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Text
Workplace Safety in the Psychiatry Department
The Problem
The Results/Progress to Date
Safety and the perception of safety are essential to the provision of
effective psychiatric services, are linked to the IOM Dimension of
Safety, and are continuous quality improvement goals for the
Psychiatry Department. An annual workplace safety survey provides
a metric for the perception of safety and solicits input for how we can
improve.
Overall Safety
60%
54.5%
2008
38.5%
40%
2011
33.9%
25.8%
21.5%
20%
13.6%
6.2% 6.1%
0%
Very Safe
Goal
The goal of the project is to demonstrate continuous quality
improvement in terms of the perception of safety by improved ratings
on an annual survey of workplace safety.
Rohn Friedman, Vice Chair, Psychiatry
Stephenie Loux, QI Data Analyst, Psychiatry
Greg Ludlow, Quality Specialist, Psychiatry
Amanda Tjonahen, Nurse Educator, Inpatient Psychiatry
The Interventions
Establish a convenient system for annually surveying staff
utilizing a URL emailed to staff linked to Performance Manager
Create a transparent system for engaging staff, sharing
results, and soliciting feedback
Develop action steps to address opportunities for improvement
Implement those steps and demonstrate improvement. Steps
implemented to date include:
o Install panic buttons in ambulatory offices.
o Install locked doors to the ambulatory office area
requiring keyed ID badges
o Add a security officer to Deaconess 4 staffing
o Initiate departmental M&M Rounds
Neither
I Know How to Obtain Help or Support for
Threatened/Actual Violence
Very/
Somewhat
Unsafe
Confident Safety Concerns are Addressed (Percent
that Agree or Strongly Agree)
100%
100%
95.8%
95.6%
95.4%
88.6%
100.0%
91.7%
89.5%
90%
The Team
Somewhat
Safe
76.5%
86.4%
75.0%
75%
66.7%
81.5%
80%
70.0%
70%
71.4%
50%
33.3%
25%
60%
All
Ambulatory
2008
Inpatient
Consultation
2011
Other
Psychiatry
Nursing
Psych/SW
2008
Other
2011
Lessons Learned
Annual safety surveys focus attention on safety issues,
increase staff sense that concerns are addressed, and
increase awareness of resources for staff support.
Next Steps
Present findings to staff in meetings and via the intranet and
obtain feedback
Explore new strategies to better keep all staff informed about
safety issues across the department.
Include survey of patient perception of safety
Continue iterative process for improving safety.
For More Information Contact
Rohn Friedman, Vice Chair, Psychiatry
rfriedma@bidmc.harvard.edu
�
Dublin Core
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Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Rohn Friedman (<a href="mailto:rfriedma@bidmc.harvard.edu">rfriedma@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Psychiatry
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Rohn Friedman<br />Stephenie Loux<br /> Greg Ludlow<br /> Amanda Tjonahen
Dublin Core
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Title
A name given to the resource
Workplace Safety in the Psychiatry Department (2012)
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
Format
The file format, physical medium, or dimensions of the resource
pdf
Safety
-
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1cb743a89c4f8c067887d718f7a347cc
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“Where’s the Thing”?
The Red Book and Our Visual Database - Improvements In Our Supply Chain
The Problem
The Results/Progress to Date
The problem with our supply ordering system was a lack of search ability and
resources around identifying the supplies we need and use for day to day patient
care. Items would get ordered and delivered to floors only to be returned because
they were the wrong item.
Aim/Goal
For our Visual Database found on our shared drive we have over 1000
photos taken and available for viewing to date.
As of today we have uploaded the new formatted Red Book with the
addition of the AKA Names Column. We currently have updated AKA
Names for 648 of 1448 names in the Red Book.
The goal was to create an online resource with search capabilities that would make it
easy for the end user to identify and confirm the items they were ordering before
delivery. This capability will reduce the time spent by materials handling staff that
then retrieve and restock incorrectly ordered products. There will also be less rework
for the end user by being able to verify the proper item prior to ordering.
The Team
Ryan Erskine, Project Manager (Materials)
Brian Bertrand, Supervisor (Materials)
Bill Pyne, Director (Materials)
Jeff Berry, Materials Contract Manager (Contracting)
Old & new photos available on our shared drive.
The Interventions
Lessons Learned
Through our Rapid Improvement Events (RIE) we look for ways to improve upon the
foundation of established processes we have already put in place here at BIDMC.
Through ongoing discussion with the purchasing department we took
ownership of the Red Book from them as we have a more direct relationship
with the end user for supply consumption.
After taking over the process we were able to add a column to the current Red
Book called AKA names. This column will allow a better search ability for the
end users as the names more commonly reflect the true items use or purpose
as opposed to the standard generic description set forth by the distributor.
Over the past couple of years we have been compiling and updating an AKA
database from the units that we have Leaned. This data was key in adding
the new column to the Red Book.
To create an online database for a visual representation of the items we spent
many hours photographing items with their respective packaging to show not
only how the item may come individually but as a box or sometimes a case.
Once the items are photographed they are then photo shopped and uploaded
to our online materials shared drive.
Red Book with AKA names.
AKA names vary from unit to unit and may cause confusion going unit to unit.
There are many items that need to be updated still and there are many ways we
can still enhance the Red Book functionality.
Photographing and updating our database is very time consuming but well worth
the effort for the end product.
The pictures have been an amazing tool for our own department use as we deal
with day to day activities within BIDMC.
We cannot give access of our shared drive to the whole institution due to the
volume of people, so access is given per request of end users or through staff
participants of our RIE events.
Next Steps/What Should Happen Next
We will try to finish the AKA names for all missing items by reaching out to staff.
We will strive to update all missing photos for our Leaned floors.
We will update old or outdated photos with new photos for correct representation.
Look at ways to incorporate our tools to the portal, with possibly our own page.
For More Information Contact
Ryan Erskine, Project Manager/rerskine@bidmc.harvard.edu
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Ryan Erskine (<a href="mailto:rerskine@bidmc.harvard.edu">rerskine@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Support Services
Materials Management
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Ryan Erskine<br />Brian Bertrand<br />Bill Pyne<br />Jeff Berry
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Where's the Thing? The Red Book and Our Visual Database - Improvements In Our Supply Chain
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
Format
The file format, physical medium, or dimensions of the resource
pdf
Efficiency
-
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3a639d71cb9b13076f7b8dcdc4b65e56
PDF Text
Text
“Where’s the Thing”?
Making it Fit - Innovation In Our Supply Chain
The Problem
The Results/Progress to Date
We always need more space for supplies when dealing with small areas like
secondary med rooms or very small clean utility rooms.
As of today we have mounted not one but two wall mounted systems in this med
room. The wall mounted bins are a success and give not only functionality but also
versatility to the space.
Aim/Goal
The goal is to find the right supply chain solutions as we work through spatial
constraints in the variety of clean supply and medical supply rooms here at BIDMC.
Our goal is to individualize and optimize supply storage while making it easy for the
staff to work within the space as they perform their daily roles.
The Team
Ryan Erskine, Project Manager (Materials)
Brian Bertrand, Supervisor (Materials)
David Mangan, Pharmacy Supervisor (Pharmacy)
Deb Mcgrath, Operations Administrator
The Interventions
Through our Rapid Improvement Events (RIE) we look for ways to improve upon the
foundation of established processes we have already put in place here at BIDMC.
With the opening of a second med room on West Campus CC6 we were
forced to look at alternative options for supply storage.
Materials Management staff together with key members from Facilities,
Nursing, and Pharmacy planned for space solutions for the limited space in
the second med room.
Working with the staff we came to an agreement on what items would be
needed in the second med room on the unit.
Unlike a typical supply room we also needed to incorporate a work surface for
med preparation which would take away from space we could use to house
supplies.
After discussions with the nursing staff and pharmacy we decided to use a cart
with cantilevered shelves. This would serve the function of allowing supplies
above the work are for supply storage.
Finally we decided a wall mounted bin system would also serve well for the
space. This would give the functionality of a supply cart for additional storage
while maintaining the openness needed to work within the space.
Lessons Learned
Communication is a key factor when working on a project such as this. Open
communication between all members of the team involved with the opening of the
room was integral in success.
We learned that our new idea works great and will serve as a solution to many
supply issues we currently face not only in small med rooms but other areas we
serve in the hospital.
We learned that sometimes you have to take a chance and sometimes good
ideas turn into great solutions.
Next Steps/What Should Happen Next
We plan to roll this process out in future med rooms where we are constrained by
space and mobility within the work space
We will continue to keep an open communication with the staff and the unit to
ensure they are happy with their supply needs.
Applying our lessons learned from this events solution we identified that the
second med room on Farr 9 was also an ideal candidate for the wall mounted
bins. We are in the process of getting these added on their unit.
We will continue to look for better and more efficient supply solutions at BIDMC.
For More Information Contact
Ryan Erskine, Project Manager/rerskine@bidmc.harvard.edu
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Ryan Erskine (<a href="mailto:rerskine@bidmc.harvard.edu">rerskine@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Support Services
Materials Management
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Ryan Erskine<br />Brian Bertrand<br />David Mangan<br />Deb Mcgrath
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Where's The Thing? Making It Fit - Innovation In Our Supply Chain
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
Format
The file format, physical medium, or dimensions of the resource
pdf
Efficiency
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/7cc4e3bebf98bba959d5216423fb3c73.pdf?Expires=1712793600&Signature=G8PpUxEnjnBWlB%7EgtT%7E-onbE6wDMiqMylXze0UmN0V4MRQ90U%7Ez8nvblqVYBjzPmCjp1Lg6JjM%7EPCFcEeCOz1nNSMnYpm1zMm84N1f%7EQn5mDevTrsN09ryftP8vjB-D3TDwRU9DvFPgxF%7EHx9fqNyk3adMpGYWDUO9W8zrIjtZ9yZL0hDnJPWNLq5XIH531V6wIkYRY8jKQISkOc7uvaKsO52rvoG2enjHW%7E9QMSdA0XGUMlD4mQqgIm8E2RmQVIfr2O-Jxk7vhzKxm47w8T69wtZ1tmK5AcYKnVSGyRc-%7E35bisirR%7EW4iUqxx-pdf7VRAZBT0TAyBsqM7QcdoZSQ__&Key-Pair-Id=K6UGZS9ZTDSZM
9d6b3332ea6d183e4ac064007356b4ec
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Text
“Where’s the Thing”?
Can Kanban Improve Efficiency? - Spread in our Supply Chain
The Problem
The problem is the variance in setting par levels for supplies stocked on patient units.
