2
20
350
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https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/e58de54a2c9fcf23f4b5eaba7558691b.pdf?Expires=1712793600&Signature=RBiQjIxOJQVR4CVHiE9Voz1P6Gaf06CdbOIRCS12cIApvCWmn1VKA9ppe6DwUHfaU7GEoyyLpAI3sDPmpM97jRK-QnUof0hGak8DazwliGTpDtHJfvRRabIYkgVlXQVu3DrfXEeIBgJ4FRBkH7bPEelaIQfu2UREqEWOrwiw9SN7ZsWPLQkOcG6rZU4f3svgumfWxINNuQ8jCU0xKQj0uR8w44L07qvCjE4qXu3Up4obk-tcv8Pd%7EPjAgOA0mrWL9RPJtEKaXKZi0%7EojAbAKpxhS3wwI8JKdIupLSJ%7EsJLxemci-y03Kx%7EO38ZAkldAYJ%7Eey65yx60tMzTuzV6PJdQ__&Key-Pair-Id=K6UGZS9ZTDSZM
a35074b77c0c3f3f077f33a7c2921e14
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Violence Experienced by Nurses Working in Hospitals
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Susan Holland EdD, MSN, RN
Major Themes
Introduction/Problem
The problem of violence experienced by RNs working in hospitals is important to solve for a
variety of reasons. There can be significant physical and psychological harm experienced by
these healthcare workers who experience violence, including physical injury, disability,
psychological trauma or death (National Institute for Occupational Safety and Health (NIOSH),
2002).
Aim/Goal
To explore the results of an evaluation of nurses’ experiences and beliefs about physical
violence and/or aggression in the workplace and how the Code of Ethics for Nurses with
Interpretive Statements of the American Nurses Association (ANA) may support and guide
decision making and recommendations for organizations (ANA, 2015).
1. Lack of Reporting
➢ 83.2% of RNs reported that on average they experience aggression
or physical violence from patients or visitors at least a couple of
times a year,
➢ Only 19.8% of RNs actually report these incidents most
of the time or always.
Methods
The methodology and analysis was based upon Clark and Estes (2008) Gap Analysis Framework
and focused on knowledge, motivation and organizational elements related violence experienced
by RNs working in hospitals in Massachusetts. Snowball sampling was used to invite RNs to
participate in an electronic survey that included fixed responses and some open ended items. To
analyze the open-ended responses within the survey this investigator coded the data and
developed a codebook reflecting the conceptual framework in relation to answering the research
questions. Descriptive statistics was applied to for the quantitative analysis.
Results
The sample size was 254. The data collected included demographics, frequency of experiencing
acts of aggression and/or physical violence, frequency of reporting these incidents, and an
assessment of the knowledge, motivation, and organizational influences related this problem of
practice. The two major findings were that there was a lack of reporting of these types of
incidents and there was low self-efficacy of RNs related to this problem of practice.
2. Low Self Efficacy
0 (being not at all confident) to 10 (being very confident)
Recommendations for Practice
Address the knowledge, motivation and organizational influences using Clark and Estes (2008)
framework supported by the ANA Code of Ethics for Nurses with Interpretive Statements,
specifically the “Promotion of Personal Health, Safety, and Well-Being” as well as the
“Preservation of Integrity” (ANA, 2015).
For more information, contact:
Susan Holland, EdD, MSN, RN, sholland@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.
Susan Holland (<a href="mailto:sholland@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">sholland@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Nursing
Critical Care
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Susan Holland
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
Violence Experienced by Nurses Working in Hospitals
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/59819e43297d7d8b020264b5444d8f9b.pdf?Expires=1712793600&Signature=Nr4XBw4ti0b-5JUqNwBY4RKvuHjgrO-Losra%7EAZS295Cwd6VyL6k3UZEd5FYVj-Bw8jiMVYagXSbnZ0nP0Lo6Ly9QCeEzWOAHbXqNdwxKX89rUrbl8H5k6YLuIxnig6MU%7E4tCD%7EWlkfujZGax8aSd8fxspN6l7aimoXkeXVhdY9cZ%7E0BPQk1PFdYEgpcrSI3sOmPgNgHErz2%7Ewclcyc4V7jF0lUriCwQSXcakl7uVRbaozBtugbIT0uWyfe68MBKLD8-neNtNfTSWyMRLAEEs3cZ1pAUvIgzaxEml1vuPl14MSnVjfnzhjS9twh3T0wmSpzxQy%7EPgK3tdeE5Z3UmUA__&Key-Pair-Id=K6UGZS9ZTDSZM
bddd4dfb54f8fbd56c6ccf3286fe5269
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Use of Academic Detailing for Clostridioides difficile Diagnostic Stewardship
Ahmed Abdul Azim MD, Preeti Mehrotra MD MPH, Sharon B. Wright MD MPH
Introduction/Problem
Academic detailing (AD) is an educational outreach tool used to conduct two-way
communication with clinicians to assess baseline knowledge and motivations for certain
practices1. Our institution noted an increase in Clostridioides difficile (C. diff) positive test
results, raising concern for over-testing. The Infectious Diseases Society of America (IDSA)
and our hospital guidelines recommend C. diff testing (CDT) if a patient has ≥ 3 loose stools
in 24 hours2. Some institutions use electronic clinical decision support tools to decrease
inappropriate CDT3. We ran a pilot QI project using AD to improve appropriateness in CDT.
This was done with the aim to deliver the results of the pilot to IS to develop a POE-based
solution for providing educational and patient-specific information at the time of CDT order.
Aim/Goal
1. Use AD to improve appropriateness of CDT based on current guideline recommendations
in order to reduce over-testing and reduce both publicly reported C. diff infections and
potential overtreatment of patients.
2. Assess baseline knowledge and attitudes of providers towards AD in diagnostic
stewardship for CDT
Timeframe for pilot was 6 months.
The Team
➢
➢
➢
➢
➢
Infection Control/Hospital Epidemiology
Antimicrobial Stewardship
C. difficile Reduction Taskforce
Hospital Medicine
Medicine Residents
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The Interventions
•
•
Study period: Select weekdays in Nov-Dec 2018 and Mar 2019
Study population: Resident/teaching attending or hospitalist-only teams caring for
patients on the inpatient Medicine service. We excluded clinicians of patients with
immunocompromised patients and providers of patients with results CDT order by a
different provider.
•
AD was delivered one-on-one with each included clinician to:
•
Discuss appropriateness of the CDT on their respective patient(s)
•
Assess baseline knowledge on the appropriate indications for CDT
•
Assess the clinician’s attitude towards CDT diagnostic stewardship
Methods/ Definitions
• Aim 1: Determination of CDT appropriateness
o Definition of appropriate CDT
▪ ≥3 loose stools in 24 hours
AND
▪ No laxatives for 24 hours prior to CDT
OR
▪ Clinical syndrome consistent with C. diff infection (≥1 of the following):
− Unexplained leukocytosis
− Fevers
− Colitis/ileus on abdominal imaging
• Aim 2: AD delivered on CDT (face-to-face or by phone)
o Knowledge assessment: “Are you aware of the indications for appropriate CDT put forth by
the IDSA or our hospital policy?”
o Attitudes assessment:
▪ “Did you find this peer-to-peer discussion geared towards improving diagnostic
stewardship helpful?”
▪ “Do you believe an electronic decision support tool that includes current laxative order
alerts and testing algorithm could impact your decision on CDT ordering?”
For more information, contact:
Ahmed Abdul Azim MD, aabdul@bidmc.harvard.edu
�Use of Academic Detailing for Clostridioides difficile Diagnostic Stewardship
Ahmed Abdul Azim MD, Preeti Mehrotra MD MPH, Sharon B. Wright MD MPH
More Results/Progress to Date
Figure: Study Cohort and C. difficile Testing (CDT) Appropriateness
➢ Aim 1
• Overall, 7/23 (30%) of CDT were considered inappropriate
o All inappropriate tests were canceled following AD
o 3/7 (43%) canceled CDT after AD highlighted prior test pending and/or resolution of loose
stools
➢ Aim 2
• All clinicians receiving AD described it as helpful
• Examples of feedback:
o An internal medicine resident felt this would inform their future CDT ordering practices
o A hospitalist appreciated discussing C. diff diagnostic stewardship with an infectious diseases
clinician
• 14/15 (93%) of clinicians felt that an electronic clinical decision support tool would be a helpful
alternative to AD
Lessons Learned
1. In our limited sample, academic detailing improved appropriateness of C. diff testing
2. Academic detailing was well accepted by clinicians, mirroring antimicrobial stewardship
experiences
3. Electronic decision support and timeouts for C. diff orders may be resource-sparing options for
diagnostic stewardship
Next Steps
•
Work with C. difficile Reduction Taskforce to develop a proposal for an electronic clinical
decision support tool for submission to BIDMC Information Services to include:
•
cPOE algorithm for C. diff diagnostic stewardship to improve appropriateness of
CDT
•
CDT electronic order “timeout” 24 hours post order if not yet collected
For more information, contact:
Ahmed Abdul Azim MD, aabdul@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.
Ahmed Abdul Azim (<a href="mailto:aabdul@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">aabdul@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Infection Control / Hospital Epidemiology
Hospital Medicine
Infectious Disease
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Ahmed Abdul Azim
Preeti Mehrotra
Sharon B. Wright
C. difficile Reduction Taskforce
Antimicrobial Stewardship
Medicine Residents
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
Use of Academic Detailing for Clostridioides difficile Diagnostic Stewardship
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Effectiveness
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/d41d7a3a3c87bab75017f62c122b54d4.pdf?Expires=1712793600&Signature=jYWNSYmA%7EEpH1bygLWxleKToH-1ymvH8YvfzZ2AnLFhPhg%7EZnaJcrRaLK7QlJYP8gqmi65sTQyKYryPWeWA7cEl4GxWfQUhLTBHuP7SaIhTDEOTttw9-KKtjMdFYJNzsR4w7V%7EqSk2pyPx%7EXoujNYRw15YpeC4bwCSTAB3OYtG5cI%7E5sHktq%7E%7E7-j7l02H47FmD-nB0buz8cYGabO9vDO95I5Rl-RaPWqP2znK5RZS28I0T88p-YEQGmuQFkPGY3-nizf9Ai7X1HNfwsOlIAdjwcH7YxBp1As6feOkKuPAazHPHzKgIzksII4qJ%7EUTREkuqRHahc3G7EHpOAjOZXuQ__&Key-Pair-Id=K6UGZS9ZTDSZM
0c89e40c425a209c31989d6b0e1b3465
PDF Text
Text
TJC Blog: Utilizing Social Media to Engage and Educate
Jennifer Barsamian, MSN, RN, Ann Marie Darcy, MSN, RN, ACNS-BC
Introduction/Problem
The window for our medical center’s Joint Commission (TJC) survey was approaching fast. It was
recognized that, since the last survey, there were many people new to leadership roles on the inpatient
units (Nursing Directors, Nurse Specialists, and Unit-based Educators). Both new and experienced nurse
leaders had many questions about the survey and expressed anxieties about planning.
A preparation plan for the TJC visit had already been developed that would be executed closer to the
survey window. There was a need for a more interactive forum in order to provide education that would
engage nurse leaders. Further, this forum would afford an opportunity to ensure that everyone was
receiving the same information.
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The Interventions
Nursing and informatics team members partnered to develop a secure and private social media
platform via myPATH.
In the format of a blog, posts were published every 2-3 weeks. Each post tackled the assessment of
a different room on the unit. Participants were encouraged to post questions and photos.
Blog posts continued from June 2018- August 2018.
Interactive learning was facilitated by Nurse Specialists.
Prizes were awarded to participants for creative posts.
Social media has more recently been explored in the literature as a teaching methodology for nursing
education. The team utilized this platform for the first time in order to prepare for a TJC survey in a
collaborative manner.
Aim/Goal
Over a period of 12 weeks, the team will engage as many nursing inpatient leaders as possible in
preparing their units for the upcoming Joint Commission survey.
Identify any potential, centralized issues that could be resolved in real-time in order to help deliver a
successful TJC survey.
The Team
Jennifer Barsamian, MSN, RN, Nurse Specialist, Inpatient Surgery
Jean M. Campbell, MS, RN, Informatics Nurse Specialist
Ann Marie Darcy, MSN, RN, ACNS-BC, Nurse Specialist, Inpatient Medicine
Jamie Levash, MSW, Project Manager, QI & Professional Development
Kim Sulmonte, DNP, MHA, RN, CPHQ, Associate Chief Nurse, Operations, Quality & Safety
For more information, contact:
Jennifer Barsamian, MSN, RN, jbarsami@bidmc.harvard.edu
�TJC Blog: Utilizing Social Media to Engage and Educate
Jennifer Barsamian, MSN, RN, Ann Marie Darcy, MSN, RN, ACNS-BC
Results
Storage of
Hemoccult
Developer
Multi-dose
Vials
# of Participant Posts/Likes by Month
140
120
100
Tube Feed
Delivery and
Storage
Preventative
Maintenance
Stickers
80
60
40
20
0
Food “Best
By” Dates
Reference
Binders
Inpatient
Welcome
Guides
18” Lines
Likes
Blog Posts/Responses
Jun-18
Jul-18
Aug-18
Total # of participants registered for the blog = 124
Total posts/likes = 239
Lessons Learned
Contact List for
Soiled Utility
Issues
Labeling of
Patient-Specific
Food Items
Issues Identified by Participants and Resolved
Social media can be a fun and interactive learning platform and is a generalizable teaching
methodology for various education topics.
