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Posterboard Number:
219
Organization Name:
University of Iowa
Contact Name:
Hillary
Contact Email:
hillary-johnson@uiowa.edu
Description:
Each year in the US, new physician trainees begin graduate medical education with graduated competency and independence in patient care. Simulation-based training for frequent office-based procedures and pateint examination in dermatology has not been studied but has proven effective in reducing workplace injury and improving patient safety in other medical fields. About 8 sharps-related injuries are reported by trainees each year. A new training day using simulation for common skin procedures and full skin examination was implemented before new trainees started providing care to patients.
Aim:
Improve skills and knowledge of patient care practice and workplace safety for resident physician trainees
Actions Taken:
Didactic, video, and hands-on simulation and team-based training was conducted for all dermatology trainees during orientation. Full day practice for procedures like biopsy, injection, and excision and mock-patient visits for full skin examination occurred. Pre-and post-surveys measured gaps in knowledge and perceived skill.
Summary of Results:
Of a total of 29 residents respondents the pre-test survey, the newest trainees showed greatest improvements in knowledge and confidence in their procedural and examination skills. Following the training, more trainees felt comfortable reporting future workplace injuries. Actual reporting of sharps-related injuries remained consistent with prior rates.
Track(s):
Patient Safety
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Posterboard Number:
457
Organization Name:
UT Southwestern Institute for Healthcare Improvement Open School
Contact Name:
Patty
Contact Email:
Patty.brown@utsouthwestern.edu
Description:
The healthcare industry frequently misses opportunities for self-improvement due to the general lack of a standardized process for the collection of event reports. Furthermore, a systematic means of mining vital information from collected event reports does not currently exist in healthcare. The combination of both of these problems presents a barrier to the improvement of patient care not only on an institutional level, but on an industrial level. So, a Quality Improvement team was formed in order to investigate the current problem and attempt to develop a more systematic means to address both aforementioned problems.
Track(s):
Student
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Posterboard Number:
372
Organization Name:
UC Irvine Health
Contact Name:
Lynn
Contact Email:
mwillis@uci.edu
Description:
UC Irvine Health consolidated endoscope reprocessing to three primary locations in 2013. This early adoption of centralized high-level disinfection (HLD) practices resulted in significant improvements in quality and safety. However, varied approaches to pre-cleaning and transportation of endoscopes remained, placing the organization at risk for quality and safety issues, as well as regulatory non-compliance. In response to these findings, the Executive Leadership team chartered a multidisciplinary Disappearing Task Force (DTF) focused on system redesign which would result in standardization and best practices for the pre-cleaning and transportation of endoscopes while remaining FTE neutral and eliminating waste /unnecessary complexity.
Aim:
Rapid-cycle implementation of best practices for precleaning and transportation of endoscopes while remaining FTE neutral.
Actions Taken:
The DTF used Lean Six Sigma methodology to identify causal factors/root causes for process variation and determine optimal improvements. Existing best practices for transportation from the GI endoscopy lab were scaled for house-wide implementation. Standardized precleaning workflow, aligned with pre-made supply kits (channeled vs unchanneled scopes) was also implemented.
Summary of Results:
Through shared leadership/accountability for system redesign, cost control and team commitment to eliminating unnecessary complexity, quality, safety, staff satisfaction and regulatory compliance were improved. The organization was able to reduce pre-cleaning and transport process variation by 75% and 83% respectively, and had no finding during their recent Joint Commission survey.
Track(s):
Patient Safety
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Posterboard Number:
525
Organization Name:
The Stephen and Alexandra Cohen Children’s Medical Center of New York
Contact Name:
Sharon
Contact Email:
sgoodman3@northwell.edu
Description:
Average Length of Stay for children with Special needs at Cohen’s was 0.6 days higher than children without. These children were provided the same services as children without unique needs leading to lower patient satisfaction. Research supports the individualization of care to prevent aversion to future medical treatment.
Aim:
Decrease the average hospital length of stay by .6 days for children with special needs
Actions Taken:
A multifaceted program for all providers caring for children with special needs was designed to individualized care. The program included an assessment tool and a special symbol to identify children with special needs. The “Bee Mindful” program was implemented utilizing a multi-modal e-learning module identifying unique needs of this population.
Summary of Results:
Average Press Ganey scores for “staff addressing personal needs” after implementation increased. The average length of stay for children with special needs was decreased from 4.5 days to 2.60, representing a 1.9 day decrease. This improvement leads to a projected cost savings of $378,000 annually
Track(s):
Quality Cost and Value
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Posterboard Number:
260
Organization Name:
Massachusetts General Hospital
Contact Name:
Jordan
Contact Email:
jpbloom@partners.org
Description:
Coronary artery bypass grafting (CABG) is a complex surgical procedure typically requiring cardiopulmonary bypass and high-dose anticoagulation. As a result, it has historically resulted in the need for significant intraoperative blood product usage (IBPU). Many studies have found a direct association between blood product usage and increased cost, morbidity and mortality. Using autologous blood and colloid fluid replacement, it’s often possible to perform CABG without donor blood. However, there is significant variation in IBPU at the surgeon and institutional level. We sought to reduce IBPU at our institution by developing a decision support algorithm and notification system.
Track(s):
Student
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Posterboard Number:
472
Organization Name:
University of Minnesota School of Nursing
Contact Name:
Razaq
Contact Email:
aded0014@umn.edu
Description:
The project is conducted in a nursing home, made up of multiple disciplines (nursing, therapy, social work, dietary, housekeeping, maintenance, etc) whose members lack communication and teamwork skills. The resulting negative work culture places patients at risk for safety/quality errors. In this project, the change team implemented the tools of TeamSTEPPS including education on effectiveness of communication, team and teamwork, and culture change, using Kotter's Model, and involving TeamSTEPPS-trained instructors/content experts, specially trained coaches/mentors and an embedded continuous approach to patient safety. Pre-implementation data using two survey tools and staff/patient interviews are compared with similar data at post implementation.
Aim:
To evaluate staff perception of interdisciplinary communication and teamwork following implementation of TeamSTEPPS
Actions Taken:
Between July 20 and August 20, 2016, resident interviews, staff interviews, resident focus group and staff focus group sessions, all revealed the extent of communication problem in the facility. Two staff surveys (NHSPS and T-TPQ) were given while initial training was conducted in September.
Summary of Results:
The pre-implementation qualitative and quantitative data indicates that significant number of both staff and residents perceive communication and teamwork as lacking in the system. Respondent see a correlation between safety problems and poor communication. One month after (October 2016), a repeat survey would be distributed to compare results.
Track(s):
Patient Safety
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Posterboard Number:
528
Organization Name:
Scottish Government
Contact Name:
Shaun
Contact Email:
54maher@gmail.com
Description:
Relational elements of care are vital to our ambition to create a health and social care system in Scotland that is person-centred, safe and effective. The prevailing culture and pace of activity often makes prioritising these important skills difficult.
Using the strapline 'Ask what matters... Listen to what matters... Do what matters' we set out to raise the profile of the 'What matters to you?' approach. Our aims were:
-to connect people working in health and social care,
-create space for people to have more meaningful conversations,
-provide care and support based on what matters to people using services
Aim:
To hold a national ‘what matters to you? day on June 6th 2016
Actions Taken:
We created a guiding coalition to lead the work.
Website and free materials including badges, stickers and posters.
Encouraged participants to adapt and use materials locally.
Promoted the day widely using traditional communication channels into organisations as well as into informal networks through social media.
Attempted to engage political leaders.
Summary of Results:
578 teams took part. 527 teams in Scotland and a further 48 teams from 13 countries around the world.
Teams from a range of backgrounds participated including health, social care, prison healthcare, primary and secondary schools and early years.
Some good examples of conversations leading to QI activity.
