and downtime blood procedures.

6%21%

43%

22%7%0%

20%

40%

60%

80%

100%

ExtremelyConfident

VeryConfident

SomewhatConfident

Not soConfident

Not at allConfident

How Confident is your understanding of the process in the blood bank after you have

requested blood or blood products?

Utilizing the EHR for Care Improvement

Expanding the Outpatient Parenteral Antimicrobial Therapy Interdisciplinary Team to Include Inpatient Infectious Disease

Pharmacists

Meagan Adamsick, PharmD; Ronak Gandhi, PharmD; Samantha Steiger, PharmD; Monique Bidell, PharmD; Sandra Nelson, MD; Kevin Ard, MD; Ramy Elshaboury, PharmD

Massachusetts General Hospital / MGPO

Aim: To measure the impact of inpatient infectious diseases (ID) pharmacists as a member of the Outpatient Parenteral Antimicrobial Therapy (OPAT) Program on the management of outpatient vancomycin at Massachusetts General Hospital (MGH).

Interventions: In June 2017, the OPAT team, including ID physicians and clinic nurses, incorporated inpatient ID pharmacists to assist with outpatient intravenous (IV) vancomycin management. ID pharmacists assess vancomycin plasma concentrations and weekly surveillance laboratories. Recommendations for dose adjustments and monitoring are documented in a note in the electronic medical record (EMR) for review by the OPAT team.

Summary of Results: A sample of 100 patients each from June 2016 through May 2017 and June 2017 through May 2018 served as a control group and intervention group, respectively. The percentage of vancomycin levels within the patient-specific goal range was significantly higher in the intervention group compared to the control group (66.8% vs. 54.2%, OR 1.70, 95% CI 1.31-2.21, p<0.0001).

Description of Impact to Patients: As of October 2019, ID pharmacists supported 484 unique patients (1,518 documentations). In this analysis there was no difference in the development of acute kidney injury between the groups however, fewer patients in the intervention group had a vancomycin serum concentration greater than 25 mcg/mL (24% vs. 29%, OR 0.77, 95% CI 0.41-1.45, p= 0.52). The percentages of patients who experienced adverse drug events (39% vs. 43%; p = 0.66) and hospital readmission (5% vs. 13%; p = 0.08) were similar between the two groups. A detailed analysis of each hospital readmission was performed and readmissions due to adverse drug events were similar between the groups and other episodes were often due to non-infectious reasons.

Consideration of Spread: Incorporation of a similar service at other Partners facilities would require assessment of current workflow of individual OPAT programs. At MGH, ID pharmacist integration was accomplished via remote assessment and largely electronic communication. Capability for remote support without requirement for pharmacist presence in the clinic can facilitate implementation of similar services.

First Look at Epic Predictive Models

Sayon Dutta, MD MPH; Dustin Mcevoy; David Rubins, MD; Ronelle Stevens; Julia Haywood; Timothy Stump; Steven Le; Jacqulene E. Brzozowski; Zbigniew Lech

Partners HealthCare

Aim: The aim of this presentation is to describe the build, validation, and deployment of the Epic-released predictive analytics models - specifically models for the early detection of sepsis, remaining inpatient length of stay, and readmission risk. These machine learning models have the advantage of being able to evaluate dozens (if not hundreds) of clinical variables, and therefore can provide insight into a patient's condition that may be difficult for a clinician to identify.

Interventions: Beginning in 2019, Partners eCare began developing several Epic-released predictive models. These models aim to make predictions in near real-time of future events such as the development of sepsis, no-show for an ambulatory appointment, or readmission to the hospital after discharge. We will describe how these models were built within Partners, how well they perform on real patient data, and how they are implemented across the Epic build. We will discuss the pros and cons of using models trained with external data, and discuss plans for future model development. We will provide examples of potential implementations for each model within Epic, and describe how decisions around implementation were made in consideration to provider workflows.

Summary of Results:

Early Detection of Sepsis: The sepsis detection model uses a penalized logistic regression model that evaluates greater than eighty clinical variables for every ED and hospitalized patient every 20 minutes. Using the CDC objective standard definition of sepsis, we found that the Epic model has a PPV of 8%, and a C-statistic of 0.76. We are currently comparing the performance of this model against the existing rule-based early sepsis detection BPAs that are currently in the system. The model may eventually replace the existing BPA altogether, or we may utilize the model prediction in combination with existing logic of the current alerts.

