“WE CAN LEARN FROM EVERY DEATH”

11/20/19

For this post, we asked one of our Department of Quality and Safety medical directors, Mallika Mendu, MD, MBA, to discuss a mortality-review tool being utilized to drive improvements in medical errors that lead to unnecessary deaths.

Patients depend on hospitals to get the care they need. But sometimes, health care institutions fall short for many different reasons. Research estimates that each year, medical errors cause between 210,000-400,000 deaths nationwide.1 Every one of those deaths represent an opportunity to ask questions, learn from mistakes and improve systems going forward. At Brigham Health, we want to ensure that we learn from every error that contributes to death at our hospital.

Safety science experts have emphasized that the most crucial step towards reducing deaths due to medical errors is rapid identification of these errors and potential errors, or what we refer to as “near-misses.” This identification can be extremely challenging, particularly when a patient’s treatment is complex, involving multiple physicians, medications and procedures.

When we began the process of identifying errors or potential errors at Brigham, we realized the caregivers involved in the patient’s care at the time of death were often the most capable of identifying any potential issues that may have contributed to the patient’s death.

For these reasons, over seven years ago, Brigham Health developed and implemented a hospital-wide electronic tool used to capture real-time information about patient deaths from frontline providers. Using this tool, the team members involved in a patient’s care at the time of death almost immediately receive an email with questions around the circumstances of the patient’s death. The goal is to get providers’ perspective in real time, to understand if there was a medical error that contributed to the death, or if we, in any way, could have done things better. The information provided is then investigated confidentially by safety leadership, and steps are taken to address errors or implement improvements suggested. Using these investigations, our goal is to educate ourselves, and to learn from mistakes moving forward.

Since the implementation of this tool, there have been many positive changes made because of the information provided through these reviews. Some examples include improving our process of transferring patients from other hospitals, improving communication between various teams at the Brigham and enhancing end-of-life conversations led by physician trainees.

Brigham Health believes that we can continue to learn from every death that occurs in the hospital by using this tool and continuing to increase our efforts to promote transparency and feedback from staff. Reflecting on how we can provide better care on an ongoing basis is a key part of our mission.

You can read more about our inpatient mortality review system work in BMJ Quality and Safety, published here.

References:

1Makary MA, Daniel M. Medical Error-The Third Leading Cause of Death in the US. BMJ. 2016 May 3;353:i2139.

GETTING TO KNOW OUR NEW CHIEF QUALITY OFFICER

10/28/19

The Department of Quality and Safety is thrilled to welcome Andrew Resnick, MD, MBA, our new chief quality officer and senior vice president at Brigham and Women’s Hospital. Andrew joins us from his prior role as chief medical officer of Froedtert Hospital, where he served as associate dean of Clinical Affairs Adult Practice and associate professor of General Surgery at the Medical College of Wisconsin. Additionally, he previously served as chief quality officer at Penn State Milton S. Hershey Medical Center. For this post, we asked Andrew to share how he became interested in quality and safety, why he feels the field is important and the vision he has for his new role.

I consider my personal entry into the administrative side of medicine to be unique. As a surgical intern at the Hospital of the University of Pennsylvania I quickly noticed there were many opportunities, both large and small, for improvement across the work I was doing. For example, there was a constant pressure to send patients home from the hospital early in the day, a task that may sound simple. Yet there were often lab tests and results we would have to wait for before patients could leave. I was fortunate enough to join a committee that recognized this problem and focused on making the system more efficient. Improvements made by this committee resulted in patients getting to go home earlier and more sick patients being able to receive care, a win-win. This was my first true experience in quality-related work and it ignited my career interests from that point forward.

While hospitals are measured against many nationally-imposed guidelines as part of our work, for me the meaning of Quality and Safety goes far beyond the data. My top priority is making sure patients receive the best care possible. To accomplish this, I recognize it is critical to involve, and learn from, front line staff when redesigning our systems and optimizing the quality of care delivered to patients. I learned this well as an intern and have never forgotten. In my new role, I look forward to engaging with the diverse Brigham Health community on what it believes are opportunities for improvement and how we can work together to accomplish system-wide change.

Growing up in the Boston area, this is a homecoming for me and my family. I look forward to sharing the challenges of this work with our providers and patients.

Ambulatory Safety Nets: Catching Cancer Diagnoses

10/1/19

For this post, we asked one of our Department of Quality and Safety medical directors, Sonali Desai, MD, MPH to discuss a safety improvement initiative related to patient diagnoses of cancer.

