2
20
1686
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https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/db6543a6217c9d295bd4f880d602a104.pdf?Expires=1712793600&Signature=UsffdsOKHoAOlmmaMCDFwyYwo0BnmGWanQoMjpY-lnGqUVi6ukE6JnjUIkxaxO9t2OIXahTPfXRF6DaEPM3-YdwgxH7ZdK54aBqwN5H-diDVmH-wszJha6FQGYy93RCDZamNOeCzQsutD7sT7k9acT18l-Z5K3Yz3JT9qj3prHRJ%7Ebs8nSnhq22VgDZ883dzbmKHAbtaRwiAyag6csOcjGExMhwosPTXAlKtyIpHz1ntpF3PE95578CJvZuNp-0D4Z16ImYxwz2Vx5KyoMLCHF4LVfivLnMoOdUWO0z3qc8G3JEUQbTQAbC3gnA0MqaUBVIFL2aDOREuWA7h-F4JHg__&Key-Pair-Id=K6UGZS9ZTDSZM
49281c8cd1a099f1ae28e9a9946fdcec
PDF Text
Text
A Culture of Safety: myPATH for Safe Patient Handling
BIDMC: Meghan Church PT, DPT & Danielle Nugent PT, DPT
Introduction/Problem
Results/Progress to Date
BIDMC is committed to a safe work environment for all employees; there is a written policy in place which states
that direct patient care staff will use safe patient handling (SPH) equipment, where available, to limit the manual
lifting and handling of patients to less than or equal to 35lbs, unless in an emergency situation. This is in
accordance with the National Institute of Occupational Safety and Health (NIOSH) guidelines. At BIDMC, the SPH
team is responsible for the coordination, installation and management of SPH equipment as well as training staff.
Patient care staff were under utilizing equipment and did not understand the benefits of SPH. We hypothesized
this could be attributed to lack of knowledge. There was not a consistent introduction to the SPH program for new
employees or consistent education for existing patient care staff. Additionally, research has shown that staff
require training every six months due to a drop off in usage of SPH equipment and techniques (Nelson, 2006).
Therefore the SPH team sought to create a standardized way to educate all patient care staff consistently.
Annual SPH Module (n=1851)
Initial Hire SPH Module (n=799)
In Progress
0%
In Progress/
Past Due
1%
In Progress
1%
In Progress / Past
Due
0%
Registered
9%
Completed
88%
Aim/Goal
Registered/
Past Due
2%
Completed
93%
Registered
4%
Registered / Past
Due
2%
The goal of the project was to engage and educate all direct patient care staff in a standardized way about the
importance of safe patient handling, benefits for staff and patients, equipment available throughout the medical
center, answer frequently asked questions and how to contact the safe patient handling team.
The Team
Safe patient handling team
•
•
•
Jacki Chechile PT, MSPT
Meghan Church PT, DPT
Danielle Nugent PT, DPT
•
•
•
Learning Council
myPATH team
•
Presented to Learning Council for approval of plan to develop myPATH modules:
• Introductory for new employees
• Annual training for existing staff
Radiology
Ambulatory
Operating Room
Units can assign modules at any time; some units assign modules multiple times throughout the year
Joe Sanchez, Sr. Learning Specialist Team Lead
The Interventions
Need to individualize myPATH modules for different areas based on equipment available:
Attended training for SNAP! software to create myPATH modules
Developed relevant content
Obtained approval from CNS Council and Nursing Competency Council for the distribution of modules to
nursing staff
Contacted local learning agents for all appropriate departments to assign myPATH training
Create myPATH module with training videos for Ambulatory to encourage use of available equipment
and ensure compliance with Americans with Disabilities Act
Create myPATH module for OR
Annually update myPATH modules to include updated information for injury rates and costs of injuries
Update myPATH modules to include branches for units with specific needs
Consider creating new module to be assigned biannually to address 6 month drop off in usage
For more information, contact:
The Safe Patient Handling Team at safepatienthandlingteam@bidmc.harvard.edu
�
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Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Meghan Church <a href="(mchurch@bidmc.harvard.edu)">(mchurch@bidmc.harvard.edu)</a>
Department
Any departments listed on the poster or identified in the spreadsheet.
Safe Patient Handling
Location or Affiliate
BIDMC
Project Team
Jacki Chechile
Meghan Church
Danielle Nugent
Learning Council
myPATH team
Joe Sanchez
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
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Title
A name given to the resource
A Culture of Safety: myPATH for Safe Patient Handling
Date
A point or period of time associated with an event in the lifecycle of the resource
2017
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/b5ba24aecb2bce3e018731d86029e043.pdf?Expires=1712793600&Signature=jDfxq2Ri4bl5sQ1u9MP4Hzq6Nk8Vaj0lUFS9bAaZ%7ERGMLL%7E4p80BaI4lKwnTSLV80e-7etbAThArbzIQT2cvegqhWRvnJUpcuOGwzNSEerMqTZOyhNGTi%7EoAVEis3MjQZfIaQeM4xgUi%7ExRf5xGcF9w2CHq5fN8BnQwKi1wCfdU5Fp9B%7EbulUewyb5uWSWvKxj2KCmxoPATOCeTY9qPE5U0eqwHYJvHWFnu8GzCQFt6JVCYNPTAeYg4dAdQCqLt2x77DGu7q1xMlWoef-k-TEPZBF5pQqXfuE0MgtrKLW83fxB9OMP28sVIwo8UZAjc5CFpNk1pybXXrKUqnoUk4Gg__&Key-Pair-Id=K6UGZS9ZTDSZM
fa6674ff90a08431d1fd0e06d3416f62
PDF Text
Text
A Curricular Strategy for Training in Opioid Prescribing and Opioid Use Disorder
TAP TO GO BACK
TO KIOSK MENU
Stephanie B. Jones, MD, Jaime Levash, Christopher F. Rowley, MD, M. Moris Aner, MD
Introduction/Problem
• Massachusetts ranks among the top ten states with the highest rates of drug overdose deaths involving
opioids (Fig 1).
• Overprescribing of opioid medications may lead to misuse by the patient or diversion to others.
• Education on appropriate prescribing has been shown to reduce the quantity of opioids prescribed
without increasing the rate of patient refill requests in the postoperative period.
• Treatment of opioid use disorder (OUD) is subject to provider bias, lack of resources, and substantial
relapse risk.
• Medication assisted therapy is evidence-based, but remains underutilized.
• The BIDMC Opioid Care Committee (OCC) is charged with integrating existing resources and creating
new strategies to address the continuum of opioid use and abuse.
• This includes primary prevention via patient and provider education on opioid prescribing and use,
opioid alternatives, and treatment of OUD.
Figure 1
Data Brief: Opioid-Related Overdose Deaths among Massachusetts Residents, Massachusetts Department of Public Health, November 2018
Aim/Goal
The OCC will create, curate, and distribute a series of education modules for providers that can be
customized by specialty, acute vs chronic pain management, provider type (trainee, attending, NP/PA)
and location (BIDMC, community affiliates and clinics).
The Team
Stephanie B Jones, MD, Chair, Opioid Care Committee; Vice Chair for Education, Department of
Anesthesia, Critical Care and Pain Medicine
Christopher F Rowley, MD, Department of Medicine, Division of Infectious Diseases
Jaime Levash, Senior Project Manager, Silverman Institute for Health Care Quality and Safety
M. Moris Aner, MD, Department of Anesthesia, Critical Care and Pain Medicine, Division of Pain
Medicine
The Interventions
• Two content experts recruited from OCC assessed program director (PD) interest in creating a
centralized curriculum.
• Overall, PDs agreed with need, however expressed reservations about adding further required web
modules without meaningful learning.
• Survey emailed to all PDs (Table):
• Do Accreditation Council for Graduate Medical Education (ACGME) program requirements include
OUD and/or opioid prescribing?
• Does current relevant training exists?
• If so, which teaching formats were utilized?
• Small-group brainstorming yielded consensus on a hybrid approach
• 2 web-based training modules by Boston University School of Medicine (www.scopeofpain.org and
www.opioidprescribing.org) which cover:
o Safe prescribing methods, assessing pain and prescription opioid misuse risk, how to educate
patients, identifying opioid-taking behaviors, understand safe taper methods, and identify and
manage patients with an opioid use disorder
• Create a bank of case stems to assess knowledge, identify gaps, and facilitate small group
discussions.
• Programs will select a set of relevant cases for use.
For more information, contact:
Jaime Levash, Senior Project Manager, 617-975-9732, jlevash@bidmc.harvard.edu
�A Curricular Strategy for Training in Opioid Prescribing and Opioid Use Disorder
Stephanie B. Jones, MD, Jaime Levash, Christopher F. Rowley, MD, M. Moris Aner, MD
Results/Progress to Date
Table: Program Director survey on existing opioid training
14 out of 55 programs responded
ACGME program
Formats utilized for
Training program
requirements
opioid education
Grand rounds
Anesthesiology
No
Small group
Cardiac Electrophysiology
No
None
Endocrinology
No
None
Hematology Oncology
No
• “Champions” representing a cross-section of specialties meeting to produce case stem bank.
• Curriculum will be initiated for the 2019-20 academic year.
• PDs and trainees will be surveyed:
• satisfaction with approach
• improved knowledge regarding opioid prescribing, OUD recognition and treatment
• Improved comfort with opioid prescribing, OUD recognition and treatment
Small group
Internal Medicine
No
Small group
Clinical rounds
Grand rounds
Interventional Radiology
No
None
No
Yes
Scheduling of PD meetings for review of education plan and case stem writing was challenging and delayed roll out.
Important to identify interested and available champions (not necessarily PDs).
Feasibility is important. Combined use of existing resources and customization rather than reinventing the wheel.
Time must be dedicated outside of committee meetings to create case stems. Examples were key to getting process
started.
Small group
Grand rounds
Small group
Grand rounds
Lessons Learned
OB/GYN
Pain Medicine
Pathology
No
Next Steps
•
None
Reproductive
Endocrinology/Infertility
No
Grand rounds
Rheumatology
No
Grand Rounds
Surgery
No
Grand Rounds
Small group
Surgical Critical Care
No
Grand Rounds
No
MA BORM online CME
Grand rounds
•
•
•
•
The long term goal of the OCC is to improve prescribing patterns in pain treatment (fewer opioids, more multimodal
therapies) without sacrificing patient satisfaction, and increasing recognition of and access to treatment of OUD.
Consistent education of our front-line prescribers is the first step, fully integrated into program curricula.
Development of an opioid prescribing dashboard is in progress to provide practice-level feedback to trainees.