Readmission Risk: The readmission risk model uses a logistic regression model that evaluates demographic and clinical variables and creates predictions three times a day for each hospitalized patient. We found the model had a PPV of 20% and a C-statistic of 0.70. When compared to the existing readmission risk model that was in the system, the R2 was 0.635. After discussion with clinical leadership, the Epic machine learning model replaced the existing rule-based model. An model that is trained using internal data is under development.

Remaining Length of Stay: The remaining length of stay model uses a general linear model to create a prediction of remaining inpatient days. The model creates predictions three times a day between 24 to 96 hours of each hospitalized patient. When the predicted discharge date was compared against the actual discharge date, the model predicted a later discharge date by a median of 0.91 days. The model

guessed the exact discharge date 11% of the time, and was within a +/- 3 day window 70% of the time. The model performed less well for longer lengths of stay. Additional analysis of the model's performance is ongoing, but for now the calculated remaining length of stay according to the model is available for case managers in patient lists.

Description of Impact to Patients: Only two Epic-released predictive models have been implemented into production, and only within the last month, so it's still too early to evaluate the full impact they are having. Ideally, we envision these models as providing additional information to treating providers in their clinical decision making. The early detection model could prompt the earlier initiation of antibiotics, while the readmission risk model might result in more robust discharge planning by case managers when warranted. As our experience with predictive models at Partners is still early, we will provide data on the impact these models have made at other health systems that implemented them.

Consideration of Spread: As these predictive models are built within Epic, their implementation across the enterprise is relatively straightforward. Two of these models already have enterprise-wide dissemination, and as additional models are built and validated, they will also have enterprise-wide implementation.

Adrienne Allen, MD - SponsorStacey Pappacostas, Director of Business Support & Innovation – Workshop LeadKendra Bird, Senior Improvement Specialist – Team Lead

Hypertension and Medication Refill Management

North Shore Physicians Group

AIM: Lead time: reduce the time between when patient is due for BP reading to when the patient is at goalSub-lead time: reduce the time between when a patient is due for a BP reading to when the patient is contacted via outreachWork in process (WIP): decrease the number of patients not at goal per week

TEAM: Colleen Koscielecki, Process OwnerSandy Skinner, RN, Process OwnerMeaghan Kearns, MD, Process OwnerEmilie Maloy, PharmD, Process OwnerDeb Clemenzi, Process OwnerAllison Morrissey, Team MemberThao Nguyen, Team MemberDaphkar Pelletier, Team MemberGina Testaverde, RN, Team MemberChristine Roberto, RN, Team MemberKristin Aveni, Team MemberKate Anno, Patient, Team Member

INTERVENTION: Leverage Epic Medication Refill Protocols – these help improve the efficiency and quality of the refill process by checking the refill request against pre-set criteria for visit schedule, labs, or other monitoring parametersCreated .RXTOOL smartphrase which helps address overdue/almost overdue blood pressure readings during every refill Leverage MA and PSR Pools in Epic to facilitate communication between the population health coordinators and office staff. Allow sites to spread outreach work across the entire team. IMPACT:

This process will significantly improve the patient experience, their safety, and clinical outcomes.

It will build upon the current performance of the Gemba team and help to further develop a process that can be universally applied to all NSPG primary care practices and some specialty practices. The areas of impact will be:1. Increased capture of blood pressure values2. Elimination of batching, moving to a daily production management system3. Just in time registry management4. Standard work for just in time medication refill management for all hypertensive patients

CONSIDERATIONS FOR SPREAD: The spread of this process can be helpful to other chronic diseases. We aim is to use this process to track our diabetes patients with a focus on capturing the patient A1C when due and to also include patient outreach and coaching

RESULTS: HTN & Med Refill Management – 60 Day Remeasures

PROBLEM: Patients are at risk for Cardiovascular disease and Stroke when blood pressure exceeds 140/90. In NSPG there are approximately 28,275 patients on the registry. Sites are currently using a batch process to manage the patients who are not at goal for a blood pressure. Batching Population Health lists creates the possibility for missed opportunities to capture a blood pressure reading. There is variation in how the medication refill protocols are followed for hypertensive patients. Often medications are refilled without outreach to patients despite patients being over due for a BP reading or not being at goal for BP