A social media platform is familiar to most participants and, therefore, easy to navigate.
Setting guidelines for participation at the beginning ensure that all posts by learners adhere to an
established etiquette.
In order to keep learners engaged, facilitators are required to be active participants, and blogs should
be kept to brief timelines.
Next Steps
Continue follow-up on any pending issues that were identified by units.
Explore the use of this blog format for other methods of education and support. Target groups
include Unit-based Educators and nurse preceptors for professional development and growth.
For more information, contact:
Jennifer Barsamian, MSN, RN, jbarsami@bidmc.harvard.edu
�For more information, contact:
Jennifer Barsamian, MSN, RN, jbarsami@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.
Jennifer Barsamian (<a href="mailto:jbarsami@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">jbarsami@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Nursing
Healthcare Quality and Patient Safety
Nursing Informatics
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Ann Marie Darcy
Jennifer Barsamian
Jean M. Campbell
Jamie Levash
Kim Sulmonte
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
TJC Blog: Utilizing Social Media to Engage and Educate
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Effectiveness
Efficiency
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/65fc616ab04124f40031f800df65b0f1.pdf?Expires=1712793600&Signature=QKL1J-EpoOX7qt5qLjyoWz8PDMkJIZ3q1%7EyYvMB9EWk0tc2PKkUqjohvzwnDxve3GFWVY6dVB6lgTIo8b6g3fFHM4Yy7lqwyApmk%7E6NVs25uZRhkuwIcSV4kJQV7mxtP0ctaGn5miqbqD88O4skgQFx8qidL1dNmpgoXA2iNoqBewJVqyV1eM3vVGmJ4cY-LQE4gOx6XKTLdP0ebkR9h5Z9vbcSdSsaPdKSrPTI8RpXagKlUaL-lgIbcyxVocK%7EA7y7M2b0rNb942igAYtWt-npggydnBHSzoSt0jPpNn9JtLC3l787ELryu0iSpVVtSFiPPFVUQTmvpA1kLCByPSg__&Key-Pair-Id=K6UGZS9ZTDSZM
ec0723e3206694a511c10eaec4f26495
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Text
Shared Medical Group for Diabetes Education
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Barbara Luker RN MHA CDE, Barbara G. Rosato DNP ANP-BC CDE
Introduction/Problem
Healthcare Associates (HCA) uses population health tools to identify the total number of patients with
Type 2 Diabetes (T2D) and determine if they met recommendations set by the American Diabetes
Association. (Standards of Medical Care in Diabetes. Diabetes care 2019 Jan; 42 (supplement 1): S1S2)
We care for about 5,000 patients with diabetes and offer no formalized education program. Most
education is done during scheduled visits, some by phone. Many patients visit a diabetes specialist
but we see a growing number of patients who do not have the time or means to get this additional
care.
The American Diabetes Association (ADA) and European Association for the Study of Diabetes
(EASD) Consensus report of 2018 recommended all people with T2D be offered access to ongoing
Diabetes Self-Management Education and Support (DSMES) programs. Best outcomes were
achieved in programs that were theory-based and a structured curriculum with content time of over 10
hours.
Our project was patient-centered, offering care that is respectful and responsive to individual patient
preferences, needs, and values. It also showed efficiency by teaching in a group visit to avoid
redundancy.
Aim/Goal
Create a monthly group for patients with Diabetes and offer DSMES to enable them to make informed
decisions and to assume responsibility for day-to-day diabetes management.
Provide education and watch the group to use the information to teach and support each other.
During the visit have the Nurse Practitioner (NP) assess and treat patients who report medical issues
and titrate diabetes medications to help the patient achieve their A1c goal.
Monitor performance measures recommended by the American Diabetes Association.
The Team
Barbara Rosato DNP ANP-BC CDE
Barbara Luker RN MHA CDE
Yvette Duplessis, Phone Staff Representative
Started a Shared Medical Group for patients with diabetes and met once a month for 90 minutes.
Leaders included a NP, RN and practice assistant.
The NP assessed and treated patients during the visits and made changes to diabetes medications
to help the patient improve their A1c.
Each group offered education on a diabetes related issue followed by a group discussion where
members asked additional questions, discussed feelings, shared coping skills and discussed tools
and solutions that worked for them.
Progress to Date
Elements of each Visit:
Data collected: Patients’ vital signs, weight, blood work. Patients completed a review of symptoms and
set a personal goal to obtain that month.
Theory Based Topics on Diabetes
Pathophysiology
Complications
Foot care
Goal setting
Diet, meal planning
Dealing with the holidays
Losing weight
Blood glucose testing
Exercise
Dealing with family members
Perseverance, staying motivated
New technology
Edna Henry, Practice Assistant
The Interventions
For more information, contact:
Barbara Luker RN –Bluker@bidmc.harvard.edu
�Shared Medical Group for Diabetes Education
Lessons Learned- Seeing the magic in group settings
Patient Outcomes
The stories told by the patients create a memorable experience for the group that resonates long
after the group has ended.
Building community takes time but once created can allow patients to share more of their
weaknesses and work together to create solutions.
Cultural diversity impacts decisions and choices that patients make to manage their diabetes. Having
patients sit together in a room to discuss their commonalities is more impactful than giving
patients recommendations that are not culturally sensitive.
Changing habits takes education, time and practice.
6 patients
had eye
exams
2 patients
with an
A1c<9
There were
13 total
attendees.
On average
6 patients
were present
in the group
6 patients
with an A1c
<8
8 patients
attended 4 or
more
Shared
Medical
Group
Appointments
7 patients
had a
cholesterol
level <200
7 patients
had a microalbumin test
8 patients
with a
BP<140/90
Next Steps
Shared stories, laughter and understanding, lots of empathy, pearls of wisdom. The take-home messages
are relatable and crystal clear.
Advertise the group to patients and providers in Healthcare Associates
Replicate the group and offer it at another time to enhance patient choice. Use the same curriculum
so patients could attend either group to avoid scheduling conflicts.
Use the Confidence in Diabetes Self-Care Scale (CIDS) to collect information from patients as a
measurement tool when they start the group and measure again after 6-12 months.
For more information, contact:
Barbara Luker RN - Bluker@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.
Barbara Luker (<a href="mailto:bluker@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">bluker@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Health Care Associates
Nursing
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Barbara Rosato
Barbara Luker
Edna Henry
Yvette Duplessis
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
Shared Medical Group for Diabetes Education
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Efficiency
Patient and Family-Centeredness
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/db64c0f19edbb103ea3272aedb303c21.pdf?Expires=1712793600&Signature=eVcVE57Lknef00tHE4jzjnRGNxb6NGXjVATxJ-bOU-EvNKSwUe-VsdHcl6WNWMs4YFkoNIBeMCReaKD-51mFBuCTQa4NIjbvbR3oro2dAivkXnoCMsV4nKccbIwPZ7zeggjXNwyfPdgPOjFUBfoPou8%7ERvLMXICFfwT8U9mLecgVtprKTK%7EMIFDt3nhiZS2S7YLyllaydPidSmJYk33jwXSbjZ4bmwrATWqidV2rMG0QD0150Qw2vDSq99MiQqUs3nNI-fDGoFBk9Ouo%7Eb1TpvEbZiTExaNZ5nSExmKPPfk-7M1Sl6cysxiJAZ5PptVJMnvqgAuV8ehonTYc6N4jvQ__&Key-Pair-Id=K6UGZS9ZTDSZM
3e435ac2b4165be1169071f49ed71c1d
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Text
Safe Handling of Hazardous Medications
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Kathy Baker RN, MSN and Barbara Donovan, RN, MSN
The Interventions
Introduction/Problem
Definition: A hazardous drug (HD) is an agent that exhibits one or more of the following characteristics in
humans or animals:
carcinogenicity
teratogenicity or developmental toxicity
reproductive toxicity
organ toxicity at low doses
genotoxicity
Hazardous drugs are identified via NIOSH’s list of Antineoplastic and Other Hazardous Drugs in Healthcare
Settings. United States Pharmacopeia (USP) General Chapter <800> Hazardous Drugs provides standards for
safe handling of hazardous drugs to minimize the risk of exposure to healthcare personnel, patients and the
environment. Beginning in December 2019 this will be a new standard of care for hospitals. Certain personal
protective equipment (PPE) must be worn, depending on the route of the administration. Previously the focus
had been on antineoplastic medications .With new information on drug toxicity and recent studies showing
drug metabolites in the urine of health care workers (HCW), the focus has shifted to protecting the HCW.
Aim/Goal
Examined current National Institute for Occupational Safety and Health (NIOSH), the Centers
for Disease Control (CDC), and USP recommendations and developed BIDMC inpatient nursing
and pharmacy education. Education to include new PPE, disposal of hazardous waste, clean
up hazardous waste spills reflecting the new standards.
Developed patient education to support nursing with new PPE.
Scripted answers to potential patient and nurse questions and concerns.
Results/Progress to Date
Training has been developed and assigned to all inpatient units.
Training has been shared with Respiratory Therapy colleagues.
Training will be adapted for other groups after the rollout to the inpatient MedSurg areas.
To protect HCW during administration and discontinuation of hazardous medications.
To educate staff about the new PPE recommendations for routine medications where PPE had
not previously been required.
The Team
Kim Sulmonte, Associate Chief Nurse Quality and Safety
Pharmacy: Peggy Stephens,MS< RPh ,Christine Huynh ,Pharm D BCPS, Denise Arena RPh
Nursing: Kathy Baker, Sharon O’ Donoghue, Barb Donovan, and Jillian Dooley
Environment: Gary Schweon
Materials MGMT: Brian Bertrand
EOHS: Matt Rabesa
EVS: Chris Minette
For more information, contact:
bcdonovan@bidmc.harvard.edu
�Safe Handling of Hazardous Medications
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Kathy Baker RN, MSN and Barbara Donovan, RN, MSN
More Results/Progress to Date
Education has been prepared to help Nurses address patient concerns
Example
“Why are you wearing a gown to administer this medication to me? Is it harmful to me?”
You are receiving this medication for its therapeutic benefit to you. Nurses administer these frequently and
that exposes us to small amounts of medications on a regular basis. The greatest risk of exposure to staff
occurs during our preparation and administration of this medication.
By wearing gloves and gowns we reduce the unintended absorption through the skin of the nurse. By
wearing the mask this prevents the inhalation during the preparation of the medication. We are trying to
reduce the unintended exposure to staff who administer this medication frequently.
This Appendix to the Hazardous medications policy has been made into a poster and will be shared with
inpatient units. We recommend they are displayed in medication rooms in the inpatient areas
Currently MyPath training has been sent out to 2100 nurses. Pharmacy staff have been trained and this
training was shared with the respiratory and medicine physician groups.
This patient education is available as a handout via the portal
Lessons Learned
Supply chain disruptions of PPE resulted in a delayed implementation timeline. Since
USP <800> will become a standard December 1,2019 many institutions are increasing
their par levels of PPE whci may have contributed to these disruptions.
Next Steps
Surveillance of the environment and staff by EOHS will be developed.
For more information, contact:
bcdonova@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.
Barbara Donovan (<a href="mailto:bcdonova@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">bcdonova@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Nursing
Pharmacy
Environmental Health and Safety
Materials Management
Empoyee Health Services
Environmental Services
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Barbara Donovan
Kathy Baker
Kim Sulmonte
Peggy Stephens
Christine Huynh
Denise Arena
Sharon O’ Donoghue
Jillian Doole
Gary Schweon
Brian Bertrand
Matt Rabesa
Chris Minette
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
Safe Handling of Hazardous Medications
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/716892ac7919779f1f458ea719a9660c.pdf?Expires=1712793600&Signature=HISpLFC8ZzOJYyb3hraS3o-uh%7E%7ECY7VancXH%7EGu3wQBBNCxtvHZwADjymwqOasRhZ7xdbdTUOh9ucChYRAlDOe7YsohaBbu9VGYZF3c7AIgGiXJxeYUoN6A2dqg12JNTxBeNBkbtipAispTDWPKs6nXhNSXbSwyGGU94ypgO%7ExV5wJjsB9kPKcDr3t7F4C1kYTcXSeonU0nwiRzmWfXZNjPdzaPRx3RVi%7ENFpXDLMh6Vv6Vh1SGd9ZyliQPU1J2xiW53W29eBDBbH-ubA9YSfFUmXshrTRhb0wVr0Au5ivfwrLyvwJngFHF8WYdtSfshnnXb7FWov-M1a4Lk6OxahQ__&Key-Pair-Id=K6UGZS9ZTDSZM
76a345d76bed102aa5a311851b944208
PDF Text
Text
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�
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.