Plan to expand curriculum to advanced practice providers (APPs) at BIDMC and community affiliates.
Make OUD training available on a regular basis so patients throughout the medical center can readily obtain
counseling and treatment.
Vascular Neurology
For more information, contact:
Jaime Levash, Senior Project Manager, 617-975-9732, jlevash@bidmc.harvard.edu
�
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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.
Jaime Levash (<a href="mailto:jlevash@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">jlevash@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Opioid Care Committee
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Stephanie B. Jones
Jaime Levash
Christopher F. Rowley
M. Moris Aner
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 Curricular Strategy for Training in Opioid Prescribing and Opioid Use Disorder
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
Effectiveness
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/716e81728ca1fb8daadf680cef484719.pdf?Expires=1712793600&Signature=Xvwvu3ZRaW45ekGSeJ5qHEW1RZvDnEDwUNlfUOpL8iDURSr4-qALfgMCUP5Pr41J15EIysBziHrt6g8A2%7E7qAp%7EOr5Bit0MmC0rklbLUS2XLN3h6SscHSPf3R3gmOOlcStqhDpZenv1kzmgbL1AAUsIbMWck4tmyVUBSZ2WCDKWdialgkGbW6goOYPMYVY4g9vWjAnfIFa17bmP3G78Vre4yWzPO2BOVbBynzeHvly12o129ZpqUkYbIBRk0HnSKM--bA6za3KHVd7MmnIi0OaC2Q8kOwRK3SSbCL0SUxtC%7EMZ8sMTMePpR04AQ6sZV7Vejc1ypCVIQIqhD-%7EIqsUQ__&Key-Pair-Id=K6UGZS9ZTDSZM
7986d49832c86d23f40b8bc6740ee370
PDF Text
Text
A Human Factors Approach to Electronic Medication Reconciliation
David Feinbloom, MD
Silverman Institute for Health Care Quality and Safety
Beth Israel Deaconess Medical Center, Boston MA
Background
44.The completed PAML can be imported into all clinical documentation.
. The completed PAML can be imported into all clinical documentation.
4
Implementation of effective medication reconciliation processes has proven
Implementation of effective medication reconciliation processes has proven
difficult due to incomplete admission medication information, lack of
difficult due to incomplete admission medication information, lack of
standardized processes, and paper-based systems which limit the ability to
standardized processes, and paper-based systems which limit the ability to
access, manage, and compare medication information. Some electronic health
access, manage, and compare medication information. Some electronic health
records (EHRs) provide electronic medication reconciliation functionality, but
records (EHRs) provide electronic medication reconciliation functionality, but
often suffer from poor design and lack of integration with the inpatient
often suffer from poor design and lack of integration with the inpatient
computerized physician order entry (CPOE)
computerized physician order entry (CPOE)
77.As each medication is reconciled, the computer identifies any that are
. As each medication is reconciled, the computer identifies any that are
new or discontinued, as well as any changes in the dose, route, or
new or discontinued, as well as any changes in the dose, route, or
frequency of medications that are being continued. Each decision is
frequency of medications that are being continued. Each decision is
automatically recorded, and the provider can edit and add additional text to
automatically recorded, and the provider can edit and add additional text to
these computer generated descriptions as needed. Because every
these computer generated descriptions as needed. Because every
medication must be reconciled, the system assures that there are no errors
medication must be reconciled, the system assures that there are no errors
of omission or commission, and that every decision is clear to the patient
of omission or commission, and that every decision is clear to the patient
and the next provider
and the next provider
7
BIDMC is aa631 bed academic medical center with aamature, homegrown EHR
BIDMC is 631 bed academic medical center with mature, homegrown EHR
and CPOE system built using the Cache programming language with aaweb
and CPOE system built using the Cache programming language with web
based interface for clinical use. We sought to design an electronic medication
based interface for clinical use. We sought to design an electronic medication
reconciliation (eMR) application using our existing EHR/CPOE architecture.
reconciliation (eMR) application using our existing EHR/CPOE architecture.
Methods
55.At the time of discharge, the PAML and the existing active CPOE orders are
. At the time of discharge, the PAML and the existing active CPOE orders are
To facilitate the design and programming of the eMR application, we
To facilitate the design and programming of the eMR application, we
assembled aamultidisciplinary team of doctors, nurses, pharmacists, and
assembled multidisciplinary team of doctors, nurses, pharmacists, and
programmers. The design principles were that the application allow the user to
programmers. The design principles were that the application allow the user to
import, assemble, reconcile, order, and document the PAML using aasingle,
import, assemble, reconcile, order, and document the PAML using single,
intuitive interface.
intuitive interface.
assembled in aamatrix sorted by medication. This allows for direct comparison
assembled in matrix sorted by medication. This allows for direct comparison
of each medication without referring to an external data source (e.g. admission
of each medication without referring to an external data source (e.g. admission
note, other applications).
note, other applications).
5
88.On discharge, the patient receives aareconciled medication list; the list
. On discharge, the patient receives reconciled medication list; the list
is stored electronically in the EHR, and sent via aaHealth Information
is stored electronically in the EHR, and sent via Health Information
Exchange to the next provider.
Exchange to the next provider.
8
Description of Innovation
1. On admission, the eMR application assembles the patient’s medications from
1. On admission, the eMR application assembles the patient’s medications from
electronic sources (ambulatory EHR, prior discharge medication list), and by
electronic sources (ambulatory EHR, prior discharge medication list), and by
manual entry, to create an electronic preadmission medication list (PAML).
manual entry, to create an electronic preadmission medication list (PAML).
2. The user then records planned actions (continue, discontinue, continue at
2. The user then records planned actions (continue, discontinue, continue at
different dose/frequency/route), and documents the accuracy of the PAML . .
different dose/frequency/route), and documents the accuracy of the PAML
3. The user can then edit and bring preadmission medications into the active
3. The user can then edit and bring preadmission medications into the active
inpatient CPOE system without manually re-entering the order.
inpatient CPOE system without manually re-entering the order.
6. The user builds aadischarge medication list by choosing from the PAML or
6. The user builds discharge medication list by choosing from the PAML or
the active POE medications, editing and adding medication as needed.
the active POE medications, editing and adding medication as needed.
6
Conclusions
The implementation of eMR is aacomplex process which often fails due to
The implementation of eMR is complex process which often fails due to
poor design. We have developed an easy to use eMR application which
poor design. We have developed an easy to use eMR application which
seamlessly integrates into existing workflow, and provides robust
seamlessly integrates into existing workflow, and provides robust
discharge reconciliation functionality which merges disparate data sources.
discharge reconciliation functionality which merges disparate data sources.
�
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.
David Feinbloom (<a href="mailto:dfeinbloom@bidmc.harvard.edu">dfeinbloom@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Health Care Quality
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
A multidisciplinary team of doctors, nurses, pharmacists, and programmers.
Dublin Core
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Title
A name given to the resource
A Human Factors Approach to Electronic Medication Reconciliation
Date
A point or period of time associated with an event in the lifecycle of the resource
2011
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/f61080512c11c53a982bf330d8e021d0.pdf?Expires=1712793600&Signature=ey5SldjJWPI16apxXWInSked--5v4lXkHNC3cal6K7N%7EbsA--dYwNEo4NKDRjumK%7ExhSVlL7w5XUxRKw6y69Xaxm-DMwKJ5XL-Q3Z%7E%7EhVce58C7XuJifQ7Kh7I16jhHeMd35d8nuKZr1zSQtbps0y2mAx887GShRESVuHRAtY1jD5MyLH7sip%7EOiWgVXWgu4zAwlESrIh-NKh3Vnzmbr-z1G9POcJh7ZWbL2MqrUf9HJSX3IJkYYQ%7Eq5le444ju9uuy2UvGZCSgBeL9FEFaAT8I%7EJXVFdMlssN944GoMfKSrfs5ZmxBRsrkSmDhqz8VuNrZLVod4DcdpeyZci5SrXg__&Key-Pair-Id=K6UGZS9ZTDSZM
b876366c3527b75ed0c24056a8a9d812
PDF Text
Text
A Lean Story: Improving Pre-Analytic Lab Workflow
for Bone Marrow Specimens at BIDMC
Yigu Chen, MPH, CSSBB; Stefanie Mattson, MLS(ASCP); Brenda O’Brien, MT(ASCP); Cheryl Demeo, MHA, MT(ASCP); Parul Bhargava, MD; Gina McCormack, MS, MT(ASCP).
Introduction
Bone Marrow aspirates and core biopsy specimens are used
to diagnose and monitor blood and marrow diseases,
including some cancers. Hematopathology, Flow Cytometry,
Cytogenetics, and Molecular tests can be carried out on
Bone Marrow specimens. These tests play a critical role in
assisting physicians with making the most accurate
diagnosis.
The Hematology Lab is the central hub to coordinate and
process Bone Marrow specimens collected from BIDMC
and its network hospitals. However, preparation and
coordination of Bone Marrow specimen is not an easy task.
It takes 30-40 minutes on average for our well-trained
technologists to complete registration and preparation for
one Bone Marrow specimen. Without an interface to
different Lab Information Systems, the efficiency of
specimen handling is gravely impeded by duplicate
specimen registrations, handwritten documentations, and
manual entries. In addition, a suboptimal workflow makes
things worse. It not only causes enormous waste in the lab,
but also can expose us to severe consequences such as
turnaround time delay, labeling errors, or even specimen
loss.
Goal
We are determined to apply the Lean concept to identify
and reduce waste, streamline and standardize the preanalytic workflow for all Bone Marrow specimens.
Progress to Date
Process map – current workflow
Spaghetti map – current workflow
Lessons Learned
Spaghetti map – proposed changes
Methods
Gemba Walk – shadowed , observed and interviewed the
frontline technologists; collected baseline cycle time of
processing Bone Marrow specimen.
Process Mapping – Created a flowchart to identify and
visually represent all possible steps in the process.
Spaghetti Diagram – Used flow lines to indicate the
movement in the lab.
Brainstorming – Identified bottlenecks in the process, and
generate creative short-term or long-term solutions to
mitigate the problems.
SOPs may not reflect what is actually happening in the workflow. Real life
observation is crucial to conducting a successful baseline assessment.
(“Go to the Gemba”)
Due to the lack of systematic workflow design, inefficiencies can still exist
even in a best case scenario handled by our most well-organized
technologists.
Small, rapid, continuous improvement ideas are particularly important
when infrastructure related changes are not achievable in the short-term.
Next Steps
Handwritten labels and documents
Relocate Bone Marrow workbench to create a centralized work area and
reduce unnecessary movement in the lab.
