Continuous Quality Improvement: It’s a Bit Like “Groundhog Day”

A large, multi-ethnic audience in a movie theater, watching a movie, eating popcorn and drinking soda. The group of people are mixed ages, including children, teenagers, young adults, mid adults and mature men and women, families, friends and couples.In this piece, Jen Beloff, MSN, RN, APN, executive director of Quality and Safety at Brigham and Women’s Hospital, looks at how we use continuous quality improvement to identify and solve program and process challenges.

February 1, 2019

If you are working in a health care setting, you’ve undoubtedly heard of the term “Continuous Quality Improvement (CQI)” to describe the process of systematically identifying, delineating and analyzing a quality or safety problem, testing, implementing and learning from the process, and then repeating the process.

It’s a bit like the movie “Groundhog Day,” where Phil Connors, played by Bill Murray, repeatedly relives the same day, known as Groundhog Day, turning moments of monotony and at times hopelessness into opportunities for enlightenment and decisive action.

Despite being stuck in a perpetual time loop, Phil continuously learns from his daily observations and associated outcomes, and adapts his behavior and processes, sometimes leading to a different and often more positive outcome the next day.

The same can be said of introducing successful quality and safety improvement initiatives in health care. Creating a shared need and vision, gaining stakeholder support and implementing and sustaining improvement initiatives can often feel like you are waking up every morning in a perpetual time loop. This is partially because most quality and safety improvement initiatives will not be solved with one fix. Designing for continuous improvement and success means your work is never done. Some interventions simply won’t work, and that is perfectly OK.

Take, for example, Catheter-associated Urinary Tract Infection (CAUTI) prevention. In 2009, Brigham leadership and care providers formed a multidisciplinary taskforce charged with reducing the rate of infections related to urinary catheter devices. Over the last decade, the taskforce has implemented close to 50 interventions, such as back-to-basics education and the development of clinical-decision support. Some interventions were more successful than others, like eliminating yeast from the CAUTI definition and cancelling urine cultures for those patients with a negative urinalysis.

Just as Phil eventually learns to incorporate the knowledge gleaned from one day into the next, so too can quality improvement leaders. We strive to transform the monotonous and sometimes frustrating moments of quality and safety program implementation into moments of ingenuity and innovation, ultimately leading to better patient outcomes and experiences.

As I compare the 2009 and 2019 CAUTI Taskforce improvement plans, I can’t help but reflect on the fact that many of the initiatives are eerily similar. However, like Phil, I also know that tomorrow is a new day and that we will apply the lessons and successes of the past 10 years to advance the cycle of continuous quality improvement. Our CAUTI standardized infection rate at the Brigham is down 34 percent since we first started publicly reporting it in 2012 and I know through our efforts we will continue to improve.


-Jen Beloff, MSN, RN, APN, executive director, Quality and Safety



“Groundhog Day.” Directed by Harold Ramos et al., Columbia Tri Star Home Video, 2002.

Scientific Update: Hand Hygiene

January 15, 2019

At Brigham and Women’s Hospital, we are fortunate to have unparalleled access to some of the best health care researchers in the world. Our quality and safety initiatives often involve top researchers, who not only help us design and evaluate our initiatives but keep us updated with the latest discoveries and inventions that are transforming health care. In this blog post, we highlight some of these latest research findings about hand hygiene.

According to the Centers for Disease Control and Prevention and the World Health Organization, performing improper hand hygiene is one of the main drivers for hospital-acquired infections. It is no surprise that Brigham and Women’s Hospital, like many other leading health care institutions in the nation, dedicates significant resources to measure hand hygiene compliance among staff and develop ways to improve it.

There are two major barriers to improving hand hygiene compliance: knowing how to encourage the correct behavior and measuring that the said behavior is working.

Here are a few examples of recent research related to hand hygiene:


-Hojjat Salmasian, MD, PhD, medical director, Data Science and Analytics

Sound the Alarm – Or Perhaps Not

street repair

If you live or work in a city, you’re likely used to the everyday sounds of car horns honking, jackhammers drilling, sirens ringing and trains rumbling. If you’re like me, you may have developed the ability to tune out these noises without even knowing it. So how do we know which sounds we really need to pay attention to?

That’s the question being asked in hospitals. With so many audible alarms on patient units, clinicians can become desensitized and fail to respond when an emergency arises. And the constant noise of alarms certainly doesn’t make for a restful patient experience either.

