Quality Fellows Use New Skills to Improve Patient Care

Helping children with sickle cell disease in the ED get needed pain medication quickly.

Decreasing the time it takes for admitted patients to move from the emergency department to a patient floor.

Creating real-time alerts to address urgent inpatient needs.

Reducing physician errors in electronic entry of patient medication orders.

These are just some of the quality of care improvements successfully championed by the 2015/2016 class of the Clinical Quality Fellowship Program, who have just completed an intensive 15-month program to learn proven techniques to advance quality and patient safety programs in their hospitals. The fellows and their Capstone projects were celebrated and featured at a culminating meeting and dinner at United Hospital Fund on April 14. The program's seventh class—sixteen physicians and four nurses—were joined by the dedicated CQFP volunteer faculty, program alumni, members of the 2016/2017 class, and other leaders from the graduates' hospitals.

Rohit Bhalla, MD, MPH
“This program provides uniquely practical training in quality, which is challenging to find elsewhere,” noted Rohit Bhalla, MD, MPH, Vice President and Chief Quality Officer at Stamford Health and the fellowship program's chair. Since it began, he said, “more than 125 projects have been generated by the program's 125 graduates—125 bursts of positive energy and creative thinking to address real-world health care challenges.” Dr. Bhalla acknowledged the extraordinary commitment of program faculty, who have generously given their time and energy to shape the program into what it is today. He also thanked United Hospital Fund and Greater New York Hospital Association for founding the program in 2008, and for providing structure and leadership for it ever since.

In addition to presenting the graduates with certificates documenting their completion of the program, the event featured presentations on four of the capstone projects undertaken as a major element of the program.

John Babineau, MD
John Babineau, MD, of NewYork-Presbyterian's Morgan Stanley Children's Hospital, discussed his project, “Improving Opioid Administration in Pediatric Patients with Sickle Cell Vaso-Occlusive Crisis,” in which he worked to reduce the amount of time between arrival in the emergency department and the administration of pain medication for children suffering a sickle cell crisis. Bringing together a multidisciplinary team of clinicians, Dr. Babineau led a discovery process to assess the root causes of delays and implemented a series of Plan-Do-Study-Act cycles to incrementally tackle the challenge. One strategy was recruiting a patient's family member to help inform the project, and he and his team plan to involve other patients and family members in future work. His project effectively reduced the average time to initial pain medication from 51 minutes the year before to 41 minutes—10 minutes that are critically important to the children and their families.

Amrite Gupte, MD, MPH
“A Multidisciplinary Initiative to Decrease Emergency Department Boarding Time”—the time patients remain in the emergency department (ED) awaiting transfer to an inpatient unit after admission—was the topic of the capstone project of Amrite Gupte, MD, MPH, of Mount Sinai Queens. Extended ED waits can cause patient anxiety, delay treatment that begins on the floor, and compromise patient safety in a busy and crowded ED. Using a complex “fish-bone analysis” to help identify and rank root causes, Dr. Gupte was able to tackle the most common causes of delay by using the team engagement tools she learned through the program. Of special note, she solicited participation from a broad range of colleagues, including ED and inpatient nurses, admitting staff, unit clerks, and housekeeping; their feedback was a key to success. Over the project's first nine months, the average ED boarding time was reduced by 28 percent, from 425 minutes to 306 minutes.

Robbie Freeman, MSN, RN
Robbie Freeman, MSN, RN, who started his project at Mount Sinai Beth Israel and is now at Mount Sinai Hospital, discussed “Reducing Missed Care on Medical-Surgical Units with a Real-time Quality Dashboard,” his work to draw critical information from electronic health records to alert staff in real time of missed or overdue care required by patients. The dashboard he created flags time-sensitive care components, such as adherence to infection-prevention protocols, the use of restraints, and measures related to pressure ulcers. It also tracks length of stay, a critical measure for hospital administrators. With data refreshed every 15 minutes, the dashboard was tested on two units, and compared to outcomes on a third “control”; the goal of reducing missing and overdue care by 30 percent was achieved on both units, which outperformed the control unit for the duration of the project. The project was such a success that it is being rolled out hospital-wide in the coming months. “The dashboard Robbie Freeman created, developed for the unit level, is truly innovative and will be of enormous value to front-line staff,” observed Lorraine Ryan, RN, senior vice president, legal, regulatory, and professional affairs, at Greater New York Hospital Association.

Daniel Lombardi, DO
In his capstone on “Improving Misidentification through Computerized Physician Order Entry,” Daniel Lombardi, DO, of SBH Health System, sought to reduce the number of “near-miss” occurrences of medication error resulting from patient misidentification in computerized physician order entry. Even a single actual error should never happen, so the focus on “near misses” is critically important. Raising awareness of the frequency of “wrong patient, right order” near misses was the project's first challenge, since the problem was rarely reported and therefore under-recognized. Once colleagues were convinced of the value of the work, Dr. Lombardi was able to build and test a new “double ID system,” in which clinicians are required to manually enter a patient's initials and year of birth as a secondary verification to accompany the inputting of physician orders. The project has succeeded in reducing near-miss events by 35 percent.

Hillary Jalon
“Selecting which projects are presented at the annual culminating dinner is always difficult, but this year even more so,” said Hillary Jalon, director of quality improvement at United Hospital Fund. “Each of the 20 fellows' capstone projects is notable and worthy of being shared. They address issues ranging from handoffs in care transitions to innovation using information technology to improving the patient experience, and many have been so successful, they've been adopted in other parts of the hospital. Every one of the graduates, and the institutions they represent, have reason to be proud.”

April 21, 2016
Focus Area
Clinical-Community PartnershipsQuality and Efficiency
Quality Institute