We have all been susceptible to the effects of multi-tasking: you unlock your smartphone to call someone, but are interrupted by an incoming text message, followed by an email from your supervisor. Before you know it, you have forgotten what you were doing with your phone in the first place. Health care is no different  —  the rapid pace of delivering care in the ambulatory setting, coupled with the wealth of data to process complex medical decisions, poses a similar multi-tasking risk to busy clinicians. What often keeps clinicians up at night is worrying about missing a diagnosis of cancer due to not following up on an abnormal test result.

You may wonder, how could this happen? Imagine that you undergo a CT scan of your chest for shortness of breath — although a serious diagnosis such as a blood clot or lung cancer is not found during the exam, a small incidental lung nodule is discovered. The nodule may or may not lead to cancer, but it often requires a follow-up CT scan in several months, or up to one year.

Or, consider a colonoscopy to screen for colon cancer that detects a few polyps.  These polyps are not cancerous but they warrant another colonoscopy be performed in a few years. The issue with these follow-up exams is that physicians’ offices often do not have reliable recall systems to ensure that all patients with incidental lung nodules or abnormal polyps return for the repeat testing they need months or years from when the first test was done – this is how something can fall through the cracks.

Recently at Brigham Health, we  piloted the concept of Ambulatory Safety Nets to help catch potential findings that could lead to cancer diagnoses, modeled after work done through the Kaiser Permanente SureNet programs.1 Ambulatory Safety Nets provide a way to help offload the cognitive burden on busy clinicians by creating a team that can help to centrally identify, coordinate, contact and track patients who need follow-up tests. At the Brigham, this project is being piloted for colon and lung cancer screenings. Ambulatory Safety Nets take a more proactive and centralized approach that can leverage technology to work closely with primary care practices. In our early efforts for the colon cancer safety net, we have been able to complete over 200 colonoscopies for patients at-risk for colon cancer based on abnormal prior colonoscopies and symptoms such as rectal bleeding and iron deficiency anemia. To date, we have identified at least one patient with a high-risk precancerous finding requiring surgery and several patients with polyps.

For our lung cancer safety net, we have found over 300 patients with incidental lung nodules using artificial intelligence on radiology reports. We have developed follow-up care plans with primary care and radiology for determining whether patients need further imaging or referral. We have launched a new program, Radiology Result Alert and Acknowledge for Development of Automated Resolution (RADAR), which leverages a web-based radiology result notification system to create collaborative care plans between radiologists and ordering clinicians, assists with scheduling and patient outreach of follow-up imaging, and tracks whether appropriate care has been delivered to patients.2

Reducing the burden on our physicians and developing an engaged team has provided the opportunity to raise the standard of care that we provide to our patients. We are working on expanding our pilot to encompass more preventive opportunities in breast, cervical and prostate cancer and to design safety nets for ambulatory medication errors and diagnostic errors.

References:

1 Emani S, Sequist TD, Lacson R, Khorasani R, Jajoo K, Holtz L, Desai S. Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer. Jt Comm J Qual Patient Saf. 2019 Jul 05. PMID: 31285149

2 Hammer MM, Kapoor N, Desai SP, Sivashanker KS, Lacson R, Demers JP, Khorasani R. Adoption of a Closed-Loop Communication Tool to Establish and Execute a Collaborative Follow-Up Plan for Incidental Pulmonary Nodules. AJR Am J Roentgenol. 2019 Feb 19; 1-5. PMID: 30779667

The Conference for Professionals Who Plan, Manage, or Support Quality and Safety Initiatives

9/18/19

Within both ambulatory and inpatient settings, there is mounting pressure to improve quality, safety and efficiency. The key question, however, is how? Attendees of the 2019 Healthcare Quality & Safety Conference will leave with evidence-based quality and safety strategies from Brigham Health and Harvard Medical School leaders that will enable them to effectively execute these approaches for sustainable daily practice. This year, the conference will have a new addition of quality and safety in radiology.

At the internationally attended conference, professionals come together to learn from each other’s experience towards improving our systems. The conference will take place on Nov. 6 and 7, at the Wyndham Hotel in Boston. To learn more about the conference and register, visit the conference website: https://quality.bwh.harvard.edu.

Topics include:

  • Health care quality and compliance
  • Innovative care delivery
  • Learning health systems and high reliability
  • Leveraging technology to advance care and improve quality performance
  • Improving patient and provider experience
  • Leadership and governance
  • Quality and safety in radiologyHealthcare Quality and Safety Picture