15

38

55

40

35

2522

28

0

10

20

30

40

50

60

Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20

Number of Patients Identified by JFC Malnutrition Screen

Erin Gordon MS, RD, LDN, CDE Riley Mahan MBA

Identifying Pediatric Oncology Patients in Need of Nutritional Consultation

Dana-Farber Cancer Institute

Problem: Poor nutritional status can greatly influence attainable, relevant and time bound patient clinical outcomes and quality of life during and after cancer treatment. Pediatric oncology patients are particularly vulnerable to malnutrition due to the disease and its associated treatment. At the Jimmy Fund Clinic (JFC) of Dana-Farber Cancer Institute, there is not a routine, systematic process to identify malnourished patients or those at risk for malnutrition.

TEAM: Oliver FriedmanElizabeth Hill

INTERVENTION: To identify malnourished patients in the JFC a weekly report is generated from the electronic medical record (EMR) to provide anthropometric data on every patient seen within the clinic in the past week. The initial report contained the patient’s age and BMI z-score, an indicator of malnutrition. The dietitian at JFC reviews this report weekly and identifies patients at risk for malnutrition using a cut off z-score value of <-2, a value suggestive of moderate malnutrition. Over the course of this pilot an additional indicator was added to the report, the BMI value, in order to more appropriately screen patients above the age of 18. For adults over the age of 18, a BMI <18.5 kg/m2 is considered underweight. Using the JFC QueueView electronic communication system, the dietitian notifies the care team if the patient is identified to be at risk for malnutrition / underweight. With medical team consent, the patient is scheduled for a nutrition consult and a full nutrition assessment is conducted. The use of this screening tool identified on average ~32 patients a month who would benefit from further nutritional assessment.

IMPACT: The use of a screening tool to identify malnourished patients targets efforts to improve quality of care delivered to pediatric oncology patients based on their need for nutritional interventions during treatment. Notifying care teams of a patient’s nutritional status increases interdisciplinary management and increases nutrition services utilization.

CONSIDERATIONS FOR SPREAD: An electronic report derived from an EMR can easily be adapted at pediatric and adult treatment programs to determine those at risk for malnutrition.

*The months outlined in red signify impact from COVID-19, which resulted in an increase in virtual appointments and decline of in-person visits to the JFC, thus not providing necessary BMI inputs into the EMR to allow nutritional screening.

AIM: Pilot a screening tool to increase identification of patients at risk for malnutrition and subsequently, increase the rate of nutrition appointment utilization.

BMI value added to weekly report

Improving CAUTI measurement by Urine Culture Reflex Testing

Marc Pimentel, MD, MPH, CPPS; Casey McGrath; Kathleen Avery; Athena Petrides; Kristen DiBlasi; Michael Klompas

Brigham & Women's Hospital / BWPO

Aim: The project aimed to increase urine culture appropriateness to 90% (% resulted urine culture with positive urinalysis, in catheterized patients) and eliminate CAUTI with false-positive urine culture within 3 years.

Interventions: Interventions:

1. Created a new BWH policy for prevention of unnecessary urine culture testing. 2. Modeled the change by hiring Infectious disease fellows to pending urine cultures daily and

having a discussion with interns to cancel the culture if the urinalysis had a WBC <10. 3. Created an automated process for handling a combination urinalysis with reflex urine culture

test in the lab. 4. Introduced new containers for both the urinalysis and urine culture specimens, with a culture

tube containing a preservative to prevent bacterial overgrowth. 5. Used an Epic BPA to redirect users to use the reflex urine culture test instead of the standalone

urine culture test. 6. Implementing an IS solution in the lab that allowed urinalysis and urine culture samples to be

collected and sent simultaneously by clinicians to the lab, but did not allow for processing of the urine culture unless the urinalysis resulted as positive.

Summary of Results: Within a few months of implementing our initial unnecessary urine culture reduction program with the calls from infectious disease fellows, our observed CAUTI rate dropped by 30%. Following the rollout of the automated process in 2019, the appropriateness of urine culture testing increased from ~50% to greater than 90%.

Description of Impact to Patients: As a result of the new automated workflow, there have been zero CAUTI with false-positive urine culture at BWH, with a presumed reduction in unnecessary antibiotic treatment.

