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

Quality Measurement for Clostridium Difficile Infection: Turning Lemons into Lemonade

May 20, 2019

For this post, we asked one of our Department of Quality and Safety medical directors, Marc Pimentel, MD, MPH, CPPS, to discuss hospital-acquired health conditions, specifically quality measurement for Clostridium difficile (C. difficile), an infection that can occur in the hospital after receiving antibiotic medicine.

We use quality measures to drive improvements in caring for our patients — focusing our efforts on preventing patient falls, blood clots and infections. Quality measures, such as how often we wash our hands, help us focus efforts on our trouble spots. Quality measurement is not perfect, but what if a hospital’s measured rate of patients who get a C. difficile infection was off by 20–40 percent? Could we still use this quality measurement for improvement?

In an article published last year in BMJ Quality and Safety, Brigham Health experts wrote about how pursuing a seemingly imperfect measurement still led to improved care. During hospital stays, up to 15 percent of patients will have diarrhea, usually from medication side effects or their own illness.

For some of our patients, there’s another reason: C. difficile infection, which causes up to 20 percent of inpatient diarrhea, usually as a complication of receiving antibiotic medicine. When patients have diarrhea in the hospital, we often send a test for C. difficile in hopes of identifying a treatable cause for the diarrhea.

Unfortunately, the test (like most) is not perfect. Because C. difficile is part of the normal gut flora, at least one out of five patients will have a false-positive test result for C. difficile. Despite this issue, we still count every positive C. difficile result toward our infection rate to allow hospitals to compare their performance to each other, without having to review every single case. Unfortunately, this method of reporting can lead to artificially inflated rates of C. difficile infections in our quality measures.

A team at the Brigham took the time to understand all our care processes that contribute to our positive C. difficile tests. We found several items to address, such as our clinician education for proper testing and interpreting the results. After this and other efforts were performed, such as improving our room disinfection practices, we were able to reduce our measured infection rate by 30 percent, while improving the accuracy of our quality improvement data.

This work has led to more transparency and trust from our patients that we are ensuring delivery of high-quality care and their safety, always.

Promoting Opioid Safety for Student Athletes

March 6, 2019

Scott G. Weiner, MD, MPH, a medical director in the Department of Quality and Safety and director of the Brigham Comprehensive Opioid Response and Education (B-CORE) program at Brigham and Women’s Hospital, discusses promoting opioid safety for student athletes.

The opioid epidemic continues to take a record number of lives in this country — 47,600 people died from opioid-related overdoses in 2017 (1). It is staggering to see that the average U.S. life expectancy has declined over the past two years, which is attributed mainly to preventable deaths, such as those caused by drug overdose (2).

To ultimately solve the opioid epidemic, an important step is working to prevent new cases of opioid use disorder from occurring. I like the mantra: “keep patients opioid naïve whenever possible.” If you don’t start taking an opioid, then you can’t get hooked on one. Of course, I don’t advocate for undertreating pain, but multiple studies about conditions ranging from back pain (3) to hip replacement (4) demonstrate that non-opioid pain relievers like ibuprofen and acetaminophen work just as well as opioids for many types of acute pain. From a safety perspective, Brigham and Women’s Hospital has also demonstrated that, for inpatients, adverse reactions to opioids are quite common (5).

One of the most at-risk groups for developing an opioid use disorder is athletes. Think about it: Athletes are prone to injury, particularly at the elite level. Sometimes, despite better judgment, athletes want to do whatever it takes to get back to their sport, even when not completely healed. Several colleagues and I collaborated with athlete Alex White, an alumnus of Harvard University, who had suffered a sports-related injury while in school. We spoke to him about the mindset of an injured athlete amidst the opioid epidemic. Combine that desire with lenient opioid prescribing and a recipe for disaster is created. Athletes need to know the dangers of these opioids, the fact that non-opioids can work just as well as opioids, and — most importantly — that opioids only mask pain so the body thinks it’s healed.

The Brigham is grateful for a donation from two non-profit organizations, Hanging with Ted and the ADK Charities, to create a video (see below) for student athletes that educates them about opioid use. Our goal is to have student athletes and their families view the video and be prompted to talk to their physicians about how to safely take opioids if prescribed and discuss alternative pain-relief options. We encourage you to share the link widely with your network.

Alex White, the student athlete featured in the video, has experience with sports-related injuries, but has not personally experienced opioid misuse or dependency. An earlier version of this post incorrectly stated that Alex had struggled with opioid dependency.

Additional Resource:

References:

  • Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and Opioid-Involved Overdose Deaths – United States, 2013-2017. MMWR Morb Mortal Wkly Rep. 2018 Jan 4;67(5152):1419-1427.
  • NBC News. U.S. life expectancy falls for second straight year — as drug overdoses soar. Available at: https://www.nbcnews.com/storyline/americas-heroin-epidemic/u-s-life-expectancy-falls-second-straight-year-drug-overdoses-n831676
  • Friedman BW, Dym AA, Davitt M, Holden L, Solorzano C, Esses D, Bijur PE, Gallagher EJ. Naproxen with Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial. JAMA. 2015 Oct 20;314(15):1572-80.
  • Thybo KH, Hägi-Pedersen D, Dahl JB, Wetterslev J, Nersesjan M, Jakobsen JC, Pedersen NA, Overgaard S, Schrøder HM, Schmidt H, Bjørck JG, Skovmand K, Frederiksen R, Buus-Nielsen M, Sørensen CV, Kruuse LS, Lindholm P, Mathiesen O. Effect of Combination of Paracetamol (Acetaminophen) and Ibuprofen vs Either Alone on Patient-Controlled Morphine Consumption in the First 24 Hours After Total Hip Arthroplasty: The PANSAID Randomized Clinical Trial. JAMA. 2019 Feb 12;321(6):562-571.
  • Urman RD, Seger DL, Fiskio JM, Neville BA, Harry EM, Weiner SG, Lovelace B, Fain R, Cirillo J, Schnipper JL. The Burden of Opioid-Related Adverse Drug Events on Hospitalized Previously Opioid-Free Surgical Patients. J Patient Saf. 2019 Jan 21. [Epub ahead of print]