Kelly Hart (<a href="mailto:khart4@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">khart4@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
Kelly Hart
Suzanne Swedeen
Radiology Residents
RL Committee
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
Quality Improvement and Employee Engagement: 2017-2019
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/9fde1c5c4a00d6dc3beeb941bbfc9bf6.pdf?Expires=1712793600&Signature=mBnoGuVuLdMF7F8zIajy6V7eXvpZcUde16s7LmlwkzdmkTvq4sjBF9itGFypWO%7EFtNrLwZGMc3JzpB5OZ24Fg6wDWH6%7Es2SdeP3Lx2-zysl112Onx4DWLVzs31TlbzGp-Lhp6v8JILv%7ExeDDhEL8RNmJU4FYBvukTS4Gl6JYUKubKy7EudKH-BhHtiEL%7EaFafNdcV3Xt3rcHn0fsuzG23lDcvQyog8mgVYNhsgDomW%7EVcg8xAsIAb6HXjSH12bBhMe6oJQIvk-pAqwaO%7EykDxAN11ab%7EUPC9VDaNpcDq401roxrfqYvPdzsULBSVwHtiuI5ZTliGe9SCY44pKRkF-A__&Key-Pair-Id=K6UGZS9ZTDSZM
0e307f58ad8d654ca52eef63b6cd6180
PDF Text
Text
Optimization of the Ordering and Dispensing of Coagulation Factors
Introduction/Problem
• Coagulation factors and anticoagulation proteins (factors) had historically been ordered and
dispensed through the BIDMC Blood Bank
• It was recognized that admixing products for intravenous infusions outside of a cleanroom
environment posed an increased risk for contamination
• Variations in ordering and dispensing of coagulation factors increased the potential for waste,
particularly with an increase in volume and utilization
Aim/Goal
• The goal of transitioning the management of coagulation factors to the Pharmacy Department
was to:
• Optimize and standardize the ordering and dispensing process
• Promote computerized provider order entry (CPOE) indication directed dosing
• Ensure regulatory compliance and dose preparation in a USP compliant cleanroom
• A Clinical Review and Approval Process was developed in collaboration with Transfusion Medicine
to ensure safe and appropriate utilization of Coagulation Factors
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MENU
The Interventions
•
•
•
•
•
A multidisciplinary group was convened to develop a process and timeline for implementing the
transition
Potential barriers and the impact of the practice change were identified
Intravenous administration guidelines and cleanroom dispensing procedures were developed
Decision support and a dosing calculator was incorporated within CPOE
Following dissemination of the new process through Nursing, Pharmacy, Transfusion Medicine, and
Hematology meetings, pharmacy took over the responsibility for coagulation factor dispensing in
November 2017
Results
The Team
•
Mary Eche, PharmD, BCPS, BCCCP, CACP; Pharmacy
•
Monique Mohammed; Blood Bank
•
Katherine Cunningham, MHA, PharmD, BCPS; Pharmacy
•
Kerry O’Brien, MD; Transfusion Medicine
•
Sarah Warack, PharmD; Pharmacy
•
Barbara Donovan, RN; Nursing
•
Wendy Chen, PharmD; Pharmacy
•
Transfusion Medicine and Hematology Team
•
Denise Arena, RPh; Pharmacy
•
Pharmacy Purchasing Team
•
Peggy Stephan, MS, RPh; Pharmacy
•
Pharmacy IS Team
Workflow improvements included: Development of a Transfusion Medicine approval process, implementation
of Clinical Decision Support and CPOE ordering
For more information, contact:
Mary Eche, PharmD, Clinical Coordinator - Critical Care; ieche @bidmc.harvard.edu
�Optimization of the Ordering and Dispensing of Coagulation Factors
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Results/Progress to Date
Results
Metric
Percent Compliance (%)
Hematology/Transfusion Medicine approval
95.8*
Pharmacist Intervention
Decision support
for Indication
Based Dosing
No change
Number of doses
n = 120 (%)
Urgent Order Metrics
95 (79.17)
Vial size rounding
18 (15)
Incorrect dose
3 (2.5)
Both rounding & incorrect dose
Link to
Factor
Guideline
4 (3.33)
Average
(min.)
Min
Max
Time from POE order entry to
RPh verification
13.2
3
30
Time from RPh verification to
eMAR documentation
47
19
76
• The majority of factor orders were approved by transfusion medicine and/or hematology.
• Pharmacist intervention was required for vial size rounding or incorrect dose
• Purchasing of factor products within the pharmacy resulted in increased financial stewardship and cost
savings
Lessons Learned
•
Successful transition of coagulation factor dispensing from the blood bank to pharmacy required
multidisciplinary effort, planning and education
•
Development of administration guidelines, CPOE Decision Support, and dose preparation in a USP
compliant cleanroom have led to improved safety and efficiency of the ordering and dispensing
process
Automatic dose
calculator
Next Steps
Workflow improvements included: implementation of clinical decision support (indication based dose calculator,
imbedded guidelines); prospective order review by a pharmacist; development of guidelines for intravenous
administration, and documentation in the electronic medication administration record (eMAR)
•
•
•
Ongoing review of the ordering and dispensing process for areas of improvement and adjustment
Ongoing multidisciplinary education on the new process
Identification of opportunities for clinical guideline development in collaboration with providers
For more information, contact:
Mary Eche, PharmD, Clinical Pharmacy Coordinator - Critical Care ; ieche @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.
Mary Eche (<a href="mailto:ieche@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">ieche@bidmc.harvard.edu)</a>
Department
Any departments listed on the poster or identified in the spreadsheet.
Pharmacy
Pathology
Blood
Nursing
Information Systems
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Mary Eche
Katherine Cunningham
Sarah Warack
Wendy Chen
Denise Arena
Peggy Stephan
Monique Mohammed
Kerry O’Brien
Barbara Donovan
Transfusion Medicine and Hematology Team
Pharmacy Purchasing Team
Pharmacy IS Team
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
Optimization of the Ordering and Dispensing of Coagulation Factors
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Compliance
Efficiency
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/e2de39cc2f30add5a9e6b056571d7f0a.pdf?Expires=1712793600&Signature=FpQXO1G9S4vC7DfL7-PBJ%7EvDAxD2Sq7uBUr%7EHQA91aixhmSC5tSUOkifQ9DKV14VNc9tW1ulcUvRyI1yZDBFhwo%7EG57N9OsIgFx7oolIhAClfasuTzJoAwla9HLc2ifx-ZS%7EPwGr4Rfk7D6tx5GALzLPVtWcCh5t0y9DnIS5OIjyJTZwCOJoSDJ%7EDLMfwFQV3LbPH3s5ZD9WFK0AO1DNVOShs1CVlzmi2qOuksnkNxG-vzpF51FvWtijhdBYAhddwcViD7pbaniQmnNZiDjmqx4eWA2kI9ZBcqSdxR8-m0-Ne3cDrhqJseGy33o8O1m5BVsXJKZPZTFoSm0BaJB0-g__&Key-Pair-Id=K6UGZS9ZTDSZM
dd810d17924db96fa8294ce2f7178d32
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Text
Minimal Effect of Universal Extended Prophylaxis on Rates of Venous Thromboembolic Events After
Colorectal Surgery in a Tertiary Care Center. Is Compliance the Problem?
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Córdova-Cassia Carlos, Wong Daniel, Cotter Mary B, Ward Mary F, Messaris Evangelos, Cataldo Thomas, Poylin Vitaliy
Introduction
• Venous thromboembolic events (VTE) are a significant source of
morbidity following colorectal surgery.
• Several studies have shown a reduction in VTE with extended
duration post-operative prophylaxis with enoxaparin.
• Despite guidelines endorsing extended prophylaxis in high risk
patients, provider compliance is poor.
Aim
• To determine whether
universal post discharge use of
enoxaparin after colorectal surgery is safe and can decrease the
rates of VTE by avoiding provider compliance issues.
Results
• A total of 316 patients underwent elective colorectal surgery during
study period, out of which 270 patients were eligible and received
extended prophylaxis.
• The rate of VTE during study period was 1.85 %. There was no
significant difference when compared to previous years of selective
prophylaxis: 1.26 % for 2016, 2.32 % for 2017.
• The clinical significant bleeding rates were similar between universal
versus selective prophylaxis with one episode of bleeding related to
enoxaparin in selective and one in universal prophylaxis.
• 36% of respondents to phone survey reported non-adherence to
enoxaparin injections.
Methods
• Prospective quality improvement project of patients undergoing
colorectal resections.
• All patients undergoing colectomy were prescribed extended
duration VTE prophylaxis (30 days) of enoxaparin based on
weight.
• Patient adherence was evaluated via phone survey.
Conclusions
• Universal use of extended duration enoxaparin prophylaxis in
post-operative colorectal surgery patients is safe, but does not
decrease rates of thromboembolic events.
• High risk for VTE including previous events and more
comorbidities was associated with low compliance; on the other
hand, longer hospital stay was associated with improved post
discharge compliance.
• High rates of non-adherence, especially in high risk patients, are
likely a significant contributing factor.
�
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.
Carlos Cordova-Cassia (<a href="mailto:ccordova@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">ccordova@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Surgery
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Carlos Córdova-Cassia
Daniel Wong
Mary B. Cotter
Mary F. Ward
Evangelos Messaris
Thomas Cataldo
Vitaliy Poylin
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
Minimal Effect of Universal Extended Prophylaxis on Rates of Venous Thromboembolic Events after Colorectal Surgery in a Tertiary Care Center. Is Compliance the Problem?
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Effectiveness
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/367244f8e030684a4f944ac15a3cb5e8.pdf?Expires=1712793600&Signature=GZl%7EoFkkOTzw-ndnE8dZ04qRVj-ehwklPtQ9NPEQaFfykjvFFsXPeHp1jOc5uUGzK0elhZRdS9c-r07Di5T3AlT-QjogFWB8vbSTajRZDuunfTp1dHjAToiRtbfUFj4SfCr5AxZHsOaXlDKMcseh1nJe5wWp08rwNan1sGZ0T6EdFBFO-bINh4LYQO4wNF9aoG4iVbHeWqx-VKkJC0ThLylJdRMm8ZhotwJtzZUbvJI%7EzPSbMdLDuwxGG9ekuBvj1yiaTObsqEkmkk1kgwuh5FV-GKOPsQbjmoNKaqaL2zKo%7EgWzP4qyWKUAAFJ1WFlBIG26vdTezjQdwrVleCDpCQ__&Key-Pair-Id=K6UGZS9ZTDSZM
d33b82ecf3bf582c1fd65effd60fab99
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Medications and Solutions Appropriate for Midline Infusion
Isabel K. Hopper, RN, VA-BC
Monica V. (Golik) Mahoney, PharmD, BCPS-AQ ID, BCIDP
Introduction/Problem
• The Venous Access Team (VAT) has been the resource for medications appropriate for midline use.
This information was not available on the intranet .
• Venous access options for clinicians is now streamlined with this tool that identifies medication
appropriate for peripheral IV (piv), midline and PICC. The medications requested for midline infusion
has been increasing, making it difficult for the VAT to have that information readily available to the
clinical team.
• Medications and solutions can be given via a PIV and/or central line but not through a midline.
• An on-line search will not yield a midline infusate list consistent with BIDMC policy.
• Options for patient vascular access have increased with new technology. Often a patient’s access is
diminished with long hospital stays; this has changed the reason/volume for midline requests.
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The Interventions
•
The venous access team had been working with a list of antibiotics appropriate for home infusion for midlines requested for discharge. The
list became incomplete as the indications for midlines increased ie difficult venous access, frequent lab draws, out-patient contrast bolus
injection.
•
The pharmacy department was consulted when the midline list did not include the specific medication or solution on the midline list.
•
The Vascular Access nurses kept a list of the added medications; the list needed to be validated by the pharmacy department and made
available to BIDMC clinicians and nurses.
•
The vascular access nurse worked closely with pharmacy to develop a tool listing the most common infusates used in the medical center.
•
Creation of a quick reference tool on the portal for all to access when patients have a midline or require selection of appropriate vascular
access device when medications are ordered.
The Results
50
Aim/Goal
45
40
Midline Use Over 5 Years
35
30
• Provide an intranet resource identifying commonly requested medications for midline placement
requests.
• Utilize tool to appropriately identify patients where a midline would help to decrease number of repeat
PIV insertions throughout admission
The Team
➢
➢
➢
➢
➢
Isabel K. Hopper, RN, VA-BC, Venous Access Team
Marie Horgan, RN, Venous Access Team
Andrew Mackler, RN, MHA, CNIV, VA-BC Venous Access Team
Monica V. (Golik) Mahoney, PharmD, BCPS-AQ ID, BCIDP
Blanche Murphy, RN VA-BC, CNIV, BSN, Venous Access Team
25
20
15
10
5
-
west
east
• Increased compliance with less risk of inappropriate medications being infused via midlines.
• Less delay in treatment of patients with ability to quickly validate proper access.
• Increased use of midlines on both campuses (see Chart: Blue=West Campus/Orange=East)
Guidelines for Midline Catheter Medication Administration added to Pharmacy Clinical Guidelines (2019)
after approval by Pharmacy Committee and Nursing Practice Council
For more information, contact:
Isabel K. Hopper, RN VA-BC Venous Access Team 617-632-0952
�Medications and Solutions Appropriate for Midline Infusion
Isabel K. Hopper, RN, VA-BC
Monica V. (Golik) Mahoney, PharmD, BCPS-AQ ID, BCIDP
More Results/Progress to Date
Midline Appropriateness Chart for use by Clinicians (Found on the Portal)
Lessons Learned
50
45
Midline Use Over 5 Year Period
➢ Working with a collaborator from a different department brings depth to a project.