There was no standardized process for reordering supplies causing variance for par
stockers and end users resulting in the over and under stocking of supplies.
Aim/Goal
The goal is to create a standardized process that will remove variance from
reordering supplies for the benefit of both the par stockers and the end users.
The Team
Kanban in the other two stocking areas of the unit to complete the full
implementation in the unit.
Using the lessons learned from implementing the system on CC7 we decided to
implement it on Farr 9 to get better baseline metrics from having the system
operate with two different par stockers.
The Results/Progress to Date
Kanban completed on CC7 and Farr 9 but we are early in the process of gathering
metrics to be able to get a full grasp of the benefits or disadvantages this process
has on the two units.
CC7 Staff
Farr 9 Staff
Jenine Davignon MBA, Management Engineer (Business Transformation)
Ryan Erskine, Project Manager (Materials)
Brian Bertrand, Supervisor (Materials)
Bill Pyne, Director (Materials)
Judy Hebert, O.R. Material Manager (Peri-operative Services)
The Interventions
Through our Rapid Improvement Events (RIE) we look for ways to improve upon the
foundation of established processes we have already put in place here at BIDMC.
Through meetings with Business Transformation and the staff on CC7 we
decided to try a Kanban supply replenishment system.
Many hours were spent on CC7, the first unit we attempted to Kanban, going
through data and meeting with the end users to try to adopt functional par
levels.
Starting with the med room on CC7 we went through each item and created a
two bin trigger system that would set a signal for the par stocker to reorder.
Beginning with just the med room we were able to create a controlled
environment where we would be able to trial our concepts in a real time setting
while causing little disturbance to the daily functions of the unit.
Once a successful process was established in the med room we prepared to
launch the new system to the two other supply areas on CC7 using a power
point presentation with strong visual representation of the process and how
the system would work.
After staff assimilated to the medroom and the new system seemed to be
working well over the next couple of months we began implementing the
Lessons Learned
There was and still is a large learning curve in how the system works and
operates.
We learned we had to create ways to make a side by side bin system work so
only one bin would be used before the other, in order for the system to flow.
We are all still learning. Being new to this process and the intricacies that work
within it we work to make this system better day by day.
Constant communication and feedback from all parties is crucial for success.
Next Steps/What Should Happen Next
Our next steps in the process are to continue to gather and study the data from
the floor over the next couple of months to see how the system is working.
We will reconvene and weigh the pros and cons of the new process and decide
whether to spread this process to other supply areas.
For More Information Contact
Ryan Erskine, Project Manager/rerskine@bidmc.harvard.edu
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Ryan Erskine (<a href="mailto:rerskine@bidmc.harvard.edu">rerskine@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Support Services
Materials Management
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
CC7 Staff<br />Farr 9 Staff <br />Jenine Davignon <br />Ryan Erskine<br />Brian Bertrand<br />Bill Pyne<br />Judy Hebert
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Where's The Thing? Can Kanban Improve Efficiency? Spread In Our Supply Chain
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
Format
The file format, physical medium, or dimensions of the resource
pdf
Efficiency
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/338b12bb80c34c34727c34acbbf45d95.pdf?Expires=1712793600&Signature=TDtgxQmyaHqZhgUc-58peHy6QiCyAcFsGZBD7J8kp%7E4RkblZGyWOyZZ0pKjp6brSNPvZGXKBjoersNg3RPXHA3jJTOZ3B64PfF9cY9xmjEsxQEs6cRHmh3y9ajhexAYgJ7%7EBEycjcDHceJ%7EhQmwU2YiYpQmEQeUXgLlPSK45f4nBS2vtp4hZ3KIvMvxNp3KzImAKGcs5MC2iF47HDKfszgRVT6HcqNOme6x-tN5UaOryf0T9APKh4TWAA-HOotxh8xY4KBZex9CZHT3ubHKDe%7EDZXjAHTMBI3BwjeYI0OnXGK7f1CbjShzMaFq6wz6F7rTKvdlnWzK-JcKM35Sy4PQ__&Key-Pair-Id=K6UGZS9ZTDSZM
d4c2b5331cf11b07e019a111fff1fdf2
PDF Text
Text
Where’d Our Fentanyl Go?
Responding to a major drug shortage
The Problem
The Results/Progress to Date
On October 25th BIDMC was made aware of a national Fentanyl Shortage that would
have an immediate impact on patient care. Fentanyl is short acting opioid or
analgesic used commonly in critical care, procedural areas and the operating rooms.
The two manufacturers of the drug had different reasons for their low production.
However both predicted that they could not guarantee a full supply of the drug in its
various doses and sizes for 3 to 6 months. Several questions had to be answered
quickly and a contingency plan needed to be developed and implemented
immediately. No single agent can be substituted for Fentanyl.
Aim/Goal
Develop a house wide reaction / contingency plan to respond to the national shortage
and prepare BIDMC Physicians and nursing teams.
The Team
Interventional Procedure Committee
Anesthesia Services
Pharmacy Services
Transparency Site Project Management
The Interventions
A multidisciplinary team emergency meeting was held: together the group worked out
an action plan involving a multifaceted approach:
• Conserving current supply
o Critical Care would stop using fentanyl infusions and implemented
a plan to manage patient needs with alternatives.
o A call out to others to reduce use immediately – in the ORs there
was a dramatic switch from fentanyl to hydromorphone (Dilaudid) a
different opioid.
• Identify and prioritize high need areas:
NICU, Cath Lab and the GI sedation areas were considered priority areas
• Eliminating drug waste
o Pharmacy prepared prefilled 2cc fentanyl syringes for the
moderate sedation GI areas, thus reducing waste
• Alternative drugs, dosing, and education
o Winter Update: Fentanyl Alternatives created
o MAOI & Meperidine Interactions Education
• Modification of policies and Guidelines
o Revised BIDMC Moderate Sedation Training
o NEW Clinical Practice Guidelines for Medications used in Moderate
Sedation @ BIDMC created
• Fast tracking new forms to match new approved Moderate Sedation Drug Policies
• Communication Plan to BIDMC via email and then an up-to-date web page
Lessons Learned
Drug shortages have a wide impact on patient care and partnership with the pharmacy
and clinical leaders is critical for all patient care areas. The Pharmacy can provide
accurate and up to date information about usage patterns that can lead to very targeted
and creative solutions.
Forms need to be ‘timeless’ .Our forms contained basic dosing guidelines for ‘some’
medications but ‘not’ all. This required a very fast and costly overhaul of current forms.
Similarly our policies and annual competencies only spoke to a narrow list of preferred
medications for use in moderate sedation, alternatives were not included. This left us
very vulnerable from a shortage of any of the preferred agents. We have now posted a
wider list of medications with reformations for first and second choice.
Next Steps/What Should Happen Next
Continue to monitor and respond to the on going fentanyl shortage. Due to
the rapid action taken we have been able to continue to supply fentanyl to
critical areas.
Work with pharmacy to develop a standard plan / assessment tool that can
be used for any future drug shortages. Tool can outline things to consider
when creating a contingency plan for a shortage.
For More Information Contact
Jason Laviolette, HCQ, Project Manager,
jlaviole@bidmc.harvard.edu
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Jason Laviolette (<a href="mailto:jlaviole@bidmc.harvard.edu">jlaviole@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Health Care Quality
Interventional Procedures Committee
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Interventional Procedure Committee <br />Pharmacy Services <br />Anesthesia Services <br />Transparency Site Project Management
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Where'd Our Fentanyl Go? Responding to a Major Drug Shortage
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Efficiency
Safety
-
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cd042703612d9ab2429b7b45bc1df33c
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Visual Menu: Addressing the Needs of the Limited English Proficient Patient Population
The Problem
BIDMC offers an “At Your Request” room service system for feeding inpatients.
Typically, the Limited English Proficient (LEP) patient population is not provided the
same choices. Upon admission, LEP patients are often categorized as “send a nonselect tray” (NS) or “needs assistance to order” (assist). With a NS tray, the patient is
sent the daily rotated predetermined meal. As an “assist” patient, they’re given a
paper menu closest to their native language. The paper menus are out of date,
unattractive and sometimes not even close to the patient’s dialect. They can lead to
frustration, miscommunication and decreased consumption.
Meetings held with nursing pilot floors (5F, 6F, 6S, Farr 7) to discuss distribution
of visual menu to non-English speaking patients
On-going analysis of “non-select” & “needs assistance” categorization
Progress to Date
Aim/Goal
1. Ten percent of BIDMC’s patient population is LEP, necessitating the development
of more accommodating ways of providing preferences for food selection. This meets
BIDMC’s 2011 Annual Operating Plan goal to specifically assess and address the
patient experience of minority and non-English speaking patients.
2. Develop a visual menu with pictures of all food items available to be translated into
the most common languages: Spanish, Traditional Chinese, Russian and Portuguese.
3. Increase the number of patients participating in our At Your Request Room Service
Dining program by decreasing the number of non-select trays by 10%.
Previous Translated Menu
The Team
New Visual Menu
Shana Sporman, MS, RD, Sodexo Food Service
Allyn Roberts, RD, Sodexo Food Service
Lessons Learned
Mitch Lawson, MBA, RD Sodexo GM Food Service
Nora Blake, Sodexo Director Food Service
Ediss Gandelman, Community Benefits
Jennifer Luszcz, Media Services
Shari Gold/Gomez, Interpreter Services
Bruce Wahl, Media Services
When patients are categorized as “non-select” and “needs assistance” with room service,
it is not clear for what reason. Some are categorized for language barriers, others for
cognition, dementia, blindness, or it can be as simple as patients not being able to use
the phone. This makes it difficult to measure the effectiveness of the visual menu and
also difficult to measure when the visual menu is actually being used.