Program an electronic spreadsheet to document Bone Marrow case
information, generate send out requisitions and QA worksheets
automatically using pre-built templates.
Replace cover slips with glass slides. Labeling accuracy will be improved
since labels produced by slide label printer can be applied on glass slides.
This will also improve slide staining efficiency since glass slides are
compatible with automated slide stainers.
For more information, contact:
Yigu Chen, MPH; ychen17@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.
Yigu Chen <a href="(ychen17@bidmc.harvard.edu)">(ychen17@bidmc.harvard.edu)</a>
Department
Any departments listed on the poster or identified in the spreadsheet.
Pathology
Location or Affiliate
BIDMC
Project Team
Yigu Chen
Stefanie Mattson
Brenda O’Brien
Cheryl Demeo
Parul Bhargava
Gina McCormack
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Dublin Core
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Title
A name given to the resource
A Lean Story: Improving Pre-Analytic Lab Workflow for Bone Marrow Specimens at BIDMC
Date
A point or period of time associated with an event in the lifecycle of the resource
2017
Format
The file format, physical medium, or dimensions of the resource
pdf
Efficiency
Timeliness
-
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8805358dc26e4ac96f133eb4f8da7cb4
PDF Text
Text
A Model for Quality Improvement and Patient Safety
Programs in Academic Departments of Medicine
The Problem
Academic departments of medicine care for large populations of often
underserved patients, conduct research designed to improve medical care,
and educate the next generation of physicians. As part of delivering patient
care, they must assure that the care they provide is of the highest possible
quality. To do this well, they must determine which approaches to care are
most effective, and disseminate these practices within the department.
Aim/Goal
To successfully design and implement a comprehensive QI/PS program for
the BIDMC Department of Medicine that engages front line clinicians and
may serve as a blueprint for other Departments of Medicine.
The Medicine QI/PS Program
Patient Care Committee
Peer Review
Medical Peer Review Committee
Setting clinical priorities;
Mortality and Morbidity Rounds
Oversight and coordination
QI Directors
of the multiple disciplines;
Medical Executive Committee
Selection of QI/PS initiatives,
PCAC Sub-Committee
Including identification of resources
Division-Based Dashboards
and Divisional QI Projects
Multidisciplinary
Working Groups
Waiting Times for Appointments;
Heart Failure Committee;
Medical Record Documentation;
Diabetes Working Group;
Service Quality and Patient Satisfaction;
Anticoagulation Working Group;
BIDMC Medicine
Clinical Management and Outcomes;
Central Venous Catheter Infections
QI/PS Program
Colonoscopy Withdrawal Time;
Ventilator-Associated Pneumonia
Follow Up on Screening Tests Results;
The Team
Mark D. Aronson, MD, Medicine, Vice Chair for Quality
Naama Neeman, MSc, Medicine, QI Specialist
Alexander Carbo, MD, Hospitalist
Anjala V. Tess, MD, Hospitalist
Julius J. Yang, MD PhD, Hospitalist
Patricia Folcarelli, Director, Professional Development /Nursing
Kenneth F. Sands, MD, Senior Vice President for Health Care Quality
Mark L. Zeidel, MD, Chair, Department of Medicine
The Interventions
Incorporation of quality into departmental operating plan by Chair of
Medicine; establishment of Vice Chair of Quality with designated QI
administrators; engagement of clinicians from all divisions to serve as local
QI leaders; an inter-departmental collaboration with the Hospital’s
Departments of Health Care Quality, Nursing, Pharmacy, and Information
Technology; integration of QI/PS into the teaching programs.
The Triggers Program
Documentation of Allergies;
Geographic re-Configuration
Epinephrine for Anaphylaxis;
Multiple Urgent Sepsis Therapies
Procedural Notes for Injections;
Drug Dosing and Administration Polices
PPD for Patients Receiving Infliximab
Educational Programs
Procedure Service;
Stoneman Elective;
Partners in Quality;
ABIM Practice Improvement Module;
Education Innovation Project
Lessons Learned
Our experience suggests that key ingredients for a successful Medicine
QI/PS program include: direct involvement of leadership; appointment of QI
administrators; engagement of clinicians from all disciplines to serve as “QI
champions”; an effective approach to dealing with resistance to change;
alignment with hospital administration; and an inter-departmental
collaboration.
Next Steps:
Broaden focus to outpatient care, particularly with follow up of abnormal test
results and verification of referrals for tests and consultations.
For More Information Contact
Naama Neeman, MSc
Medicine QI Specialist
(nneeman@bidmc.harvard.edu)
�
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Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Patricia Folcarelli (<a href="mailto:pfolcare@bidmc.harvard.edu">pfolcare@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Health Care Quality
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Mark D. Aronson<br />Naama Neeman<br />Alexander Carbo<br />Anjala V. Tess<br />Julius J. Yang<br />Patricia Folcarelli<br />Kenneth F. Sands<br />Mark L. Zeidel
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 Model for Quality Improvement and Patient Safety
Programs in Academic Departments of Medicine
Date
A point or period of time associated with an event in the lifecycle of the resource
2008
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Safety
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e001ed3b54a26396845653387ee2fb79
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Text
A Monitoring Tool for Detecting Harm: Global Triggers
The Problem
The Results/Progress to Date
Traditional methods of identifying adverse events (such as incident reporting)
may not be comprehensive enough to capture all adverse events. The IHI
(Institute for Healthcare Improvement) Global Trigger Tool provides a way to
measure and monitor the overall level of harm within a hospital from the
perspective of the patient. BIDMC began using this process in March 2008.
Aim/Goal
The Global Trigger Tool provides a mechanism to identify sources of harm
so that performance improvement interventions may be developed to
prevent these events in the future.
The Team
Bonnie Austin RN – Quality & Safety Data Abstractor
Alex Carbo MD - Hospitalist
Mary Fay RN – Patient Safety Coordinator
Cheryle Totte RN – Patient Safety Coordinator
Mary Ward RN – Patient Safety Coordinator
Dotted red line represent the average percentage for hospitals as they begin to use the
Trigger Tool . Blue bars represent BIDMC findings .
Lessons Learned
Results from a pre-Global Triggers chart review (2006) were not
significantly different from current chart review findings. Levels of harm at
BIDMC are below the IHI benchmark.
Trends of vulnerability that have emerged (delirium, UTI, SSI) are
consistent with issues previously identified and support process
improvement interventions already underway.
The Interventions
The Trigger Tool is applied in a retrospective review of 20 records per month.
10 patient records from the total population of discharged
patients are randomly selected every 2 weeks.
A team of 2 RN’s review each record for triggers
(i.e. elevated INR, readmit within 30 days, glucose < 50 mg/dl)
If a trigger is found there is a focused review to determine if
harm is associated with the event
If harm has occurred there is a scale of severity assigned to
each event
Findings are reviewed each month with physician leader
Cases noted to have a higher level of harm are reported to the
QI Director of the department involved
Next Steps/What Should Happen Next
Continue to utilize the IHI Global Triggers Tool to monitor areas of vulnerability
previously identified and to identify additional issues that may contribute to
patient harm.
For More Information Contact
Mary Fay, RN Patient Safety Coordinator
mfay@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 Fay (<a href="mailto:mfay@bidmc.harvard.edu">mfay@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Health Care Quality
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Bonnie Austin
Alex Carbo
Mary Fay
Cheryle Totte
Mary Ward
Dublin Core
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Title
A name given to the resource
A Monitoring Tool for Detecting Harm: Global Triggers (2010)
Date
A point or period of time associated with an event in the lifecycle of the resource
2010
Format
The file format, physical medium, or dimensions of the resource
pdf
Patient and Family-Centeredness
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/476aee4be8db4e0e200f55d53978c916.pdf?Expires=1712793600&Signature=m6OhaRr4GuHeYTBKCahxlNdldlG-ItAYieLiOaiWiYmbcTiObN4RQBeEvq5-5GN0IWQhnZSAx6vZysYcxij%7E1BC%7EpeuDhV1JBbdmjCRGiC8JsSkBhJ6Rv29p%7Ee5Qf0G5Olru3R18RcnWGa9y8xWIDj%7EAMH0xNZQXBgpLMXDdiaEVajjkoVsYOVnGraS-Ctrf2wEicTriTx7bOpL0jK7ULOzb6Dg6Zu1olHU7EhMXfTkoDfVAYIJbTbdHFtKFyzBigGnonVpWF5RGX88iJLhddBhChMJh-haqVfOQlXz1j%7EaoFrkbQfsC-2MzB6SRpmuu1BChPR-tfRlWbpOzAK7P%7EA__&Key-Pair-Id=K6UGZS9ZTDSZM
0301c25dd02232d2e7e21b5fc77ba514
PDF Text
Text
A Monitoring Tool for Detecting Harm: Global Triggers
The Problem
The Results/Progress to Date
Percent of Admitted Patients Experiencing an Adverse Event
(2006, 2008-2010)
Percent of Admitted Patients Experiencing an
Adverse Event
Traditional methods of identifying adverse events (such as incident reporting)
may not be comprehensive enough to capture all adverse events. The IHI
(Institute for Healthcare Improvement) Global Trigger Tool provides a way to
measure and monitor the overall level of harm within a hospital from the
perspective of the patient. BIDMC began using this process in March 2008.
Aim/Goal
The Global Trigger Tool provides a mechanism to identify sources of harm so
that performance improvement interventions may be developed to prevent
these events in the future.
The Team
Bonnie Austin RN – Quality & Safety Data Abstractor
Alex Carbo MD - Hospitalist
Mary Fay RN – Patient Safety Coordinator
Cheryle Totte RN – Patient Safety Coordinator
Mary Ward RN – Patient Safety Coordinator
Carolyn Wheaton RN – Patient Safety Coordinator
The Trigger Tool is applied to retrospective review of 20 records per month.
10 patient records from the total population of discharged
patients are randomly selected every 2 weeks.
A team of 2 RN’s review each record for triggers
(i.e. elevated INR, readmit within 30 days, glucose < 50 mg/dl)
If a trigger is found, a focused review is conducted to determine
if harm is associated with the event
If harm has occurred, there is a scale of severity assigned to
each event
Findings are reviewed each month with physician leader
Cases noted to have a higher level of harm are reported to the
QI Director of the department involved
20
15
10
5
0
2006
FY09
Q1
FY09 FY09 FY09 FY10
Q2
Q3
Q4
Q1
Percent of admits with AE
FY10 FY 10 FY 10
Q2
Q3
Q4
Linear (Percent of admits with AE)
Lessons Learned
The Interventions
25
Harm events have decreased compared to results from a pre-Global
Trigger chart review (2006). Levels of harm at BIDMC are below the IHI
National Average benchmark of 35%.