Consideration of Spread: Following the success of this project, this new process is in the process of being implemented across BWH ambulatory areas over the next year. Considerations for spread include the availability of specimen collection containers and readiness in the laboratory for reflex testing workflows and lab IS.

Hojjat Salmasian, MD, PhD, Medical Director, Data Science & Analytics (BWH)David W. Bates, MD, Chief, Division of General Internal Medicine (BWH)Elizabeth Mort, MD, Senior VP Quality & Safety (MGH)

Measuring Harm in the Safe Care Project: Determining Incidence of Inpatient Adverse Events (AEs) in a Pilot Chart Review

Brigham and Women’s HospitalMassachusetts General Hospital

AIM: Determine the incidence of inpatient AEs during 2018 in selected CRICO-affiliated institutions from a pilot sample of medical records, and assess inter-rater reliability among nurse reviewers.

TEAM:

NursesData AnalystsProgrammersResearch Assistants

INTERVENTION:• Developed AE coding scheme to classify patient harm using literature and expertise from team• Nurse reviewers were trained on the protocol for reviewing medical records and coding AEs • Physician reviewers will adjudicate cases identified by nurse reviewers to determine if an AE has

occurred, and, if so, determine whether the AE was preventable • In an initial pilot study, 90 medical records were reviewed to assess the incidence rate and types of

AEs. 54 of those records were randomly assigned to multiple reviewers to assess inter-rater reliability between 8 nurse reviewers

IMPACT:

• Understanding the risk of patient harm has the potential to impact local patient safety initiatives and improve patient care

• Given potential variation in nurse reviewer assessments it is important to conduct pilot studies and retrain as necessary to maximize consistent application of review methods

• The full study will review and adjudicate 5800 charts across the participating institutions to determine the overall AE rate in 2018

CONSIDERATIONS FOR SPREAD: • These AE data will help to inform an electronic

surveillance tool that will prospectively assess the frequency and types of harm for organizations to use in ongoing operations

RESULTS:

PROBLEM: Despite ongoing efforts to minimize adverse events, patient harm due to medical management continues to occur. Understanding the frequency and type of AEs is important to improving patient safety.

• Nurse reviewers conducted 252 reviews of 90 medical records • 36 charts read by only one reviewer each (N=36 reviews)• 54 charts read by 4 different reviewers each (N=216 reviews)

• AE rate among reviewers ranged from 15%-80% (# cases with >= 1 AE/total cases)• 7 reviewers reported AEs between 32%-80% of charts reviewed • 1 reviewer reported AEs in 15% of charts reviewed

• Inter-rater reliability kappa = 0.33; if we remove data from the reviewer with the lowest AE rate, the kappa increases to 0.63

• Nurses were encouraged to include all potential AEs

• The pilot study AEs have not yet been adjudicated by physician reviewers which is a critical step in determining final AE rates

Alice Lorch, MD, MPH – Chief Quality Officer, Department of Ophthalmology, Massachusetts Eye and Ear

Monitoring Ophthalmic Emergency Department (ED) Visits During the Coronavirus Pandemic

Massachusetts Eye and Ear

AIM: To investigate characteristics of reduced ophthalmic emergency visits during the height of the Coronavirus pandemic in Boston from April 1st to June 30th of 2020.

TEAM: Alice Lorch, MD, MPHNathan Hall, MSThong Ta, BS

INTERVENTION: Data from the emergency department was extracted from Epic to be analyzed for diagnoses, race, ethnicity, and insurance type forvisits of a 4 month period (April 1-June 30) for 2018,2019,2020. A 2-sample test for equality of proportions was used to compare prevalence of urgentdiagnoses presenting to the ED in 2018/19 and 2020. A negative binomial regression model was fit to investigate the effects of socioeconomic factorson patients presenting to the ED in 2018/19 and 2020.

IMPACT:While there was a significant decrease in the number of ED visits between April 1st and June 30th in2020 compared to 2018 and 2019, the distribution of urgent diagnoses remained similar to prior years.Even during a pandemic, patients still sought care from emergency departments for both urgent andnon-urgent issues. This suggests patient education is required to educate patients on appropriateemergencies. Pitfalls of self-diagnosing via internet queries should be addressed as well as they have animpact on emergency visits.

