Q Report Spring 2015

Spring 2015

NOT SO BASIC TRAINING QUALITY IMPROVEMENT HAS BECOME A KEY PART OF RESIDENCY TRAINING

WORKING TOGETHER TO ENHANCE QUALITY AND OUR PATIENTS’ EXPERIENCE

We’re listening.

Are you and your team helping to improve quality and patient safety at UF Health? Tell us how your team is involved in improving quality and the patient experience.

The first five people who share their stories with us before June 1 will be featured in an upcoming issue of The Q Report.

In addition, if you want to share your thoughts on any of the stories featured in this issue, please click on the “We’re Listening” link on the top of The Q Report homepage, qreport.health.ufl.edu.

table of contents:

1 In the Q 2 Quality Leader 4 Medication Safety 6 Cover Story

12 A Year of Great Catches

IN THE Q Randy Harmatz, M.B.A. Chief Quality Officer, UF Health Sebastian Ferrero Office of Clinical Quality and Patient Safety

Celebrating our Heroes National Patient Safety Week was March 9-13, and at UF Health we celebrated in a big way. During the course of the week we recognized both teams and individuals who truly embrace our mission of making quality Job No. 1.

Events included national speakers on patient safety and improving the patient experience, informational sessions about safe practices, a virtual tour of unit-based patient safety and quality initiatives, and much more.

One highlight of the week was the poster session, which showcased more than 80 ongoing projects across UF Health focused on improving some important aspect of patient safety and quality.

The three winning entries are all excellent examples of projects that not only improve care to our patients but also help drive us closer to achieving our goal of receiving five stars from the University HealthSystem Consortium. The entries included: First Place, “Pharmacy Driven Medication Reconciliation: Results of a Four-Month

Pilot Program;” Second Place, “COPD Readmission Reduction;” and Third Place, “Interdisciplinary Intervention to Decrease ED Utilization by Sickle Cell Disease Super Utilizers.”

A recognition dinner was also held to honor and thank the more than 30 individuals who stepped up, intervened and prevented potential harm to our patients — our Great Catch Award winners. In addition, five individuals were recognized for their outstanding contributions to patient safety and quality over the past year. Those honorees included: Carolyn Holland, M.D.; Nicole Iovine, M.D.; Amy Rosenberg, Pharm.D.; Eric Rosenberg, M.D.; and William Lee Titsworth, M.D., Ph.D. Taking the time to recognize and celebrate the heroes among us is so important to fostering a culture of safety — and something we should do more frequently. So the next time you see a coworker stepping up for patient safety, be sure to say thank you.

— RANDY HARMATZ

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by MICHELLE CHAMPALANNE

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“Some people go on a boat and some people go hunting, and I try to fix these issues in a hospital ...”

College of Medicine department of neurosurgery

Lee Titsworth For Lee Titsworth, M.D., Ph.D., chief resident in the College of Medicine department of neurosurgery and chair of the Housestaff Quality and Patient Safety Committee, quality improvement is more than just a job. It’s a hobby.

“Some people go on a boat and some people go hunting, and I try to fix these issues in a hospital,” he said.

He enjoys challenges such as reducing hospital-acquired infections, especially when there’s a simple solution. However, two years ago he noticed that UF Health lacked a system of communication when it came to discussing quality improvement ideas between departments.

Titsworth wanted UF Health staff to be able to share ideas easily and improve the patient’s stay efficiently and effectively.

“The science of improvement through streamlining processes so you can build cars better is not that vastly different from improving processes so that you can treat patients better,” he said.

He worked with Randy Harmatz, M.B.A., UF Health Clinical Quality and Patient Safety senior vice president and chief quality officer, to develop a 12-person committee where UF Health staff could discuss together patient safety or quality issues within their hospital departments

QUALITY LEADERS

— Lee Titsworth, M.D., Ph.D., chief resident in the

and create improvement projects that offer a solution.

“If I can get one person from every area of the hospital, and mention a problem, between the 12 people there, you’re going to be able to figure out a really good answer,” he said. “It’s because doctors don’t think like nurses, nurses don’t think like housekeepers and housekeepers don’t think like doctors.”

The committee has also pushed education, especially for incoming housestaff, who now enroll in six hours of quality improvement training before joining the UF Health team. This has allowed new members to strengthen their communication skills, confidence levels and knowledge about the UF Health system.

“Just the fact that this committee even exists is a demonstrable improvement from where we were two years ago,” he said.

One example of quality improvement stemming from this is a 300 percent increase in the rate of filing patient safety reports. Data research has allowed Titsworth to see the importance of fixing small problems that lead to greater positive changes.

“I think the success of fixing problems we have in medicine comes from reaching across department lines and reaching across staffing lines all along the chain,” he said.

— MICHELLE CHAMPALANNE

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Quality researchers to address benefits and challenges of e-prescriptions UF Health will soon provide classes that address and counteract common problems associated with electronic prescribing. Electronic prescriptions, or e-prescriptions, enable providers to quickly, safely and effectively order medications for patients. The process eliminates errors associated with handwritten prescriptions, such as illegible script, and improves patient safety and quality of care.

4 | The Q Report | Spring 2015

the pharmacy will receive two sets of conflicting guidelines.”

E-prescribing is used throughout UF Health at UF Health Shands, UF Health Physicians outpatient practices and UF Health pharmacies.

Providers enter prescriptions into Epic, an electronic medical record system that processes orders and sends them to a pharmacy for staff or patients to collect.

However, switching from handwritten to electronic prescriptions is a more complex process than simply shifting communication to an online medium. Because of this, a team of UF Health Physicians quality and medication safety researchers are developing continuing education classes for UF Health Shands pharmacists and providers. Courses are slated to begin later this year.

“It’s crucial to understand that the system is vastly more complicated than it appears,” said Anzeela Schentrup, Pharm.D., Ph.D., C.P.H., BCPS, a clinical assistant professor in the College of Pharmacy and UF Health Physicians director of ambulatory clinical quality. “There’s more to the process than putting information online.

Epic fuses technology and security, providing both quality-improvement triumphs and new complications to overcome.”

Benefits include alerts to irregularities, access to insurance information, managed medication

costs, reduced wait times and increased patient satisfaction.

However, the system is susceptible to errors that pharmacists are left to catch. Differing medication instructions is a common problem associated with e-prescribing.

“For example, for some medications, when providers enter a prescription, directions for taking the medication are automatically filled by Epic,” said Omjoy Ganesh, Ph.D., Pharm. D., C.P.H., a UF Health Physicians and College of Pharmacy health care quality and safety fellow. “If doctors write their own set of instructions specifically for the patient and don’t delete the automatically generated directions, the pharmacy will receive two sets of conflicting guides.”

The classes will explore issues providers and pharmacists face with More information about the courses e-prescribing and equip attendees will be available with the knowledge to correct them. in the coming months.

More information about the courses will be available in the coming months.

“Our goal is to help them better understand the e-prescription system so they have the tools to deal with potential problems,” Schentrup said. “It’s our job to ensure the system is continually working to provide the highest quality care for our patients.”

MEDICATION SAFETY

“If doctors write their own set of instructions specific for the patient and don’t delete the automatically generated directions,

— LAURA CASTRO

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NOT SO BASIC TRAINING QUALITY IMPROVEMENT HAS BECOME A KEY PART OF RESIDENCYTRAINING

Andrew Pierce, M.D., a resident in the College of Medicine department of psychiatry, and Aili Mildh, a nurse at UF Health Shands Hospital 6 | The Q Report | Spring 2015

COVER STORY As a medical student, San Chang, M.D., attended lectures on medical errors, quality improvement and patient safety. But it wasn’t until he started his residency in psychiatry at UF Health and was assigned to tackle a quality improvement project that he began to grasp what the term truly meant.

“Coming into residency, you think if you know your science and make the right medical decisions, that is all you have to do,” said Chang, now in his last year of residency and serving as a chief resident in the College of Medicine department of psychiatry. “Over time, you realize there is a lot more to it. There are a lot of things that affect the patient every day — how you communicate, your computer systems … There is an additional layer of complexity and things you need to be aware of to take good care of people.”

For residents, entry into residency means not only learning the ins and outs of their chosen specialty, but also becoming a crucial part of a health care team.

Ensuring residents understand the myriad things within a health care system that can affect a patient’s care — and that they can effect the change needed to make improvements — is vital, which is why UF Health leaders have increased the focus on it in recent years.

— APRIL FRAWLEY LACEY

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Not only are individual residency programs focused on quality — typically involving residents in quality improvement projects and holding annual events centered around quality and patient safety education — the College of Medicine Graduate Medical Education Office has launched several measures to ensure that quality improvement and patient safety are integral parts of residency training across the board.

“Improvement of the quality of patient care has always been an integral part of the practice of medicine, but it is only relatively recently that we have recognized the need for a structured, disciplined approach to the evaluation of quality measures,” said Lisa Dixon, M.D., who was recently appointed associate dean of graduate medical education in the College of Medicine. “It isn’t until we pause, reflect and investigate that we identify the changes that can positively impact the care we deliver.”