Track(s):
Person- and Family-Centered Care
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Posterboard Number:
78
Organization Name:
Tulane University School of Public Health & Tropical Medicine
Contact Name:
Catherine
Contact Email:
ccounts@tulane.edu
Description:
The IHI Open School Change Agent Network (I-CAN) curriculum aims to provide students with project-based leadership training during their Leadership and Organizing to Improve Population Health course. A master’s level Quality Management course with students from MHA, MPH, and MD/MPH programs integrated pre-existing coursework with the internet-based I-CAN curriculum in collaboration with the IHI Open School. For the class project, students were split into interdisciplinary teams and assigned a medical school student run clinic. Students were responsible for reaching out to the organizations and developing a project that would evaluate an existing process or care gap.
Aim:
Evaluate students’ interpretation of the integration of live classroom, online learning, and hands on experience.
Actions Taken:
At the end of the semester long course students were surveyed on their perception of various aspects of the implementation of this integrated model. This serves as a summary of those results such that other programs considering a similar model can apply lessons learned to their own unique circumstances.
Summary of Results:
The expectations entering the course followed a bell curve, and those expectations were met or exceed for 90% of the students. Reactions to the course and its various components were diverse, however overall most students finished with a positive and applicable experience of a real-world quality improvement project.
Track(s):
Student
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Posterboard Number:
59
Organization Name:
Nationwide Children's Hospital
Contact Name:
Bob
Contact Email:
bob.feeney@nationwidechildrens.org
Description:
Transplant recipients face many challenges during the post transplantation phase. Lung recipients have the lowest survival rate of all solid organ transplants with a 5 year survival rate of 46%. Therefore it is important that proper care is maintained to promote adherence to a complicated medical regimen. The objective of this project is to decrease the missed opportunities to provide comprehensive care as indicated on the Lung Transplant Index for outpatient lung transplant recipients from a 2014 baseline of 101 missed opportunities to less than 24 cumulatively for 2015.
Aim:
Decrease the missed opportunities to provide comprehensive care as indicated on the Pediatric Transplant Index.
Actions Taken:
A measurement system was implemented to track the number of times we successfully completed each of 12 care categories. Definitions for each category of comprehensive care were agreed upon by a multidisciplinary team. Transplant coordinators collected data from the electronic medical record to be analyzed by the Transplant QAPI team.
Summary of Results:
Significant improvement in performance occurred in the lung transplant program. There was an 89.5% decrease in the number of missed opportunities, from 46.7% missed in 2014 to just 4.9% missed in 2015. This project shows the importance of measuring performance and can quickly and easily be applied to other hospitals.
Track(s):
Improvement Capability
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Posterboard Number:
314
Organization Name:
Arizona State University
Contact Name:
Kristen
Contact Email:
kkwill@asu.edu
Description:
The healthcare system is dynamic and complex. Comprehensive, high value patient-centered care incorporates many facets of the healthcare system that are often lacking in traditional healthcare training models, particularly in postgraduate physician training programs. To close this gap, the Accreditation Council for Graduate Medical Education (ACGME) developed the Clinical Learning Environment (CLER) “Pathway to Clinical Excellence” program. Despite these measures, medical educators continue to find integration of a system-based practice curriculum difficult to implement.
Aim:
We describe an innovative new pilot program, integrating system-based practice curricula into graduate medical education.
Actions Taken:
The curriculum was developed through partnership between university faculty and a regionally adjacent academic medical center. Curriculum implementation was developed to span over 8 months with a blended learning format (in person and online learning). Pre- and post-course evaluations were developed for a summative review.
Summary of Results:
A total of 21 participants were enrolled in the course. Pre-course evaluations found participants were lacking in system-based practice knowledge (average Likert Score of 2.79; p-value <0.001). Post-course evaluations were analyzed at culmination of the course and showed improvement in the participants understanding (average Likert Score of 4.35; p-value <0.001
Track(s):
Triple Aim for Populations
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