40
35
30
25
20
Next Steps
15
10
➢ When a medication revision is due the Pharmacy Policies & Procedures Manual (Pharmacy)
midline appropriateness will be added.
5
-
west
east
Chart demonstrating increased use of midlines over 5 year period
For more information, contact:
Isabel K. Hopper, RN VA-BC Venous Access Team 617-632-0952
�
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.
Isabel Hopper (<a href="mailto:ihopper@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">ihopper@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Venous Access Team
Pharmacy
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Isabel K. Hopper
Marie Horgan
Andrew Mackler
Monica V. (Golik) Mahoney
Blanche Murphy
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
Medications and Solutions Appropriate for Midline Infusion
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Effectiveness
Efficiency
Safety
Timeliness
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/e5c316d038d2bf4402c6964f6ea3d72d.pdf?Expires=1712793600&Signature=UmCD22J49dstH-6XpBih7ZYTdFkcnOW74Q4PvRL%7EQsoyvnpMWgToltLpWJoZQYz8JTScsVhJuvkNHfqgSaBAOTeWvAFgl-fExABAx9lyEzidHj%7EV0sCx4LDzX0b0VryOVGaAUy-VPRGB679U6CUrx25KcKOc5H1t98BXHJ3Yd1em3XbnBygBkgSHc6q02JSzj9%7EokFkDQMp1bTwn0MTZuOJyoSbTzd4iNcOAkmtCsxYF9y6DWhXwdnA85is2pnsVQfKHQItlfr1dWvPN-m7-7u%7E70ko1wGmonFqb3LT6xvvDOdz7T8kmL8dmqJK9x1HtmhE1O8zTeNY0CAD0s21goQ__&Key-Pair-Id=K6UGZS9ZTDSZM
b572ea2f221a0f4a497b0a1577eb6a28
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Text
Keeping Up With Sterile Preparations & USP <797>
Patricia Gerrin CPhT CSPT, Denise Arena Raphe Clinical Pharmacist Supervisor, Julie F Lanza CPhT CSPT
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Introduction/Problem
The Interventions
USP <797> requires the skill of personnel that aseptically prepare CSPs (Compounded
Sterile preparations) be evaluated using sterile fluid bacterial culture media fill
verification. Media fill test represent the most challenging or stressful conditions
encountered by personnel being evaluated when they prepare all risk level CSPs.
Train multiple staff to perform media fill verification in order to complete testing in more timely
manner
Working with pharmacy supervisors and the scheduler(s) for both Pharmacist & Technicians as
well as the Sterile Products team to develop a timeline of events that wouldn’t effect the day
today operations of the Pharmacy Department.
Creating a spreadsheet of materials. times, places, staff & verifications processes that need to
happen for the total number of staff to be tested
Data (including time it takes for each test) in monitored throughout the time frame to maintain
the timeline & improve processes for next testing session.
Media fill test verification are done annually or biannually depending on risk level.
At BIDMC, in order to comply with this regulation – we were faced with the challenge of
coordinating media fill test verification of all risk levels for approximately 160
employees for a total of 400 tests (knowing these numbers would increase each
year with staffing levels).
Aim/Goal
Aim: trying to coordinate 400 different tests in an organized fashion while not disrupting
existing work flow or interrupting the attention to patient care that our employees are
providing.
Goal: Develop a system that allows us to compete media fill verification for all employees
within a short time frame.
The Team
Denise Arena – RPh Clinical Pharmacist Supervisor
Patricia Gerrin – CPhT CSPT – Lead Technician Sterile Products
Bzunesh Abrha CPhT – Lead Technician Scheduling & Training Coordination
Julie Lanza CPhT CSPT – Pharmacy Compliance Specialist
Results/Progress to Date
Media Fill Verification 2017
June 9th thru August 8th
210
82
LowMedium
Hazardous
140
Media Fill Verification 2018
August 2nd thru Sept 13th
211
170
81
82
152
High Risk
Finger Tip
Low Medium
Hazardous
High Risk
Finger Tip
2017 time lapse of testing was 60 days. Upon implementation of new processes,
2018 testing was decreased to 42 days with an increase number of staff tested.
Through new processes, we were able to decrease testing by 18 days.
For more information, contact:
Patricia Gerrin CPhT CSPT (pgerrin@bidmc.Harvard.edu)
�Keeping Up With Sterile Preparations & USP <797>
Patricia Gerrin CPhT CSPT, Denise Arena Raphe Clinical Pharmacist Supervisor, Julie Lanza CPhT CSPT
More Results/Progress to Date
Both USP <797> & the MA Board of Registration in Pharmacy are due to release
new standards for media fill test verification in 2019. We have already begun to
develop ideas by which these proposed changes will affect our current testing
processes.
Test
Old Regulation
New <USP>
regulations
New board of
Pharmacy
Regulations
Low/Medium
Annually
Biannually
Biannually
High Risk
Biannually
Biannually
Quarterly
Chemo/Hazardous Annually
Biannually
Biannually
Finger-Tip
Biannually
Biannually
Annually
Based on the changes to regulations proposed above, we will be tasked with
having to revise our testing processes & invest exponentially more to purchase
testing supplies
In addition to the Media Fill Verification Testing, all BIDMC Pharmacy employees who
compound Sterile Products are required to complete & pass three didactic exams as well as
attend an Annual Lecture on the updates/changes of <USP> 797. This allows us to maintain
competency & compliance in regards to the laws/regulations.
In addition to USP & MA Board of Pharmacy regulations, The Pharmacy
Technician Certification Board (PTCB) has launched an optional certification for
Advanced Sterile Products (CSPT) technicians in 2018.
BIDMC has six technicians who have taken this certification exam which has
allowed us the flexibility and ability to have more advanced trained sterile products
employees performing these verification tests to ensure compliance with national
standards.
Lessons Learned
Pertaining to the world of Sterile Products and USP <797>; lessons are
continually evolving as the regulations and parameters set around
compounding and patient safety are constantly changing.
Our lessons involve continuous education around the best way to maintain our
quality assurance & performance standards here at BIDMC.
Next Steps
Maintain monitoring of our current processes & use metrics to implement measures that
will improve processes.
Keeping up with all the changing regulations that are published by the USP
Promote current and future pharmacy technician staff to sit for CSPT exam allowing for a
more comprehensive group of sterile products employees
For more information, contact:
Patricia Gerrin CPhT CSPT (pgerrin@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.
Patricia Gerrin (<a href="mailto:pgerrin@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">pgerrin@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Pharmacy
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Denise Arena
Patricia Gerrin
Bzunesh Abrha
Julie Lanza
Dublin Core
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Title
A name given to the resource
Keeping up with Sterile Preparation & USP <797>
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Effectiveness
Efficiency
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/4c86cb7b1a27b3dc624fa43434cf95df.pdf?Expires=1712793600&Signature=uAzziJIt91RpeqxhZRsCJW-vQDymOTZEI2A2TzPR6qjP6K4u-uEkvkyx5uJzIwFkhVxmbCcQE15U3iK3EVEo8mTeKemeuEtcMSMDfzS8Rc7DKEPo4OuQhNHNlnDV4%7EAjmJla64WbC-SYiyfzqbwKc6AdxiCNLRTeOw4Zl35HyXRYwTOpwFe850S07a8Tex93iDMF2Ixnwm3EjRqxJFao7c4adaJVJc3HOtSI3z3uRnpihR0maQ4pNulNRaKeJ092BJkha1damvJMRWdalN-kP0J9mSFh-pPQzdw1WFXQncjICm2lq4rOAyrgJI2aZn923biFbDz0JS1%7E0FSFaFh23A__&Key-Pair-Id=K6UGZS9ZTDSZM
a61e74f5f43f5f872af86f41d0e086f1
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Job Safety Behavioral Observations (JSBO) - Food Services
Carol Clancy; Rob Seeley; Matt Rabesa; Brandon King, Kelsey Whalen; Elizabeth Haley; Gary Visnick, Stephane Ost
Introduction/Problem
The Strategy
Healthcare workplaces are among the most hazardous in the nation. In 2010 health care
employees reported 653,900 workplace injuries and illnesses, more than 152,000 more than
the next most afflicted sector, manufacturing. In 2013 we launched the first job safety
behavioral observations process in the East OR. A technique and tool used in industry, Job
Safety Behavioral Observations (JSBO) make the workplace safer through observations of
work performed and subsequent mitigation of hazards recognized.
Building on the success of this first team, similar teams were launched in CPD, and
Environmental Services. In 2016 we launched this JSBO Food Services Team, providing an
opportunity to spread to Food Services the learning we developed and deployed in the OR,
CPD and EVS which significantly reduced employee injury. It originally launched on east
campus with great results so we implemented this best practice on west campus in 2017.
Less than 1.65 injuries per month (injury was defined as any treatment beyond First Aid).
The Team
Stephane Ost
Brandon King (Co-Leader)
Kelsey Whalen, RD
Title
Nurse Practioner
Executive Chef
Safety Officer
PFS Manager
Director, Employee Health
Management
Assistant Director, Food Services
PFS Manager
PFS Manager
• Determined lost work days for Food Services in 2015. Categorize injuries
appropriately (i.e.: sharps, MSK, slips & falls, etc.)
• Delivered “Job Safety Behavioral Observations Tool Kit” to the team and
Food Services staff.
• Developed and launched a survey for Food Services staff to solicit their
input on causes of injuries.
• Performed observations; create a schedule for these to include common
hazards
• Utilized Food Safety Handler’s Guide, OSHA and NIOSH standards as
they apply to this project.
• Utilized Food Services Huddles on Wednesdays as a forum for safety callouts, specifically near misses and injuries.
Results/Progress to Date
Aim/Goal
Team Member
Carol Clancy, MSN, ANP-BC (CoLeader)
Gary Visnick
Rob Seeley
Elizabeth Haley, RD
Matt Rabesa
TAP TO GO BACK
TO KIOSK MENU
Department
Employee Occupational Health
& Safety
Food Services
EH&S
Food Services
Employee Occupational Health
& Safety
Food Services
Food Services
Food Services
220 employees in our
department and only 19
injuries in 2018.
For more information, contact:
Carol Clancy, MSN, ANP-BC, caclancy@bidmc.harvard.edu; Brandon King, bking3@bidmc.harvard.edu
�Job Safety Behavioral Observations (JSBO) - Food Services
Carol Clancy; Rob Seeley; Matt Rabesa; Brandon King, Kelsey Whalen; Elizabeth Haley; Gary Visnick, Stephane Ost
The Interventions
Upgraded step stools to
provide 3 points of contact
After
Before
Purchased shoe covers for
staff that may have
forgotten their shoes at
home.
With this new APP we are able to improve our audit process to
provide feedback for both “safe” and “unsafe” observations. These
observations generate action plans to be completed by managers.
With this real time data entry system we are able to correct safety
hazards before an incident happens and also run reports to increase
safety in the future.
Pareto Analysis of
internal audit results
illustrate where the team
should concentrate its
efforts:
PPE is the current
number one issue.
New chemical
implemented in
pots to help break
down stuck on
grease and food
particles to reduce
repetitive
movement.
Offered vouchers for staff
to purchase discounted
shoes, 112 pairs of shoes
sold between both
campuses!
Walk-in door signs
for exiting
fridges/freezers
safely.
Lessons Learned
• Using the Job Safety Behavioral Observation methodology within a cross-functional team setting can
significantly reduce injury to employees.
• All accidents are preventable.
Next Steps
2019 AOP goal of 7.5 observations per month – 20% increase from 2018(6/month).
Reorganized clean dish storage that caused a
head injury
Increased the amount of floor mats in the dish
room due to slips
For more information, contact:
Carol Clancy, MSN, ANP-BC, caclancy@bidmc.harvard.edu; Brandon King, bking3@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.
Carol Clancy (<a href="mailto:caclancy@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">caclancy@bidmc.harvard.edu</a>)<br />Brandon King (<a href="mailto:bking3@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">bking3@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Food Services
Employee Occupational Health and Safety (EOHS)
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Carol Clancy
Gary Visnick
Rob Seeley
Elizabeth Haley
Matt Rabesa
Stephane Ost
Brandon King
Kelsey Whalen
Dublin Core
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Title
A name given to the resource
Job Safety Behavioral Observation (JSBO) - Food Service
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Effectiveness
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/1f98cbd3ca19a48497f8cc8bb8074afd.pdf?Expires=1712793600&Signature=OEzwvgcCF3YW%7E6DVoRESNJc0dwVnRcXSxpPJhqUz0i8ECxhi6xcr35AHF%7EDgU1F-Dd1d9D2-mdRZNGhWqGruai63S39Ks7qE-fQAXS71yphDzfxA7nI8qaXftiZkXHFmRnB7JnVIeqKy-26rMQI1TO9IwmIMa11xGjCQHHdwpvaDMFiCpDNOVUnn043s-kwRdcp3kwIRWgoyDNaLjNfNNpGCaM94RxpurfWFNFdFLAeV1hX7JhiYMWsqJ2KM9VQcEQ4nsnRqNF9U62haPBFqmNPngZh2eNGfYAHZm58pbD%7EAcwV94n6NKfAOzYulk3u46U7xMZNt2BlMbKc9UxeSHQ__&Key-Pair-Id=K6UGZS9ZTDSZM
fb7197018a57cae5b86492041a8673a3
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Text
Infection Control-Led High Level Disinfection Audits
Improved Consistency of Practice
TAP TO GO
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Jamie McGloin; Nithila Asokaraj RN, BSN; Preeti Mehrotra MD, MPH; Aleah D. King, RN, BSN, CIC
Introduction/Problem
Across BIDMC (on campus and offsites), 22 non-OR departments reprocess equipment
using high level disinfection (HLD) by three different methods:
The Interventions
1. Step-by-step reprocessing walkthroughs by ICPs several times per week with
real-time feedback including:
a.
b.
c.