Diana Steinberg, Interpreter Services
Next Steps
The Interventions
Implement menus on pilot floors in February 2012
Food Service, Community Benefits and Interpreter Services met in May 2011
to discuss menu options for minority groups
All food provided was photographed, layout and translation of menu was
provided by BIDMC Media Services and Sodexo GMSP printing
Develop a modifier in nursing admission screening to clarify reason behind
choosing “non-select” tray or “needs assistance” when ordering meals. For
example: language barrier, cognition/dementia, inability to use phone system
Implement Health Touch System – a tracking device in room service to measure
when nursing is using visual menu
Create survey to measure impact of visual menu on patient experience
For More Information Contact
Shana Sporman, MS, RD, LDN, Patient Services Ambassador,
ssporman@bidmc.harvard.edu
�
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Shana Sporman (<a href="mailto:ssporman@bidmc.harvard.edu">ssporman@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Support Services
Food Services
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Shana Sporman<br />Allyn Roberts<br />Mitch Lawson<br />Nora Blake<br />Ediss Gandelman<br />Jennifer Luszcz<br />Shari Gold-Gomez<br />Bruce Wahl<br />Diana Steinberg
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Visual Menu: Addressing The Needs of the Limited English Proficient Population
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
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The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Patient and Family-Centeredness
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https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/79c346483d7d8ac2c6a4436997879459.pdf?Expires=1712793600&Signature=VymFPMIrVuq-xYpedmjeSTItEJzrk8k4fOCwyIfmSpDn0HXWaG4zVBXr0fJCwTmhHjEQzHXvCbREWDR26C3yAiJc8SWPJ5nbCjY3nQLS8A3r6NxkrWUD2Ugx1NjJgrpBltIVbh7J1tSlxNhIk3Wl6Bg7DK0e2a4pOwzby75Bdxx1RoYUNWIc-jvABQQZT5jjSUHqNsUw1KsRPH8LXlo0E7GpWQy6lCDRCwsdaHDq-UTztNDbDnx-cPAODVgtx9w1N4bIbkAzs%7Er%7EftKhWpKkoY%7EW2WC%7EoUXUI30cBZ8S4VcK9FnawDDbd9tdYUwLbHL6%7EX517JSYy8TalTEYRIlZtA__&Key-Pair-Id=K6UGZS9ZTDSZM
c47275db23650b66605daa68771491a5
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Spread of
Best Practice
Award
The Problem
While the fall rate in the Med/Surg population was decreasing hospital-wide, the fall
The Results/Progress to Date
rate in on the Oncology Units continued to rise.
# Patient Falls on 7 Feldberg Oncology Unit
The Morse Fall Score was not capturing our patients that were most at risk to fall.
M ay - September 2011
Chemotherapy treatments, supportive medications increased patients risk to fall.
4
Patients were not educated on their heightened risk to fall
3
2
Aim/Goal
1
To decrease the fall risk in this specific patient population.
0
Evidence illustrated that the Institute for Healthcare Improvement’s (IHI) Falls
Pre-pilot (May- July 19 )
bundle could do a better job of capturing patients who are at a true risk to fall. By
IHI Bundle Implemented (July 20 )
focusing on these patients, we could concentrate our fall prevention efforts more
efficiently and potentially reduce chair and bed alarm fatigue.
IHI Bundle Start
Decreasing the Fall Rate on the Oncology Units
May
June
July 1-19th
July 20th-31st
August
September
th
The Team
Baker, RN, CNS
Kathy
Chris Kristeller, RN, CNS
th
Pat Folcarelli, RN, PhD
Kim Sulmonte, RN, MHA
Meggie Galligan, RN, UBE
Erin Tardanico, RN, UBE
The Interventions
had an improvement opportunity to more accurately
We hypothesized that we
identify patients at high risk to fall by using criteria from the IHI Fall Bundle for
evaluating ALL patients.
1. ensuring that the bed is in the lowest, locked position
Lessons Learned
is in reach
2.
the nurse call light
Patients should be an
active part of their care team. By educating patients about their
3.
the IV pole is on the side of the bed where the patient would exit
risks to fall, we can decrease the potential for falling and falls with injury.
Upon completion of the above, the nurse must answer the following question:
“Is the patient able and willing to reliably and
Next Steps/What Should Happen Next
consistently use the call light to ask
for help?” If the answer to that question is ‘No’, fall interventions will be
Continue
to assess the fall rate on the Oncology Units
implemented, such as bed and chair alarms, low beds, room close to the nurses
Spread the IHI fall bundle hospital-wide
Continue
station, etc.
to have patients be a part of their care and work with the interdisciplinary
team to decrease their risk to fall
In addition, a former oncology patient wrote a letter to current patients describing
Look at medications contributing to the fall risk and evaluate dosing and the patient’s
her personal experience with a fall as a patient, and how she
thought it would
need for these medications
never happen to her. She then shares practices that patients should take to help
protect themselves from a fall. This letter and list of interventions was given to
each patient upon admission.
For More Information Contact
Chris Kristeller, RN, CNS
ckriste1@bidmc.harvard.edu
agoldma2@bidmc.harvard.edu
47
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Amy Goldman (<a href="mailto:agoldma2@bidmc.harvard.edu">agoldma2@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Ambulatory Services
Emergency Services
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
WebOMR User Group<br />WebOMR Support Team<br />IS Clinical Development Team<br />HMFP<br />Outpatient Departments
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Visit Summary in WebOMR
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2012
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pdf
Effectiveness
Patient and Family-Centeredness
-
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a63a020b1c2a85ca5d1726d044a94514
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Using Narratives to Improve ICU Care
The Problem
The Results/Progress to Date
The Intensive Care Unit is a high stress environment for family members who may
find it difficult to communicate with staff. Frequently, important questions go
unanswered. Using the narratives from the Family Satisfaction Survey, we developed
a process of real time feedback to increase patient and family centeredness.
Anonymous weekly verbatims from surveys are
emailed to appropriate Nurse Managers, the
Social Work Director and/or the Pastoral Care
Director to encourage real time quality
improvement initiatives based on family
satisfaction narratives. As a result of sharing
patient and family feedback the following actions
have occurred:
Aim/Goal
The family members of ICU patients (both survivors and non-survivors) will have an
opportunity to share their experience and have their questions/concerns about ICU
care answered in a timely manner.
A letter was created describing the process of
The Team
Pam Browell, RN, MS
Rev. Julia Dunbar, MA, MDiv.
Susan Holland, RN
Peter Clardy, MD
Wendy McHugh, RN, MS
Kristin Russell RN
Jean Campbell, RN, MS
Claire Gerstein, LICSW
Michael Howell, MD, MPH
Mary McDonough, LICSW
Kristin O’Reilly RN, MPH
Margie Serrano RN, MS
obtaining autopsy results be given to next of
kin at time of consent to autopsy.
(excerpt from FS-ICU Survey)
Family members referred to Social Work for
bereavement support.
Three former ICU family members were referred to Patient Relations for help in
obtaining their deceased loved one’s medical record.
The Interventions
FS-ICU survey mailed to all non-survivor families 7 weeks after the death of an
ICU patient.
In person interview with ICU families using FS-ICU survey within 3 days of
discharge out of ICU.
Created a cover letter for FS-ICU survey with contact number and address so
that families can contact Health Care Quality representative if they have
concerns about ICU care.
Held targeted meetings arranged as soon as possible with Patient Relations
representatives, ICU Nurse Managers, Social Worker Manager and/or Pastoral
Care Director depending on family/pt concerns.
Communication was facilitated between patient/family and SICU and CVICU Nurse
Managers regarding ICU nursing care issues on numerous occasions.
Lessons Learned
The FS-ICU survey was initially used as a tool to examine family satisfaction. We were
intrigued at the intense desire of many ICU families to relate their experience and to what
depth the non-survivor families wanted to clarify some aspects of their loved one’s ICU
care. The real time problem solving provided satisfaction for the ICU family as well as
the staff members even after the patient was discharged from ICU. Important quality
improvement initiatives were generated from family narratives.
Next Steps/What Should Happen Next
We will continue to conduct the FS-ICU survey and address any Health Care Quality
concerns we learn about in the narrative section. We are also planning on studying the
PTSD of family members of ICU patients and we will evaluate whether real time problem
solving decreases PTSD.
For More Information Contact
Wendy McHugh, RN, MS
Coordinator, Person-Centered Care Project
wmchugh@bidmc.harvard.edu
�
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Wendy McHugh (<a href="mailto:wmchugh@bidmc.harvard.edu">wmchugh@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Health Care Quality
Critical Care
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Pam Browell<br />Jean Campbell<br />Julia Dunbar<br />Claire Gerstein<br />Susan Holland<br />Michael Howell<br />Peter Clardy<br />Mary McDonough<br />Wendy McHugh<br />Kristin O’Reilly<br /> Kristin Russell<br />Margie Serrano
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Using Narratives to Improve ICU Care
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
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The file format, physical medium, or dimensions of the resource
pdf
Patient and Family-Centeredness
-
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a41405b741403b7535fe6bf6991e13a3
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Text
Universal Radiology Time Out
The Problem
To address persistent errors in procedures outside
of the OR, the Interventional Procedures Committee
(IPC) mandated a standardized Time Out process be
implemented in all procedural areas.
Root cause analysis of procedure cases resulting
in complications from errors found that if a more
robust time out had taken place the error could
have been avoided.
Each area within the IPC was tasked to draft a
scripted Time Out that contained the 7 elements
recommended by TJC (The Joint Commission).
We had to develop one script that would cover a
range of different procedures across our entire
department.
Aim/Goal
Develop a standardized Time Out script for all procedure
personnel regardless of procedure or modality. Procedures
are performed by rotating staff and at various locations,
such that having a universal script became essential for
personnel to have the same expectations and the same
tools. A universal Time Out would promote consistency and
compliance, preventing errors and increasing patient safety.
The Team
Radiology: Misti Mullins, RN; Bridget O’Bryan-Alberts RN BSN;
Jonathan Kruskal MD PhD; Donna Wolfe, Michael Larson,
Section Chiefs, Managers, and Staff.
Interventions
Met with radiology section chiefs to draft one script to fit all procedures, e.g., liver biopsy, dialysis catheters,
therapeutic injections, vertebroplasties, etc. across all modalities, i.e., interventional, musculoskeletal,
abdominal, CT, ultrasound, fluoroscopy etc.
Invited feedback from radiology managers on roles in the Time Out process, best way to educate staff and
implement new script.
Educated staff on new script at section staff meetings, laminated scripts and produced video demonstrating
Time Outs across the department.
Progress to Date
Since implementation of a universal Time Out script
in interventional radiology procedures, compliance
rates have been consistently high and we have not
experienced any procedure errors.
Lessons Learned
When we developed the time out script we looked to
the Radiology Technologists to be the leader for our
script because they are the common denominator
in all interventional procedures. During piloting of
the script, several technologists voiced concerns
about leading the time out due to clinical elements
not within their scope of care, e.g., they felt that
leading the time out made them responsible for
knowing acceptable lab values and medications. To
address this, we discussed their role issues during
staff meetings and clarified that leading the Time
Out ensured that the procedure team covered each
of the Time Out elements but did not make them
responsible for elements not within their scope of
care.
This project brought to light another discovery we
made during the implementation of our script, that
leading the Time Out empowered technologists
to feel comfortable calling out any issues they
encounter.