Next Steps/What Should Happen Next
Continue to utilize the IHI Global Trigger Tool to monitor for areas of
vulnerability and to identify issues that may contribute to patient harm.
For More Information Contact
Mary Fay, RN Patient Safety Coordinator
mfay@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.
Mary Fay (<a href="mailto:mfay@bidmc.harvard.edu">mfay@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
HCQ, Patient Safety
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Bonnie Austin
Alex Carbo
Mary Fay
Cheryle Totte
Mary Ward
Carolyn Wheaton
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Title
A name given to the resource
A Monitoring Tool for Detecting Harm: Global Triggers (2011)
Date
A point or period of time associated with an event in the lifecycle of the resource
2011
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Safety
-
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e970ef42bfc369bba3b881d82ab47331
PDF Text
Text
A Monitoring Tool for Detecting Harm: Global Triggers
The Problem
The Results/Progress to Date
Traditional methods of identifying adverse events (such as incident reporting)
may not be comprehensive enough to capture all adverse events. The IHI
(Institute for Healthcare Improvement) Global Trigger Tool provides a way
to measure and monitor the overall level of harm within a hospital from the
perspective of the patient. BIDMC began using this process in March 2008.
25
Aim/Goal
15
20
Percent
5
The Team
The Interventions
The Trigger Tool is applied to retrospective review of 20 records per month.
10 patient records from the total population of discharged
patients are randomly selected every 2 weeks.
A team of 2 RN’s review each record for triggers
(i.e. elevated INR, readmit within 30 days, glucose < 50 mg/dl)
If a trigger is found, a focused review is conducted to determine
if harm is associated with the event
If harm has occurred, there is a scale of severity assigned to
each event
Findings are reviewed each month with physician leader
Cases noted to have a higher level of harm are reported to the
QI Director of the department involved
6
Q
FY
1
09
FY Q2
09
Q
3
FY
09
Q
4
FY
10
FY Q1
10
FY Q2
10
FY Q 3
10
FY Q 4
11
FY Q 1
11
FY Q 2
11
Q
3
0
Alex Carbo MD – Hospitalist
Mary Fay RN – Patient Safety Coordinator
Stacey Lunetta RN – Patient Safety Coordinator
Christine Saba RN– Patient Safety Coordinator
Cheryle Totte RN – Patient Safety Coordinator
Carolyn Wheaton RN – Patient Safety Coordinator
20
0
10
FY
09
The Global Trigger Tool provides a mechanism to identify sources of harm
so that performance improvement interventions may be developed to prevent
these events in the future.
Percent of Admissions Incuring an Adverse Event
Percent of admits with AE
Linear Trend Line (% of Admissions incuring an Adverse Event)
Lessons Learned
Ongoing surveillance using the Global Trigger Tool demonstrates efforts
to decrease preventable harm have been sustained at less than 15% for
the last 7 Quarters.
Harm events have decreased compared to results from a pre-Global
Trigger chart review (2006). Levels of harm at BIDMC remain well below
the IHI National Average benchmark of 35%.
Next Steps/What Should Happen Next
Continue to utilize the IHI Global Trigger Tool to monitor for areas of
vulnerability and to identify issues that may contribute to patient harm.
For More Information Contact
Mary Fay, RN Patient Safety Coordinator
mfay@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.
Mary Fay
Department
Any departments listed on the poster or identified in the spreadsheet.
Health Care Quality and Safety
Patient Safety
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Alex Carbo
Mary Fay
Stacey Lunetta
Christine Saba
Cheryle Totte
Carolyn Wheaton
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 Monitoring Tool for Detecting Harm: Global Triggers (2012)
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
Format
The file format, physical medium, or dimensions of the resource
pdf
Safety
-
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9b301ddfb065547fa1393e709dcba107
PDF Text
Text
A Motion-less Blood Bank
The Problem
Excess human movement is one of the 8 wastes of LEAN.
The Results/Progress to Date
The layout of the East Campus Blood Bank impeded workflow adding excessive
human steps and double-backs for medical technologists in the preparation and issue
of blood products.
Aim/Goal
Our goal is to streamline the layout of the blood bank, by removing obstacles and
decreasing the number of steps required to prepare and issue blood components.
The Team
Blood Bank Team - Medical Technologists, Leads and Manager
Business Transformation- Alice Lee, Vice President, Business Transformation
Facilities management- Doug Barletta, Senior Project Manager, Facilities
Total length 156ft
Total length 61ft
The Interventions
39% decrease in walking length
The opportunity to implement a LEAN project in the blood bank arose due to a broken
sink. The affected plumbing was under a counter that was a known obstacle in our
daily workflow.
Blood bank requested a GEMBA walk from the Business Transformation
team. They agreed with the inefficiencies of our workflow. An increase in the
scope of the project was then approved and budgeted.
A team effort was undertaken on all shifts to map out potential solutions by
using sticky notes for equipment placement and suggesting different
workflow patterns. Ultimately a mutually agreeable proposal was conceived.
Blue prints were drawn and work proceeded in stages, minimizing disruption
to patient care.
Lessons Learned
Including staff from all roles and shifts is critical when reconfiguring a
shared space.
Planning the staging of construction project in a busy 24/7 location is
critical.
The timeframe for involvement from IS, telecommunication and other
non-project staff needs to be carefully mapped out.
Once construction started some adaptations to the plan were made,
but the final result was very close to our original plan and on budget.
Staff report increased satisfaction with the layout.
For more information, contact:
Pamela Doty, Blood Bank Medical Technologist
pdoty@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.
Pamela Doty (<a href="mailto:pdot@bidmc.harvard.edu">pdot@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Blood Bank
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Blood Bank Team
Alice Lee
Doug Barletta
Dublin Core
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Title
A name given to the resource
A Motion-less Blood Bank
Date
A point or period of time associated with an event in the lifecycle of the resource
2014
Format
The file format, physical medium, or dimensions of the resource
pdf
Efficiency
-
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30fd7dd6f7c953f561a003f9a3b00d46
PDF Text
Text
A Multidisciplinary Approach to Improve Anticoagulation Safety:
Improving Patient Re-engagement and Adherence to their Anticoagulation Care Plan
The Problem
BIDMC Anticoagulation Management Service (ACMS) is composed of nurses and a
pharmacist who manage about 700 patients referred by Healthcare Associates (HCA)
physcians.
Patients prescribed warfarin (Coumadin) who do not adhere to their care
plan are at significant risk for serious health complications.
Aim/Goal
Prevent warfarin-related clinical complications arising as a result of nonadherence or engagement in recommended treatment protocol.
Re-engage patients in their anticoagulation care plan.
Collaborate with physicians to optimize patient outreach efforts.
Systematically identify and address potential adherence barriers.
Patients at least one week overdue for an INR test are identified through an
electronic patient registry.
Reminder telephone calls and letters are generated from the Clinic.
Continued non-adherence prompts contact with physicians to encourage both
patient outreach and assessment of common potential adherence barriers.
Appointments involving the physician, Coumadin Clinic, and patient are
recommended to formulate patient-specific plans to improve adherence.
Patients are discharged from the Clinic after 12 consecutive weeks of nonadherence and referred back to the MD who prescribes warfarin for their future
warfarin management. These patients may be re-enrolled if they demonstrate
three months of improved anticoagulation adherence with the physician.
The Results/Progress to Date
The Team
Diane M. Brockmeyer, MD, Medical Director, ACMS
Jennifer E. Mackey, PharmD, ACMS
Scot B. Sternberg, MS, Administrative Director of Quality Improvement, Medicine
Special Acknowledgement to the Anticoagulation Management Service team members: Patricia
Glennon-Colby, RN; Lisa Jachowicz, LPN; Marie Mahony, RN; Colleen Monbleau, RN; Kathleen
O’Rourke; and Carolyn Wheaton, RN
The Interventions
499 outreach efforts were made following the protocol.
On 54 occasions, patients had an overdue INR of 4 weeks, or more, resulting
in ACMS contacting the prescribing MD. Physician outreach efforts, including
subsequent telephone calls, letters, emails, social work referrals, and/or
scheduled clinic visits, were documented in patients’ medical records.
Most common factors identified as preventing INR adherence were: patient
ambivalence over anticoagulation need, perceived lack of vulnerability for clot
development, transportation, significant life events, and mental health.
The percentage of Clinic patients in therapeutic INR range compares favorable to
the national benchmark average of 64% (see Figure below).
No adverse events were reported with these patients.
Lessons Learned
A standardized multidisciplinary process for addressing non-adherence to INR draw
recommendations is effective in re-engaging patients.
Primary care physicians are willing to partner with ACMS in working together to
improve patient engagement.
Successful anticoagulation requires ongoing patient education.
Re-engagement processes require continued refining to decrease episodes of
recurrent non-adherence.
Next Steps
A patient re-engagement protocol was created to standardize outreach efforts to
non-adherent patients.
Continue to monitor and refine protocol
Implement and incorporate patient experience survey data to refine protocol
For more information, contact:
Jennifer E. Mackey, PharmD: jemackey@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.
Jennifer E. Mackey (<a href="mailto:jemackey@bidmc.harvard.edu">jemackey@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Medicine
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Diane M. Brockmeyer
Jennifer E. Mackey
Scot B. Sternberg
Glennon-Colby
Lisa Jachowicz
Marie Mahony
Colleen Monbleau
Kathleen O’Rourke
Carolyn Wheaton
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 Multidisciplinary Approach to Improve Anticoagulation Safety: Improving Patient Re-engagement and Adherence to their Anticoagulation Care Plan
Date
A point or period of time associated with an event in the lifecycle of the resource
2013
Format
The file format, physical medium, or dimensions of the resource
pdf
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/b51a0590a5a9ba1c0c1c835e6879ad94.pdf?Expires=1712793600&Signature=SVZoUCPWkvVs%7ESR422QuXKZjDG9wbm0jUcbVFa345sjF3zCmutRS3E8dpUdcKcti-xzz31%7Eaw%7EJ7wuVowQAyZu7lAMYmz2ONCrG7zTNucNGsVCKKZZv0oIkf33NuuWjaTu4eFT3w6YpG8xIn5Adqmk7LPjGjP7pU4q9dpKD-oPupLu7bwIOeOrhDkzgJJAW70KVC0LHleZLKKL%7EmdzFKQ9jfSCMCmGJjjOTVwNZbiM66iMBWk4KVzDCvkSjMeXluYc-1PCPFn7M3FlWJtGXy7bgUDAGQX3ya0siQp17B0p2URDC3nC-hbockrse5w6p%7Ev5%7EArtjQAzvPrn-Ilr6jcg__&Key-Pair-Id=K6UGZS9ZTDSZM
e9b1739b336bd5d7586692899158cb0d
PDF Text
Text
A Multidisciplinary Approach: Improving the Care of
Patients with Spinal Cord Injury and their Families
The Problem
The Interventions
Patients with spinal cord injury (SCI) make up only a very small percentage of the
Met bi-weekly for multidisciplinary discussion.
overall patient population, and as a result, maintaining an updated set of
treatment guidelines for this unique patient population has been overlooked.
