Clinical Quality Fellows: Agents of Health Care Change

GNYHA's Lorraine Ryan, CQFP Chair Rohit Bhalla, MD, MPH, graduating Fellow Janine Duran, RN, MS, one of the evening's Capstone presenters, and UHF's Jim Tallon
“Nine years ago we started with a simple idea—helping doctors and nurses learn the science of quality improvement while also building their leadership skills could create a new generation of change agents,” UHF President James R. Tallon, Jr., told the latest graduates of the UHF/Greater New York Hospital Association Clinical Quality Fellowship Program (CQFP) at their culminating event this spring.

“This graduating class affirms yet again that we've turned that vision to reality, and have helped our area's hospitals and health systems systematically advance their efforts to improve patient care and safety.”

With their completion of the intensive 15-month program of webinars, in-person learning sessions, and individual mentoring, the 2016-17 class—16 physicians, 4 registered nurses, and 2 nurse practitioners—brings to 148 the total number of CQFP graduates. Many of those earlier alumni have advanced to top leadership positions in their institutions' quality improvement efforts, bolstered by the program's unique combination of providing exposure to key public policies driving health care reform, teaching of proven techniques to improve patient care, and empowerment of Fellows to be quality and patient safety champions.

The program itself has advanced as well, “moving beyond the bread and butter of quality and patient safety to address timeliness, efficiency, and the increasing emphasis on patient-centered care,” said Rohit Bhalla, MD, MPH, chair of CQFP and vice president and chief quality officer at Stamford Health. Focusing not just on the challenges of acute care and the inpatient setting, but also on community-based care and the interconnectedness of health care systems, “this unique program,” he concluded, “is all the more important as the American health care delivery system continually evolves.”

Cheering on the newest graduates at the dinner event at UHF were Fellows from the seven earlier classes and a number of the program's faculty and mentors—acclaimed quality improvement and leadership experts from throughout the metropolitan area. In addition to the awarding of certificates of completion, the evening highlighted one of the most important elements of the training program, the Capstone project that each Fellow is required to develop and implement, leading an interdisciplinary team, in his or her own home institution.

“All of the Capstones this year were amazing efforts, taking your hospitals' quality improvement work to a higher level,” Lorraine Ryan, senior vice president for legal, regulatory, and professional affairs at GNYHA, told the crowd. “These initiatives are one of the reasons that CQFP is the ‘jewel in the crown' of the many important quality improvement programs that GNYHA and UHF have co-sponsored and led.”

Four of the Fellows had the opportunity to present their work to the gathering, giving a taste of the range of clinical challenges being tackled—and the teamwork at the heart of each. They and the rest of the Capstones reflect, as well, “the force of health care reform,” noted Dr. Bhalla.

Ilseung Cho, MD, MS
Overprescribing for stress ulcers
For Ilseung Cho, MD, MS, of NYU Langone Medical Center, the goal was a reduction in prophylactic prescribing of proton pump inhibitors without clear clinical indications. Although these drugs lessen patients' risk of stress ulcers, which can cause bleeding and other complications, continued use raises risks of C. difficile infection and other dangerous complications. Dr. Cho led a team of colleagues including hospitalists, critical care doctors, infection control specialists, and pharmacists to develop a new evidence-based protocol for prescribing, create an electronic medical record “dashboard” for clinical pharmacists on each unit, and provide additional risk/benefit education—including clear illustrations that “put it all in perspective” for residency doctors—all leading to a significant decline in overprescribing.

John McMenamy, MD, CMQ
Standardizing inpatient MRI work flow for improved performance
Standardizing the entire inpatient MRI process was the focus for John McMenamy, MD, CMQ, of New York City Health + Hospitals/Bellevue, to prevent delayed diagnoses that can threaten patient care, decreased patient and staff satisfaction, and delayed discharges that increase costs. Redefining the process from start to finish, clarifying expectations, and improving communication were all priorities, yielding a 40 percent decrease in order-to-performed and order-to-final-report time by month two—an improvement that has been sustained. Lesson learned? Have a list of needed projects and the major obstacles preventing their accomplishment, so if circumstances or the environment changes, you can take advantage and drive through improvement. “Never let change momentum go to waste,” said Dr. McMenamy.

“Hardwiring” hand-offs in the ED
Janine Duran, RN, MS, of SBH Health System/St. Barnabas Hospital targeted safe and effective care transitions through improved communications and nursing handoffs in the emergency department. Using a specific analytic methodology, a team including the chief nursing officer, chief quality officer, chairman and co-chairman of emergency medicine, patient safety officer, and others set out to “hardwire” the handoff process with a new real-time sign-out tool to be used during changes of shift, an improved nursing transfer note for patients admitted to the hospital from the ED, and an ED-specific clinical summary tab. Results included an expedited admissions process, fewer charting errors and omissions, increased patient satisfaction, and improved communication between inpatient and ED nurses.

Theresa Madaline, MD
Sepsis and septic shock
Improving the diagnosis and management of severe sepsis and septic shock in the emergency department was the challenge for the team led by Theresa Madaline, MD, of Montefiore Medical Center. A multipronged approach included a new decision support tool for the electronic medical record, a marketing campaign for staff, peer review of case management, and formation of a “code sepsis” team. Results included improvements in time to diagnosis and implementation of a sepsis management protocol. The need for more timely reporting of data—regular, real-time feedback rather than quarterly reports—and the powerful impact of talking to staff about individual patients' stories were among key lessons learned, Dr. Madaline noted.

Sharing these Capstones, in both their successes and continuing challenges, is an integral and essential part of the CQFP experience, and members of both this most recent graduating class and earlier classes agreed that continuing that process is an important next step—one that is coming to fruition this year with the launch of an ongoing online CQFP community.

For more photos from the 2016-17 culminating event, click here.