Next Steps
Continue audits and analyses
Develop and implement a post procedure
“closeout” process to cover the 5 D’s:
Disposal of sharps
Disposition of the specimen
Documentation
Discharge of the patient, & any remaining
Details
On-going monthly audits to measure compliance with script use. Any problems or issues are examined using
root cause analysis.
For More Information Contact:
Misti Mullins RN (mmullin2@bidmc.harvard.edu)
Bridget O’Bryan Alberts, RN (bobryan@bidmc.harvard.edu)
Jonathan Kruskal, MD PhD (jkruskal@bidmc.harvard.edu)
�
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Misti Mullins (<a href="mailto:mmullin2@bidmc.harvard.edu">mmullin2@bidmc.harvard.edu</a>)<br />Bridget O’Bryan Alberts (<a href="mailto:bobryan@bidmc.harvard.edu">bobryan@bidmc.harvard.edu</a>) <br />Jonathan Kruskal (<a href="mailto:jkruskal@bidmc.harvard.edu">jkruskal@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Radiology
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Misti Mullins
Bridget O’Bryan-Alberts
Jonathan Kruskal
Donna Wolfe
Michael Larson
Section Chiefs, Managers, and Staff
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Universal Radiology Time Out
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A point or period of time associated with an event in the lifecycle of the resource
2012
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Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/71d4a1957a3503ca6f0a43b511c2aacd.pdf?Expires=1712793600&Signature=sttna-u2sOIJ89UKXZl6HLrTjs-B7I0a8ZBW21qxfVcME9PQlkSIuUdB%7EaoSdddyC2IwvMSK1hdqPxTjEdTE1QMZ3Ncj88sdTjS323XKUXoxDcOoMsnpZ3034K0EfPSEcTqpcBxWYr6kuUcg%7Ei9tRToOBBuNdGJB8lR7oC%7E3l4LLqyyDH6k1Kh822EsFXdKh2v6l8E51aMje6Mr%7EgddLZFkyHZtxVk4If%7EhcTFIAyKYvRWy2ttzYPA7GCgYUUmmpthkox9pVwa60TQDGgMO1egvmaps9OOsOt-Se%7EQdHtDaTn5G0j0HomminpWcv329tHoVUP%7ErtyPrkMYhBDhyWoA__&Key-Pair-Id=K6UGZS9ZTDSZM
efbc2e24a3cc20dc7c00441f841383e8
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Nursing Time Required for VAP Prevention
The Problem
The Results/Progress to Date
Ventilator associated pneumonia (VAP) is a common healthcare-associated
infection, with high attributable morbidity and mortality.
The Institute for Healthcare Improvement (IHI) Bundle is a widely used
prevention strategy introduced in 2005. Elements of the 2005 IHI Bundle
include: daily assessment of readiness to wean, daily sedation holiday,
elevation of head of the bed, stomach ulcer prevention, and deep vein
thrombosis prevention.
In 2006, to improve patient care, BIDMC implemented its own VAP prevention
bundle, which includes all aspects of the IHI Bundle, plus oral care with
chlorhexidine.
Although these strategies are widely in use, no work has established the cost
of these bundles in terms of health services utilization or nursing time required.
Aim/Goal
To determine the nursing resources required for successful implementation of VAP
prevention, in order to inform further decision making regarding the most costeffective strategy.
Reported Nursing time required for VAP prevention (Minutes per Day)
Median
45
20
30
Intraquartile Range
30-62
10-34
20-60
Total IHI Bundle Time
95
60-156
Oral Care
Chlorhexidine Oral Washes
Toothbrushing
115
20
74-182
10-30
Total BIDMC Bundle Time**
210
134-338
Bundle time*
DVT Prevention
Stomach Ulcer Prevention
* Bundle time includes assessment of readiness to wean, daily sedation holiday, and elevation of head of the bed.
** BIDMC bundle time includes assessment of readiness to wean, daily sedation holiday, elevation of head of the bed, and
chlorhexidine oral care.
The Team
Westyn Branch-Elliman, MD, Infection Control/Hospital Epidemiology
Sharon Wright, MD, MPH, Infection Control/Hospital Epidemiology
Jean Gillis, RN, MS, Critical Care Nursing
Michael Howell, MD, MPH, Critical Care Quality
Critical Care Nursing
The Intervention
We conducted an anonymous, online survey of all critical care nursing staff at
BIDMC.
119/291 critical care nurses (41%) responded to our survey.
Critical care nurses from all critical care units responded.
More than half of the respondents had over 10 years of critical care nursing
experience.
VAP prevention utilized high levels of critical care nursing time.
23.5% (28/119) survey respondents reported that time spent on VAP prevention
competed with other patient-care tasks, requiring prioritization of other activities,
such as: Turning the patient, medication administration, cleaning the patient, and
patient and family teaching and support.
Lessons Learned
Current strategies of VAP prevention require high levels of critical care nursing
resources, and the optimal prevention strategy remains unknown.
Next Steps/What Should Happen Next
Our study is a single center study; further investigation is needed to determine
how VAP prevention impacts all aspects of intensive care unit care.
These results provide a critical piece of information regarding ongoing
investigation into future VAP prevention strategies, which will include an
assessment of approaches not currently in use, such as specialty endotracheal
tubes and probiotics.
For More Information Contact:
Westyn Branch-Elliman, MD
wbranche@bidmc.harvard.edu
Division of Infection Control/Hospital Epidemiology
�
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Westyn Branch-Elliman (<a href="mailto:wbranche@bidmc.harvard.edu">wbranche@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Infection Control
Hospital Epidemiology
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Westyn Branch-Elliman
Sharon Wright
Jean Gillis
Michael Howell
Critical Care Nursing
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Title
A name given to the resource
Nursing Time Required for VAP Prevention
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
Format
The file format, physical medium, or dimensions of the resource
pdf
Efficiency
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/a9e0785c2f6184f5fbc607ab76e5a3e0.pdf?Expires=1712793600&Signature=CK%7EsJ5MBxKjJVxMZKHfEX4ibxi%7E5-iDeLr63paNe%7EX0YbAX6w4annWNbimikJ9c4YCY2Hy6cSBx%7E9B5sjOyX6EcymsGyPbTvv9QjkX2B-jhmRD4wYlN6hU%7EBWR2KxXuYWTxqVEzIpucvdPaJF6YCyQOuy4tmmMDgLbGqyRR4y2m6R3AOX0Epmq4iQ16LMicqEBoQpqKPs3Jtq6Kq4eNRixryiupyuYswy9rmTJDnK4LlAz%7E%7ETgGv6ADTFnak0K67y6k5GAj-C7y9cBE4AbLgO1kwazRBjDXoV23irohuns5eEtik5b4XbXK3U5DcbpZq73rwL1xz49xQMlFG3esjKQ__&Key-Pair-Id=K6UGZS9ZTDSZM
4bff42dbeb29e6034ba7a911d6eefd60
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Text
Unexpected Staffing Accuracy Gains from Visual Hospital
The Problem
The Results
“We do not have length of stay right for every patient”
Scope:
Patient enters
our system
ED
Transfer
to Bed
Transition
of Care
Inpatient Diagnostic & Treatment
Patient exits
our system
Demand for discharge is not
understood & expected number of
discharges vary by who you ask
Aim/Goal
Understand each patient’s ‘medically fit for discharge’ status and raise awareness of
patient needs so providers are able to prioritize their work in an effort to discharge
patients as soon as they are medically fit to leave
The Team
Tricia Bourie , Farr 3
Mary Jo Brogna, PCS
Alicia Clark, MD, Medicine
Donna Clarke, Farr 7
Denise Corbett-Carbonneau,
Farr 2
Maureen Cunniffe, PCS
RoseAnne Cunniffe, PCS
Richard Knowles, Farr 2
Sarah Moravick , HCQ
Mary O’Connell, 5 ST
Norma Wells, CC7
Julius Yang, MD, HCQ
Alice Lee, BT
Kimberly Eng, BT
Bonnie Baker, BT
A process was developed to review each unit’s expected number of discharges
(participating units: Farr 2, Farr 3, Farr 7, CC7, Stoneman 5) and each patient’s
‘medically fit for discharge’ status, 4 times per day – previously expected number of
discharges were reviewed once per day at the 10a Bed Meeting.
As expected, problems and delays surfaced as patient status and needs were made
visible close to real time. Unexpectedly, the problems and delays have been difficult to
quantify and report in fine enough detail to create system-wide countermeasures.
Further study and refinement of the process is needed.
An unexpected gain was an increase in staffing accuracy for inpatient nursing. Inpatient
nursing flexes their staffing based on patient census. The increased awareness of each
patient’s status positively impacted the Staffing Office’s ability to accurately staff.
Each floor has a standard number of ‘direct nursing hours of care’ allocated per patient
per day. Variation from that standard indicates the unit is over or under staffed for the
number of patients that are on the unit. The graph illustrates this deviation over time:
*Stoneman 5’s data excluded
– ST5 was merged with other
units in Dec
The Interventions (June 20, 2011)
Visu a l H ospita l – u n d erstan d in g d em an d to get ou t
Pu rpos e: Understand current state of each unit by identifying expected discharges, potential
barriers to discharge and how to act upon them, in an effort to plan the flow of the hospital
Bed Office
Inpatient Unit
Over
staffed
(Organization level)
Under
staffed
Bed & Staffing Office representatives
Resource RN collects each patient’s status
from the patient’s MD or RN and records it round on each unit (4x/day) and reviews each
patient's status with the Resource RN & Case
on the unit’s board, 4 times per day
Managers and notes specific reasons for delay
(9a, 12p, 3p, 5p), Monday - Friday
Data from each unit is
collected & displayed
on central board
Patient Status Key*
•
Not medically fit for discharge
•
? Awaiting results/decision for discharge
•
X Medically fit for discharge, but requires
externally controlled resources
•
Medically fit for discharge
*Designed by a
multidisciplinary team
with situational examples
Data collected to understand
current state:
• Delays reasons
• Delay hours
• Changes in status
• Predicted discharges
Other non-related
efforts to improve
staffing accuracy
Lessons Learned
Understanding the status of each patient, at a glance, allows staff to focus on throughput
and make more accurate operational decisions (e.g. more closely matching RN staffing
to patient census).
Next Steps
Study, in detail, the processes containing sources of delay that have surfaced through
the visual hospital experiment.
For More Information Contact
Alice Lee, VP, Business Transformation, alee1@bidmc.harvard.edu
Mary Jo Brogna, Associate Chief Nurse, mbrogna@bidmc.harvard.edu
�
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Mary Jo Brogna (<a href="mailto:mbrogna@bidmc.harvard.edu">mbrogna@bidmc.harvard.edu</a>)<br />Alice Lee
Department
Any departments listed on the poster or identified in the spreadsheet.