RESULTS: During a four month period (April 1-June 30) 2018 there were 3962 visits to the ED, 4144 visits in2019, and 2801 visits in 2020. After categorizing each year’s visits into urgent and non-urgent categories, theobserved percentages were 28.2%, 26.9%, and 30.6% for 2018, 2019, and 2020, respectively for urgentdiagnoses.

The top urgent diagnoses between 2018/2019, and 2020 were relatively similar (Table 2). A 2-sample test forequality of proportions was conducted for all of the top urgent diagnoses comparing the frequency of eachdisease in 2018/2019 to 2020. Of all the diagnoses, the only diagnosis with a significant p-value washerpesviral keratitis. Therefore, we can conclude that a significantly larger proportion of patients werediagnosed with herpesviral keratitis in 2020 as compared to 2018/2019.

A negative binomial regression model was fit on the data. The covariates included in the model were: yeargroup (2018/2019 or 2020), race, ethnicity, and insurance with interaction terms between year group andeach other covariate. The reference groups were 2018/2019, white, non-Hispanic, privately insuredindividuals for year group, race, ethnicity, and insurance, respectively. The covariates that were statisticallysignificant at the alpha = 0.05 significance level were ethnicity, race, and the interaction term between yeargroup and ethnicity = Unknown. The significance found within levels of ethnicity and race indicate thatadjusting for all other covariates in the model, minorities in both of these demographics are seen in the EDless than their majority counterparts. Of note, the statistically significant incidence rate ratio of theinteraction terms between year group and ethnicity = Unknown indicates that patients with Unknownethnicity in 2020 were seen at 7.99 times the rate of those seen in 2018/2019. Although, given the nature ofnot knowing these patients’ true ethnicity, it is difficult to draw clinically meaningful conclusions from thisresult without more information. Given that none of the other interaction terms were statistically significant,we can conclude that there was not a general demographic shift in Emergency Department patients duringthe height of the Coronavirus pandemic, when comparing 2020 to 2018/2019 patients.

CONSIDERATIONS FOR SPREAD:While this data set is specific to MEE’s ophthalmology EDpatients and ophthalmologists the data suggest a need foroverall patient health literacy, such that emergency servicescan be used appropriately.

Table 1. An incidencerate ratio test wascompleted comparingApril 1st – June 30th of2018 and 2019 to2020.

Table 2. A 2-sampletest of equality ofproportions wasconducted for April 1st

– June 30th for 2018and 2019 compared to2020. These were thetop five diagnosesbetween the threeyears.

DiagnosisProportion of 2018 & 2019

Proportion of 2020 P-value

Herpesviral keratitis 0.06 0.10 0.0157Unspecified corneal ulcer, right eye 0.10 0.10 0.9607Unspecified corneal ulcer, left eye 0.10 0.09 0.6538Unspecified iridocyclitis 0.18 0.17 0.7849Serous retinal detachment, right eye 0.10 0.07 0.2724Serous retinal detachment, left eye 0.08 0.05 0.0588Viterous hemorrhage, right eye 0.07 0.04 0.0659Diplopia 0.07 0.07 0.8316Foreign body in cornea, right eye, intitial encounter 0.13 0.16 0.1304Foreign body in cornea, left eye, intitial encounter 0.11 0.14 0.1053

Rate Ratio 95% Confidence Interval P-valueYear 2020 0.37 0.07, 1.93 0.239Ethnicity Hispanic 0.14 0.05, 0.39 <0.001Ethnicity Unknown 0.01 0.00, 0.03 <0.001Race Asian 0.12 0.03, 0.54 0.005Race Black 0.2 0.08, 0.52 <0.001Race Other 0.11 0.02, 0.59 0.01Insurance Public 0.84 0.37, 1.9 0.673

1.54 0.36, 6.56 0.5587.99 2.21, 28.93 0.0020.78 0.14, 4.36 0.781

0.6 0.14, 4.36 0.4850.67 0.07, 6.5 0.7270.61 0.13, 2.83 0.5311.01 0.33, 3.04 0.988

Year: 2020 & Race: UnknownYear: 2020 & Ins: Public

Parameter

Year: 2020 & Eth: HispanicYear: 2020 & Eth: UnknownYear: 2020 & Race: AsianYear: 2020 & Race: BlackYear: 2020 & Race: Other

Emilie Maloy, PharmD – Population Health Pharmacist

Opioid Monitoring Initiative

North Shore Health System

AIM: Increase compliance with opioid monitoring parameters for patients on the Chronic Opioid Registry. Initial focus is on Controlled Substance Agreements and urine drug screens for patients on Schedule II and III narcotics.

