Quality & Patient Safety in the Department of Medicine

THE CLINICAL MISSION:
Quality and Patient Safety in the Department of Medicine

The Department of Medicine (DOM) considers quality and patient safety to be one of its core missions, and continues to focus its efforts on assuring that the care provided is patient-centered and of the highest quality. The department has served as an early and integral partner to the UVA Health System’s “Be Safe” initiative, and continues to invest considerable resources to support a robust quality infrastructure throughout its ten divisions. The aim is to be a national leader in quality and patient safety (Q/PS); the cultural transformation necessary to achieve that goal is well underway, as faculty, fellows, residents, and staff lead and participate in numerous initiatives across a broad range of issues, as highlighted below.

Mortality Reduction: DOM service line rankings for mortality index are stable-to-improving, with sustained excellent performance by the divisions of Gastroenterology and Hematology-Oncology. Overall, trends are encouraging; however, the department has not yet achieved its goal of placing in the top 10th percentile in national rankings. Efforts to strengthen supervision of residents, improve documentation of patient care, and streamline the admission and transfer processes are on-going. Based on learning from daily case reviews, the department’s greatest opportunities to reduce morbidity and mortality lie with “upstream” (preceding) events, and these are being addressed on multiple fronts.

 

Sepsis Reduction:  Sepsis care remains a priority. George Hoke, Kyle Enfield and John Voss provide leadership to the Medical Center Sepsis Steering Committee, Medical Intensive Care Unit team, and Medical Emergency/Rapid Response Team (MET), and liaised with pharmacists and housestaff to implement improvements. The SPRINT program, which brings pharmacists to the bedside for sepsis alerts to assist in antimicrobial selection and administration, has resulted in improved antimicrobial delivery within the one-hour target after sepsis recognition for ~90% of patients, which represents excellent performance. Future work will focus on refinements to early recognition and response (through SIRS-based Best Practice Advisories [BPAs] in Epic), greater attention to follow-up assessments, launch of an Epic-based early warning score to identify upstream events, and transition of the successful interprofessional sepsis simulation training to a local unit-based program.

Early Warning Scores:  John Voss, Kyle Enfield and George Hoke partnered with the MET, Epic, and unit leadership teams to begin evaluating use of electronic-health-record-based continuous early warning scores. The CART and NEWS nationally validated scores are designed to reduce the incidence of cardiac arrest and unexpected transfers to the intensive care unit. Scores are continuously updated based on vital signs entered by the nursing staff. Once validated in the local environment, scores are available in Epic for use in monitoring patient acuity and risk of clinical decompensation, and to identify patients who may benefit from more sophisticated cardiac monitoring. Pilot testing begins in September 2015.

Aspiration Prevention:  Clint Merritt initiated and leads an ongoing multidisciplinary workgroup focused on improving risk recognition and mitigation for aspiration. With Paul Helgerson, John Voss, and resident representatives, the group developed and piloted on 3 West guidelines for interdisciplinary risk assessment, standard methodology for the bedside swallow test, and standard work for oral feeding of at-risk patients; it will move next to standard work for tube feeding and eventual dissemination of this learning across other units and medicine services.

Outside Hospital Transfers:  Kyle Enfield, Larry Gimple, George Hoke, Charles Malpass and Clint Merritt worked to improve the safety and efficiency of the process of transferring patients from outside hospitals to UVA, with particular attention to ensuring that important documentation and communications are transmitted as well. Work continues with hospital administration and the bed center to create an Epic-based communication pathway for sharing of information. To improve triage of admissions, faculty from the divisions of gastroenterology (Argo, Bickston, Northup) and pulmonary/ critical care medicine (Enfield), together with the bed center and the rapid response team, implemented a novel guideline based on MELD (Model for End-Stage Liver Disease) clinical risk scores, with results showing greater accuracy in placing patients at the appropriate level of care (i.e., ICU vs. acute care).

