Bringing Frontline Staff to the Forefront of Quality and Safety Improvement

10/13/20

For this post, the Department of Quality and Safety asked one of our team members, Casey McGrath, RN, MSN, senior director of Clinical Quality Improvement, to discuss Brigham Health’s latest project to engage frontline staff in hospital-wide quality improvement and patient safety initiatives.

As a large academic medical center, our employees pride themselves on having innovative ideas. On a daily basis you can hear chatter amongst staff across the hospital as they discuss “light-bulb moments” about new ideas on how best to care for a patient, identify opportunities to improve our workflow and processes, and one of the latest new research projects.

It is well-established in patient safety research that these frontline staff members, those who are responsible for caring for patients at the bedside, are key to identifying hazards in the workplace and proposing the best ways to eliminate them.1 However, it can be challenging to translate the ideas of frontline staff into action. This problem is not specific to Brigham Health; it is something large academic medical centers and hospitals face throughout the country. Recognizing this problem, many academic medical centers have created unit-based team (UBT) structures, allowing frontline staff to be closely involved in continuous patient safety and quality improvement.1,2 This past summer, Brigham Health began the process of launching our own UBT system across our inpatient floors. As part of the UBT model, frontline staff are paired with members of hospital administration and other key stakeholders with the goal of having staff feel empowered to ensure their voices are heard and they are engaged in changes and improvements in the work they do every day to care for patients.

Our UBTs meet weekly and focus on key hospital patient safety and quality improvement initiatives (e.g. catheter-associated urinary tract infections, central line-associated bloodstream infections, hand hygiene, patient satisfaction) as well as local quality, safety and operational metrics. The team reviews data, discusses concerns and identifies and implements improvement initiatives. Currently, BWH has seven active UBTs and is working on expanding to other inpatient units throughout the hospital. By providing units with a standardized structure for identifying concerns, improving performance and sharing ideas, as well as administrative support to assist with designing and implementing improvement initiatives at the frontlines of care, we hope to turn these “light-bulb moments” into reality so that the Brigham and its staff can continue to provide the safest and highest-quality care to patients and their loved ones.

References:

  1. Pottenger, BC., Davis, RO., Miller, J., Allen, L., Sawyer, M., Pronovost, PJ. Comprehensive Unit-based Safety Program (CUSP) to Improve Patient Experience: How a Hospital Enhanced Care Transitions and Discharge Processes. Quality Management in Health Care. 2016 October/December.
  2. Kim CS., King E., Stein J., Robinson E., Salameh M., O’Leary K. Unit-based Interprofessional Leadership Models in Six US hospitals. Journal of Hospital Medicine. 2014 May.

COVID-19 Contact Tracing at Brigham Health

8/21/20

Throughout the COVID-19 pandemic, contact tracing has played a critical role in preventing the virus’ spread. Historically used for several other infectious diseases, contact tracing has been shown to be especially important at the early stages of an outbreak when there is scarce information about the disease and treatments are not yet available.1  Given how little was known about COVID-19, particularly early in the pandemic, the Brigham’s rapid ability to create its own COVID-19 contact tracing program was critical to ensuring our patients and staff remain safe as possible.

According to the Centers for Disease Control and Prevention, contact tracing consists of three main steps:2

  1. Letting people know they may have been exposed to COVID-19 and should monitor their health for signs and symptoms of COVID-19.
  2. Helping people who may have been exposed to COVID-19 get tested.
  3. Asking people to self-isolate if they have COVID-19 or self-quarantine if they are a close contact.

Brigham Health’s Occupational Health, Infection Control and Quality and Patient Safety teams came together early in the pandemic to create a process by which each of these contract tracing steps could be accomplished within our hospital and community so that possible COVID-19 exposures are identified and communicated, and patients and staff with possible exposures are supported as much as possible. The communication strategies we have undertaken have even been published in The Joint Commission Journal on Quality and Patient Safety. Additional details on our health care staff communication strategies can be found here, and patient communication strategies here.

Through our program, any patient or staff member who tests positive for COVID-19 within the Brigham Health system is thoroughly reviewed for possible exposures. Interviews are conducted with all staff with confirmed positive test results and any possible employee or patient exposures are identified.

Additionally, all patients who test positive at a Brigham Health site, either at the hospital or at an ambulatory clinic, have manual reviews performed of their medical record to identify any possible exposures to COVID-19 that may have occurred. Exposures are also analyzed using a medical record tracing function, allowing Infection Control to identify staff who interacted with the patient and subsequently may have been exposed.