Business Transformation
Nursing
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Tricia Bourie <br />Mary Jo Brogna<br />Alicia Clark<br />Donna Clarke<br />Denise Corbett-Carbonneau<br />Maureen Cunniffe<br />RoseAnne Cunniffe<br />Richard Knowles<br />Sarah Moravick<br />Mary O’Connell<br />Norma Wells<br />Julius Yang<br />Alice Lee<br />Kimberly Eng<br /> Bonnie Baker
Dublin Core
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Title
A name given to the resource
Unexpected Staffing Accuracy Gains from Visual Hospital
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Efficiency
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/df688e4592f63d8fc17873a9a8a03da5.pdf?Expires=1712793600&Signature=FAzCPR1bnUxQj143tMDafgWdglgx-EUpaWQ65WJqOwIYj6Ax1QxBhicz01oe7KOqbRPRg42ovnxwE3oICebrZNSLxpistcXdczu8OBkGEfXtCnq41-9YntFNTpNL8Iy8CSmdJ2kPLicfihR4mqpAfG5CrX1lX25iWeJzYZV80bDPJfNN0fTurfwo-3dFQxvXKYDF5oKV7PmZQINTUNpOHroUjIXrnHNi6g8%7EjsqqXZwB85I56r9c1DIxLh%7EJJpq%7Eht-BzCuCTo9fmqBNfwlzoAhCw46JdqLg396ne5iYmCNPh8EFWFau5HviSHv9Xkhbe10P0izadyPzjKi1sMX06w__&Key-Pair-Id=K6UGZS9ZTDSZM
5f8e911f70334befb8a9f3b66828a084
PDF Text
Text
Unexpected Consequences of a Well-Intended “Fix”
The Problem
The Results/Progress to Date
In preparation for the 2004 Joint Commission triennial survey, we noticed that there
was a pattern of clean supplies being stored under the sinks in patient care areas.
This was a violation of infection control standards.
Aim/Goal
To eliminate storage under sinks in patient care areas across BIDMC
To comply with Joint Commission recommendation to improve adherence to
Infection Control standards
BIDMC had three successful Joint Commission visits - with no findings related to
under sink storage.
We also began to notice that we were unable to clean under the sinks or to
respond in a timely fashion to leaks and that when we did – there was an
apparent build up of mold under the sinks behind the bolted doors! We did not
anticipate this!
The Team
Pat Folcarelli, Health Care Quality;
Richard Marini, Maintenance Operations;
Brendan Raftery, Maintenance Operations;
Gary Schweon, Environmental Health and Safety;
Linda Baldini, Infection Control and Hospital Epidemiology;
Kim Sulmonte, Patient Care Services
The Interventions)
The Joint Commission prep team made a decision to bolt down all of the
cabinets to prevent under sink storage.
All cabinets under the sinks were bolted down
Leaks under sink and mold build up inside cabinet
Lessons Learned
Interventions require a mechanism for monitoring and routinely checking back to fully
appreciate the downstream effect of the intervention.
Next Steps
We are bolting all of the cabinets and cleaning/reparing the areas under the sinks. We
are working with our staff to reinforce the reasons for not storing supplies under the
sinks.
Example of Bolted Cabinets underneath sinks in patient care areas
For More Information Contact
Pat Folcarelli, Director of Patient Safety,
pfolcare@bidmc.harvard.edu
�
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Pat Folcarelli (<a href="mailto:pfolcare@bidmc.harvard.edu">pfolcare@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Health Care Quality
Patient Safety
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Pat Folcarelli<br />Richard Marini<br />Brendan Raftery<br /> Gary Schweon<br /> Linda Baldini<br />Kim Sulmonte
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Title
A name given to the resource
Unexpected Consequences of a Well Intended "Fix"
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/124b1fa3782248ce8f20506d9bc74509.pdf?Expires=1712793600&Signature=vJJtdevXEy9p7NatvMt6BY8Qkq32OKt5zLUoRu1LG0i8ZWh%7EGcRRZVjXbY%7Ex6DvHaKaTrapBbdWe4flXaa6-DW5vdFk2BkrrlrgGh8NszZNaTpXzTKIHoiHo8me-4LIeBnvpSzR5354VRS8XvhU84u4frRfIE4MztuWQuBjx-7fvHH32eup0XSghg1WmFKB51yVws1grqtTYHyvrcokejJd1GF4Kp6D7gS4Fsh7aFfxzT2zudHPCboYX%7Ev56XcWSu0Yn064eOsc789Ytj-wpDNXc5n4LdoXqxJbaqI35SlVOfCwNeizSEXJ9MtIvGvIgAQsjamcruTFo5xS1sabupA__&Key-Pair-Id=K6UGZS9ZTDSZM
0e661ff3249c48dfc1091d3f7b4a7d51
PDF Text
Text
Transitioning Hemodialysis to POE
The Problem
The Results
Paper-based order sets were used in the Inpatient Hemodialysis (HD) Unit. This manual
process lacked the same quality and safety “checks” of the hospital’s electronic
systems, and required Renal Fellows to be physically present in the HD Unit to write
orders. Additionally, Inpatient Services had limited insight into when treatment was
scheduled, and the medications that would be given in HD.
Decreased Variability
Hemodialysis Fellows and
Attendings now have a
standardized way to enter orders
anywhere on campus.
Aim / Goal
Successfully transition the Hemodialysis Unit from paper-based systems to the
hospital’s electronic provider order entry system (POE) to decrease variability, increase
transparency, and improve patient safety .
Increased Transparency
A “HD Orders” notification appears on
the Inpatient Floor Dashboard when
orders are written by Renal staff for
medications or interventions to be
administered during dialysis. Orders
are visible to all POE users, and
appear in light blue.
The Team
Mark Williams, MD; Barbara Carney, RN; Jean Hurley; Dave Mangan, PharmD; Steve
Maynard, PharmD; Ali Poyan Mehr,MD; Mihran Naljayan,MD; Sarah Moravick; MBA,
Mary Biagotti, RN; Julius Yang, MD; Jennifer Thomas, RN & Hemodialysis Nursing Staff
Improved Patient Safety
The Pharmacist who reviews the patient’s floor based orders also reviews the
patient’s Hemodialysis orders to enable awareness of all the medications the
patient is receiving.
The Interventions
A sanctioned
Hemodialysis
environment was
created within
POE where only
HD staff can
enter and
activate HD
orders, but
orders are visible
to all POE users.
The environment
went “live” in
June 2011.
“HD” appears on the Pharmacist's dashboard
when the patient is checked-in at HD so any
special medications are sent to the appropriate
location.
A Dialysis specific Medication
Administration Record (MAR) was
developed to ensure providers could
easily identify what was given in HD.
Next Steps
Continue to monitor implementation and develop proactive alerts to inform Renal Staff
when a dialysis patient is admitted to BIDMC.
For More Information Contact
Barbara Carney, RN, Nurse Manager
Venous Access Team & Dialysis; bcarney@bidmc.harvard.edu
�
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Sarah Moravick (<a href="mailto:bcarney@bidmc.harvard.edu">bcarney@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Health Care Quality
Inpatient Quality
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Mark Williams<br />Barbara Carney<br />Jean Hurley<br />Dave Mangan<br />Steve Maynard<br />Ali Poyan Mehr<br />Mihran Naljayan<br />Sarah Moravick<br />Mary Biagotti<br />Julius Yang<br />Jennifer Thomas<br />Hemodialysis Nursing Staff
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Title
A name given to the resource
Transitioning Hemodialysis to POE
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
Format
The file format, physical medium, or dimensions of the resource
pdf
Efficiency
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/791a5d34a8de7e93cef257e1a6b0a7b3.pdf?Expires=1712793600&Signature=vf97dngkcyoW5ghdUHG-xlCqRf5zl4umOfB-XFdunydV-FE56BFIPvozhFmAhk9K70fnwCTF17eSvUrkQi4O5w-PrTBtCgl2SAxTr6BJago4DLzjK0cKGwd6o6E%7EHh3YRaQqJ0K1DiHcT7fAHRdUiCYqfckC6nG7IAmiNzXeSoHRewPCL2-5R9anICM55hXLAI%7EGWVaiKGX8bsBBSw%7EJ%7Eo0NmY4ohX2EBMPb-IvOgZNQavSVqGMv10I1zAQOACJO4-vRXRIL4Gg-NkuA-Ene5Jfy8VOuSdyiAFnRFZRPQx7yC4DZWtvQd%7EuW6v3jS-fT83YKhbesAhxVdmtYTUFdxg__&Key-Pair-Id=K6UGZS9ZTDSZM
9279a953aaec68cf6ce160030735e419
PDF Text
Text
Tracking Performance Improvement in Hospital Emergency Management
The Problem
Emergency Management is fairly new to the hospital arena; currently there are no
standard methods to evaluate the effectiveness of our emergency management
program. After every incident and exercise that occurs at the Medical Center we
identify areas for improvement in our response and procedures. What we hadn’t
realized was that all of the areas for improvement are the best learning tools we have;
these are termed corrective actions.
Summary of Results/Progress
Diagram depicting the breakdown of corrective actions by critical functionIn FY 2011 there were a total of 140 areas for improvement identified.
Communications and staff responsibility issues had the highest volume of the six
critical areas tracked
EM Corrective Actions 2011
Aim/Goal
1
Utilizing the Corrective Action Matrix, Emergency Management (EM) has developed a
Performance Metric used to evaluate the effectiveness of the Emergency
Management Program at BIDMC. The EM Performance Metric compiles the
corrective actions for each quarter and sorts them by date observed and date
recommendation completed. We then use that quarterly data to track our
performance goal of completing 90% of all corrective actions within 90 days of the
event or exercise. The EM Program was effective in 2011 through the
accomplishment of reaching our target of over 90% for 3 of 4 quarters.
45
48
Communications
Resources & Assets
Patient Care Services
Safety & Security
Staff Responsibilities
3
Utility Management
13
30
Spark line depicting Emergency Management performance metric by quarter
The Team
Meg Femino, Director, Emergency Management
Bryan Sears, Project Manager, Emergency Management
John Mangino, Project Manager, Emergency Management
All participating departments across the BIDMC community
The Interventions
Areas for improvement are identified across all areas of the medical center
during an event or exercise debrief, in 2011 BIDMC responded to 15 drills and 19
events
In order to accurately track all of these corrective actions we developed a
Corrective Action Matrix tool. The matrix differentiates the corrective actions into
the six critical functions in emergency management according to The Joint
Commission. This system also allows us to track when we complete
recommendations, by whom and retest each of these items.