“Be Safe” Activities:  The Department of Medicine has fully supported the health system-wide transition to the unit-based, real-time, problem-solving model of patient safety. DOM faculty assumed leadership for implementing “Be Safe” principles in the MICU, CCU, 3W, 3C, 3E, 4E and 8W units and, with nursing partners, engaged in all aspects of the “Big Six” improvement priorities including CAUTI and CLABSI prevention methods (MICU, CCU, General Medicine acute units), innovative work around falls prevention (3C), creating collaborative practice models (3W), testing and modifying interdisciplinary rounding (4E, 3E, 3C, 3W), and CLABSI prevention in neutropenic/mucosal-barrier-risk patients (8W). Faculty will assume further unit-based leadership (UBL) roles as the Be Safe program is more fully implemented in the ambulatory clinics. Department leaders have also advocated for the “Uber-UBL” concept, to make connections across unit-based teams; this has been realized on the 3^rd floor units through their work on falls prevention, aspiration, and piloting of the early warning scores.

General Medicine Inpatient Redesign:  A work group of faculty, residents, and nursing leadership helped steer dramatic changes in FY 2015 that culminated in the new “3+1” resident scheduling structure, which allows housestaff to focus on clinical inpatient work and their ambulatory-continuity practice in a more concentrated fashion. The department partnered with UVA Systems Engineering to conduct time-and-motion studies of residents’ daily activities on the general medicine service, and multiple opportunities for reducing waste and streamlining work processes were identified. In addition, nearly 100 faculty, residents, and staff have been actively engaged in planning a new “geographic” structure to produce better cohorts of patients in the 3rd-floor general medicine service units. Launched in September 2015, this initiative is already showing early gains in enhancing interdisciplinary teamwork, communication, and discharge planning, with the potential to improve patient outcomes.

Division-Based Efforts:  Across the divisions, a wealth of quality improvement work is underway, under the leadership of each division’s faculty quality liaison, as well as other faculty and staff.

• Allergy & Immunology (liaison: Scott Commins, MD) – Developed and adopted standards for communicating with patients regarding laboratory results, studies and clinical questions, via MyChart. Evaluated and standardized the use of spirometry in clinic for patients with asthma. Established yearly monitoring of patients on immunotherapy (allergy shots), with a focus on patients receiving such therapy at off-site locations.
• Cardiovascular Medicine (liaison: Larry Gimple, MD) – Unit-based leadership activities include model real-time team huddles in the critical care unit; launching an A3 to improve coordination of outside hospital transfers, including Epic-based communication and documentation tools; implementing the “bed ahead” strategy for ICU beds; and developing new standards for transfers. John Dent spearheaded creation of “Rounding with Heart,” a patient-centric, team-based rounding model that has resulted in significant improvements in patient satisfaction and patient safety outcomes.
• Endocrinology (liaison: Jennifer Kirby, MD) – Collaborated with Medical Center partners to implement a personal insulin pump protocol for inpatients. Developed standard work for division clinic attending and Epic inbox coverage. Provided leadership for the Medication Use Safety and Informatics committee on endocrine and metabolic drugs.
• General, Geriatric, Palliative and Hospital Medicine (liaisons: Ira Helenius, MD, and George Hoke, MD)  – In addition to key leadership on topics mentioned above (sepsis, aspiration, general medicine geography), the division: (1) trialed innovative “falls reduction” rounds on 3C; (2) collaborated with the Department of Orthopedics to implement a new care pathway for hip fractures; (3) collaborated with Pharmacy on A3 to standardize medication reconciliation processes; (4) provided key leadership on Accountable Care Organization (ACO) operations and informatics; (5) developed standard work for depression screening in ACO clinics; and (6) launched panel-coordinator-assisted population management in the University Medical Associates clinic. The division’s Palliative section received a Buchanan Award for “Comprehensive Assessment with Rapid Evaluation and Treatment (CARE Track) for Advanced Oncology and Congestive Heart Failure” project that will use patient-reported outcomes, based on the NIH’s PROMIS” items built into EPIC, to help guide clinical care for seriously ill cancer and cardiology patients.
• Gastroenterology & Hepatology (liaison: Anne Tuskey, MD) – Implemented a MELD-score-based triage for hepatology patients being transferred from outside hospitals that has resulted in improved patient placement in the appropriate setting (ICU vs. acute-level of care). The division is working to reduce readmissions of patients with cirrhosis and, with UVA Systems Engineering, has developed an IT linkage that enables easy calculation of adenoma-detection rates in screening colonoscopy, a key quality measure. The division has also developed a new colonoscopy order set that standardizes patient prep and diabetes medication management, and is expected to improve patient preparation and provider satisfaction. A current A3 is in progress that is aimed at improving patient access and satisfaction after the transition to “Patient-Friendly Access” appointment scheduling.
• Hematology-Oncology (liaison: Tamila Kindwall-Keller, DO) – The division streamlined the process for obtaining and reviewing pathology specimens from outside hospitals for transfer patients, and is in the process of standardizing central line care for cancer patients across inpatient and outpatient areas, in order to further reduce the incidence of CLABSI. It is also developing practice guidelines and an Epic best practice alert to speed and streamline care of patients with febrile neutropenia and improve interdisciplinary team communications.
• Infectious Diseases (liaison: Joshua Eby, MD) – The division implemented mandatory ID consultation for inpatient cases of S. aureus bacteremia, in conjunction with initiation of rapid diagnostics by gene microarray in the microbiology lab, and the creation of a database developed with the Department of Public Health Sciences. With support from UVA Systems Engineering, the division conducted a time-motion analysis of ID fellows’ activity and involvement in the consult process; it also began a collaboration with Orthopedics to improve management of joint infections by limiting the amount of tobramycin and vancomycin in antibiotic-impregnated spacers, and starting a database to track outcomes for this patient population.
• Nephrology (liaison: Charles Brooks, MD) – The division designed and launched a major project to reduce readmissions for end-stage renal disease (ESRD) patients. Interventions are directed at three time-frames: peri-admission, inpatient, and post-discharge. Current challenges being addressed include coordination of care for ESRD patients with non-UVA nephrologists and primary care physicians, and collaboration with UVA ACO-based practices.
• Pulmonary & Critical Care Medicine (liaison: Kyle Enfield, MD) – The division led multiple UBL efforts in the MICU, resulting in a mortality index <1.0, 80% reduction in CAUTIs, and a 50% reduction in CLABSIs. New discharge criteria were implemented that reduced the “bounce-back” rate (i.e., percentage of patients transferred back to ICU from acute care) from 10% to 2%. The division also developed a standing nurse practitioner service that allowed for a reduction in housestaff service size, creating potential for unit growth while maintaining educational quality.
• Rheumatology (liaison: Janet Lewis, MD) – The division standardized the work flow to improve recognition of glucocorticoid-induced osteoporosis and improve vaccination rates in patients on immunosuppressive medications. It also implemented measures to optimize control of disease activity and improve recognition of cardiovascular risk factors in patients with rheumatoid arthritis.

Epic & Information Technology:  The department continues to support Epic development and decision support for quality initiatives. Amy Mathers led implementation of Epic-based, nurse-driven protocols for inpatient influenza and pneumonia immunization, which boosted immunization rates and performance on Core Measures. Joshua Eby and John Voss partnered with Epic to develop and implement a hospital-wide order set for community-acquired pneumonia to improve pneumonia care. John Dent, Kyle Enfield and John Voss are members of UVA Health System’s Clinical Informatics Technology Oversight Committee (CITOC), and participate in or lead five CITOC subcommittees, including the Licensed Independent Practitioner (LIP) reaction group for the Clinical Informatics, Clinical Decision Support, and Reporting and Analytics subcommittees that is providing clinical direction for the health system’s growing capabilities in population management and reporting and analytics. Work continues on improving inpatient care documentation, with a focus on producing more effective and timely discharge summaries and ensuring a smooth transition to ICD-10.

Education:  The department-sponsored Quality and Safety Leadership in Academic Medicine (QSLAM) course ran again this year, incorporating key principles of Lean management in support of the BeSafe initiative. Over 200 UVA Health System healthcare professionals have completed the course since its inception. “Just-in-time,” Q/PS training has occurred in multiple venues, including division-based morbidity & mortality conferences, the DOM Longitudinal M&M conferences, and a newly expanded quality and patient safety curriculum in the internal medicine residency program. As part of the “Wednesday A.M.” curriculum, residents voted and worked on eight longitudinal quality projects focused on improving the care of boarding ED patients, streamlining the hospital discharge process, standardizing the medication reconciliation process, and enhancing communications with consultants and case managers. Upper-level residents also designed, implemented and evaluated individual quality projects derived from data on their continuity practice panels in the diabetes and hypertension registries in Epic.

As payor-sponsored, value-based purchasing and pay-for-performance programs proliferate, the Department of Medicine has performed well. For calendar year 2014, greater than 98% of eligible clinical providers successfully attested for the CMS Meaningful Use program, yielding approximately $1.7 million in incentive payments to the department.