Once any possible exposure risks are identified, staff are contacted by Occupational Health, and patients received a phone call from a physician. The physicians ensure all patients’ questions and concerns are addressed and that appropriate resources, such as social work and communication with the patient’s primary care provider, are offered. Staff and patients are also educated on the latest Centers for Disease Control and Prevention recommendations around symptom monitoring and isolation precautions and are given assistance and information on how to get testing.

We firmly believe that our efforts to implement contact tracing within our hospital helped to prevent countless additional infections from occurring. As the pandemic is ongoing, we are committed to ensuring this process continues and that transparency and the safety of our staff and patients remains our highest priority.

References:

1Keeling, MJ., Hollingsworth, TD., Read, JM. Efficacy of Contact Tracing for the Containment of the 2019 Novel Coronavirus (COVID-19). J Epidemiol Community Health. 2020 Jun 22. PMID: 32576605

2Centers for Disease Control and Prevention. Notification of Exposure: A Contact Tracer’s Guide for COVID-19.

https://www.cdc.gov/coronavirus/2019-ncov/php/notification-of-exposure.html

A Near Miss, An Important Reminder

7/23/20

While the COVID-19 pandemic continues to pose a significant global health threat, one recent near-miss patient safety event at Brigham and Women’s Hospital was a reminder of the need for continued focus on all public health issues, transparency and our culture of safety.

According to the U.S. Department of Health and Human Services, over 130 individuals die daily from opioid-related drug overdoses across the country, with over 10.8 million Americans misusing prescription opioids in 2018.1 In 2017, the opioid crisis was declared a public health emergency and efforts have been ongoing to, among other things, reduce the number of opioid prescriptions written overall, as well as reduce the number of opioid pills ordered per prescription. Research shows that electronic medical records, computer systems used to manage patients’ information while at the hospital, may make the issue of overprescribing opioids worse by setting automatic suggestions for the number of pills doctors should prescribe following certain procedures.2

In June of this year, one of our General Surgery residents experienced this problem when ordering opioids for several of his patients in our electronic medical record system. When prescribing oxycodone, an opioid typically prescribed for severe pain management, like that experienced after surgery, the pre-populated quantity in the electronic medical record prescription suggested he order 450 pills, far more pills than necessary, rather than the five he originally intended to prescribe. Concerned that this suggestion would result in his patients receiving many more pills than they needed, and aware this can put patients at an increased risk for addiction, overdose and even death,3 he alerted the Information Technology, Pharmacy, and Patient Safety teams so they could work to eliminate this automatic suggestion. The teams worked quickly, and within 10 hours, the issue was fixed not only at our organization, but across all hospital systems that use the same technology.

We are grateful that we can consider this event a “near miss” in which no patients received more opioid pills than they needed. We are fortunate to have a culture of transparency in which this physician was willing to speak up about the patient safety issue he identified.

References:

1U.S. Department of Health and Human Services. What is the Opioid Epidemic? https://www.hhs.gov/opioids/about-the-epidemic/index.html.

2Makary, MA., Overton, HN, Wang, P. Overprescribing is a Major Contributor to Opioid Crisis. BMJ. 2017 Oct 19. PMID: 29051174

3Centers for Disease Control and Prevention. 2018 Annual Surveillance Report of Drug-Related Risks and Outcomes — United States. Surveillance Special Report.

https://www.cdc.gov/drugoverdose/pdf/pubs/2018-cdc-drug-surveillance-report.pdf.

The Healing Power of Connection

6/12/20

Now more than ever, we need to connect with those we love to stay healthy and well. Even as we self-quarantine, we have all made changes and found creative ways to communicate and connect with each other using video chats, phone calls, texts, or even hand-written notes. COVID-19 has created many challenges for hospitals and healthcare organizations globally, one of the most difficult being the struggle to connect patients with COVID-19 with their loved ones and to provide the emotional support they need while they are in the hospital.

Because COVID-19 is passed from one person to another, hospitals have been forced to put in place strict visitor policies. Recognizing how important physical and spiritual connection to loved ones is to a patient’s recovery and wellbeing, Brigham and Women’s Hospital has created several projects to bridge this connection and give patients the opportunity to connect with their loved ones even while they are in the hospital.

While family members are unable to be physically present in the hospital, one project created by Palliative Care doctors and first-year medical students, called “Get to Know Me,” has helped loved ones stay connected to patients and their caregivers during their hospital stay. Medical students interview family members by phone and make a small poster with photos and important facts about the patient as a person, aside from their illness, such as their pet’s name and their favorite television show. The poster is then hung outside the patient’s room for their care team to view and learn from.