Determining why the area needed improvement and recommending a corrective
action
The EM Team weekly reviews and works with groups to provide solutions to
actions listed that require correcting
Lessons Learned
Capturing data and sorting by critical function gives us a useful picture of our greatest
area needing improvement. This is essential information when developing EM goals for
the next year in continuous improvement. It is important to track these corrective actions
on a weekly basis to ensure a high level of completion.
Next Steps/What Should Happen Next
Our next step in “tuning” the EM Performance Metric is to implement a “point
scale” for different categories of corrective actions (i.e. Rating a corrective action
involving life safety higher than a corrective action involving a laptop in the
command center not functioning)
Developing an “EM Performance Cycle” from our performance tracking system
that can duplicated across all hospital emergency management as a performance
standard
For More Information Contact
Meg Femino- Director, Emergency Management
mfemino@bidmc.harvard.edu
�
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Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Meg Femino (<a href="mailto:mfemino@bidmc.harvard.edu">mfemino@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Health Care Quality
Emergency Management
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Meg Femino<br />Bryan Sears<br />John Mangino<br /><br />
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Title
A name given to the resource
Tracking Performance Improvement in Hospital Emergency Management
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/4bd7213c90d1e544af9c36d5a98135d3.pdf?Expires=1712793600&Signature=umbla73Idll52xFIWhbRi2y8lciOFORuhf58-Qe%7EVmEQ4WDgDDe-siTZJ8AYneSkzQb9HP24X1rYVzfNCW6vD7yl5hEVRfhjVzmNo-BhFvakIW8jZRnfBjXqQe8XVBiL-W7qpyrTG3xqjwGaXchPKhrbf5ZrleseLHkyhjHDAdxJUjGj-A8PW-ZNeHu0BqEZtBAy8nUysHSz6Rc7lReX%7EZq2EpogjZ2xIvQPWrmTncjrkPrI7FL2YPSwAKgbVruZOSIXRrk3XXJgrbzp-f3spNbKQlgsfGkxDFNZo-iz9bVGpdQb9IdCjYuOePNinNrmamPT-qxmdTqM4u08Dz3N5A__&Key-Pair-Id=K6UGZS9ZTDSZM
8cbc200a4bedb13cae1fe747385492ec
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Text
Tracking Cumulative Chemotherapy Doses at BIDMC
The Problem
Tracking cumulative chemotherapy doses contributes to patient safety by giving
providers information they can use to determine if their patients are close to
receiving an unsafe amount of chemotherapy.
Prior to this effort, in order to tabulate the total amount of chemotherapy that
patients received, providers needed to reference every individual administration’s
record and manually calculate, which was time-consuming and error-prone.
The Division of Hematology/Oncology at Beth Israel Deaconess Medical Center
has applied for Quality Oncology Practice Initiative (QOPI) Certification, offered
by the American Society of Clinical Oncologists (ASCO).
o One requirement of this quality improvement effort is the ability to track
cumulative doses of chemotherapy associated with cumulative toxicity risks.
The Results/Progress to Date
A new screen in the OMS administration history has been implemented which
shows the cumulative chemotherapy doses for BIDMC patients.
Detailed information about each administration is available by expanding every
medication:
Aim/Goal
Develop and implement a new function in the Oncology Management System (OMS)
to display the cumulative doses of chemotherapy patients have received at BIDMC
The Team
Peter Yang, MD - Clinical Fellow, Division of Hematology/Oncology
Jeremy Warner, MD - Clinical Fellow, Division of Hematology/Oncology
Jean Hurley, BA - Programmer, Information Systems
Holly Dowling, RN - Clinical Nurse Educator, Division of Hematology/Oncology
Reed Drews, MD - Faculty Advisor, Division of Hematology/Oncology
Christine Manuel-McGuiggin, RN - OMS Set Coordinator, Hematology/Oncology
Members of the OMS Steering Committee
Mark D. Aronson, MD, Vice Chair Quality, Department of Medicine
Scot B. Sternberg, MS - Quality Improvement, Department of Medicine
The Interventions
The OMS Steering Committee built upon the existing OMS administration history
in hopes of maximizing accuracy with minimal change to existing workflow.
Oral and research medications were omitted since they are not ordered through
OMS.
A new screen was created in the OMS administration history that automatically
tallied up doses of chemotherapy that were logged as “given” by nursing.
During the design process, several rounds of quality assurance (QA) were
performed on a test server to check the accuracy and completeness of the
cumulative doses of chemotherapies and to inform design changes.
In the most recent QA review, over 200 inpatient and outpatient chemotherapy
administrations were checked, 89% of administrations were properly logged,
and the system accurately added up 100% of them.
Lessons Learned
It is important for all of the disciplines which will be affected by a system change to
work together, as potential problems may be uncovered and straightforward,
practical solutions may be available.
Next Steps
Further QA to assess the completeness of the dosing record and to identify the
causes of any deficiencies.
Address barriers that affect the ability to log all chemotherapy doses, such as the
need to document administrations in multiple places (“double charting”).
Provider education regarding availability of cumulative chemotherapy dosing.
Survey providers to evaluate patterns of utilization of this feature.
Incorporate cumulative dose information into patient chemotherapy treatment
summaries.
For More Information Contact
Peter Yang, MD, pyang@bidmc.harvard.edu
Jeremy Warner, MD, jlwarner@bidmc.harvard.edu
�
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
<p>Peter Yang (<a href="mailto:pyang@bidmc.harvard.edu">pyang@bidmc.harvard.edu</a>)</p>
<p>Jeremy Warner (<a href="mailto:jlwarner@bidmc.harvard.edu">jlwarner@bidmc.harvard.edu</a>)</p>
Department
Any departments listed on the poster or identified in the spreadsheet.
Medicine
Hematology Oncology
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Peter Yang<br />Jeremy Warner<br />Jean Hurley<br />Holly Dowling<br />Reed Drews<br />Christine Manuel-McGuiggin<br />Mark D. Aronson<br />Scot B. Sternberg<br />Members of the OMS Steering Committee
Dublin Core
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Title
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Tracking Cumulative Chemotherapy Doses at BIDMC
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
Format
The file format, physical medium, or dimensions of the resource
pdf
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/bb889d0bcfdb27e9366cde79830841d4.pdf?Expires=1712793600&Signature=lC98z1ClsbNKVQXE0E9rCsNfTHx8j1y7ZX6otY9ZTlmbKuP1UDkqiy-gZwCyXkaxHgse1eb%7EkOUzNk%7EzEstVIFJc1ihS-vFYU5ucTctSqa2Tai2GC7UUMrTPZgVEa8E8b9G2uMlm1a5PEnumtLBLiWdoLvqyinEv1EpKDxUP4HTM7boBphq%7EqLtIlj1MYbyVGs93Qx6lfhjrFKwB2AG0M81iSYWqL1tOCuUdJJFod3pMuLv1b9%7EQETpTRFGF%7E0IyLz94U3IrMjyf%7ES29L8uYH5RdWPYMF5stlb8liQCogNOE9MCeeSFjkLeu3FsPNssDZ3QPsY4PtMy1NQmpsyNKgQ__&Key-Pair-Id=K6UGZS9ZTDSZM
6db563719641bb8a07c5b3d722f050fd
PDF Text
Text
The Use of Mitomycin in the PACU: A Competency for Nurses
The Problem
The Interventions (continued)
Intravesical Mitomycin was being administered to selected Transurethral
Resection of Bladder Tumor (TURBT) patients in the PACU.
Antineoplastic therapy requires adherence to guidelines for the safe administration
of Chemotherapy
The Institute for Safe Medical Practices (ISMP) identifies Mitomycin as a High Risk
Medication with increased patient harm when used in error.
A current guideline for use was not available to the nurses in the PACU, therefore
safe handling precautions were not being adhered to during ordering and
administration.
Development of an Education Plan
• Manufacturer’s representative in-serviced staff on the use of a closed-system drug
transfer device.
• In-services were held with simulation of a chemo spill and return demonstration of
safe handling procedures assessed.
• A Mitomycin reference book was developed
• Mitomycin box to be taken to the bedside was assembled
• Annual competency was developed and distributed to the staff
The Results/Progress to Date
Aim/Goal
To ensure that best practices were demonstrated in the care of patients
receiving Intravesical Mitomycin in the PACU
The guidelines for Mitomycin ordering and administration were successfully
implemented in the East Campus PACU in November, 2011.
To provide PACU nurses with the tools required to practice safely.
Surgeon’s informed consent now includes the administration of Mitomycin.
Closed loop communication is being utilized between the OR, Pharmacy and
PACU Nursing staff to ensure safe patient care.
A 3-way Foley catheter is utilized to ensure a closed system of medication administration.
Staff are practicing appropriate safe handling methods, including the safe
disposal of the medication.
Entire staff has completed the annual Mitomycin competency.
The Team
Rick Caswell, RN, Clinical Advisor
William DeWolf, MD, Chief of Urology
Holly Dowling, RN, Unit Educator
Mary Ellis, RN, Clinical Advisor
John Hrenko, Pharm.D.
Karen Lanning, RN
Marianne McAuliffe, MSN, RN
John Miltner, RN
Erin Tardanico, RN, Unit Educator
Zaven Norigian, Pharm. D.
Lessons Learned
The Interventions
A multidisciplinary work group formed in August 2011 to address the issue. Work
included:
A process is in place if the surgical consent does not reflect the use of Mitomycin
perioperatively.
A multidisciplinary approach utilizing strengths from each group member to
successfully implement change that improves patient care may apply to other issues in
the PACU.
Assessing the current state:
• Collaboration with Oncology Unit Educators as subject matter experts
(SME) to assess the current state.
• Gain knowledge of best practice from the SME.
Creating a safe care process:
• Consent
• Orders
• Handoffs
• Handling
Next Steps/What Should Happen Next
Annual competency to maintain consistent standard of care. .
Mitomycin administration in the PACU needs to be incorporated into a BIDMC policy
for the administration of an Antineoplastic medication outside of the hematology
oncology area.
Mitomycin competency spread through sharing with OR nurses.
Plan in place to develop a patient education sheet, and teach-back to educate
residents rotating to BIDMC.