A spinal cord injury is an unexpected, emotionally and physically traumatic, life
altering occurrence. There is currently no prepared informational material in
place at BIDMC to educate and support patients and their families in this
challenging time.
Ideally, patients with spinal cord injury are transferred to a rehabilitation facility
after receiving acute management at BIDMC. As a result, the hospital only goes
so far as to prepare patients for discharge to a rehab facility, where they will
gradually prepare for their transition home. However, a number of patients with
spinal cord injury are uninsured and consequently have no option other than to
go directly home after their hospital stay. There is no standardized system in
place at BIDMC to provide these particular patients with basic resources to assist
them with this difficult transition from hospital to home.
The Results/Progress to Date
Aim/Goal
The goal of this project has been to create a functional, multidisciplinary SCI
pathway that smoothly transitions the patient from trauma bay → ICU → floor →
extended care/home. Due to the wide variation between individual cases, the
team aimed to create a pathway that is standardized, while also allowing for the
flexibility to be appropriately modified for each individual patient.
The team also decided to design educational Spinal Cord Injury packets that will
provide patients and their families with an overview of SCI. This packet will
educate them about what to expect during their hospital stay and the physical
and emotional aspects of their condition and recovery.
The team aims to begin implementation of this project by the end of 2015.
The Team
Trauma Program Staff: Darlene Sweet, BSN, RN, Trauma Program Director;
Melissa Voisine, BSN RN, Trauma Educator/Injury Prevention and Outreach
Coordinator; Diana Johnson, Trauma Administrative Coordinator
CC6 and TSICU: Alison Small,MSN, RN, Nurse Manager CC6 and TSICU; Luci
Lima, MSN, RN, TSICU Unit based educator; Danielle Souza BSN RN, Clinical
Advisor CC6A; Kerri Cellucci Albert BSN RN, Unit Based Educator CC6A
Case Management: Christine Hunt, RN
Social Work: Mary McDonough, LICSW; Margot Cronin-Furman, LICSW
Rehab/Physical Therapy: Deb Adduci, PT, Inpatient Rehab Manager;
Shannon Carthas, PT, DPT, Physical Therapist; Katelyn Campbell, OTR/L
Occupational Therapist
Special thanks to: Jane Wandel, Program Director, Patient and Staff
Communication; Dr. Hauser, MD, ACS/ Trauma; Dr. White, MD, Orthopedic
Surgery; Dr. Stippler, MD, Neurosurgery; Lori DeCosta, Director, Nutrition;
Murray Corliss, CWOCN
Rewrote the clinical pathway by comparing past guidelines with current practices,
sample pathways from outside organizations and personal experience.
Created patient and family educational packets that provide resources that are
valuable for patients with spinal cord injury who will be transferred to rehab as
well as those who are discharged directly home.
Distributed four copies of the Christopher and Dana Reeve’s Foundation’s
Paralysis Resource Guide (two in English and two in Spanish) to the CC6 and
TISCU patient care areas for patients and families to utilize during their stay.
An eight-day clinical pathway has been created and is currently awaiting final
committee approval from BIDMC’s Trauma Care Committee.
Patient and family informational packets are currently a work in progress. Topics
will include: mobility, equipment, bowel and bladder, coping, skin care, nutrition,
recovery expectations, orientation to the multidisciplinary team, and an overview
of their stay at BIDMC. Packets will also include a glossary of relevant terms, a
resources page, a health care proxy form, and a welcome letter.
Lessons Learned
Creating a standard spinal cord injury pathway is a challenge given the variety of
causes and presentations that may exist across patients with spinal cord injury.
Discussion between disciplines allows for a more complete understanding of the
wide range of physical and emotional challenges that patients with spinal cord
injury face throughout the hospital stage of their recovery.
Educational materials collected and produced can be used in the hospital to
educate the interdisciplinary team on this relatively uncommon type of injury.
The effectiveness of an informational packet for patients and family is largely
dependent on both visual presentation and language geared towards nonmedical readers.
Next Steps/What Should Happen Next
Bring the clinical pathway to Trauma Care Committee for review and approval.
Complete Patient and Family Spinal Cord Injury Packets.
Discuss pursuing transfer agreements with rehabilitation centers for patients with
spinal cord injury.
Implement new guidelines and stock patient and family informational packets
immediately after receiving final approval.
Evaluate the effectiveness of all aspects of this project one year after roll out.
For more information, contact:
Darlene Sweet, BSN RN, Trauma Program Director
dsweet1@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.
Darlene Sweet (<a href="mailto:dsweet1@bidmc.harvard.edu">dsweet1@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Trauma Administration
Nursing
Rehabilitation
Social Work
Case Management
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Darlene Sweet
Melissa Voisine
Diana Johnson
Alison Small
Luci Lima
Danielle Souza
Kerri Cellucci Albert
Christine Hunt
Mary McDonough
Margot Cronin-Furman
Deb Adduci
Shannon Carthas
Katelyn Campbell
Jane Wandel
Dr. Hauser
Dr. White
Dr. Stippler
Lori DeCosta
Murray Corliss
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 Multidisciplinary Approach: Improving the Care of Patients with Spinal Cord Injury and Their Families
Date
A point or period of time associated with an event in the lifecycle of the resource
2015
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Patient and Family-Centeredness
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/b341465cf3f49098c617ceeb6441a657.pdf?Expires=1712793600&Signature=KPQuGXTZNXMktiE1AopKc1f-schw0K792mz4mmqUDbRW3xbjOs%7EFc1utzPfDT2zIMFBgD0IkNNdqJs28RHPqPREO0UfpBDSHcJlww-CCeidItzRa0-G-gK0QOko9vS7DnQjT-9hUncE8d2vsgvNt-W3MLbuBdiMoEHzxbaGDCRIYX4W0sjx8X6JXW1fXtKTSXE5dy3iy7-KXfvZ-1kHvU0vRirNbADT-GEDl13j7hMKczjL2Mfc1KeWQWjqcPimnlH%7ExgLrwa%7EHURm7qtUtMnUkYhUUrM%7EaQtI1grq6GufKatJGJIB6rloFq8R2sKOQLfU6-vDSqlfOPXy-7Soshng__&Key-Pair-Id=K6UGZS9ZTDSZM
bacb10695ca5931e150ab2d509d71c98
PDF Text
Text
A Multidisciplinary Effort to Improve
PAPR Availability and Maintenance
The Problem
PAPR Model Change
Emerging infectious diseases, such as Ebola and Middle Eastern Respiratory
Syndrome (MERS) coronavirus, increase the demand for respiratory protection. In
addition, healthcare workers (HCW) at BIDMC care for patients daily on airborne
isolation for more common infections, such as tuberculosis. All HCW1, 2 and 3 are
now required to be fit tested annually by OSHA. HCW who are unable to pass a fit
test for an N95 respirator must wear a Powered Air Purifying Respirators (PAPR).
Last year alone, 376 HCWs fell into this category. PAPR availability and maintenance
were raised as concerns after a specific incident involving a patient on Code 1
Isolation for possible MERS in July 2015.
Bullard PA20 Model
Goals
To improve the processes for obtaining and maintaining PAPR at our institution and
to mitigate the potential and actual risks to patient care operations. These risks
include a delay in delivery of patient care, HCW exposures to potentially
transmissible infectious pathogens, disruption of workflow to multiple
departments, and workarounds and shortcuts by front-line staff.
The Team
Emergency Management
Environmental Health & Safety
Infection Control/Hospital Epidemiology
Materials Management/Distribution
Technology Management (Paul Anderson)
Respiratory Therapy
The Interventions
Multidisciplinary meetings began in Nov 2015 to assess and resolve the issues
around PAPR availability and maintenance.
• Standardize all PAPR from Bullard PA20 model to Dover Sentinel Xl model
• Create accountability by using RFID tagging on PAPR
• Provide instructions for use, including donning/doffing and how to obtain
additional materials at the point-of-use
• Educate clinicians and distribution staff on the new model
Dover Sentinel XL Model
Progress to Date
•
•
•
•
10 Dover model PAPRs have been purchased and are on the HIMDE list of
medical equipment
PAPRs have been RFID tagged
EH&S and Infection Control are planning education sessions for clinicians
and distribution staff
Distribution leadership has been familiar with the new equipment and staff
responsibilities
Lessons Learned
Standardization
• Improves safety by minimizing variability in practice
• Allows for one education plan
Communication
• Front line staff need to know who to contact for resources to avoid
workarounds and shortcuts
• Key departments should be notified when a patient is placed on a type of
precautions (such as Code 1 Isolation) that may increase need for PAPRs
Considerations for Next Steps
•
•
•
•
•
Train clinicians and distribution staff on the new model PAPR
Upload training video on to MyPath
Create PAPR donning/doffing cards for ID badges
Discuss methods to potentially decrease the number of HCW required to
be fit tested annually in order to decrease demand for PAPR
Increase PAPR availability to off-site locations
For more information, contact:
Aleah King, RN, BSN, CIC Infection Control Practitioner,
adking@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.
Aleah King (<a href="mailto:adking@bidmc.harvard.edu">adking@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Health Care Quality
Emergency Management
Materials Management/Distribution
Environmental Health & Safety
Technology Management
Infection Control
Hospital Epidemiology Respiratory Therapy
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Paul Anderson
Aleah King
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 Multidisciplinary Effort to Improve PAPR Availability and Maintenance
Date
A point or period of time associated with an event in the lifecycle of the resource
2016
Format
The file format, physical medium, or dimensions of the resource
pdf
Efficiency
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/a813ca36adbdcb3ed740921655ff8a26.pdf?Expires=1712793600&Signature=OQbXrHA5nSpd0umbiPcIxpPmXHGYlEko0vPNZnYlRVv5nPOU1MbgDk-vvloBelr09%7EOVjVIiZkp%7ENe2wEPSz6sjVxxjsVZ5PAOs85EV6pPTXv-g9z9ogXbjR2-YZaQiljmp9aHH6mbbzkwvB978-hljFRu3uRuCYQoiOAx36n7caKsR1rdNHmCKmvybDmWtktXkuGhsV7Ek4%7Em8QmtCEi31WjxfD9Tg4%7ExnS0%7EaEvW5VCdcMHAnTpH1Y0Z5Fck-8%7EuM%7EdsMlZQyGrrCvP3wdvnCFm8k1DLiKh%7ExaCguiYCw94VqJq3runS-2y6LL9oiEcwO3nw0KiQ76QcDXFWdbIQ__&Key-Pair-Id=K6UGZS9ZTDSZM
e39e788bd308d4504ff0eedbdd7e3dd5
PDF Text
Text
A Multidiscipline Approach to 96 Hour Sustainability
Declan Carbery, Manager, Emergency Management
The Problem
During any natural disaster, hospitals are one of the most critical facilities within a
community. Because hospitals are so critical to the public’s well-being, they do not have the
luxury of being able to close if, for whatever reason, it is unable to maintain operations.
Evacuations of hospitals, like those that occurred during Hurricane Sandy, put a
tremendous strain on an already resource-strapped system. Also, due to larger and more
intense storms becoming more frequent, hospitals must develop plans that allow the
institution to support critical functions for a goal of up to 96-hours before making the critical,
resource-intensive, and dangerous decision to evacuate.
At Beth Israel Deaconess Medical Center, Emergency Management and a team of
departments have all been working towards putting mitigation strategies into place that will
increase BIDMC’s chance of sustaining critical services during a natural disaster. This
means that BIDMC may have to sustain critical functions without community support, such
as deliveries of medical supplies, pharmaceuticals, fuel, food, and even drinking water.
Steps have also been taken to prevent flood waters from damaging critical equipment, such
as the emergency generators.
The Goal
Our collective goal is to be as prepared as possible to sustain critical functions of BIDMC
throughout a disaster in which community support is extremely limited. This requires
maintenance of critical stockpiles, development of plans and standard operating procedures
related to functioning with limited resources, and annual drills in which we test our vendor
Memorandum of Understandings and actions taken by various departments.
TAP TO GO
BACK TO
KIOSK MENU
New Mitigation Strategies In Place
Creation of 6 Critical Infrastructure Binders for the Command Centers
Development of the Severe Weather Plan
Improved Planned Utility Shutdown Planning Process
Facility’s Campus Hardening Program
Annual 96 hour drill
Over 20 vendors with Memorandum of Understanding agreements to deliver supplies
upon request in or right before a disaster
Stockpiles of essential supplies (Pharmaceuticals, PPE, Water, Food, Lighting Sources,
etc.)
Multidepartment Collaboration
Emergency Management
Facilities
Maintenance
Environmental Services
Food Services
Materials Mgmt. / Distribution
Blood Bank
Research Operations
Patient Transport / Linen
Environmental Health & Safety
Respiratory Therapy
Pharmacy
A Boston firefighter wades through floodwaters
from Boston Harbor on Long Warf during winter
storm flooding in January of 2018. Photo from
Boston Globe
For more information, contact:
Declan Carbery, Manager, Emergency Management dcarbery@bidmc.harvard.edu
�A Multidiscipline Approach to 96 Hour Sustainability
Declan Carbery, Manager, Emergency Management
Example Matrix: Generator Fuel Consumption
Generator
Numbers
FUEL TANK
CAPACITY
(90%)
FUEL
BURNED
After 24hr
FUEL
BURNED
After 48hr
FUEL
BURNED
After 72hr
FUEL
BURNED
After 96hr
GALLONS
REMAINING IN
TANK
After 96hr
E 1,2,3,5,6
22,500gal
4,300gal
8,450gal
12,680gal
16,900gal
5600gal
E-11
2,700gal
820gal
1,635gal
2,450gal
3,265gal
-560gal
W-1 & W-2
7,200gal
1,680gal
3,360gal
5,040gal
6,720gal
480gal
W-10 & W-11
5,400gal
720gal
1,440gal
2,160gal
2,880gal
Example Matrix: Food
2,520gal
Note: This is without any load shedding and assuming the fuel tank is only at 90% capacity, meaning
these generators may be able to sustain for longer than shown.
Note: This is assuming 450 patients in house, 550 staff, totaling 1,000 people to feed for 96 hours
Next Steps
Improve stockpiles of critical supplies (water, masks, pharmaceuticals, etc.)
Create SOP for utilization of the East Campus Flood Gates
Continue Facility’s Campus Hardening Program
East Campus Generators
For more information, contact:
Declan Carbery, Manager, Emergency Management dcarbery@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.
Declan Carbery (<a href="mailto:dcarbery@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">dcarbery@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Emergency Management
Facilities
Maintenance
Environmental Services
Food Services
Materials Management / Distribution
Blood Bank
Research Operations
Patient Transport / Linen
Environmental Health and Safety
Respiratory Therapy
Pharmacy
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Declan Carbery
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 Multidiscipline Approach to 96 Hour Sustainability
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
Effectiveness
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/526183883d1538c684f79d7d01189501.pdf?Expires=1712793600&Signature=IekCSQT57j3gXR5gulGnXUMXIafBBUY9bE3t38aWeRalRVU2KG8InQnmsDq2QCO%7ERsdySvLAbNJRrYyIjYTHbu4YFFSGYXKeaY2x3v6-j6Jcm05htdaRStf93EfAS3wdjKSwuFP7ZQz16qguBrfRyuxnVeLkmKcw57P1cJRU%7EHoL3exCK3X2Y-BeG3%7EbKkSxBNPwVK-Sxy1DbhJYMzA33Fg3Ily4GJsxl3ZmsoBNyQ8G0wcqt%7ENzga2d5IeXpecIGd0b0knP2exAEkoUIAktSJOvIgU54aGkHKnzhs35RH2sxHgl4CGSLPOvT6O0OdlgMhAz3EWRRgBJYjfjX3d4ZQ__&Key-Pair-Id=K6UGZS9ZTDSZM
f9880a554cf00cf35bb2401afae655f3
PDF Text
Text
A Multimodal Approach to Improve Hand Hygiene on a Medical Unit
The Problem
The Results/Progress to Date
Hand hygiene is critical to efforts to reduce nosocomial infections and
transmission of antibiotic resistant pathogens such as MRSA which are
spread primarily through the contaminated hands of health workers.
However, even subsequent to intensive educational efforts to improve hand
hygiene, the rates of compliance in hospitals often remains poor. Local
ownership of the improvement process has been advocated by infection
control leadership at BIDMC and in consensus based guidelines.
Hand hygiene rates over time
0.80
Rate of handwash
0.70
Aim/Goal
An educational intervention using a multidisciplinary and multimodal
approach was used to improve the hand hygiene practice on 11 Reisman.
Direct observation data on hand hygiene was used to understand and
analyze the patterns of hand hygiene among the various providers
(physicians, nurses, aides, and other staff.
0.60
Aides
Physicians
Nurses
0.50
0.40
0.30
Other Staff
0.20
0.10
0.00
11/14 - 11/17
11/18 – 11/21
1/7 - 1/9
1/28 – 2/17
Time periods of observation
The Team
Lessons Learned
Team Leaders: Joseph Dubin, MD, Daniele Olveczky, MD,
Caleb Hale, MD, Mary Oconnell, RN, Sharon Wright, MD, MPH
Nursing staff, patient aides, and other staff members on the 11
Reisman patient care team.
Hand hygiene behavior on a medical floor varies significantly by
provider function (MD, RN, aide) and is relatively stable over time.
Nurses accounted for 57% of observed patient encounters
followed by aides at 27% and physicians at 8%
Patient aides were observed to have to lowest adherence with
hand hygiene at 17% of observed patient encounters, compared
with 54% and 44% for physicians and nurses, respectively.
The Interventions
A multidisciplinary meeting was held to discuss quality
improvement efforts and hand hygiene
A patient care aide dinner was held
Direct observation data was collected for hand hygiene to
provide information regarding the variation in hand hygiene
compliance between provider role (RN, MD, aide, etc.) and
variation between individuals
Various educational efforts were tested including awards and
interactive games to encourage hand hygiene
Next Steps/What Should Happen Next:
Hand hygiene will remain a priority area for 11 Reisman and for
BIDMC more generally.
11 Reisman will continue educational efforts to encourage hand
hygiene with feedback from both direct observation as well as the
product usage data.
Local efforts to improve hand hygiene that are based in individual
nursing units or departments will be encouraged.
For More Information: Joseph Dubin, MD
Hospitalist. jdubin@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.
Daniele Olveczky (<a href="mailto:dolveczk@bidmc.harvard.edu">dolveczk@bidmc.harvard.edu</a>)
Project Team
Joseph Dubin<br />Daniele Olveczky<br />Caleb Hale<br />Mary Oconnell<br />Sharon Wright<br />11 Reisman Nursing<br />11 Reisman patient aids
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Department
Any departments listed on the poster or identified in the spreadsheet.
11 Reisman
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 Multimodal Approach to Improve Hand Hygiene on a Medical Unit
Date
A point or period of time associated with an event in the lifecycle of the resource
2009
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Safety
-
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bd848c27df5f08b1435fe6d587da7616
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Text
A Novel Approach to Getting Boards on Board
The Problem
The Results...
The Institute of Medicine has stated that the governance function of
healthcare entities needs to fully understand and accept accountability for
patient safety and clinical quality. However, few members of governance are
familiar with this topic matter
Responses to a post-event survey were extremely favorable. For each major
component of the program there was no negative feedback and most individuals
responded “strongly agree to the usefulness of each element. :
Aim/Goal
Educate the governance of our institution with regards to the
imperative for clinical quality and safety , and governance
responsibility for that imperative
Strongly Agree
The Team
Paul Levy, Chief Executive Officer
Kenneth Sands, MD, Senior Vice President for Health Care Quality
Eric Buehrens, Chief Operating Officer
Dianne Anderson, Senior Vice President, Clinical Operations
Stephanie Huang, Chief of Staff, Office of the President.
Agree
Program met my expectations
Presentation: "Boards on Board" was valuable
Patient Panel was Useful
HCW shadowing was effective
Neutral
The Interventions
We created a unique, 1.5 day curriculum for our Board of Directors and
members of the Board Committee on Quality. Key elements of the
curriculum included:
Disagree+Strongly
Disagree
1) An experience for each board member shadowing a health care worker as
they performed their job.
0
5
10
15
20
Number of Responses
2) Group Discussion of the shadowing experience
25
30
3) Facilitated Session with a panel of 3 patients who had had both positive
and negative experiences at the institution.
4) Overview of justification for getting Boards on Board, and approach at
other institutions, facilitated by a nationally prominent expert.
For More Information Contact
Kenneth Sands, MD, MPH – SVP Health Care Quality
ksands@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.
Kenneth Sands (<a href="mailto:ksands@bidmc.harvard.edu">ksands@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Health Care Quality and Safety
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Paul Levy<br />Kenneth Sands<br />Eric Buehrens<br />Dianne Anderson<br />Stephanie Huang
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 Novel Approach to Getting Boards on Board
Date
A point or period of time associated with an event in the lifecycle of the resource
2008
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Safety
-
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3a19e63b323fe9fbfd69b051238fc9e0
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Text
A Novel Approach to Getting Boards on Board
The Problem
The Results...
The Institute of Medicine has stated that the governance function of
healthcare entities needs to fully understand and accept accountability for
patient safety and clinical quality. However, few members of governance are
familiar with this topic matter
Responses to a post-event survey were extremely favorable. For each major
component of the program there was no negative feedback and most individuals
responded “strongly agree to the usefulness of each element. :
Aim/Goal
Educate the governance of our institution with regards to the
imperative for clinical quality and safety , and governance
responsibility for that imperative
Strongly Agree
The Team
Paul Levy, Chief Executive Officer
Kenneth Sands, MD, Senior Vice President for Health Care Quality
Eric Buehrens, Chief Operating Officer
Dianne Anderson, Senior Vice President, Clinical Operations
Stephanie Huang, Chief of Staff, Office of the President.
Agree
Program met my expectations
Presentation: "Boards on Board" was valuable
Patient Panel was Useful
HCW shadowing was effective
Neutral
The Interventions
We created a unique, 1.5 day curriculum for our Board of Directors and
members of the Board Committee on Quality. Key elements of the
curriculum included:
Disagree+Strongly
Disagree
1) An experience for each board member shadowing a health care worker as
they performed their job.
0
5
10
15
20
Number of Responses
2) Group Discussion of the shadowing experience
25
30
3) Facilitated Session with a panel of 3 patients who had had both positive
and negative experiences at the institution.
4) Overview of justification for getting Boards on Board, and approach at
other institutions, facilitated by a nationally prominent expert.
For More Information Contact
Kenneth Sands, MD, MPH – SVP Health Care Quality
ksands@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.
Kenneth Sands (<a href="mailto:ksands@bidmc.harvard.edu">ksands@bidmc.harvard.edu</a>)
Project Team
Paul Levy<br />Kenneth Sands<br />Eric Buehrens<br />Dianne Anderson<br />Stephanie Huang
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Department
Any departments listed on the poster or identified in the spreadsheet.
Administration
Health Care Quality and Safety
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 Novel Approach to Getting Boards on Board
Date
A point or period of time associated with an event in the lifecycle of the resource
2006-2007
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Effectiveness
-
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45b6830c8f4b9aa6f06017dd718084b7
PDF Text
Text
A Novel Quality Improvement Curriculum is Associated with Increased Housestaff Engagement and
Improved Clinical Outcomes
A teaching hospital of Harvard Medical School
Elliot B. Tapper, Anjala Tess, Amy Sullivan
Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
Problem:
Quality Improvement (QI) education is required by the ACGME
Clinical services are increasingly busy and duty-hour limits mean that limited
time is available for new educational requirements is limited
Housestaff are frontline clinicians whose systems-based insights would benefit the
development of QI interventions
Results/Findings to date:
QI education must be relevant to the learners and is ideally applied directly to
and immediate to the clinical environment
One important QI initiative on our liver services involves improving poor outcomes
for patients with renal failure. A major opportunity is to avoid combining
contraindicated medications (e.g. fluids and diuretics or
betablockers)
Aim/Goal:
We aimed to improve patient outcomes while teaching and engaging frontline
housestaff in the application of QI principles
Description of the Intervention
An iterative QI curriculum that builds on the contributions of successive groups
of residents rotating through the service
Didactic intervention to education on pathophysiology and best practice
QI interventions developed by the housestaff incude: An emergency department
pathway, POE alerts, Standard care plans in personalized team census,Handheld
checklist
Measurement
Left: Engagement (Top) and
Knowledge (Bottom) scores
before and after the
curriculum
Right: Proportion (Top) and
effect on creatinine (bottom)
of contraindicated
combinations. Farr 10 is the
location of the intervention
Survey to assess changes in knowledge and QI engagement before and after
the curriculum. 7 questions based on ACGME CLER standards and 3 questions
assessing disease-specific knowledge. The sum of affirmative or correct
answers were converted into engagement and knowledge scores
Clinical outcomes measured by review of clinical data and pharmacy records
provided by George Silva (InSIGHT Core)
Key Lessons Learned
An iterative approach to education is feasible and effective
QI education can be incorporated into the busy schedule of a clinical rotation
QI education can be linked with clinical outcomes
Some electronic interventions could not be implemented due to a lack of
support/resources in the hospital's Information Systems division.
Electronic interventions may not be feasible at BIDMC for QI
Next Steps
Study long term outcomes such as mortality, initiation of hemodialysis
Disseminate this knowledge to other centers through publication of the
curriculum
This initiative has been funded by a grant from the Shapiro Center for Education. For More Information, Contact Elliot B. Tapper; etapper@bidmc.harvard.edu
�The Iterative Curriculum
Our curriculum seeks to teach all housestaff the core
principles of quality improvement while involving
them in the longitudinal process of QI intervention
development
Each set of rotating housestaff contribute to the
development on an intervention by focusing on one
specific QI development tool.
The QI tools are described to all housestaff but each is evaluated indepth by only one group.
The tools employed are standard QI techniques such as the Fishbone
or Ishikawa Diagram and the PICK chart.
�Man
Process
PROBLEM
Equipment
Team
�Design the intervention
• Once we understand the options we need to decide
which to pursue
• Tool : PICK chart
High impact
IMPLEMENT
CHALLENGE
Low impact
POSSIBLE
KILL
Easy to do
Hard to do
�
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.
Elliot Tapper (<a href="mailto:etapper@bidmc.harvard.edu">etapper@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Medicine
Gastroenterology
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Elliot B. Tapper
Anjala Tess
Amy Sullivan
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 Novel Quality Improvement Curriculum is Associated with Increased Housestaff Engagement and Improved Clinical Outcomes
Date
A point or period of time associated with an event in the lifecycle of the resource
2015
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Safety
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0eb54b2cc4d0e71e591c9ccec49d4659
PDF Text
Text
A Novel Role for Team Members in Review of Adverse Events
TAP TO GO
at the Anticoagulation Management Service
BACK TO
Afrah Alkazemi PharmD; Beata M. Rucinski, PharmD, CACP; Diane Brockmeyer, MD
Introduction
Anticoagulation management is a high risk area, and maintaining a balance between thrombosis
prevention and bleeding risks while on anticoagulation therapy can be challenging. Adverse events
associated with anticoagulation therapy have a potential for significant morbidity and mortality.
QI cases arise several times a year in our 700 patients on warfarin. QI Review and Root Cause
Analysis have been historically conducted for each case, gathering information from involved team
members, from systematic chart review, and from others involved in the case (inpatient care team,
prescribing doctor, procedure team, etc.). Two reviews are conducted in parallel by the Medical Director
and the Pharmacist Team Lead, who then meet to compare reviews and start to plan interventions and
improvements. Further improvements are then designed in consultation with the full team.
We have three new staff members hired in the past 6 months, and we identified some reluctance
around the QI process (perception of QI as punitive, uncertainty about rationale for reporting cases,
worry about making trouble for a peer).
We identified two interventions that we hypothesized could help: 1. Increased familiarity with the QI
process and culture at BIDMC, and 2. Individual participation and voice in performing case reviews and
designing potential solutions.
Aim
To improve our QI process by 1. Training new team members explicitly on the role of QI at
BIDMC and 2. Initiate a process that adds a 3rd review to each case, to be performed by a
rotating front line clinical team member, from all disciplines on our team (LPN, RN BSN, Pharm
D, MD).
To ensure that all team members feel comfortable bringing potential cases forward frequently,
and understand the Culture of Safety.
The Team
DIANE BROCKMEYER MD
BEATA M. RUCINSKI, PHARM D, CACP
AFRAH ALKAZEMI , PHARM D
PATRICIA GLENNON, RN, BSN
STACY MASK, LPN
I-CHUN CHE, RN, BSN
LOANKIM CHU, PHARM D
KIOSK MENU
The Interventions
We had explicit training at team meeting for the entire team, including our three new team
members. The content was on QI at BIDMC (Culture of Safety, how to speak up, non-punitive
model).
We implemented a protocol in which each case would undergo a 3rd review by an additional
rotating team member, to include LPN, RN, and staff Pharmacist. We trained all members on
how to conduct a review.
As a training exercise, we identified a case, had all 6 team members perform a full case review
using a standardized structured approach, then compared the issues different team members
identified.
The standardized structured approach included a one page rubric for performing a case
review, and also a reference article on applying The 5 Whys in Root Cause Analysis.
Results/Progress to Date
New staff who have worked in other settings may view QI process as punitive, and may be
reluctant to engage in QI or to report potential cases of their own or of peers.
Explicit training on the Culture of Safety and the benefits of QI can help to shift this perception
(see team member comments on next page).
People with different disciplines (LPN, RN, PharmD, MD) review cases with a different eye,
commenting on various aspect of clinical decision making, communication, documentation, and
patient education. This multidisciplinary review has the potential to offer a holistic, 360 case
review, with the potential for better identification of opportunities for systems improvement.
For more information, contact:
Diane Brockmeyer MD, Medical Director ACMS, dbrockme@bidmc.harvard.edu
�Root Cause Analysis of Adverse Events at the Anticoagulation
Management Services Clinic: “5 Why’s” Technique
Afrah Alkazemi PharmD; Beata M. Rucinski, Pharm D, CACP; Diane Brockmeyer, MD
More Results/Progress to Date
ACMS Quality Improvement Review
What do our team members say about this new process? Reflections
On The Quality Improvement Initiative
• Event description
• Assessment of patient factors (e.g. renal, hepatic function)
• Assessment of dosing (adherence to algorithms, policies and guidelines)
• Assessment of patient education
•It was great working together as a
team in an effort to determine the root
cause of the problem.
