Beth Israel Deaconess Medical CenterEducational Innovation Project:INSPIREIntegrating Safe Patientce

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Beth Israel Deaconess Medical CenterEducational
Innovation ProjectINSPIREIntegrating Safe
Patient-centered Care into Residency Education

• Program Director Eileen Reynolds
• Associate Program Directors
• Carol Bates
• Christopher Smith
• Anjala Tess
• Julius Yang

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Beth Israel Deaconess Medical CenterResidency
Training Program in Internal Medicine

• BIDMC is a 600-bed tertiary care hospital
• Core teaching hospital of Harvard Medical School
• 158 residents, 5 chief residents
• Firm system
• CPOE, partial online medical record
• Integrated primary care track

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BIDMC EIP INSPIREIntegrating Safe
Patient-centered Care into Residency Education
EIP as opportunity and challenge

• The Quality Agenda, the Outcomes Agenda

IMPROVES
Innovation in Quality of Patient Care
Innovation in Resident Education
IMPROVES
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BIDMC EIP INSPIREIntegrating Safe
Patient-centered Care into Residency Education

• Our approach
• Educate, engage, and empower our residents to be
  the architects and engineers of continuous
  improvement in patient-centered health care
  quality at BIDMC

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Institutional Committees
Quality Improvement
Patient Safety
Analysis
Design
Patient Care Services
Global Measures
Throughput
Patient Satisfaction
Policies
Protocols
Core Measures
Schedules
Resource Utilization
CPOE changes
Clinical Outcomes
Interventions
The System
Resident Experience
DDx, Tests, Orders, Family Meeting
Practice
Passive Learning Model Show me the problems,
and then tell me what to do about them
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Committees
Quality Improvement
Patient Safety
Patient Care Services
Design
Analysis
Patient Satisfaction
Throughput
Policies
Core Measures
Protocols
Practice
Resource Utilization
Schedules
Clinical Outcomes
CPOE changes
Active Learning Model Ill show you the
problems,
and then Ill show you the solutions
Interventions
Local Measures
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BIDMC EIP Organizing Principles

• Step 1. Geographic Teams
• Step 2. Unit-based Dashboards
• Step 3. Unit-based Governance Boards
• Step 4. Link Inpatient/Unit-based and
• Outpatient/Clinic-based Quality Improvement
• Step 5. Required Rotation in Patient Safety and
  Quality Improvement
  
• Step 6. Individualized Patient Safety / Quality
  Improvement Portfolios

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Step 1 Geographic Teams

• Geographic assignment of physician teams
• Patients no longer distributed based on day of
  admission, but rather by bed location
  
• Potential to alleviate workload bolus
  associated with traditional call cycle
  
• Create integrated, unit-based multi-disciplinary
  teams

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A Firm
B Firm
CC7
FARR 7
C Firm
D Firm
patient
intern
case mgr
nurse
resident
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A Firm
B Firm
CC 701- 714
FARR 701- 714
case mgr
CC 715-728
FARR 715- 728
MDs
RNs
C Firm
D Firm
patients
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Step 2 Unit-based Dashborads

• Display real-time unit-based process and outcome
  measures
  
• Institute multi-disciplinary dashboard rounds
  at beginning and end of each shift
  
• Use visible system measures/outcomes to inform
  providers daily practice

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Dashboard Concept Status
CC 7 Medical Unit 12.22.05 732 AM
Census
32 / 36 (89)
28 medical 4 other
ED/ICU
3 admit / 4 request
ADT
Triggers
Telemetry
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Fall Risk
Restraint
Contact
Respiratory
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Dashboard Concept Process
CC 7 Medical Unit 12.22.05 732 AM
DVT PROPHYLAXIS
FOLEY
CVL
GLYCEMIC CONTROL
PNA
CAD/MI
CHF
ABX
SMOKING
EF
ACE-I
ASA
BB
SMOKING
PNEUMOVAX
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Step 3 Unit-based Governance Boards

• Organize/empower unit personnel to review
  unit-based outcome measures on monthly basis
  
• Assess needs and identify areas for improvement
  specific to each unit
  
• Support personnel in design and implementation
  of unit-based quality improvement initiatives
  
• Include patient representatives to reinforce the
  patient perspective in all interventions

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Dashboard Concept Outcomes
CC 7 Medical Unit Monthly Report Period 11/1/0
5 12/1/05

PATIENT SATISFACTION Communication 8.2 Comfor
t 6.5 Response 3.1 Overall satisfaction 8
.5

COMPLICATIONS CVL INFECTIONS 0 PRESSURE ULCER
1
ASPIRATION 2 FALL 2 DELIRIUM 8
THROUGHPUT AVG LOS 4.2 days AVG capacity
89 AVG ADT 36 OUTCOMES 3-day re-a
dmit 4 (2) 30-day re-admit 16 (8) Triggers
16 Code Blue 2 ICU transfer 4 CMO 1

CORE MEASURES CAD/AMI ASA 100 BB
86 SMOKING 72 STATIN 96 CHF AC
E-I 88 EF 78 SMOKING 60 PNA
ABX 100 SMOKING 68 PNEUMOVAX 88
STAFF RATINGS Communication 7.6 Quality 9.0
Efficiency 6.5 Workload 7.4 Overall
satisfaction 8.0

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Governance Board
Unit Dashboard Outcomes Core Measures P
atient
Satisfaction
MDs (faculty and residents), RNs (manager and
floor nurse), case manager, social worker, patie
nt representatives Meet once every 1-2 months to
review unit-based outcomes Oversee development
and implementation of unit-based
quality improvement initiatives
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Step 4. Link Inpatient and Outpatient Unit-based
Quality Improvement Initiatives

• Ensure quality of care across the disease
  continuum acute illness to recovery to health
  maintenance
  
• Maintain awareness of the patients experience
  across different care environments

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Step 4. Link Inpatient and Outpatient Unit-based
Quality Improvement Initiatives
Inpatient Units
Outpatient Clinics
Inpatient-Outpatient Outcomes Core Measures

Patient Satisfaction
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Step 5. Required Rotation in QI and Patient
Safety

• Hands-on, immersion experience in systems-based
  practice
  
• Patient Safety Core Faculty to deliver core
  curriculum in QI and Patient Safety, serve as
  project mentors
  
• Experiential learning through completion of
• Adverse event review/root cause analysis
• System/process mapping
• Participation/leadership in quality improvement
  project
  

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Step 6. Individualized Quality Improvement /
Patient Safety Portfolios

• Demonstration of competency and educational
  outcomes via collection of accomplished
  projects/activities
  
• Collected and shared with peers to disseminate
  learning
  

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Patient Safety Portfolio
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EIP Anticipated Outcomes

• 1. Improve patient safety and quality of care at
  BIDMC
  
• 2. Improve institutional compliance with JCAHO
  core measures
  
• 3. Improve patient satisfaction
• 4. Improve staff satisfaction
• 5. Develop and demonstrate resident competency in
  systems-based practice
  
• 6. Promote innovation in patient care practices
  nursing, physician, multi-disciplinary teamwork

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Educational Innovations

• Formalized resident participation in the
  oversight of patient safety and quality
  improvement processes at the unit/systems level
  
• Real-time reporting of local safety/quality
  outcome measures to inform resident daily
  practice
  
• Patient Safety Core Faculty leadership/mentorship
  model
  
• QI/Patient Safety Portfolio as an evaluative
  measure of competency in PBL and SBP
  

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Leaders Challenge

• For all of our patients and in all
  circumstances, provide the type of care that we
  want for our own family members