For More Information Contact
Marianne McAuliffe, MSN, RN, Unit Educator, PACU
mmcaulif@bidmc.harvard.edu
�
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Marianne McAuliffe (<a href="mailto:mmcaulif@bidmc.harvard.edu">mmcaulif@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Patient Care Services
PACU Nursing
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Rick Caswell<br />Karen Lanning<br />William DeWolf<br /> Marianne McAuliffe<br />Holly Dowling<br />John Miltner<br />Mary Ellis<br />Erin Tardanico<br />John Hrenko<br />Zaven Norigian
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Title
A name given to the resource
The Use of Mitomycin in the PACU: A Competency for Nurses
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
Format
The file format, physical medium, or dimensions of the resource
pdf
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/245d391e269254758d5cad7ec1b4b83f.pdf?Expires=1712793600&Signature=o3zTZ3dNill9qzYr3aV0MzO4yV7LkVlXlr23UFoaxejmRmheQE0DVi0laPFAjp85Wehg%7EiD8paLC-PWdt1C5UtU1acJgsmjlQqE3POEexJLFm49huXaXZaoDuyRyDMxwGmSwTyTTow7r3r8nvi5JCmxduPyIddy05eojt4cjjKOleQt1xi-R4uVPaqiiaz4UZQvttf6W6wnEvo08nnD449yjhz0eof1pM--QBV4GEzLZ3WM1G5dSouw1R0pJyqpO3ezYUYF8wO8IHyHqJhUU-Nz2UguPYU8j8XRyq3p0D1lB66WhQZINOCaa3V2Iz-GMC2ce%7EOeO9YAk4rHZSVwuBQ__&Key-Pair-Id=K6UGZS9ZTDSZM
e6d55134c168ee0765046208aa7b533f
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Text
The Triggers Program: Sustaining Gains
The Problem
The Results/Progress to Date
Hospital ward inpatients with serious, acute decompensations are a
particularly vulnerable group. The literature documents (1) these patients
have extremely high mortality rates, (2) at least one-third of them receive
suboptimal care before ICU transfer, and (3) delay in ICU transfer results in a
30% absolute increase in mortality. Most of these patients have warning
signs (“Triggers”) before their critical decompensation. Two years after the
initial Triggers program implementation, the rate of unexpected death
decreased by more than 50%. Gains in quality improvement tend to fall off
after initial implementation.
Rates of unexpected mortaility as a result of the triggers program have not only
been sustained but have continued to further lower rates of unexpected
mortality. The patient-and family-activated trigger was instituted in Q3 of 2010.
Since that time there have been 93 patient-and family-activated triggers called
here at BIDMC.
Aim/Goal
We aimed to sustain the reduction in unexpected mortality at the Beth Israel
Deaconess Medical Center without hiring additional staff and ultimately
eliminate unexpected death by continuing awareness efforts around the
Triggers program.
The Team
Many departments across the institution participated in the creation and
implementation of this program. Particularly key participants included:
Medicine
Surgery
Patient Care Services
Health Care Quality
Graduate Medical Education
The Interventions
Continued staff education on the Triggers program
Educated all incoming medical house staff on the Triggers program
Reviewed rates of trigger events called and unexpected mortality on
a regular basis to note changes in usage of the Triggers program
and missed opportunities
Instituted a patient-and family-activated trigger
Next Steps/What Should Happen Next
In the future we plan to develop a program to prevent the need for Triggers. We
also want to continue to learn more about patient-and family-triggers, why they
are called, and how we can best support and encourage this initiative.
For More Information Contact
Kristin O’Reilly, RN, MPH,
Project Manager, Critical Care Quality
koreilly@bidmc.harvard.edu
�
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Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Kristin O'Reilly (<a href="mailto:koreilly@bidmc.harvard.edu">koreilly@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Health Care Quality
Critical Care
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Medicine
Surgery
Patient Care Services
Health Care Quality
Graduate Medical Education
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Title
A name given to the resource
The Triggers Program: Sustaining Gains
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/dc738c570786f370f6e2c43128515ebc.pdf?Expires=1712793600&Signature=Tg-PobdZdQbgCwyU4dajwl4sgCc5yZXyMRZEwSYzk7msk-0srCPa0%7EXvgobthfbymNxDyhXjsrozCqNrXPkjBMrP-BkbOfX3jl-UM9eutqSA98E5sAh8HAb2ClyTyJrshGl0J6OEXYQNS9EvJjdFZpL7XTfTtQcSbLsRTf7nUb31UsW1CgSYs0lgJwAaudctwtHtz%7EjzxjVWMk6gANo%7Ef9kR4QY5vOv57IZ0PYS%7EhCWZrCdez4kp2meNapvuYaz17wDlGdoL7vwWw2UxP7sQP2HVGSfbBx4M1Rb-n1ghmBK3K93aVsX6o%7E3h5mZCGh%7E5sINNrwCxGWsIL%7EtcYqnwMw__&Key-Pair-Id=K6UGZS9ZTDSZM
617564682f0e3616c5e348b532dd5bdc
PDF Text
Text
The Road to Implementing Smart Narcotic Pumps:
Keeping Safe Patient Care in the Headlights
p g
g
J. Foley, RN, BSN, MHA; M. Grzybinski, BSN, RN; K. Carnevale, MS, RN;
g
y
E. Carvelli, RN; David Mangan, PharmD, RPh; Bill Pyne; Patrick Thomas; Paul Anderson
Beth Israel Deaconess Medical Center, Boston, MA
The P bl
Th Problem
At Beth Israel Deaconess Medical Center, PCA and epidural pumps
Center
were end of life and did not provide smart technology.
As the institution prepared to transition to new pumps we:
Narcotic Ordering Variability
N
ti O d i V i bilit
Epidural formulas ordered BEFORE
Smart Pump Implementation
Hydromorphone 10mcg/mL, Bupivacaine 0.1%,
250mL
Bupivacaine 0.1%, 250mL
• Established an interdisciplinary pump work group
• Reviewed patient safety reports for trends regarding PCA and Epidural errors
• Queried existing PCA and epidural medication orders sets and uncovered ordering
y
variability
• Evaluated the different vendor pumps for medication library capabilities and ability
to set clinician safety limits
• Identified pump user groups to participate in pump selection
• D t
Determined b t practice f medication lib
i d best
ti for
di ti library d l
development and f patient care
t d for ti t
protocols
Team Goals
Epidural formulas ordered AFTER
Smart Pump Implementation
Hydromorphone 10mcg/mL, Bupivacaine
0.1%, 250mL
Bupivacaine 0.1%, 250mL
0 1%
Hydromorphone 20mcg/mL, Bupivacaine 0.1%,
250mL
Fentanyl 4mcg/mL, Bupivacaine 0.1%, 250mL
Hydromorphone 20mcg/mL, Bupivacaine
0.1%, 250mL
Fentanyl 2mcg/mL, Bupivacaine 0.1%,
250mL
Fentanyl 4mcg/mL, Bupivacaine 0.1%,
250mL
Hydromorphone 30mcg/mL, Bupivacaine
0.1%, 250mL
Bupivacaine 0 5% 250 L
B i
i 0.5%, 250mL
Bupivacaine 0.5%, 250mL
Hydromorphone 40mcg/mL, Bupivacaine 0.2%,
Clonidine 2mcg/mL, 250mL
Hydromorphone 40mcg/mL, Bupivacaine 0.2%,
250mL
Hydromorphone 10mcg/mL, Bupivacaine 0.5%,
250mL
Meperidine 1mg/mL, 250mL
Hydromorphone 10mcg/mL, Bupivacaine
0.05%, 250mL
Bupivacaine 0.2%, 250mL
Bupivacaine 0.25%, 250mL
Hydromorphone 20mcg/mL, Bupivacaine
0.05%, 250mL
Bupivacaine 0.125%, 250mL
Hydromorphone 60mcg/mL, Bupivacaine 0.2%,
250mL
Hydromorphone 5mcg/mL, Bupivacaine 0.1%,
250mL
Hydromorphone 10mcg/mL, Bupivacaine 0.2%,
250mL
Hydromorphone 20mcg/mL, Bupivacaine
0.05%, 250mL
Meperidine 1mg/1mL, 250mL
PCA formulas ordered AFTER
Smart Pump implementation
PCA orders placed BEFORE
Smart Pump implementation
S
tP
i l
t ti
• Improve safety of narcotic administration via PCA and epidural pumps through the
use of standardized d
f t d di d drug lib i
libraries
• Standardized practice of narcotic prescribing and administration throughout the
medical center
• Reduce the risk of adverse events associated with PCA and epidural narcotic
administration
• Improve the ability of data retrieval for QA review
• Develop a sustainable multidisciplinary education process
HYDROmorphone 12.5mg/50mL syringe
Hydromorphone 20mg/100mL bag
Morphine 50mg/50mL Syringe
HYDROmorphone 50mg/50mL syringe
Morphine 100mg/100mL bag
Fentanyl 625mcg/50mL Syringe
Fentanyl 2.5mg/50mL bag
Morphine 250mg/50mL Syringe
HYDROmorphone 50mg/100mL bag
p
g
g
Methadone 50mg/50mL Syringe
Methadone 25mg/50mL Syringe
Morphine 500mg/100mL bag
HYDROmorphone 250mg/50mL syringe
Meperidine 1000mg/100mL bag
Meperidine 500mg/50mL syringe
HYDROmorphone 25mg/50mL syringe
Fentanyl 1250mcg/50mL Syringe
What we implemented
p
General Practice Support
• Identified a potential medication safety issue with one pump capable of delivering
both treatment modalities
› Decisions to designate a fleet of epidurals and a fleet of PCA’s, both with
different medication delivery reservoirs
• Conducted a human trial of PCA and epidural pumps on a designated inpatient unit
• Evaluated and updated current practice and policy at BIDMC to support practice
• Made changes to the pain assessment flow sheet to clearly define safe patient
g
p
y
p
monitoring according to policy
Electronic T l
El t i Tools
• Queried POE data base to ascertain current narcotic use and ranges to build pump
Q
g
p p
programming
• Updated POE ordering capabilities with standardized concentrations and dose limits
• Utilized LEAN methodology to distribute pumps throughout the medical center
based on current use and availability
Comprehensive Education Plan
• Conducted multidisciplinary evaluation of the pump library for comprehensiveness
and safety prior to house wide training
• Provided a comprehensive hospital-wide, hands on staff education program to all
frontline users
f
l
• Provided on-line educational competency for ongoing support
p
y
g g pp
• Incorporated content of new pump education into the yearly educational day
mandatory for all staff
What we monitor
• Incident reports related to PCA and epidural pumps and narcotic administration
• Review of all Narcan removal and their relation to PCA and Epidural pumps
• Provider request for library additions
PCA doses dispensed (3 months)
6000
Morphine PCA
5000
Hydromorphone PCA
4000
3000
2000
1000
0
Before
After
What we’ve learned
we ve
• A senior leadership champion is essential to mobilize resources, meet equipment
needs, and guide the team with critical d i i
d
d id h
i h i i l decisions
• Development of a standardized p
p
protocol requires collaboration of a number of
q
disciplines
• Successful implementation depends on a comprehensive education plan
• Pump software allows for QA data collection making medication review process more
robust
• Limitations in wireless technology for making changes and monitoring in correct
programming
i
• This complex and well thought out p
p
g
process will p
provide a model for future p
purchasing
g
for other medical devices in the medical center
For More Information, Contact:
Mary Grzybinski, BSN, RN, mary_grzybinski@bidmc.harvard.edu
�
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Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
<p>Mary Grzybinski (<a href="mailto:mgrzybin@bidmc.harvard.edu">mgrzybin@bidmc.harvard.edu</a>)<br />Elizabeth Carvelli (<a href="mailto:ecarvell@bidmc.harvard.edu">ecarvell@bidmc.harvard.edu</a>)<br />Kerry Carnevale (<a href="mailto:kcarneva@bidmc.harvard.edu">kcarneva@bidmc.harvard.edu</a>)</p>
Department
Any departments listed on the poster or identified in the spreadsheet.
