Hospital has unique marriage of research center and QI team

Regular meetings spur new initiatives

What hospital quality manager wouldn't want to have a renowned research center that investigates the leading issues in quality and safety based right within his or her own facility? Certainly not Jan Fitzgerald, MS, RN, CPHQ, director of quality and medical management at Baystate Medical Center in Springfield, MA, which also is home of the Center for Quality of Care Research (CQCR).

"They really help give Baystate Health a place at the research table nationally, and they are into a great number of things that help our work here, which includes providing care to patients," she says. "We meet weekly, which allows for a lot of discussion and state-of-the-art presentation and review of not only what we've looked at here, but at other things going on in the research world that may relate to what we're doing. That keeps us ahead of the wave on research."

Part of her work, she adds, involves translating research into practice, "and making us aware of what's coming down the road in changes in clinical care or core measures enables us to do baseline or scout data where we know our strengths and weaknesses."

The rationale for the CQCR, which was established about two years ago, grew out of Baystate's mission, explains director Peter Lindenauer, MD, MSc. "As part of our mission around the advancement of knowledge, we felt there was an opportunity to build upon existing successes a group of investigators was having and formalize that into a full-fledged research center," he says.

"An even more central mission of Baystate Health is to be a national leader of quality of care and to be recognized for it," he adds. "One of the ways you can do that is by delivering great care, and we strive to do that, and we have a large QI program devoted to it. We can also contribute to that recognition by being a thought leader in the measurement of quality and safety." Along those lines, the center has published a number of studies in leading journals, including the Journal of the American Medical Association (JAMA).

Baystate, Lindenauer explains, is the western campus of Tufts School of Medicine. "Members of our center are faculty members who have an interest in pursuing research around quality improvement, quality of care, and patient safety," he notes.

Very strong linkages

"One of the exciting aspects of our center is that we are part of the division of health care quality at Baystate, so we have very strong linkages to the QI staff and physicians," notes Lindenauer. "Many of the faculty members within our center, in fact, have operational roles in QI at our hospital. For example, one of our investigators is the hospital epidemiologist in charge of infection control prevention. With her, we are studying C. difficile. I am medical director of clinical decision support and am intimately involved in leveraging our information systems to improve safety and quality of care — primarily around medication safety."

These linkages are not accidental, Fitzgerald notes. "Several years ago, Peter worked as one of the medical directors in the division of health care quality," she says.

All of this creates "a very fertile environment for identifying topics of study and for identifying important issues and then for feeding back the results of those investigations to our own institutions," Lindenauer says. "Members of our center attend regular divisional meetings where we hear about what the PI staff are working on this quarter, or what the latest Hospitalcompare data are, and, similarly, they hear about what we're working on. Our weekly research meetings for the center are attended by a significant number of members of our division of health care quality — everyone from the nursing director of performance measurement and improvement to the medical director of quality. Often, we will invite staff within the division to present some of the projects they are working on, with the hope we will turn some of that into scholarly work that can be disseminated."

"We have lots of different ways things get reported," Fitzgerald adds. "We have trigger tools to look through randomly selected cases; hospital-acquired conditions lists; and serious reportable events and our internal safety reporting system. We can analyze the data and come up with areas where we look for opportunities to improve. We send these along to generate baseline ideas or opportunities for some actual formal clinical research."

The Wednesday meetings, she continues, "are almost like sounding boards. It's been a great opportunity for us as well as for them. Things that have historically been conundrums can be reviewed and sometimes put through the research process. It's a great marriage for us."

Already bearing fruit

This unique "marriage," as Fitzgerald puts it, already is bearing fruit. "There's a study we did looking at about 500 hospitals at the rates of use of potentially inappropriate medications among the elderly that are associated with a high number of side effects," Lindenauer shares. "We did this study and published it in the Journal of Hospital Medicine, and it showed relatively high rates of use of these medications, and as a consequence of that and follow-up data, we've been doing a project in our hospital in which we use CPOE to alert physicians to the potential dangers of those drugs. So here's a case where we identified a problem nationally and put it to work at Baystate. Hopefully, we'll learn from our intervention whether it works — to see if alerts in CPOE led to improvement."

Fitzgerald further explains the intervention. "We've actually linked the information back through our computers, so if I am older than 65 and have this co-morbidity and the doctor orders one of these drugs, it will give me an alert that by ordering this drug the patient is at increased risk for X, Y, or Z," she says. "So, we are actually taking Peter's work and driving it to the bedside."

"We've also done a lot of studies on COPD, and have published in JAMA and in the Annals of Internal Medicine," Lindenauer reports. "As a consequence of some of our learnings, Baystate is embarking on a care redesign initiative around that. I'm helping to co-lead those efforts, and we're looking at protocols we can use with the ultimate goal of better outcomes such as lower rates of readmission."

Some protocol changes already have been instituted, Fitzgerald says. "They had published a paper that said IV steroids are not any more beneficial than 'PO' steroids," she says. "Within the past 12 months, we have taken that evidence and translated it into a care change. We took out the IV option for steroids; the only option is PO."

With that change, she adds, the physicians were given "reference texts." "We used our MD bulletin and other vehicles to let the doctors know we made the change, but the reference text gives them the rationale," she explains.

In terms of the care redesign initiative, she continues, "we're having ongoing discussions about where we are and where we need to go. We're fortunate to have CPOE so we can translate information into order sets that drive care and leverage the capacity of the computer to do alerts, tasks, and prompts."

Fitzgerald is very positive about how this "marriage" is working out. "Just the fact that you think about and talk about these things puts the care you deliver in a different echelon; it keeps you right out there in front," she says.