• Trophon® EPR,
• Automated endoscope reprocessors (AER)
• Manual disinfection using a ortho-Phthaladehyde (OPA) disinfectant
Standardized walk rounds by Infection Control Practitioners (ICPs) discovered
discrepancies and educational gaps related to multiple steps in the HLD process:
•
•
•
•
Pre-cleaning
Reprocessing
Transportation
Storage
In preparation for the Joint Commission (TJC) survey, Infection Control/Hospital
Epidemiology (IC/HE) led 3 weeks of intensive audits and education at all sites performing
HLD of equipment
2.
Step-by-step review of reprocessing
Review of equipment transport and storage
Personal protective equipment and hand hygiene observations
Development of new or updated tools
a.
b.
c.
d.
“Joint Commission FAQs” and corresponding quiz
Revision of all IC Guidelines
Checklists to facilitate staff training
signage to serve as visual cues during pre-cleaning and reprocessing
Results/Progress to Date
Pre-cleaning
Aim/Goal
• To educate and audit inpatient and ambulatory service sites on the processes related to
HLD
• To improve compliance with Instructions for Use (IFUs) for equipment in all locations
conducting pre-cleaning and HLD to ensure patient safety, prevent healthcare-acquired
infections, and comply with national accreditation standards
The Team
➢ Infection Control/ Hospital Epidemiology
➢ Ambulatory Operations
➢ Staff at all sites performing HLD
With thanks to the HLD Steering Committee
Visual Aids: Instrument pre-cleaning poster
Centralized station creation: Hand sanitizer, PPE, a
pre-cleaning enzymatic solution, and a transport bin
For more information, contact:
Aleah King, RN, BSN, CIC, Infection Control Practitioner, adking@bidmc.harvard.edu
�Infection Control-Led High Level Disinfection Audits Improved
Consistency of Practice
Jamie McGloin; Nithila Asokaraj RN, BSN; Preeti Mehrotra MD, MPH; Aleah D. King, RN, BSN, CIC
More Results/Progress to Date
Documentation:
• IC/HE updated all checklists related to HLD to reflect IFU
requirements and TJC standards
• Standardized logs were created for all sites to cover required
documentation for reprocessing, and cartridge and chemical
changes
Space:
• IC/HE identified several space constraints that resulted in
improper probe and scope storage and suggested
improvements
• Example of a new probe rack acquired by Surgical Specialties
to safely store their equipment to prevent contamination
Quality Control:
IC/HE educated and observed staff to ensure they could perform
quality control checks to meet each IFU.
• Correctly readout a pass/fail chemical indicator at the end of the
cycle
• OPA and AER reprocessing require quality testing of test stripes
(pictured to the left)
Reduce Manual Disinfection and Improve Safety:
• ENT purchased two new Olympus mini-endoscope reprocessors
(pictured to the right) to shorten reprocessing time
• IC/HE oversaw the transition from OPA to these machines to
ensure compliance with IFUs and TJC standards
Lessons Learned
•
•
•
Discovered many discrepancies in reprocessing techniques due to misinterpretation of
product IFUs
Inadequate resources available for staff to maintain product and process compliance
Encountered interdepartmental communication barriers particularly with disseminating
pertinent information to frontline staff
Next Steps
•
•
•
Continue increased ICHE collaboration with frontline staff to preserve compliance to
updated pre-cleaning and HLD process
Create an Infection Control checklist that sites can use to self-audit HLD compliance
Establish and streamline processes between onsite and offsite HLD locations
For more information, contact:
Aleah D. King, RN, BSN, CIC, Infection Control Practitioner, adking@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.
<p>Aleah King (<a href="mailto:adking@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">adking@bidmc.harvard.edu</a>)</p>
Department
Any departments listed on the poster or identified in the spreadsheet.
Health Care Quality and Safety
Infection Control / Hospital Epidemiology (ICHE)
Ambulatory Operations
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Jamie McGloin
Nithila Asokaraj
Preeti Mehrotra
Aleah D. King
High Level Disinfection Steering Committee
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
Infection Control-Led High Level Disinfection Audits Improved Consistency of Practice
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Effectiveness
Efficiency
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/8b2d7d23f8ec69bf8dfa3751bdcac646.pdf?Expires=1712793600&Signature=OZt5YoZ4uzS2BsceAw8Zsz%7EujuI2dGkY-NysxdjE-S7Tgc-iAett7gq41Pz7%7EDDh5JzXVeBuAq1KOHh4IohzrwKOPuEMO0jUe47YcvOf-uoK2OnVWZu3sBvLhmCJslFAM8%7EWkyRk5VEVhrqJbgEnoAzCr8eekI2fYkkvCl8Pk0IqEirhd6UFGM1mEwoPX92F9O9KZPELFpMwV4mdRR%7ErFQz-BitSEkbRad1VQfHqKBirqDkvvytcdpWuAUvB24PelESYZKIwr4I4xWqVtYe0X4UA%7EKcqUnPGObBnnEfxSYe9E5SHm2R6qyDwj6GzUK8SSmC64%7EHA9d0XZanDSET9Fw__&Key-Pair-Id=K6UGZS9ZTDSZM
b62b0bb49e2575a7acf2e0ce33909ccb
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Improvements in Emergency Stroke Care: Achievement of ASA Re-Certification
Gay Calo RN, Leanne Wood RN
Introduction/Problem
Prior to 2016, BID-Needham a Gold certification with the American Stroke Association (ASA) as well as
Get with the Guidelines (GWTG) recognition. In 2016, BID-N focused on other aspects of stroke
management which resulted in other stroke measure improvements but unfortunately a lower score for
t-PA administration and therefore the loss of our GWTG recognition.
In 2016 we assessed the program and planned specific interventions to improve the overall program
measures. Knowing that if these improvement methods were successful, it would take at least two years
to regain a Gold certification.
Some of the challenges for this project included the small size of BID-N as a community hospital, and the
resulting small number of patients entering the Emergency Department (ED) for evaluation and treatment
for stroke. Because of our small size and small volume of patients, it presented a challenge for nursing
staff to be educated and re-educated relative to stroke care measures and documentation. This factor
played a significant role in the identification of interventions that would not only educate nurses but also
sustain that knowledge regardless of the patient volume over time.
The Interventions
Education of Nursing Staff:
–
Education re all evidence based best practices for emergency stroke care
•
Focus on Door to Needle times for t-PA
•
Simulations for stroke management in the ED
•
Practice mixing and administering t-PA
•
Created visuals for nursing reference in the ED
Education of MD staff regarding elements of required documentation
–
Results/Progress to Date
Goal Achievement: Time to t-PA
Implement PI
Interventions
100
Aim/Goal
90
Goal
85
%Achievement
Goals:
• Improve nursing knowledge and MD documentation re: early stroke management in the ED
• Improve all measures of success regarding stroke care in the ED
• Regain GWTG certification
95
80
75
70
65
The Team
Anna Murphy RN, ED stroke coordinator
Gay Calo RN, Quality and Safety stroke coordinator
Peter Smulowitz MD, ED Chair
Leanne Wood RN, Nursing Director ED
Margot Geffroy MD, Chair of Neurology
Gregory McSweeney MD, CMO for BID-N
60
55
50
Time to tPA
2016
71
2017
100
2018
100
In 2016, prior to interventions, BID-N Time to t-PA achievement score fell to 71%, losing certification
After interventions, in 2017, Time to t-PA at 100%, regaining certification at silver level;
Sustained in 2018 at 100%- achieving gold certification and designation as a Target Honor Roll Hospital
For more information, contact:
Gay Calo RN, Q&S Stroke Coordinator gcalo@bidneedham.org
�
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.
<p>Gay Calo (<a href="mailto:gcalo@bidneedham.org" target="_blank" rel="noreferrer noopener">gcalo@bidneedham.org</a>)</p>
Department
Any departments listed on the poster or identified in the spreadsheet.
Healthcare Quality and Safety
Stroke Team
Neurology
Emergency Department
Nursing
Medicine
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BID-Needham
Project Team
Anna Murphy
Gay Calo
Peter Smulowitz
Leanne Wood
Margot Geffroy
Gregory McSweeney
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
Improvements in Emergency Stroke Care: Achievement of ASA Re-Certification
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Effectiveness
Efficiency
Safety
Timeliness
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/6bd0ede45dc1d2146d995f96bcc3fc34.pdf?Expires=1712793600&Signature=uZTu8dSov0yEVJZrJMWAhR44rgzKVABADaBwf9MOAy4hGrctz5-yMpIXe3nmx5VHFR2h%7EVCbTzDgsjRGzrVq61idJV0ysCngrgIgRrric1oOONkaoHevOrGiaJ9tJDIRwOgkQNXpYYg4jgQtfyzLxESQtvE1%7EOENvRwQ%7ERgf3aUQr%7Es5rGP8BCFaUR3%7EtwKMyk1nRwCM2h6-2Keo-vdBEOTh6g5ISw5sLhFbUxBF3RDUajS4y38sN6%7Ef6q5ywtOwatYFGNPb49wZQwyDhS7l8C%7EXh0lH46JZApeBxSw4WnMc%7EnuZtCUE%7EsiQQYS3DWqEjKQYxtAPsjFnoDuY9DlCKA__&Key-Pair-Id=K6UGZS9ZTDSZM
c163ef3c715c725b441fc5aa51024b08
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High Level Disinfection
Ross Simon, BA; Preeti Mehrotra, MD, MPH; Elizabeth Blaeser, MS, CIC; Ashley Boulanger, BS; Elizabeth Carvelli, DNP, RN; Susan Crafts, MS, RN; Nancy Doraiswami, RN, BSN, CGRN, CRCST, CFER; Kate Deary, DNP, APRN-BC; Fae Esparza;
Kervin Faustin, CBSPD, CFER; Pat Folcarelli, RN, MA, PhD; Sarah Fostello, BA, RDCS; Veronica Kelly, MSN, RN; Bernie Kennedy, BS, RDMS, RVT; Aleah King, RN, CIC; Jeff Lamson, RN, BSN, CEN; Mary LaSalvia, MD; Thomas Malboeuf, Cer. A.T.;
Jamie McGloin; Deb McKinnon, Danelle Henry Obas, CPSPD; Ed Plant, BS, CE, CBET; Amanda Poirier, AIA; Rob Seeley, CSP; Jane Sellica, RN, BSN, CNOR, CNIV; Ellen Volpe; Cynthia Wagner, MS, CCC-SLP, BCS-S; Matt Wheeler, MS, CCE
Introduction/Problem
Issues
To ensure reliable, safe, high quality care in all areas using high level disinfectant, this team made certain that we comply
with The Joint Commission, Infection Control, and the AAMI 2017 standards. We harmonized these practices across the
medical center.
Goals/Performance
1. Conducted 17 gap analyses of areas using HLD across the medical center and at off-sites. Corrected discrepancies
identified.