Patient Care Services
Nursing
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Jane Foley
Mary Grzybinsk
Kerry Carnevale
Elizabeth Carvelli
David Mangan
Bill Pyne
Patrick Thomas
Paul Anderson
Dublin Core
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Title
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The Road to Implementing Smart Narcotic Pumps:
Keeping Safe Patient Care in the Headlights
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/c9f84e70b59a74dad2b0cbbf85051058.pdf?Expires=1712793600&Signature=rBBJ%7EOM29aP21RudKMThl0djghnb2n9Ul2ZOamd2AMNa7D%7E4H5p4Byz%7EPFkPDLettPBDqX-nc0UWM0xcigrURP-xUj4TkDbCi0ai5%7EL2vZdAWabv9SwnNAiDjU8SnM5EZlg22WWdh0Z9V9mCBoeEBHVJfVzlfyFewfGtNQKQkhi-rJau5DxLttLP-PookYBNxKUncA3Id8XFHEdfk2-RfPPM5ve7rs-ogp-l6OuVdQY8sinwwugH5QsEmiGnPQ9IXFMjfk-pMoVm%7ExIHqOKzpe3SwlPI6P%7ElDai8cVdflC38xTXYi6N9Rda7PivWdwKoitNFmxKzMeGZCflObVv6pA__&Key-Pair-Id=K6UGZS9ZTDSZM
fca35eec8db8a0905f21defec4e5b737
PDF Text
Text
The Effects of a Customizable, Office-Based Surgical Safety Checklist on the
Rates of Key Patient Safety Indicators
John Stenglein, MD, Noah Rosenberg, BA, Sean Gallagher, BA, Richard D. Urman, MD, MBA, Phil Hess, MD, Fred Shapiro, DO
The Problem
In recent years, the economic pressures of medicine have incited a paradigm shift in
health care delivery, such that surgical procedures are being moved from the hospital
to the office-based setting. Recent hospital-based studies found that a
comprehensive checklist used in an interdisciplinary, team-based setting resulted in a
reduction in surgical complications as well as cost savings.
The ASA Closed Claims analysis has demonstrated higher severity, malpractice
payments, and more occurrences deemed “preventable” in review of office-based
claims. It is unclear if the safety and economic improvements attributed to the use of
checklists in hospital-based settings would also be relevant and attainable in officebased surgery.
Aims/Goals
Based on the W.H.O. checklist, we developed a checklist for use in the office-based
setting. The objectives included: training of office personnel on how to both use and
customize the checklist to the individual practice, analysis of accuracy in using the
checklist, and determining its effect on the frequency and severity of adverse events.
For baseline control values, we conducted a retrospective chart review of 219 cases
in an office-based plastic surgery practice using the checklist to assess for preimplementation rates of documentation of important safety indicators.
The Interventions
With focus-group input from office personnel, including surgeons, anesthesiologist,
and nurses, the checklist was customized to the individual setting and implemented
into daily practice, facilitated by frequent and open communication with office staff to
address barriers to compliance.
Results/Progress to Date
Site and side identification and marking showed a statistically significant, 24.6%
increase from pre- to post-checklist (p=0.0258). Verbal confirmation of
anticipated critical events, availability of case-specific equipment, and
confirmation of EMS policy increased from 0% pre-checklist to 88-100% postchecklist (p<0.0001).
Lessons Learned
Training office personnel is perhaps the most significant barrier to introducing a checklist.
It is important to initially conduct frequent reviews of documentation and assess staff
understanding of the process, as most resistence to change will occur immediately
following implementation. Checklist requirements may be incorrectly perceived as “extra
work” by office staff, and poor compliance is often linked to limited understaning or
appreciation for safety indicators.
Next Steps
The prospective, post-checklist phase of implementation is ongoing.
Customizable, office-based checklists are being explored in various
specialties including interventional radiology, dentistry, OB/GYN, GI,
ophthalmology, dermatology and pain, as the idea of furthering the culture of
safety in medicine continues to gain momentum.
For More Information Contact
John Stenglein, MD - jstengle@bidmc.harvard.edu,
Fred Shapiro, DO - fshapiro@bidmc.harvard.edu
�
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
<p>John Stenglein (<a href="mailto:jstengle@bidmc.harvard.edu">jstengle@bidmc.harvard.edu</a>)<br />Fred Shapiro (<a href="mailto:fshapiro@bidmc.harvard.edu">fshapiro@bidmc.harvard.edu</a>)</p>
Department
Any departments listed on the poster or identified in the spreadsheet.
Anesthesia
Faculty Hour
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
John Stenglein
Noah Rosenberg
Sean Gallagher
Richard D. Urman
Phil Hess
Fred Shapiro
Dublin Core
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Title
A name given to the resource
The Effects of a Customizable, Office-Based Surgical Safety Checklist on the Rates of Key Patient Safety Indicators
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
Format
The file format, physical medium, or dimensions of the resource
pdf
Efficiency
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/441ebc0c9593f9478c920843b0be3100.pdf?Expires=1712793600&Signature=JnYYBvfTr6uvDNbPVxXsvEx3w7fKBpI8AU0P1u895Pm7Sp8cbxKWcW%7EaLl8hk6Kuc0tVLbGTQmq0h2e71q1V4Q1NMiMaXYzBkwxLHkjgTOPAEuyJ8GibMtLpf-5J7mwmqBWTGlRlkZJiRVPcFW2HGNTBa5wCijAf8rV6M%7EN88M6igeoOCsbNVwusKSFG-nwsu%7Efx%7EGXVKE7aSybKqbh9MS-GsN1Susv9YeorizIUcq-Qy-al1VP7lVRqotPuaWAU%7ExGqR9kbG2e%7EUcBLNaVnb-oXvVnZ7jRLrci8NWondzp6HoDaRT-HSteWPphyzZTEP2zw6MXXcIwvgnZu4RBCrA__&Key-Pair-Id=K6UGZS9ZTDSZM
84595a9253d688dde92a1fb37702327e
PDF Text
Text
Teaching Faculty to Provide Difficult Feedback
The Problem
The Results/Progress to Date
Limited Tools to Teach Faculty to Provide Useful Feedback
Feedback by faculty is critical for enhancing performance in communication
skills and professionalism.
Existing tools are poorly suited to the needs of anesthesia faculty.
Improved resident performance in communication and professionalism would
improve the quality of patient care, reduce errors, and enhance safety.
Aim/Goal
Assessment of Video Tool and Discussion Format
The Department of Anesthesia Team
John Mitchell, M.D.
Qi Cui, M.D.
Lauren Fisher, D.O.
Sharon Muret-Wagstaff, Ph.D.
Elena Holak, M.D, Pharm D.*
* Medical College of Wisconsin
Stephanie B. Jones, M.D.
Vanessa Wong, B.S.
H. Nicole Tran, M.D., Ph.D.**
Marek Brzezinski, M.D., Ph.D.***
** Kaiser Permanente
*** University of California, San Francisco
The Interventions
A four-part video tool focusing on basic feedback, communication,
professionalism, and advanced feedback techniques was created (Figure 1).
The tool was the center of a live course for faculty consisting of four interactive
discussion sessions (average number of participants per session = 22).
Data on knowledge and perceived utility of the tool and format were collected
using an audience response system (Turning Point Technologies).
Perceived Changes in Knowledge, Comfort, and Success
5
Average Rating (1 = Poor, 5 =
Excellent)
Our goal was to trial a video-based tool to teach faculty to provide feedback to
residents regarding communication and professionalism. The tool’s effectiveness was
measured by faculty ratings of the tool and seminars.
5
4.5
4
3.5
Communication
Session
Professionalism
Session
Advanced Feedback
Session
3
2.5
2
1.5
1
Quality of
video
Utility of
video
Quality of
Utility of
discussion discussion
format
format
Average Rating (1 = Much Worse, 5 =
Much Better)
An average of 15 faculty members provided audience response in each session.
Learners rated the course highly for quality and utility (Figure 2).
Changes in scores for the knowledge questions were not statistically significant in
this small pilot sample.
Faculty reported that this course helped them improve their skills and comfort in
providing feedback (Figure 3).
4.5
4
3.5
3
2.5
2
1.5
1
Knowledge
Comfort
Success of applying
Question
Question
Figure 2: Assessment of Video Tool
Figure 3: Faculty Perceptions
Lessons Learned
The video tool is feasible and was received positively.
Impact may be increased by including the video tool in new faculty’s orientation.
A more structured schedule during the discussion sessions would ensure timely
completion of the session.
Next Steps/What Should Happen Next
Expand testing of the video tool to other sites nationwide.
Compare effectiveness of live sessions to effectiveness of a web-based system.
Measure changes in quality of feedback.
Measure changes in resident performance in professionalism and communication.
Figure 1: Screenshots from the Video Tool
For More Information Contact
John Mitchell, MD, jdmitche@bidmc.harvard.edu
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Dublin Core
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
John Mitchell (<a href="mailto:jdmitche@bidmc.harvard.edu">jdmitche@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Anesthesia
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
John Mitchell<br />Qi Cui<br />Lauren Fisher<br />Sharon Muret-Wagstaff<br />Elena Holak<br />Stephanie B. Jones<br />Vanessa Wong<br />H. Nicole Tran<br />Marek Brzezinski
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Teaching Faculty to Provide Difficult Feedback
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness