Naama Neeman, MSc, Department of Medicine, Quality Improvement Specialist
Mark L. Zeidel, MD, Department of Medicine, Chair
Alex Carbo, MD, Director of Quality Improvement, Hospital Medicine
Anjala V. Tess, MD, Director, Resident Quality Improvement Curriculum
Julius J. Yang, MD, Co-Director of Quality Improvement, Hospital Medicine
Mark D. Aronson, MD, Department of Medicine, Vice Chair for Quality

***Watch a video clip of Beth Israel Deaconess Medical Center's improvement work shared at IHI’s 19th Annual National Forum.***

To successfully design and implement a comprehensive Quality Improvement and Patient Safety (QI/PS) program for the BIDMC Department of Medicine that will enhance our institution’s quality mission, as well as serve as a road map for other Departments of Medicine committed to implementing similar efforts.

Examples of improvement measures included in the BIDMC Medicine QI/PS program:

• Compliance with recommended guidelines for colonoscopy withdrawal time
• Follow up on abnormal screening tests results
• Documentation of allergies in electronic medical records
• Prescription of self-administered epinephrine for patients at risk for anaphylactic reactions
• Documentation of procedural notes for injections and aspirations
• Appropriate initiation of tuberculosis skin testing (PPD) for patients receiving infliximab

• Focused the Department’s clinical operating plan on patient safety and quality of care and challenged the faculty to make the department a national leader in quality of care. 
• Designed and implemented a comprehensive Quality Improvement and Patient Safety (QI/PS) program for the BIDMC Department of Medicine.
• Hired administrators who were assigned to develop and manage QI/PS programs under the direction of the Vice Chair for Quality. 
• Extracted data from electronic medical records, an administrative billing system, disease-related patient registries, pharmacy and laboratory databases, patient surveys, and other information systems for the development of division-based dashboards.
• Confirmed and refined the ascertained data elements for clinical relevance and accuracy.
• Developed division-based dashboards that focus on quality indicators deemed to be highly relevant to the individual clinical discipline.
• Utilized the dashboards data to evaluate divisional performance over time and to identify areas for improvement and areas of best practice.
• Worked with multidisciplinary teams of physicians, nurses, pharmacists, and other groups invested in improving care delivery to identify weaknesses in care delivery, examine their impact, consider alternatives, and initiate processes to address these areas.
• Implemented numerous divisional improvement processes.
• Organized improvement projects around the Plan-Do-Study-Act (PDSA) model, which was used to develop, test and implement proposed changes rapidly by using a “trial and learning” approach.  
• Monitored performance and outcome measures over time to test improvement processes and refined these processes when needed.
• Presented findings and results of improvement projects in divisional faculty meetings as well as the Department’s monthly division chief meetings.
• Provided performance feedback to the divisions as well as to individual caregivers on an ongoing basis. Physicians were also provided with the names of patients whose care did not meet the standard for follow-up purposes. 
• Ensured that feedback was provided in a respectful and supportive manner which demonstrates an understanding of physicians’ current practice patterns and their impact on overall divisional performance.
• Focused performance criteria on the division as a whole, in order to enhance teamwork and motivate performance improvement. Whenever individual performance was evaluated, the data was blinded to avoid a blaming or punitive culture.
• Set a goal of 100 percent compliance for process measures and achievable benchmarks for outcome measures.

Summary of Results:

• Colonoscopy withdrawal time: Increase in compliance rate with recommended guidelines (i.e., withdrawal time => 7 minutes) from 63 percent compliance (February 2006) to 99 percent compliance (April 2007)
• Follow up on abnormal screening tests results: Attainment of 100 percent follow-up on abnormal Pap smear, fecal occult blood test, and mammography
• Documentation of allergies: Adding an electronic reminder system resulted in increased documentation of allergies in the electronic medical records. Allergy documentation rate increased from 66 percent in May 2006 to 87 percent in December 2006.
• Prescription of self-administered epinephrine for patients at risk for anaphylactic reactions: Documentation of epinephrine (Epipen / Twinject) prescription for patients with a history of a prior anaphylactic reaction, in either the medication list or progress note in the electronic medical record, increased from 50 percent (January 2006) to 100 percent (July 2006)
• Documentation of procedural notes for injections and aspirations: Documentation of appropriate procedural notes for injections and aspirations increased from 28 percent in Q1 2006 to 60 percent in Q2 2006. (An “appropriate note” includes explanation of the procedure’s risks and benefits to the patient; documentation of verbal consent; description of the procedure; reports on complications; and documentation of post-procedure instructions given to the patient.)
• Appropriate initiation of tuberculosis skin testing (PPD) for patients receiving infliximab: Attainment of 100 percent provision and documentation rate of PPD tests for patients receiving infliximab and a 100 percent INH (isoniazid) treatment rate for patients with a positive PPD

Lessons Learned:

Our experience suggests that key ingredients for a successful Medicine QI/PS program include:

• Direct involvement of leadership
• Appointment of QI administrators
• Engagement of clinicians from all disciplines to serve as “QI champions”
• An effective approach to deal with resistance to change
• An inter-departmental collaboration, particularly when relating to the development and maintenance of health information technologies, as well as a close collaborative relationship with the hospital’s Departments of Nursing, Pharmacy, and Health Care Quality

Naama Neeman, MSc, Quality Improvement Specialist
Beth Israel Deaconess Medical Center
nneeman@bidmc.harvard.edu

[Posterboard presentation at IHI's December 2007 National Forum]