TEAM: Emilie Maloy, PharmDAdrienne Allen, MD, MPHRyan Gosselin, MD, MBA

INTERVENTION: In the initial stage of this project, the Chronic Opioid Registry report was used to identify patients on Schedule II and III narcotics. The list was sorted by upcoming appointment and the pharmacist added huddle notes to the schedule in Epic to alert the provider to overdue monitoring criteria. The second stage will include outreach for patients without upcoming appointments.

IMPACT: Opioids can be dangerous and addictive medications, even when used appropriately. Proper monitoring can help identify patients experiencing adverse effects or problematic behaviors so that treatment measures may be offered.

CONSIDERATIONS FOR SPREAD: The need for proper monitoring of patients on chronic opioids is system-wide; our approach could easily be applied at other sites.

RESULTS:

PROBLEM: Appropriate and timely monitoring of patients on chronic opioid medications is essential but identifying patients in need of monitoring can be difficult and time consuming for providers, potentially leading to reduced compliance with opioid refill parameters.

2

18

34

0 10 20 30 40

Patients brought into compliance

Patients with unmet protocolcriteria

Patients on chronic opioids

Opioid Monitoring InitiativeResults of Week 1

Anuj Dalal, MD – Principal InvestigatorKevin Carr – Systems Engineer

Patient Safety Learning Lab (PSLL): Improving Safety of Diagnosis and Therapy in the Inpatient Setting

Brigham and Women’s HospitalDivision of General Internal Medicine

AIM: To leverage the EHR to quantify and assess diagnostic errors in acute care; to design and develop interventions to mitigate risk of diagnostic error; to conduct an 18-month clinical trial to measure the effect of these interventions on diagnostic error rates

TEAM: Anuj K Dalal, MD Kevin Carr, MS David W Bates, MD, MSc Jeffrey L Schnipper, MD, MPH Ronen Rozenblum, PhD, MPH Pamela Garabedian, MS Kumiko Schnock, PhD, RN Daniel Motta-Calderon, MD Maria Malik Alison Garber Nick Piniella Kerrin Bersani Hannah Fraser Jacqueline Griffin, PhD

INTERVENTION: Diagnostic Time-out Card – “Pocket guide” to encourage physicians to step back and reconsider patients whose medical history or hospital course suggest risk for diagnostic error Patient Diagnostic Questionnaire – Used to evaluate patients’ understanding of their diagnosis and satisfaction with care team communication, to address any concernsDiagnostic Safety Dashboard Domain – An expansion of the clinician-facing Quality & Safety Dashboard application to flag patients at risk of diagnostic error in real-time, and provide suggested actions with Epic links Patient-Centered Group Chat – A “microblog”-style tool for care team members to discuss diagnostic concerns around a single patient, and reduce siloed communication

IMPACT:

Integrated use of all intervention components may reduce diagnostic error rates in high-risk patient cohorts, thus leading to decreased rates of preventable harm

CONSIDERATIONS FOR SPREAD:

Interventions will be integrated into the EHR for potential hospital-wide adoption Patient- and clinician-facing interventions will be accessible on mobile devices

RESULTS:

PROBLEM: Diagnostic error in acute care patients represents a common, costly, unresolved safety issue

Maria Malik – Research AssistantAlison Garber – Research Assistant

Our suite of interventions is organized via a new diagnostic safety column on our EHR-integrated Quality and Safety Dashboard (A), which flags red forpatients at high risk for diagnostic error. Clicking on a red flag opens a description of and justification for that flag status (B), with suggestions for clinicians tomitigate patient risk. Those suggestions could include taking a diagnostic time-out (C) or administering/reviewing a patient questionnaire (D).

A B

C

D

Rebecca Bruyn, RN, MPH, CPHQDavid Soprano, BSN, RN, CRRN, CPHQ

Preventing Device Related Pressure Injuries

Spaulding Rehabilitation Hospital Cape Cod

AIM: Ensure 100% of patients with devices are identified in the EPIC Splint/Brace Report within 24 hours of device implementation by March, 2020. Multidisciplinary team will complete daily skin assessment & documentation in EMR 90% of the time by June, 2020. SCC goal is to have ZERO device related HAPI for CY 2020.