2. Determined equipment inventory
3. Determined chemical inventory
4. Standardized logs for OPA & Trophon
5. Observed & communicated compliance with Personal Protective Equipment [PPE] standards
6. Reviewed/corrected instrument storage containers/cabinets
7. Updated the Infection Control Policy, supporting workflows provided by Instructions for Use (IFU)
The Team
Name
Title / Department
Name
Title / Department
Ashley Boulanger, BS
Rehab Aide / Voice, Speech & Swallowing
Thomas Malboeuf, Cer. A.T
Infection Control Practitioner / Infection Control
Jamie McGloin
Nursing Director / West Procedural Center
Susan Crafts, MS, RN
L&D Specialist / Labor & Delivery
Kate Deary, DNP, APRN-BC
Director of Clinical Operations / ENT
Identified /
corrected scope
cabinet issues
Identified need to
test staff for
colorblindness
Identified need and
implemented securing
EPCA pumps in L&D
Instrument kits stored incorrectly
Blocked ventilation
IC Co-Op
Elizabeth Carvelli, DNP, RN
Outdated manual high level
disinfection process
Clinical Manager / Anesthesia
Elizabeth Blaeser, MS, CIC
Obsolete scopes
Deb McKinnon
Identified GEL
enzymatic product
to keep dirty
instruments moist
Practice Manager / ENT
Preeti Mehrotra MD, MPH
(Co-Leader)
Associate Hospital Epidemiologist, Infection
Control/Hospital Epidemiology
Nancy Doraiswami,
RN, BSN, CGRN, CRCST, CFER
Fae Esparza
Director / Central Processing Department
Danelle Henry Obas, CBSPD, CST
CPD Educator / CPD
Manager / Practice Operations, Surgical Specialties
Ed Plant, BS, CE, CBET
CPD Tech III / CPD
Amanda Poirier, AIA
Vice President / Healthcare Quality
Rob Seeley, CSP
Sr. Safety Officer / Environmental Health & Safety
Sarah Fostello, BA, RDCS
Clinical Manager / Echo Lab
Veronica Kelly, MSN, RN
Nursing Director / GI
Jane Sellica,
RN, BSN, CNOR, CNIV
Ross Simon, BA
(Co-Leader & Facilitator)
Ellen Volpe
Improved atomizer sterility
Sr. Project Manager / Facilities
Pat Folcarelli, RN, PhD (Sponsor)
Surfaces not cleanable
Curtailed disposing dirty sheaths in
regular trash
Anesthesia Technical Director / Anesthesia
Kervin Faustin, CBSPD, CFER
Unsecured sharps
container in L&D patient
rooms eliminated
Crowded workspaces
Nurse / Surgical Specialties
Bernie Kennedy,
BS, RDMS, RVT
Aleah King, RN, CIC
Technical Director for Ultrasound/Vascular Lab /
Radiology
Infection Control Practitioner / Infection Control
Jeff Lamson, RN, BSN, CEN
Clinical Manager / ED
Mary LaSalvia, MD
Medical Director / Ambulatory Operations
Cynthia Wagner ,
MS, CCC-SLP, BCS-S
Matt Wheeler, MS, CCE
Sr. Quality Engineer / Health Care Quality
Instructions for Use & Preventive
Maintenance
Director / Ambulatory Operations
Manager / Voice, Speech & Swallowing
Dirty sharps transport trays
Director / Clinical Engineering
Implemented use of
disposable buttons in GI
Simplified patient room turnover
by eliminating unnecessary
bagging (an Infection Control
concern) of Fetal Monitors Cardio
& Tocometer
Identified best
practices (electronic
data gathering ) to
spread
For more information, contact:
Ross Simon, BA, Sr. Quality Engineer, Healthcare Quality, rwsimon@bidmc.harvard,.edu; Preeti Mehrotra, MD, MPH, Associate Hospital Epidemiologist, Infection Control/Hospital Epidemiology, pmehrotr@bidmc.harvard.edu
�High Level Disinfection
Ross Simon, BA; Preeti Mehrotra, MD, MPH; Elizabeth Blaeser, MS, CIC; Ashley Boulanger, BS; Elizabeth Carvelli, DNP, RN; Susan Crafts, MS, RN; Nancy Doraiswami, RN, BSN, CGRN, CRCST, CFER; Kate Deary, DNP, APRN-BC; Fae Esparza;
Kervin Faustin, CBSPD, CFER; Pat Folcarelli, RN, MA, PhD; Sarah Fostello, BA, RDCS; Veronica Kelly, MSN, RN; Bernie Kennedy, BS, RDMS, RVT; Aleah King, RN, CIC; Jeff Lamson, RN, BSN, CEN; Mary LaSalvia, MD; Thomas Malboeuf, Cer. A.T.;
Jamie McGloin; Deb McKinnon, Danelle Henry Obas, CPSPD; Ed Plant, BS, CE, CBET; Amanda Poirier, AIA; Rob Seeley, CSP; Jane Sellica, RN, BSN, CNOR, CNIV; Ellen Volpe; Cynthia Wagner, MS, CCC-SLP, BCS-S; Matt Wheeler, MS, CCE
Analysis
Education
Facilitated Trophon Training 2/26/19
Nanosonics, Inc.
26 Employees Educated
2:00 - 3:30p
Audit Team
Performing
Gap
Analyses
Lessons Learned
•
•
•
•
•
Don’t take anything for granted
Observation is key
People don’t know what they don’t know
Take ACTION when you see something out of compliance
Some areas do more than what’s required, providing best practices (i.e.: electronic recordkeeping by
Anesthesia)
• This team provides a forum for sharing best practices
Next Steps
Meet the following goals in the next phase of work (HLD Phase II Team)
•
•
•
•
•
•
•
•
•
•
•
Shared Best Practices
Transport containers, bags & sheaths
Data access & storage
Access to Instructions for Use
Data collection logs
Keeping dirty instruments moist
Calibrated Infrared thermometers
Dirty sharps transport containers
Lint-free cloths
Floor elevators
One glove policy to prevent contamination to door knobs, elevator button, etc.
Pre-cleaning pads
Best
Practices
Identified
and Shared
PPE Auditing – set-up a process to periodically audit
Set manual competency compliance
Patient/Scope Tracking – where necessary, transition from paper to electronic
Preventive Maintenance – establish consistency in labeling, use the same technology managed the
same way
5. Implement use of disposable buttons for areas in addition to GI
6. Perform one or more FMEAs (Failure Mode and Effects Analysis) to proactively identify areas of
vulnerability and take action to minimize the risks
7. Have all GI reprocessors in 2019 certified to IAHCSMM
1.
2.
3.
4.
For more information, contact:
Ross Simon, BA, Sr. Quality Engineer, Healthcare Quality, rwsimon@bidmc.harvard,.edu; Preeti Mehrotra, MD, MPH, Associate Hospital Epidemiologist, Infection Control/Hospital Epidemiology, pmehrotr@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.
Ross Simon (<a href="mailto:rwsimon@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">rwsimon@bidmc.harvard.edu</a>)<br />Preeti Mehrotra (<a href="mailto:pmehrotr@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">pmehrotr@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Health Care Quality and Safety
Infection Control
Anesthesia
Facilities
Environmental Health and Safety
Voice Speech and Swallowing
Clinical Engineering
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Ashley Boulanger
Elizabeth Blaeser
Elizabeth Carvelli
Susan Crafts
Kate Deary
Nancy Doraiswami
Fae Esparza
Kervin Faustin
Pat Folcarelli
Sarah Fostello
Veronica Kelly
Bernie Kennedy
Aleah King
Jeff Lamson
Mary LaSalvia
Thomas Malboeuf
Jamie McGloin
Deb McKinnon
Preeti Mehrotra
Danelle Henry Obas
Ed Plant
Amanda Poirier
Rob Seeley
Jane Sellica
Ross Simon
Ellen Volpe
Cynthia Wagner
Matt Wheeler
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
High Level Disinfection
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Effectiveness
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/8d1c5017ebef05311e0bf8b4e87c20a0.pdf?Expires=1712793600&Signature=k-%7ExBi4V%7EFWu-vfSQ4k%7EMUCWsmNTJtzOKEAUSX96Sz4CTxytKtMWDS4glXZjRZHMUhYXBhDNONmvBKYyVLi%7EvK92XYz3E2EEFEcTLOlKL5iTvBWeU9qyY-BFdmAsygbY8MnffyP1olnj%7EzOZaSKIXG3c3uGfOrA9KPF9OkJqihcvUaIoJuoqxSYBYFSIa%7E7VhDf7gH7ibDvszbhDBAoBTeWQ3ssk15nbUrsDiqgwGIB7E6W3Kkfoy5AOzz0wsCe4DI34SyZAg4OsxffUmxtOnqDP5c90pLKZNpm%7ExSNoprqM%7ETlLxRYrs-NIfz1ZQEErF7ALPTkt3-5Dj1owz6JeoA__&Key-Pair-Id=K6UGZS9ZTDSZM
8b39217714fa5ebe94f8122b5e55ae13
PDF Text
Text
Expedited Workflow for Emergent MRIs Overnight
Introduction/Problem
TAP TO GO
BACK TO
KIOSK MENU
Progress to Date
➢ Overnight workflows can be challenging due to limited staff and
resources. Delays obtaining stat inpatient and ED MRIs overnight have
been reported and resulted in staff frustration.
➢ Identifying workflow bottlenecks could illustrate opportunities for
improvement and help prioritize interventions.
Aim/Goal
Expedite emergent MRIs overnight to enable more rapid medical decision
making for patient care. (1) Map the workflow for MRI acquisition to better
understand the steps required, (2) gather data on time for each step to
identify bottlenecks, and (3) prioritize a practical intervention to reduce
delays. (4) Increase radiology resident and MR technologist awareness of
each team-members responsibilities and time-limits to improve team
dynamics and performance.
The Team
Alexei Kudla, Ron Mercer, Kelly
Bergeron (not pictured), Kimi Ghaderi,
Amalie Thavikulwat, Ines CabralGoncalves, Jackie DePeiza, Binh
Nguyen, Vess Liakas, Karen Platcow,
Mike Luo (not pictured), Jim Rawson
(not pictured)
Special thanks: Donna Hallett and Jillian
Augusta for providing MRI data
Figure 1: Workflow map for obtaining MRIs overnight
➢ Areas of potential delays are multiple and variable with areas of concern
including the safety checklist, protocol, implant investigation, special
circumstances, and scanner availability
➢ CMS-mandated time-limit from order to image for these studies is 12 hours!
For more information, contact:
Akudla@bidmc.harvard.edu
�Expedited Workflow for Emergent MRIs Overnight
Lessons Learned
MRI timeline: Methods
➢ MRIs ordered 11pm-7am from 9/17/18-10/17/18 were reviewed (n = 77)
➢ Neuroradiology MRIs (n = 68) were evaluated separately since they are
most frequent and protocoled by radiology residents (Body and MSK MRIs
are protocoled by radiology fellows)
➢ Data recorded: time of order, page, protocol, MR start, MR complete, wet
read, final read, and whether the protocol was routine (Y/N)
MRI timeline: Results
➢Rarely were time of page or wet read readily available
➢87% (59/68) of overnight neuro MR protocols were considered routine
➢Median order to page (n=17) was 20 min (range 3 - 42)
➢Median order to protocol (n=66) was 79 min (range 4 - 849)
➢Median order to MR initiation (n=60) was 218 min (range 35 - 1419)
➢Median order to final read (n=60) was 752 min (range 124 - 5309)
➢
➢
➢
➢
Overnight MRI workflow has multiple steps potentially causing delays
Time from order to protocol, to image, and to report are highly variable
The majority of neuro MRIs ordered overnight are routine protocols
Awareness of other team member deadlines and responsibilities (MR
technologist obtaining MRIs in 12 hours and radiology residents
interpreting high acuity studies with demands from multiple sites and
services) improved team dynamics
Next Steps
➢Keep learning. Investigate outliers. Study other steps of the workflow
(such as safety checklist and investigating implants). Engage nursing
and ED staff to gain added perspective. Establish benchmarks for target
times to protocol, checklist, and image acquisition. Calculate impact on
daytime schedule, finances, and clinical outcomes if possible.
➢Design intervention. Based on what we’ve learned, options include:
(1) MRI technologists call overnight radiology resident with anticipated
protocol to review and approve over the phone.
(2) Standard communication checklist to request protocols including
phone call at 30 minutes after initial page to discuss any extenuating
circumstances and plan next step as a team.
Figure 2:
Run chart of time
from order to
protocol for
neuroradiology
MRs overnight
Median 79 min
Protocols
For more information, contact:
Akudla@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.
Alexei Kudla (<a href="mailto:akudla@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">akudla@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Radiology
Neuroradiology
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Alexei Kudla
Ron Mercer
Kelly Bergeron
Kimi Ghaderi
Amalie Thavikulwat
Ines Cabral-Goncalves
Jackie DePeiza
Binh Nguyen
Vess Liakas
Karen Platcow
Mike Luo
Jim Rawson
Donna Hallett
Jillian Augusta
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
Expedited Workflow for Emergent MRIs Overnight
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Timeliness
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/70525be936909706340733f5938e48e9.pdf?Expires=1712793600&Signature=ralDxzmiYyFh2txOk3B91zRBhP3LzGxKn0YngPbZUukcXFppvt8GK47hdSDZZCbPK48sjUHGteVqZCGpuqysxi-Phk2VMgotOfDgnkRUDd8AjgcBDdBkSaMN9j27jahQ3blZEhG9lpNcVGZ-u1%7EfoEzLj0gx6HOsE52aWOf030mo1v7XBAvwvfAp1QeScEYOrXJJjNceJbJd5cTudXLo623QWIWJuB95tg5wFoCLA5oNt1MAGP0keZTDAZ2V8o3JLk0lxWD2Mp8zk4HxBlmzW30X625z4vKWnbJQzqQjk-aQ3llolN61y09izHP8zImEJN2v2BOHdodHduxYHFMLcg__&Key-Pair-Id=K6UGZS9ZTDSZM
60e2ed17317064a7f46babfc69546068
PDF Text
Text
EverCheck- Efficient Primary Source Verification
Introduction/Problem
BIDMC is required to ensure staff meet all licensure and certification requirements both prior to
hire date and to ensure staff renew prior to their expiration date (also known as Primary Source
verification). The process was managed decentrally by both Human Resources and Patient Care
Services. Verifying that staff maintained a current license was a heavily manual process which
included running reports, verifying against job requirements and manually checking license status
via many disparate Boards and governing agencies.
During a Joint Commission visit, the need to centralize Primary Source Verification was noted and
the organization worked towards that goal- yet recognized that the effort to identify, track and notify
individuals of the pending licensure expiration was labor intensive and prone to human error in it’s
current manual state.
Given the importance of Primary Source verification in order for us to remain compliant and ensure
the safety of our patients, our two Executive Sponsors Judith Bieber, Chief Human Resources
Office and Marsha Maurer, Chief Nursing Officer formed a team to identify automated solutions to
better manage Primary Source Verification.
TAP TO GO BACK
TO KIOSK MENU
The Interventions
The project team reviewed the BIDMC cross functional population of all required licenses / certifications
All job codes were reviewed to confirm the ‘required’ license/certification stipulations were up to date
The HRIS team identified EverCheck as the vendor of choice
Data cleansing activities were undertaken to resolve any discrepancies (e.g. license numbers at the PSV being linked to an
employees maiden name while the PeopleSoft records showed a married name).