In 2015, we found that up to 490 unique alarms sounded per patient bed per day in certain units at the Brigham. That’s roughly 20 alarms per hour. About 75 percent of them were non-critical.

To address this, we conducted a six-month pilot to reduce the number of audible alarms and ensure that alarms indicating an urgent medical need would be heard.

Here are a few examples of the changes we made:

  • Widened the parameters for the high and low heart rate alarm settings to decrease the number of alarms that do not require action from a care provider.
  • Tailored alarms to the needs of each patient care unit. For example, the needs of patients in the Medical Intensive Care Unit are very different from the needs of postpartum patients, and the alarms have been programmed accordingly.
  • Implemented nursing practice changes to reduce alarms caused by poor contact of the monitor with the patient’s skin, such as the monitors that measure oxygen levels or record the electrical activity of the heart.

These efforts resulted in a 70 percent reduction of alarms across the hospital, which made the hospital safer by improving the care team’s ability to hear critical alarms and increased patient satisfaction as well.

Since then, we have heard from providers who said the units were significantly less noisy, allowing them to hear the alarms sounding for a critically-important condition. Patients reported improved satisfaction due to fewer noises, less stress about what the alarms meant and fewer interruptions.


What Every Expectant Parent Should Know about Hospital C-section Rates

For this post, we spoke with Julian N. Robinson, MD, chief of obstetrics in the Department of Obstetrics and Gynecology, about C-section rates.

Planning for the birth of a child can be a wonderful time. It can also be filled with questions and concerns.

You’re probably thinking about the quality and safety of the care you and your baby will receive during and after delivery. You may have heard about a recent Consumer Reports study suggesting that a women’s risk of a cesarean section, or C-section, depends on the hospital she chooses.

In certain situations, a C-section is the safest option for both mother and baby. For example, when the baby is positioned side-to-side in the belly or the placenta is covering the cervix, or if the baby’s heart rate drops during labor. But C-sections, like any surgery, come with risks, such as infections.

To lower or eliminate these risks, hospitals should strive to perform C-sections only when medically necessary. However, how often a hospital performs this procedure depends on several factors, including risk to mother and baby, patient choice and clinician recommendations. In addition, hospitals with strong high-risk obstetrics programs and those caring for women who haven’t received optimal prenatal care are more likely to have higher C-section rates.

In recent years, patient choice and clinical recommendations have played a bigger role in influencing C-section rates at some hospitals. For example, some patients may think a planned C-section will alleviate stress about when the baby will arrive or whether her health care provider will be available for the delivery. Although a C-section is often recommended for women with high-risk pregnancies, our goal at BWH is for women to have a vaginal delivery when possible.

Because of these factors, you won’t be able to discern from a hospital’s C-section rate how many were medically necessary and how many were not. The national benchmark for low-risk pregnancies is 23.9 percent of births by C-section. At BWH, we fall just below the national target, with 23.2 percent of births by C-section. BWH delivers more babies than any other hospital in Massachusetts and specializes in high-risk pregnancies. If the hospital you are considering has a high C-section rate that doesn’t make it a bad place to give birth, for all the reasons detailed above, but you should ask for more information and talk with your obstetrician about the safest birth plan for you and your baby.

OpenNotes: Building a More Transparent Health Care System


Seinfeld fans might remember the episode where Elaine can’t find anyone to treat her rash because of something a doctor wrote in her chart. She spends the whole episode trying to figure out what was in the note.

Although it made for very entertaining television, I’m happy to say that if Elaine were a patient at the Brigham today, she would have instant access to the note with just a few clicks of the mouse. In the spirit of transparency and patient safety, patients can now read doctors’ notes in their electronic health record through a feature called OpenNotes.

This is an important step toward improving communication and empowering patients to be more involved in their care, which improves outcomes. The Brigham introduced OpenNotes in January, giving patients access to summaries written by their physicians.

OpenNotes gives patients the opportunity to validate the information their provider wrote and correct inaccuracies. If a note says the patient has a peanut allergy and they don’t, the patient can simply mark it as incorrect.

During the course of an appointment, a patient may be taking in a lot of information and can forget something the doctor said. OpenNotes includes the doctor’s recommendations so patients can review them after the appointment.

Patients may also choose to give access to their health care proxy or family members.

We are working on making OpenNotes available to inpatients too. Soon everyone will be on the same page!


PS: If you haven’t seen the Seinfeld episode, here’s a quick video produced by OpenNotes featuring snippets of Elaine’s unsuccessful quest.