TEAM: Laura Durgin, PTKelsey Pitts, MS OTR/LMatt Keilty, MS OTR/LSuzanne Harding, RN, CRRNLaurie Shippey, RN, CRRNDr. Sherri Clayton, MDPROJECT SPONSER:Diane Galazzo, RN, MPH, CPHQEXECUTIVE SPONSER: Stephanie Nadolny, VP Hospital

Operations SCC, VP Clinical Ancillary Services SRN

INTERVENTION: • Splint/Brace Report created in Epic to identify all devices putting patients are risk for potential pressure injury.• Gap analysis completed, identifying inconsistent documentation of nursing and therapy notes. • SCC team collaborated with Partners eCare team to modify Splint/Brace Report to include prosthetic/orthotic device details

from OT/PT flowsheet.• OT/PT trained to add skin at risk LDA.• Collaboration with SCC & SRN physicians, resulting in increased specificity of orders for Splints/Braces.• Improved workflow ensuring Nursing Supervisors have access to Splint/Brace Report to communicate risks to staff in daily

safety huddles.• Clinicians instructed to include devices and skin assessment at Interdisciplinary Team Conference (ITC).• During the admission assessment nursing educated to incorporate the new skin at risk LDA for all patients within 24 hours.• Ongoing multimodal education of staff regarding device/skin at risk assessment & documentation.• Patient and family educated on multidisciplinary plan of care as it relates to devices.• Weekly interdisciplinary tissue viability rounds IMPACT:

All patients with a device are at risk for pressure injury . Stage III or greater device related pressure injuries are SREs reportable to both DPH and BORM. Patients that develop pressure injuries are impacted by greater lengths of stay, increased costs and possibly experience increased pain and risk infections.CONSIDERATIONS FOR SPREAD: Key in Post Acute setting –patients admitted from acute care with post-op devices.• Device related injuries are preventable with diligent

attention to assessment by the multidisciplinary team.• A clear process is essential to preventing device related

injuries.• Future state: Ongoing education & monitoring of LDA/Skin at

Risk utilization.

RESULTS:

PROBLEM: Inconsistent identification & documentation of patient’s with devices that may be at risk for pressure injury.

0.34

0.07

0.20.26

0

0.2

0.4

0.6

0.8

1

0

2000

4000

6000

8000

10000

12000

14000

16000

2017 2018 2019 2020Pt DaysIncidence per 1000 daysGoal

7 6 7 4

53

3

2

0

2

4

6

8

10

12

14

2017 2018 2019 2020

HaPI DR-HaPI

Six Years and Thirty Thousand eConsults: What Have We Learned?

Neelam Phadke, MD; Jason Wasfy, MD

Massachusetts General Hospital / MGPO

Aim: Grow eConsults to comprise 5% of ambulatory volume within six years

Interventions: eConsults are virtual, asynchronous, provider-to-provider, electronic health record (EHR)-based communications. Providers request eConsults through the EHR; specialists review relevant information and provide diagnostic, therapeutic, and referral advice for consideration.

Summary of Results: Massachusetts General Hospital (MGH) completed nearly 30,000 eConsults in over 40 specialty service areas (December 2013-October 2019). eConsults comprise 8.5% of MGH ambulatory volume and up to 36% of ambulatory volume in specialties like Infectious Disease. Completed in a median of 11 minutes [5,22], eConsults provided guidance in a median of 26 hours [8,69], Visit avoid rate was 83% across MGH and as high as 99% in Pediatric Hematology/Oncology. Patients, referring providers, and specialist providers all expressed satisfaction with eConsults.

Description of Impact to Patients: eConsults play a significant role in MGH's ambulatory infrastructure and are critical to improving access in an efficient, effective, and timely manner.

Consideration of Spread: The eConsult model of care is ripe for dissemination. As it relies only on an integrated EHR, eConsults can be spread to MGH and Partners family hospitals without impacting care quality.

Transesophageal Echocardiography Requiring Cardiac Anesthesiology Care

Adam Dalia, MD,MBA

Massachusetts General Hospital / MGPO

Aim: Delay (time in minutes) between patient being brought to procedural area and start of procedure will be decreased by from 35 to 28 minutes (20%) in 6 months.