Administrative processes were designed and implemented across the Medical Center to ensure individuals were licensed/certified
as required or placed on an administrative leave as necessary
Communications, process and application training sessions for both administrators and managers were held across the main
BIDMC functional areas in preparation for a formal rollout of the application, which went live during the summer of 2018
Results/Progress to Date
Aim/Goal
The team was tasked with identifying a tool to manage primary source verification renewals including
identification of, notifications to employees and managers, reporting, and dashboards, thereby removing
hours of manual work each week and greatly reducing the opportunity for human error.
The Team
SVP Sponsors- Judith Bieber, Chief Human Resources Officer, Marsha Maurer, Chief Nursing Officer
Project Manager- Frank Britton Project Management Consultant (SEI)
Suzanne Albright, HR Talent Acquisition
Laurie Bloom RN, MA, Associate Chief Nurse, Professional Development and Research
Kirsten Boyd, RN, MHA, Associate Chief Nurse, Ambulatory and Emergency
Lori Cunningham Director of Talent Acquisition – Human Resources
Rita Geller, Director of Compensation
Sheila Goggin, PCS Finance
Jessica Laverty, Director HR Systems & Learning
Kathy Murray, Regulatory Compliance
Wanda Shelton - Sr. Director, Management Information & Financial Systems Patient Care Services
Ellen Volpe, Clinical Emergency Department Program Director Ambulatory & Emergency Nursing Education
EverCheck Dashboard displaying current state of all required licensure/certification expirations
For more information, contact:
Jessica Laverty, Director HR Systems @ jlaverty@bidmc.harvard.edu
�EverCheck- Efficient Primary Source Verification
More Results/Progress to Date
EverCheck provides a dashboard to easily see License/Certification statuses across the organization
Lessons Learned
Importance of defining key roles such as administrators and setting definitions of the attributes
required to be successful in the role
Regular communication to directors and managers enabled us maintain change management
momentum.
Next Steps
Expanding the scope for BIDMC to include the ‘pre-hire’ process in additional to the current ‘post hire’
functionality.
Potentially including other BIDMC affiliates primary source verification management into the
EverCheck solution.
The EverCheck Solution checks against licensure requirements daily and automatically takes a
screenshot of the license/certification when updated, or at least once a month to provide automated
licensure verification
For more information, contact:
Jessica Laverty Director HR Systems & Learning @jlaverty@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.
Jessica Laverty (<a href="mailto:jlaverty@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">jlaverty@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Human Resources
Nursing
Patient Care Services
Regulatory Compliance
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Judith Bieber
Marsha Maurer
Frank Britton
Suzanne Albright
Laurie Bloom
Kirsten Boyd
Lori Cunningham
Rita Geller
Sheila Goggin
Jessica Laverty
Kathy Murray
Wanda Shelton
Ellen Volpe
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
EverCheck - Efficient Primary Source Verification
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Effectiveness
Efficiency
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/ac8d5a3c76d5143d3cb8920cc5701be4.pdf?Expires=1712793600&Signature=Qil34RmYCkNV5I8omQjI1oDCRr59Ut12MaDhN53rOYm%7EsTEzqth16VSVbg%7Ee32r147ixACi31QPRsgKPNQAP%7EY0dPy3in-T5ZjRgVB2k3nuP0pvceZwCM%7ETd3-g%7ENeRtca9YjYdaK2hmavJ2K-XPP%7Eh9hZka4vwmlu82gjnYU6pYY6%7ETAhjDo80ceNQN1XHOdjbYYaI%7Em8AYJY7O6QRISGwLcVeHF-bJjKn7hWdBYUhz1bIQmhJizOamaXSGCqjXNejRqnBf3mv5PBJuiN80-LMYI7MeJ9i09a0ZvsDGYQy0PfKmEKbLlJUVeRd8p01a2q8AeDsjmgdueo0KoLkfEg__&Key-Pair-Id=K6UGZS9ZTDSZM
d47541851a59296002abd41f29cf34b4
PDF Text
Text
Developing an Intensive Care Unit Acuity Tool
Robert Lombardo MSN RN CCRN, Sharon O’Donoghue DNP RN, Laura Ritter-Cox MSN RN-BC
Introduction/Problem
Patient acuity refers to the physical and psychological complexity of patients.
Tools have been developed to assess the complexity of a patient assignment, nursing workload, and
plan for future staffing patterns.
The Interventions
The Therapeutic Intervention Scoring System 28 (TISS – 28) was developed in the 1970s as a means
of stratifying patients by severity of illness and then evolved as a measure of nursing workload in
relation to the nursing needs of the patient.
Data from the electronic medical record can be pulled from the electronic health record to identify the
TISS – 28 score without the need for nurses to manually enter information.
TAP TO GO BACK
TO KIOSK MENU
A modified TISS-28 tool which was developed for another project at BIDMC, was used as a starting point to assess its
accuracy.
Certain technologies were not being addressed in this scoring system as designed and updates were made to reflect
this increased acuity and workload.
One auditor with specific instructions chose one day and scored every patient at that point in time to ensure interrater
reliability.
Once the tool was validated, a developer in the IS department extracted the data from our documentation system and
the ICU dashboard was used to display the acuity scores.
The modified TISS-28 scores were manually compared to patient assignments on every ICU patient to validate if the
most highly acutely ill patients were being scored and singled appropriately.
The scores were stratified into three levels; low 12-25, 26-35 intermediate, and > 36 high giving some guidance as to
which patients may require one on one care and which patients may be appropriate for 2:1 care.
Massachusetts law requires all ICUs to have an acuity tool to assess the level, intensity, and nursing
Results/Progress to Date
needs of patients in order to provide appropriate staffing levels.
Aim/Goal
In accordance with Massachusetts General Law regulating nurse to patient ratios in critical care units,
we developed a tool and process to approximate acuity and guide patient assignments using bio-
The scores are only a guide and provide an objective measure to support nursing judgement while making patient
assignments.
judgement is still utilized ultimately for assignments.
The Team
Robert Lombardo MS, RN, CCRN
Sharon O’Donoghue DNP, RN
Laura Ritter-Cox MSN, RN-BC
Moore Grant Nurse Consultants
Moore Grant Work Groups
and share their census and staffing needs to ensure each unit is staffed appropriately.
Patient conditions are dynamic and acuity measurement is static and only valid at the time it is measured, so nursing
psycho-social assessment measures.
The capacity dashboard is used to manage throughput at a meeting twice a day where representatives from each ICU meet
Lessons Learned
Keith Dietz MHSA, MMIS
Ayad Shammout
Ariel Mueller MA
Acuity Tool Committee Members
For more information, contact:
Robert Lombardo MSN, RN, rlombar1@bidmc.harvard.edu
�Developing an Intensive Care Unit Acuity Tool
Robert Lombardo MSN RN CCRN, Sharon O’Donoghue DNP RN, Laura Ritter-Cox MSN RN-BC
More Results/Progress to Date
Next Steps
Examine how accurate documentation is currently and assess any need for further user education.
Review how this acuity tool is being used during the staffing meeting and evaluate areas for
improvement.
Reexamining the TISS-28* weighting of therapies and possibly adjusting some of the scoring weights
for today’s technology.
Possibly interfacing with other scoring systems to provide additional considerations that impact
staffing and care delivery such as other complimentary programs/algorithms that impact nurse to
patient ratios and assignments.
Assessing the skill mix of staff and the overall acuity of each ICU may be able to assist the
management of allocation of staff across the units in a more efficient manner.
References
Massachusetts Rule 958 CMR 8.00 - Bulletin HPC-2015-04, ICU Nurse Staffing Quality Measures
Katz, A, Andres, J, Scanlon, A. (2018). Application of Therapeutic Intervention Scoring System (tiss)
to an Electronic Health Record: A Feasibility Study. Pediatrics. DOI:
10.1542/peds.141.1_MeetingAbstract.321
ICU Dashboard with all the indicators and Acuity Scoring added
For more information, contact:
Robert Lombardo MSN, RN, rlombar1@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.
Robert Lombardo (<a href="mailto:rlombar1@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">rlombar1@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Nursing
Information Systems
Anesthesia
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Robert Lombardo
Sharon O’Donoghue
Laura Ritter-Cox
Moore Grant Nurse Consultants
Moore Grant Work Groups
Keith Dietz
Ayad Shammout
Ariel Mueller
Acuity Tool Committee Members
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
Developing an Intensive Care Unit Acuity Tool
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Safety
-
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2ab5b6dab1b8eb126a2be2573e09c847
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Conversion of Paper Research Chemotherapy Orders to Electronic Orders in Oncology Management System (OMS)
Introduction/Problem
The Oncology Management System (OMS) is an electronic order entry system for chemotherapy.
Research chemotherapy orders were still on paper. Every medical center participating in chemotherapy
research studies through Dana Farber/Harvard Cancer Center consortium are required to have electronic
chemotherapy order entry.
Aim/Goal
The primary goal of the project was to convert all research chemotherapy orders from paper to an
electronic ordering system (OMS) for all inpatients and outpatients. In doing so the team’s aim was to:
• Reduce transcription errors with the use of pre-defined order sets.
• Improve patient safety with better system error checking and interaction checking where possible.
• Improve clinical outcomes by providing better transparency to all treatments a patient has received.
• Improve workflow efficiency and communication between providers (RRNs, RPhs, MDs).
The Team
➢ Robin Joyce, MD OMS Faculty Lead
➢ Will Decaneas, Administrative Director
➢ Rena Lithotomos, Pharm.D, MSHI, Clinical
Coordinator OMS
➢ Kevin McKeon, RPh., BCOP, Clinical Lead
OMS
➢ Angela Burnham, Pharm.D, Clinincal
Coordinator OMS
➢ Jenn Espiritu, Pharm.D, BCOP, CCTO
Clinical Pharmacy Coordinator
➢ Joanna Kemp, RN, BSN, OCN Nursing
Director, Clinical Trials Office
➢ Peggy (Margaret) Stephan, M.S., RPh.,
Director of Pharmacy
➢ Heena Patel, RPh., Research Pharmacy
Supervisor
➢ Steve Maynard, C.Ph.T., Pharm Supervisor
➢ Lois Hurst, Information Systems Programmer
II
➢ David Grosso, Systems Evolution Inc. (SEI)
The Interventions
➢ The team identified the paper orders that need to be converted, met with the principal investigators
of the protocols and prioritized which paper orders needed to be converted.
➢ Developed a set of system requirements needed to enhance the OMS system to accommodate
Research Chemotherapy medication orders.
➢ Worked with our information systems team to design, develop, and test the new system
enhancements, focusing on both the back-end building Research Oncology order sets as well as the
front-end ordering tools.
➢ Implemented a new process for building, reviewing, and approving order set in OMS.
➢ Staff training was provided to all users (RRNs, RPhs, MDs).
➢ We continue to meet as a team to discuss future enhancements and further refinements to the system.
Results/Progress to Date
TAP TO GO
BACK TO
KIOSK MENU
Completed Enhancements:
1. OMS system upgraded to accommodate research oncology orders and the processes they require,
including research nurse verification of the orders, modifiable drug rounding parameters based per
protocol, development of dose reduction tables, utilization of the regimen notes function to convey that
a patient was cleared to be treated mid-cycle.
2. Standardized the research order set in OMS.
Lessons Learned
➢ When converting from a paper process to electronic, it is difficult to identify which parts of the process
checks were in place because the process was done on paper. It can be hard to identify which
elements in the paper process are still critical and must be maintained, changed or eliminated going
forward in the new electronic process.
➢ Initially we focused on a few simple order sets and protocols, which allowed us to test and refine our
high-level system requirements and processes. Once we were able to establish these and enhance the
system to accommodate requests, we were better prepared to incorporate more complex order sets.
➢ While the current system covers nearly 90% of all Research oncology order sets, there are some areas
that still need further development causing some order sets to remain on paper. Those areas are as
follows:
• Oral chemotherapy dispensed initially as an outpatient prescription or an inpatient on initial
admission is crashing eMAR system during inpatient use.
• Certain protocols mandate use of Adjusted body weight to calculate the dose, regardless of the
patient’s BMI, but the OMS calculator allows providers to use Adjusted body weight for dose
calculation for patients with BMI > 30 only. A request was submitted to the IT team to have the ability
to better control the BMI setting.
• The research nurse (RRN) verification for inpatients currently only requires verification on Day 1 of
therapy. For subsequent days, e.g. 2,3 4..etc the system does not alert the RRN to verify. While a
manual verification process is in place, a request to the IT team was submitted to correct this.
• Dose adjustments to the order frequency are required in certain research protocols, due to an OMS
limitation, the system does not allow the frequency to be altered for chemotherapy orders. An IT
request was submitted to allow OMS team to control altering the frequency at the template level.
Extra regimens are currently built for a workaround to this issue.
Next Steps
➢ Continue converting paper orders to electronic order sets in OMS. While 90% of research
chemotherapy order sets have been converted to the new system there are still 24 protocols that are
still on paper.
➢ Continue to work closely with the IT team for OMS enhancements .
For more information, contact:
Rena Lithotomos, Pharm.D, MSHI, rlithoto@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.