• Communication with patient and between providers
• Documentation
The 5 Whys Method of Root Cause Analysis (Example)
Why
• Why did the patient develop abdominal hematoma?....Patient was on
warfarin and enoxaparin for LV thrombus and atrial fibrillation
Why
• Why was the patient on enoxaparin?....Patient was
initiated on enoxaparin for bridging to warfarin
Why
• Why was the patient anti-Xa level not
checked?....Not common practice unless patient is
obese
• Why was the patient injecting once
daily?....Patient informed the team she
Why
assumed it was okay to inject once daily
Why
•The 5 whys made me look deeper
into the potential cause for the
complication.
• Why was the patient not educated
on correct timing of enoxaparin?
Root causes and contributing factors: Hematoma is a rare side effect with enoxaparin use and
methods for improving safety need to be explored
Areas of Improvement: Reinforce teach-back in patient education initiatives
Reference: Graves CM, Haymart B, Kline-Rogers E, Barnes GD, et al. Root cause analysis: adverse events in
outpatient anticoagulation management. Joint Comm J Qual Patient Saf. 2017; 43:299–307.
•It encouraged each team member to
share their thoughts.
•A positive way to discuss a problem
without blame.
Team Member 1
• Creates space for investigation and
reflection.
• Help everyone involved see the big
picture.
• Saves time by ensuring repeat
mistakes or problems are avoided.
• Make best practices a common
knowledge.
• The team benefits from a short
reflection by a small group.
• Improve and refine your processes.
• Avoids placement of blame on any
individual.
• Energizes the team to pursue an
improved process rather than dwell
on disappointment.
Team Member 2
Team Member 3
Lessons Learned
Specific training of new team members on the role of QI at BIDMC and the Culture of Safety
was well received and shifted reported openness to report cases.
Engaging all team members in case reviews appears to offer benefits to team members and to
the overall QI process. The addition of case review by front line team members identified
issues that the Medical Director and Team Lead had not identified.
Next Steps/Generalizability
We will continue to engage all team members in QI case reviews and monitor impact.
Although our team is all clinical staff, we envision that this process could also be effective in
other settings with non-clinical staff, such as MA, Phone Staff, Front Desk Staff, Unit
Coordinator, etc.
For more information, contact:
Diane Brockmeyer MD, Medical Director ACMS, dbrockme@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.
Diane Brockmeyer (<a href="mailto:dbrockme@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">dbrockme@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Nursing
Pharmacy
Anticoagulation Management Service
Healthcare Associates
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Diane Brockmeyer
Beata M. Rucinski
Afrah Alkazemi
Patricia Glennon
Stacy Mask
I-Chun Che
Loankim Chu
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 Novel Role for Team members in Review of Adverse Events at the Anticoagulation Management 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
Effectiveness
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/2ad0fc161afa8f42ef24708ad307b8cd.pdf?Expires=1712793600&Signature=OjItOLArIS8ihVhTQYgJBGHS-dQ4pX1Nmt84cUJPGQKWUSNfEmJZ9LVABl1fjxPQEyDx1-Vi7v4tAmufXNmnGAJpMiPV2e3sqOBsQTltEX9fkIKW7WMD-Uc4DuIOveeBxpRair8fKhgT4iVOKCZYrEZpgeJ7Yc-9g2POAmFUhwQD-p02H4gV-JDjfUUydZwnlVhI4JWFpQ42LvFZLZO2Y6FoBBZ9f0b5qhDcrBMKCxB7-CK09%7EEgqq44mZ-NpJXVVmAXp0DOIJxc7U0wSKDh4hedvxoTtvoJjRLMeT3394Fiqpcx1Akbuwwdn2RzzX1nHx4CwTFNspQW7pfljCzijw__&Key-Pair-Id=K6UGZS9ZTDSZM
855d719fcd428469ef47034f8b46fe6f
PDF Text
Text
A novel tool to improve detection of fractures on radiography: the
digital anatomic avatar.
The Problem
An accurate history can improve a radiologist's interpretation. However, this
information is often absent from requests since detailed text entry can be time
consuming. The absence of localizing information can reduce the accuracy of a
radiologist’s interpretation or increase the need for follow-up or cross-sectional
imaging, raising costs.
location of pain for the remaining studies was recorded from the patient’s medical
record, when available.
A digital avatar increased sensitivity for a subtle fracture from 68.4% to 70%,
specificity from 89.9% to 91%, mean DoC from 8.0 to 8.3 (p<0.001) and shortened
interpretation time from 61 to 55 seconds (p<0.001), across radiologist experience
and sub-specialization.
Since the introduction of computerized provider order entry, graphical user interfaces
have become an option. If appropriately developed and implemented, anatomical
avatars can improve communication between healthcare providers.
A well-designed graphical order entry system can help referrers by reducing order
entry time, improve radiologist accuracy by improving the quality of the information
available at the time of interpretation and improve patient safety by reducing errors.
Aim/Goal
The aim for the project was to determine the influence of the avatar on the sensitivity,
specificity, degree of confidence (DoC) (scale 1-10) and time to interpret the
radiograph.
The Team
Ammar Sarwar M.D. – Resident – Department of Radiology
Larry A. Nathanson M.D. – Faculty – Department of Emergency Medicine
Philip M. Boiselle M.D. – Faculty – Department of Radiology
Max P. Rosen M.D. – Faculty – Department of Radiology
The Interventions
A randomized study set of 99 subtle foot fractures (99/226, 78%) and "non-fractured"
foot radiographs (all confirmed with follow-up imaging) was provided to radiologists
for interpretation, using an internally developed computer based order entry form
based on the patient’s medical record (Figure 1).
Lessons Learned
Approximately 50% (110/227) of the radiographs were provided with a text based
history as in current clinical situations. The remaining radiographs were provided with
an image-avatar based history.
A digital avatar complements the text history provided to an interpreting radiologist,
improves sensitivity, specificity, localizing ability and degree of confidence and decreases
the interpretation time.
The time for radiograph interpretation, radiologist’s interpretation of the radiograph
and the radiologist’s degree of confidence in their interpretation was recorded.
Next Steps
The Results/Progress to Date
A second phase “double-blind” study will be performed to confirm the results.
Other modalities and indications will be assessed and avatars developed for these
The location of the patient’s pain was provided to radiologists by the referring
physician in 36% (83/227) of radiographs in the original text based order. The
Information Systems specialists involved with provider order entry will be consulted
modalities
to determine feasibility of introduction into BIDMC systems
For More Information Contact
Ammar Sarwar M.D., Radiology Resident
asarwar@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
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Ammar Sarwar
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
Ammar Sarwar
Larry A. Nathanson
Philip M. Boiselle
Max P. Rosen
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 Novel Tool to Improve Detection of Fractures on Radiography: the Digital Anatomic Avatar
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Efficiency
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/8e12376302447cc1610da24b8bf53f13.pdf?Expires=1712793600&Signature=f9ymiEXCQfDxif4nfPGIbj7pCFXJBCwo4U0yM9z5QgVumerdXXbdohBWjjaclJvg8fdt7NbLBEduFuZI0qvu1UWKFX-x807LQhlsWcr%7ESWPlQONF69Fu%7EF2mVgf3o40fZlPujtg-Xoo1mFUkfJ-YnGTW6KKWVZhNhrvNugixqccw0aVIjBTRFoqxsRPJp0h1h0pXPMinA8Aeg9FwCCJD4F2XeErt-XfmN%7E1LyJCL40vtNAaGeblOYFtBe7U4Ekt-Nz11jKPXR9EwK48bcp6c8MGYH3LSvseBkL8qN2JCa1w23lFko53vu4iVZUKHc-38gPIBQ5bse%7ECfoTwW6nOLQg__&Key-Pair-Id=K6UGZS9ZTDSZM
e00eba360f55cb2a7d85b8fb7576b77b
PDF Text
Text
A Perfect Match: ID Banding on Shapiro 8
Aim/Goal
Progress to Date
The goal is to meet the guidelines of Joint Commission of having two patient
identifiers and improve the accuracy of patient identification. Our aim is to also be
complaint with the pre-verification process for universal protocol, and to mitigate the
amount of mislabeling mistakes which are occurring
MISMATCHED ERRORS
NUMBER OF ERRORS
6
The Team
TCC8 Front Desk/Phlebotomy Staff
TCC8 Coordinating Team
IS Programming Team
Ambulatory Systems’ Team
The Interventions
•
•
•
•
The Results
Our go-live date was Nov 5th 2008. We saw a decrease of mismatched errors in
Quarter 4 of 2008 which was due to the implementation of ID banding prior to a
visit and/or having blood drawn. We draw about 900-1000 patients a month. We
saw a peak in the number of mismatch errors in Quarter 3 2009 because we
realized that we needed to tweak how the staff delegate work when they are
drawing patients and retrieving the requisitions
2
1
FY
09
Q4
FY
09
Q3
FY
09
Q2
FY
09
Q1
Q4
Q3
FY
08
FY
08
FY
08
0
FY
08
Request the help of IS Programming Team
Request two automated ID-Band Machines from IS
Meet with IS Team and work out the flow of our patients for check-in of
scheduled visits and phlebotomy.
Meet with Ambulatory Systems to determine where in Appointments/Scheduling
to add CCC fields to inquire about ID printing at check-in, and also when patient
presents for blood work.
Request IS to activate data jacks to support cognitive printers.
Installed Printers
Work on the different types (Adhesive or Clip) of bands that will complement our
patient population.
3
Q1
•
•
•
4
Q2
•
•
•
•
5
Lessons Learned
We realized that clear distinction of responsibility when two staff are assigned to
Phlebotomy was imperative. We also realized that if a patient did not have an
appointment that staff at times forgot to band the patient. We changed our guidelines and
process to ensure that every patient is banded prior to Phlebotomy and their
appointment. We also emphasized that labeling of the tubes need to occur with the
patient as well.
Next Steps/What Should Happen Next:
We continue to monitor the type of errors and checking the trend to ensure any type of
errors are mitigated. Full review of every incident to discover system flaws and make
immediate changes.
For More Information Contact
Menrika Louis MHA, MPA Operations Manager OB/GYN
mlouis1@bidmc.harvard.edu
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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.
Menrika Louis (<a href="mailto:mlouis1@bidmc.harvard.edu">mlouis1@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Obstetrics and Gynecology
Information Systems
Phlebotomy
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Information Systems Programming Team
TCC8 Front Desk
TCC8 Phlebotomy Staff
TCC8 Coordinating Team
Ambulatory Systems 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
A Perfect Match: ID Banding on Shapiro 8
Date
A point or period of time associated with an event in the lifecycle of the resource
2010
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Effectiveness