For transesophageal echocardiograms (TEE) requiring cardiac anesthesia support for moderate sedation and ventilatory support, coordination between anesthesia and cardiology is suboptimal leading to prolonged patient wait times, inefficient use of human resources, and potentially cancellation or delay of outpatient TEEs leading to patient dissatisfaction. On average, 9 TEEs occur in the echo lab on a weekly basis (350 a year), with approximately 30-50% of these requiring cardiac anesthesia due to complex medical needs of the patient (Sleep Apnea, substance abuse, difficult airway, inability to lay flat, severe pulmonary hypertension, etc.). The goal of our study was to decrease patient wait times and improve communication between cardiology and cardiac anesthesiology to reduce inefficiencies and waste.

Interventions: Our intervention to improve these measures included daily screening of outpatient TEE EPIC EHR orders to determine anesthetic needs. Created a central scheduling software (Smartsheet) and designated certain days for Anesthesia cases: Monday, Thursday, and Friday. Lastly, we clearly identify who the daily cardiac anesthesiologists would be on a calendar sent out to the echocardiography lab in order to improve communication between the echocardiography lab and the department of anesthesia.

Summary of Results: After analyzing the data we identified 33% of TEE orders in EPIC were ordered incorrectly; meaning were ordered with anesthesia when in fact the patient did not require anesthesia. There was a reduction in patient wait time by 20% down to an average wait time of 28 minutes. There was also an improvement in communication in advance with the cardiac anesthesiology division. Additionally, after the intervention there were 0 patients who required rescheduling or cancellation of their TEE.

Description of Impact to Patients: All these measures (reducing wait time, reducing inappropriate ordering, reducing cancellations) helped improve patient safety, satisfaction, and quality of care. Screening out patients who do not need to be subjected to the risks of anesthesia, decreasing the wait time for patients who may require other procedures improves both the safety and quality of care these patients are receiving. There are approximately 350-400 of these procedures done each year.

Consideration of Spread: This type of care coordination and increased efficiency can be applied to other services that involve both anesthesia and a proceduralist; areas like Interventional radiology, electrophysiology, and endoscopy.

Zary Amirhosseini – Disability Program Manager | Michael S. Cook – Training Lead, MGPO BTMitchell Kellaway – Training Specialist, Patient Access

Using Disability Data in the EHR During the COVID-19 Pandemic

MGH

AIM: Have data on disabled patients added to COVID-19 demographic dashboards and equity conversations.

TEAM: • Clinicians• Registrars• Admitting• Schedulers

INTERVENTION: 1. Adding disabled patients as a population to be discussed during the MGH Equity and Community

Health COVID Task Force meetings, leveraging input from the Disability Task Force2. Adding disabled patients to Epic’s Demographics Dashboard for daily analysis during COVID-19

pandemic. Patients tracked by Special Needs Flag. 3. Based on inpatient report, working with admitted disabled patients on accommodations (e.g.

providers speaking through clear masks to deaf patients, flexing visitor policy for patients who need caregivers)

4. Begin conversations around how to better capture disability data throughout all MGB entities

IMPACT: When a patient is flagged in Epic as disabled (using the Special Needs flag), clinicians are able to better create a care plan, which then makes it easier for staff to be prepared and for the patient to arrive with peace of mind. Staff are also able to plan ahead if there are behavioral safety issues, coordinating with the clinic, Police & Security, etc. to make sure patient and staff are safe.

During the COVID-19 pandemic, daily reports listed disabled patients who had been admitted, which enabled staff to work with the patients to identify accommodations (e.g. flexing visitor policy).

CONSIDERATIONS FOR SPREAD: Beyond MGH, all entities can train staff on using the Special Needs flag/comments and the Demographics Dashboard.

RESULTS:

PROBLEM: Disabled patients need to be identified through the EHR to plan how to provide equitable care.

Epic Dashboard: MGH COVID Inpatient Demographics - Equity Focus

Dashboard includes demographics on: Race, Hispanic Ethnicity, Age, Sex, Disability Status,

Homeless Status, Preferred Language, Need for Interpreter, Interpreter Services used, and Top 20 Cities/Towns.

Noted that dashboard numbers on Disabled patients (12%) may be lower than actual number of admitted patients who are disabled. Will have follow-up strategizing to better capture disability information.

Disability added to Demographics Equity dashboard and run daily to track admitted disabled patients for follow-up with care planning.