Rena Lithotomos (<a href="mailto:rlithoto@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">rlithoto@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Cancer Center
Pharmacy
Information Systems
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Robin Joyce
Will Decaneas
Rena Lithotomos
Kevin McKeon
Angela Burnham
Jenn Espiritu
Joanna Kemp
Peggy (Margaret) Stephan
Heena Patel
Steve Maynard
Lois Hurst
Dave Grosso
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
Conversion of Paper Research Chemotherapy Orders to Electronic Orders in Oncology Management System (OMS)
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Effectiveness
Efficiency
Safety
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https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/791f6724e9a04e670ac7fd21cefe43f7.pdf?Expires=1712793600&Signature=cv6xXzNOdFwNmGCDE-x8C3D-m-X3VQt3SKU%7EFm2wAHfOafaJY5mp2C%7EAe02m3DHqaXKbsw0EWv7D90JMLLlxPBz2rAD1%7E7FIcgHQMlu0OUF%7EOQDv3a%7E-MXIiQhClMZ9m7RBWbUJ%7EtRzxUzDRjysjVfiyShE9aEHWS14Q2CU24W4-o64HVHKm20lnhs5yIiDvnnCZcqXJnvLVXfpAZFl2gIg3xkyTgRdVW5JCBeiMvxUeB%7EXWGmdf7c3VngXiTZlJuR9o3vkewt8t6v0Qq6iBkH%7EzmiyIcIq8z3akm%7EZfGgSpJQeGSXjGr70Vpmc4Zxxxm9ePVir4854KQGBeDy7qVw__&Key-Pair-Id=K6UGZS9ZTDSZM
50dceee5546e05c893ae47a32cffe567
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Barriers and Solutions to Survivorship Care Plan Completion
Robert Stuver, Jennifer Faig, Gerry Abrahamian, Matthew Cadorette, Michael Kent, Irving Kaplan, Jessica A. Zerillo
Beth Israel Deaconess Cancer Center
Introduction
• Advances in cancer care have led to a rapidly increasing population of cancer survivors, from 3.6
million in 1975 to 15.5 million in 2016. There will be an estimated 26.1 million survivors in 2040. 1 With
this increasing population, care of survivors has become integral.
• A Survivorship Care Plan (SCP) is one approach to care of the cancer survivor. An SCP is a
document that patients complete with their oncologist and summarizes a patient’s diagnosis,
treatment, and recommended followup, as well as provides resources for long-term coping.
• SCPs have been shown to decrease patients’ worry, increase patients’ desire to make healthy lifestyle
changes, and increase contact with primary care physicians.
• The Commission on Cancer has stated that accredited programs will be expected to deliver SCPs to at
least 50% of eligible patients by the end of 2018. Over a six month period from April 2018 to
September 2018, the SCP completion rate at Beth Israel Deaconess was 36%.
Aim
• To learn more about provider perceptions regarding SCPs and about current barriers to SCP
completion at the Beth Israel Deaconess Cancer Center.
• To identify and enact potential solutions that will increase our cancer center's SCP completion rate to
greater than 50%.
The Team
➢ Project Leaders: Robert Stuver and Jennifer Faig
➢ Project Mentor: Jessica A. Zerillo
➢ Team Members: Gerry Abrahamian, Matthew Cadorette, Michael Kent, Irving Kaplan
The Intervention
➢ We created an online survey to assess perceived barriers to SCP implementation, identify potential
solutions, and capture attitudes and beliefs towards survivorship care.
➢ Our survey was sent to all primary providers within the Medical, Surgical, and Radiation Oncology
departments.
➢ The survey was sent to 178 oncology providers. A total of 74 (41.6%) responded.
Current Survivorship Care Plan Process
A. Current SCP Process
Tumor Registrar:
Identifies eligible
patients.
B. Satisfaction With SCP Process
100
80
Provider:
Completes SCP
with patient.
SCP: Signed in
OMR and printed
for patient.
53 %
60
43 %
40
20
4%
0
Satisfied
Neutral
Dissatisfied
Figure 1. Current SCP Process. The Tumor Registrar identifies eligible patients and notifies providers via
e-mail. Providers then complete the SCP at the patient’s next visit. Survey respondents were asked their
satisfaction with this current SCP process. The majority of respondents were neutral or dissatisfied.
For more information, contact:
Robert Stuver, MD, Internal Medicine, rnstuver@bidmc.harvard.edu
�Barriers and Solutions to Survivorship Care Plan Completion
Robert Stuver, Jennifer Faig, Gerry Abrahamian, Matthew Cadorette, Michael Kent, Irving Kaplan, Jessica A. Zerillo
Beth Israel Deaconess Cancer Center
Barriers to SCP Implementation
100
Potential Solutions
100
Lack of Clarity as to
Who Completes SCP
80
Concern SCP May
Forget to Complete
Cause Patient
Insufficient
SCP During Visit
Distress
Personnel
Do Not Know How
Unaware that
to Complete SCP
Patient is Eligible
SCP Form
Lack of
47.3
Hard to Use
Reimbursement
35.1
35.1
Time
60
62.1
52.7
40
20
21.6
20.3
80
60
40
Dedicated
Personnel
84.9
Send E-Mails to
Oncology Team
Provide
Disease-Specific
(RN/NP/fellow)
Reimbursement
Templates
to Help with SCP
Schedule
Education about
61.6
Dedicated Office
SCP Process
Improve E-Mail
Visit for SCP
Notifications
48.1
43.8
42.4
42.4
28.8
20
18.9
8.1
0
Figure 2. Barriers to SCP Implementation. Respondents were asked what they viewed as current barriers
to SCP completion. Time, lack of personnel, and unclear process were identified as the greatest barriers.
Are SCPs Beneficial for Patients?
0
Figure 4. Potential Solutions. Respondents were asked what they viewed as potential solutions.
Dedicated personnel and improvements in the SCP process were identified as major themes.
Lessons Learned & Next Steps
➢ Lack of time, insufficient personnel, and lack of clarity regarding how to complete an SCP were
identified as major barriers to SCP implentation, while dedicated personal and improvements in the
SCP process were pointed towards as potential solutions to increase completion.
➢ We will work to improve the SCP process, specifically by having a pre-templated SCP placed in the
medical record system prior to a provider’s visit with the patient in order to streamline completion.
➢ We will educate providers regarding the benefits of SCPs and the new process via in-person
education and an online training module.
Yes
Citations
No
1. Shapiro, CL. Cancer Survivorship. N Eng J Med 2018;379:2438-50.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Figure 3. Attitudes Towards SCPs. Respondents were asked whether they believed SCPs are beneficial
for patients. A total of 48 (67.6%) respondents stated yes.
For more information, contact:
Robert Stuver, MD, Internal Medicine, rnstuver@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.
<p>Robert Stuver (<a title="Medical Oncology" href="mailto:rnstuver@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">rnstuver@bidmc.harvard.edu</a>)</p>
Department
Any departments listed on the poster or identified in the spreadsheet.
Medical Oncology
Health Information Management
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Robert Stuver
Jennifer Faig
Jessica A. Zerillo
Gerry Abrahamian
Matthew Cadorette
Michael Kent
Irving Kaplan
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
Barriers and Solutions to Survivorship Care Plan Completion
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Patient and Family-Centeredness
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https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/2d5a17e55ccf77f8579ff58856aeb94e.pdf?Expires=1712793600&Signature=UuQLDx-E5ZigDoDN2jLoCcXs20cZUYkGDuQJZSIY2QyST5S8xbFe9PQY43FR25pK5bkAH94J8qXoGyV-8byjp%7ESI4LNzPiJ0m5jq6aPDyKTUaxzBJTBrV80JvbKjTTM0Krn-hwWS3-z7w4Y2AJpmeF%7EqDn8DAc3sjPQ5xHtcZuT0j-QH-rokTQjoMqmgipPZAv4Lw8mDuNbzKpZFil6q1fZRpPU0SsIqR-c4TuGpfPfgszQWMUNFEQ8LOGmGbGpGqTgxz8%7EImIbDijRn7n6uGCm9DzebtP9fflroltghlNFOThrvZIxj9FiUY3ph5CWNyl0HCST6SFL0%7ECuv5aFB9w__&Key-Pair-Id=K6UGZS9ZTDSZM
9a7c9d8ebaf167214535fcd90bc2a0b6
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A Team-Based Approach to Maintaining a Successful 340B Program
Julie F. Lanza CPhT CSPT, Parth Patel BSN RN, Shawn Wood CPhT 340B ACE, Denise Young CPhT, May Adra PharmD
TAP TO GO
BACK TO
KIOSK MENU
The Interventions
Introduction/Problem
Create internal application to audit prescriptions for 340B eligibility.
The 340B Drug Discount Program is a US federal government program created in 1992 that requires
drug manufacturers to provide outpatient drugs to eligible health care organizations and covered
entities at significantly reduced prices.
BIDMC is a Disproportionate Share Hospital (DSH) that participates in the 340B program. DSH serve
a significantly disproportionate number of low income patients.
Compliance and Integrity is crucial given the complexity of the 340B program. 340B Drug Pricing
Program covered entities must ensure program integrity and maintain accurate records documenting
compliance with all 340B Program requirements. Covered entities are subject to audit by
manufacturers or the federal government. Covered entities will be audited for all 340B program
requirements. Covered entities are subject to audit by the manufacturer or the federal government.
Develop a workflow with everyday processes to share and maintain auditable records for any/all
audits that may occur.
Created workflow processes to review 100% prescriptions for 340B eligibility on the contract
pharmacy side and a percentage of all dispensations from the split billing group.
A Third Party Administrator (TPA) is contracted to determine eligibility based on a set of rules
provided. BIDMC developed an algorithm to electronically screen above and beyond what the TPA
was able to do, therefore adding a layer of adherence.
Develop a communication process for the team for day-to-day operations as well as audit
preparedness.
The three major arms of the 340B program are Contract Pharmacy, Compliance & Split Billing.
Results/Progress to Date
Created a restricted auditable records folder accessible only to members of the 340B team.
Aim/Goal
Our aim is to create an internal 340B eligibility process while working with key stakeholders to audit
outpatient prescriptions and a percentage of mixed-use dispensations to maintain compliance with the
340B program.
The goal was to create a process by which all three arms of the 340B program work cohesively as a
team in collaboration with a multidisciplinary group of leadership from across the medical center.
Any documentation related to eligibility, registration and drug purchases of/by the, Covered entity,
Child sites or contract pharmacies must be maintained for auditing purposes.
Contract to
provide services
Policies & Procedures
regarding procurement
The Team
340B Executive Steering Committee – Mike Cullen, Tom Siepka, Chirag Desai, George Ogin, Jamie
Katz, Sam Skura, May Adra
340B Contract Pharmacy Team - Nary Heng, Sonia Najdzien, Chirag Patel, Erika Perry, Juan Rivera,
Denise Young
340B Split Billing Team – Shawn Wood, Jonathan Dacey
340B Data Analytics – Parth Patel
Pharmacy Compliance - Julie Lanza
Accounts
Medicare
Cost Report
Contract pharmacy
agreements
Purchasing records
(340B & non-340B)
Types of auditable records that are readily retrievable
For more information, contact:
Julie Lanza, CPhT, CSPT (jlanza@bidmcharvard.edu)
�A Team-Based Approach to Maintaining a Successful 340B Program
Julie F. Lanza CPhT CSPT, Parth Patel BSN RN, Shawn Wood CPhT 340B ACE, Denise Young CPhT, May Adra PharmD
More Results/Progress to Date
340B Split Billing Team
Audits from Split Billing Areas
2018
2017
10 Team
Members
12 Team
Members
Algorithms
Policies & Procedures
Invoicing
Auditing of contract
Pharmacies
Auditing of contract
pharmacies
Contract Review
2019
Auditing 214 Contract
Pharmacies
340B Savings Optimization
340B Team
Expansion
340B Contract
Pharmacy Team
Contract Review
6 Team
Members
340B Data Analytics
QA Dashboard
340B Compliance
Self-auditing of program
Team Composition & Responsibilities
Lessons Learned
Split
Billing
27
Contract
Pharmacy
16
Communication is imperative is maintaining a successful program. With the development of Quarterly
Executive Steering Committee meetings, monthly 340B Operations meeting & weekly calls with each group,
we have learned to implement changed based on team member feedback
Awareness of future expansion business expansion plans is important for planning.
Next Steps
85
Develop a Medical Center wide education plan as all involved in patient care on a direct or indirect level
are an integral part of compliance. Keeping every member of the patient care team educated about the
340B program is crucial in maintaining compliance.
Expand the 340B team in alignment with the expansion of pharmacy services and Beth Israel Lahey
Health
273
Areas for Improvement
No Findings
Areas for Improvement
Results from most recent external 340b Program Audit
No Findings
For more information, contact:
Julie Lanza, CPhT, CSPT (jlanza@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.
Julie Lanza (<a href="mailto:jlanza@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">jlanza@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Pharmacy
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Mike Cullen
Tom Siepka
Chirag Desai
George Ogin
Jamie Katz
Sam Skura
May Adra
Nary Heng
Sonia Najdzien
Chirag Patel
Erika Perry
Juan Rivera
Denise Young
Shawn Wood
Jonathan Dacey
Parth Patel
Julie Lanza
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
A Team Based Approach to Maintaining a Successful 340B Program
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Efficiency