Developing a Culture of Quality in a Department of Medicine

Beth Israel Deaconess Medical Center (BIDMC)
Boston, Massachusetts, USA

Team

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.
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Aim

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.

 

Measures

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

 

Changes

  • 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.

 

 

Results
Graph_BethIsrael_Flowchart.jpg

Graph_BethIsrael_ColonoscopyWithdrawal.jpgGraph_BethIsrael_DocumentationProblem.jpgGraph_BethIsrael_PrescriptionEpipen.jpgGraph_BethIsrael_Rheumatology.jpg

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