How to get house staff involved in QI and safety

Idea from NY-Presbyterian garners award

How do you get residents interested and involved in patient safety and quality improvement? It is, after all, one of many requirements made of medical students by the American Council of General Medical Education.

But at NewYork-Presbyterian/Columbia and NewYork-Presbyterian/Weill Cornell Hospital, house staff members themselves came up with a unique way of engaging and making a difference to the safety of their patients, says Eliot Lazar, MD, MBA, senior vice president and chief medical officer for quality and patient safety at the two facilities. The residents' efforts led the National Quality Forum and Joint Commission to name NewYork-Presbyterian a winner of the 11th annual John M. Eisenberg Award for Patient Safety and Quality.

The Housestaff Quality Council was created in 2008, and since then has promoted greater house staff participation in quality and patient safety initiatives by partnering with key constituencies to ensure that processes and systems are in place to avoid medical errors, says Lazar.

He calls the results achieved by the council "amazing," including greater than 90% compliance with medication reconciliation — the result of a quick-turnaround program that in a matter of weeks produced an information technology solution that inserted a hard stop into the electronic health record and computerized physician order entry (CPOE). The results were published last year in the American Journal of Medical Quality1.

The group also achieved a 70% reduction in the use of paper in laboratory orders, and creation of a process to codify situations in which house staff need to seek advice from more senior staff.

Resident quality and patient safety officer

One of the most novel results of the council was the creation of a resident quality and patient safety (QPS) officer, Lazar says. "I think this may be the first time in the nation that there someone who is formally designated for this role."

It was such a boon to helping both a hospital achieve its patient safety goals and residents to meet the core competency requirements as defined by the ACGME, that Lazar and colleagues wrote the idea up for publication last summer in Academic Medicine2. He says the council is "an integral part of the rigorous goal setting process. We have seven main categories, 30-plus initiatives and 50 'elements of performance.' And the council members' input is a key part of the process."

House staff are in the thick of health care, and have a great perspective of what areas need attention, Lazar notes, so when some house officers and a faculty member approached Lazar and other administrators to get more involved in quality and patient safety, they thought it was a great idea.

There are now two councils, one associated with NewYork-Presbyterian/Columbia, and one with NewYork-Presbyterian/Weill Cornell. They meet monthly to discuss quality and safety issues, often come up with the solution to any problems, and then act as the conduit to get input from other house staff members — there are some 2,000 on the two campuses — and disseminate the solutions.

Recognition, validation

"I do not think we would have identified all of the issues without their input," says Lazar. There are a number of issues he does not think administration would have known about and no forum for house staff to voice their concerns or ideas about them.

"And I do not think we would have been able to make the kind of improvements as rapidly as we have been able to do because of their willingness and commitment to disseminate the message," he says. "We have a situation, we bring it to them, we say, 'Here is the problem, what is the solution?' Even if we thought of the solution, we have a venue with a dialogue that can determine if it will work. It is the ultimate beta test."

Since the council was formed, the council members have spoken about it in numerous venues, and Lazar says other training programs have contacted the hospitals to see if it is something they could incorporate into their programs.

But the recognition of the Eisenberg Award is beyond that kind of validation. "The most important element is that it is recognition for the founders and the council leaders, and it reinforces that groups like this are really important," says Lazar. "I wish we had something like this when I was a house officer. This will spur on others to follow suit and let them know they can make a significant difference."

NewYork-Presbyterian's chief executive officer, Steven Corwin, MD, says that the council is a "prime example of how engaged clinicians help the hospital to fully understand and address quality and safety challenges" and that the great progress made recently in patient safety and quality improvement at the two hospitals "would not have been possible without our outstanding residents and the culture of teamwork that has become embedded in our institution and fostered by the Housestaff Quality Council. [It] is emblematic of how we can successfully collaborate with multiple disciplines to deliver the safest and most compassionate care, and the best outcomes for our patients and their families."

Other winners

The Eisenberg Awards were delivered in Washington, DC, on April 5, 2012. They recognize major achievements of individuals and organizations in improving patient safety and health care quality, consistent with the aims of the National Quality Strategy — better care, healthy people and communities, and affordable care.

Other winners included:

Kenneth I. Shine, MD, University of Texas, "for his multiple leadership roles that have helped to improve quality and safety in health care nationwide," according to the TJC announcement.

"Over the course of his tenure as president of the Institute of Medicine, Shine established the Quality of Care in America Project, which led to the landmark reports, To Err is Human and Crossing the Quality Chasm, helping to put safety and quality on the national agenda. As the founding Director of the RAND Center for Domestic and International Health Security, he led the efforts to make health a central component of US foreign policy and guide the center's evolving research agenda," according to TJC.

A cardiologist and physiologist, Shine is now executive vice chancellor for health affairs for the University of Texas Medical System.

The Society of Hospital Medicine (SHM) of Philadelphia, PA, for "its Mentored Implementation model, designed to further frontline quality initiatives," according to TJC.

"By employing a mentor, typically a hospitalist-expert in quality improvement and other relevant content, hospital teams are provided with the guidance they need to implement best practices and improve quality more rapidly," according to TJC.

"To date, SHM's mentors are in place in more than 300 hospitals around the US and Canada in three signature quality improvement initiatives focusing on care transitions, glycemic control, and venous thromboembolism prevention," according to TJC.

Henry Ford Health System, Detroit, MI, in recognition of its No Harm Campaign, launched in 2008 "to integrate harm reduction interventions into a systemwide initiative and eliminate harm from the health care experience," according to TJC. "The campaign aims to decrease events through enhancing the system's culture of safety by reporting and studying them, researching their cause, identifying priorities, redesigning care to eliminate harm, and employing a comprehensive set of measures across their facilities. From April 2008 to June 2011, using a defined set of measures that has expanded over time, the system experienced a 26% reduction in harm events and 12% reduction in mortality."

Jerod M. Loeb, PhD, The Joint Commission, awarded an honorary lifetime achievement award to recognize his "extraordinary and sustained contributions to health care quality and patient safety."

During his 18 years at The Joint Commission, Loeb has led efforts to identify, evaluate, and implement performance for Joint Commission accreditation and certification programs.

For more information on this topic, contact Eliot Lazar, MD, MBA, Senior Vice President and Chief Medical Officer for Quality and Patient Safety, New York-Presbyterian Hospital, New York, NY. Telephone: (212) 746-0386. Email: ejl9001@nyp.org

References

  1. Evans AS, Lazar EJ, Tiase VL, et al. The role of house staff in implementing medication reconciliation on admission at an academic medical center. Am J Med Qual. 2011 Jan-Feb;26(1):39-42. Epub 2010 May 25.
  2. Fleischut PM, Evans AS, Nugent WC, et al. Ten years after the IOM report: Engaging residents in quality and patient safety by creating a House Staff Quality Council. Am J Med Qual. 2011 Mar-Apr;26(2):89-94.