Example “Get to Know Me” poster. Note: This poster and information is not of a real patient. 

In addition to the creation of these posters, several projects have been put in place so that patients can have “virtual” family and spiritual care visits while they are in the hospital. Through two different virtual family visit programs, patients in the Intensive Care Unit, with the assistance of their nurses, nurse practitioners, physician assistants or doctors, are able to have virtual visits via phone or video chart with their families or, if patients do not have their own devices, the hospital has created a program that provides patients with loaners so that they can easily stay connected with their loved ones throughout their hospital stay. These loaners are available from 7:00am-11:00pm daily.

To-date, over 600 virtual family visits have been facilitated by both virtual visit programs.

In addition to ensuring patients can stay connect with their family and loved ones, Spiritual Care Services, a Brigham service that aims to assess and serve the emotional and spiritual needs of patients and their families in moments of crisis and uncertainty, has created a program that allows patients to have spiritual care visits done entirely virtually. It is our belief that these programs contribute to the patient’s overall well-being, and that human and spiritual connection can positively affect a patient’s healing.

Our hope is that as the need for distancing continues, we will continue to expand these programs, as well as create others that address the constantly changing and unique needs of patients.

 

STARTING OFF THE NEW YEAR WITH A NEW FOCUS

2/4/20

For this post, the Department of Quality and Safety asked one of our team members, Karthik Sivashanker, MD, MPH, CPPS, medical director for Quality, Safety, and Equity, to discuss Brigham Health’s focus on equity, how it can be misunderstood, and why it is a critical patient quality and safety issue.

The New Year is a common time for people to pause and consider what’s important to them and where they’d like to be in the future. At Brigham Health, we’re excited to renew our commitment to providing equitable high-quality care to all of our patients for 2020 and beyond. To understand why this is so important, we first need to understand what we mean by equity, and how that ties into the quality and safety of our patients’ care.

We can begin by asking what matters to you as our patient? For most of us, being treated with respect and dignity is high on that list. We might even say that we want to be treated “equally,” no matter our race, religion, language, gender, etc. But is equality really the goal or is it something else?

Here’s an example to help us think through this. Consider this picture of people waiting in line for the bathroom:

Have you seen long lines for the bathroom before? If so, is it usually for the men’s or the women’s bathroom? In general, most of us would say that women’s bathrooms tend to have the longer lines. Have you ever paused to wonder why that might be? Why would we design bathrooms that lead women to wait longer than men? The answer, of course, is that we didn’t. Or at least, we didn’t intentionally design bathrooms in this way. More likely than not, these bathrooms were designed with the assumption that what works for one group will also work for others, resulting in bathrooms that are designed similarly for both.

Are these bathroom designs working well for women? Clearly not. But what about for men?

Before answering, consider men who may be with women waiting in line. Don’t many of them end up waiting as well for their wife, sister, daughter, friend, etc. to finish? What about fathers with babies using bathroom that don’t have changing stations? Or fathers with young daughters who may have to bring their daughters into a bathroom full of men?

Clearly, many bathrooms don’t always work well for men either.

This is a simple example to illustrate a complex point. If we design bathrooms to be “equal,” they may not serve the needs of the diverse people using them. In fact, they may not serve the needs of anyone in the best possible way. We considered men and women, but we can ask the same questions for other groups like transgender people or the disabled. At the end of the day, equal doesn’t mean fair.

Instead, we should be aiming for equity. The goal with equity is to design a system that works well for everybody. This is easier said than done and gets even more complicated when you think about how these ideas apply to health care.

Consider the example of access to routine preventative cancer screenings, like mammograms for breast cancer. Many people don’t have the money, social support, or the other things that are needed to access such care. Although care is equally available to all groups, inequities exist that prevent certain groups from receiving the care they need.

Here at Brigham and Women’s Hospital, we feel strongly that every single patient should get the very best and safest care (i.e., equitable care). This does not mean treating every patient the same, because who we are matters. What works for one patient may not work for another. With this in mind, we are taking a new approach that considers equity at every step of the way, starting with patient safety and quality.

When a patient suffers an avoidable harm, we try to understand what happened. This means getting at the “root” of the problem using different tools. Instead of re-inventing the wheel when it comes to equity, the idea is to take the same “root cause” approach, and to add an equity lens. Sometimes, this is as simple as asking the question: “Was there an inequity that played a role in this patient not receiving safe and excellent care?”

An article (and Podcast) in the New England Journal of Medicine this month by Dr. Karthik Sivashanker highlights this approach and explains a new way of thinking about patient safety, quality, and equity that should improve the care for all our patients and families. You can learn more by reading the article here.