Most notable among these efforts is the Housestaff Quality and Patient Safety Committee, established two years ago as a way to bring more residents into the quality and patient safety fold. Currently led by Lee Titsworth, M.D., Ph.D., chief resident in the College of

Medicine department of neurosurgery, the committee consists of residents representing nearly every UF Health residency program. The committee meets regularly to discuss systemwide quality and patient safety initiatives, information which they then share with the other residents in their programs.

“The committee communicates with the institutional quality group so that patient safety and quality goals are aligned across UF Health,” said Michael Mahla, M.D., former director of graduate medical education in the College of Medicine.

In addition, all residents are now required to complete modules from the national Institute for Healthcare Improvement as well as training to help them better teach other residents and medical students.

These focused efforts are making a notable difference in residents’ understanding of the role of quality improvement in health systems. This year, the Accreditation Council on Graduate Medical Education — the governing body for medical residency in the U.S. — released the results of a Clinical Learning Environment Review conducted at UF Health last fall. It was the first time

“IT IS VERY IMPORTANT FOR RESIDENTS TO BE EXPOSED TO QUALITY IMPROVEMENT AND PATIENT SAFETY, OTHERWISE WE WOULD LEAVE WITH AN INCOMPLETE VIEW ON HOW TO GIVE THE BEST CARE POSSIBLE.”

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— San Chang, M.D.

WE NEED TO TAKE OUR KNOWLEDGE AND CREATE A BETTER SYSTEM AND SERVE OUR PATIENTS TO THE BEST OF OUR ABILITIES.” — Andrew Pierce, M.D.

80

%

OF RESIDENTS UNDERSTAND UF HEALTH GOALS

COVER STORY

FINDINGS FROM THE ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION’S CLINICAL LEARNING ENVIRONMENT REVIEW:

93

%

OF RESIDENTS BELIEVE IT IS A SAFE, NON-PUNITIVE ENVIRONMENT FOR REPORTING ERRORS

62

%

OF RESIDENTS INVOLVED IN AN ADVERSE EVENT FILED A PATIENT SAFETY REPORT

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ACGME has conducted such a review, and the findings were promising, said Cristin Owens, manager of housestaff affairs in the Graduate Medical Education Office.

“Overall, they were really impressed with the housestaff’s and nurses’ knowledge of what is going on [with quality and patient safety],” Owens said. “They were very happy with resident and fellow engagement. They are not disconnected from quality efforts.”

Given residents’ busy schedules, loaded with clinical and teaching obligations, taking the time to become involved in quality improvement efforts may seem like too much to take on, but the projects themselves actually can help improve processes and make them more efficient — ultimately saving time, said Andrew Pierce, M.D., a second-year resident in the College of Medicine department of psychiatry .

Pierce and Chang, who serves on the Housestaff Quality and Patient Safety Committee, are both part of a quality improvement project linked to improving patient handoffs within psychiatry. The project is part of a larger, systemwide initiative to make patient transitions through the hospital system smoother and more efficient.

“This is a chronic, nationally studied issue,” Pierce said.

“During handoffs, a lot of information can get lost. That is something the hospital as a whole has recognized. We are focused on how to best implement change within our program. As you can imagine a surgeon sign-out is different from a psychiatrist’s sign-out. One of the benefits to having residents involved in this project is we really understand from the beginning how this will affect our daily workflow.”

And although time is a factor for residents, Chang feels residency training would not be complete without an emphasis on quality and patient safety.

“It is very important for residents to be exposed to quality improvement and patient safety, otherwise we would leave with an incomplete view on how to give the best care possible,” he said. “If you are working in the clinic and see a problem, we have to make sure we don’t make that mistake again. We have to decide what the problem is and follow up and implement changes. It’s not just ‘We won’t do that again.’”

There are still some opportunities for improvement, namely getting residents more involved in filing patient safety reports and getting experience participating in root-cause analyses, which try to ferret out the processes that need to be improved to solve a problem.

Jacqueline Hobbs, M.D., Ph.D., director of the psychiatry residency in the College of Medicine, has included quality and patient safety as a major part of her program for several years. And each year, the caliber of the residents’ quality improvement projects improves, she said. Across UF Health, residents have worked on various quality improvement projects such as creating electronic reminders for medication prior to surgery, improving hand hygiene and establishing a wellness protocol for psychiatric patients.

In addition to helping the health system as a whole, residents’ involvement in quality efforts can also help them in their careers, Hobbs said.

“If they put down on their CV that they have had experience in quality improvement and patient safety, that can catch the eye of an employer,” she said. “It puts them in a position to do something in their career and get them to a level they never imagined.”

“THE RESIDENTS, THEY ARE SO INTEGRAL TO WHAT WE DO HERE; IF THEY ARE NOT INFORMED, IT’S NOT GOOD.” — Jacqueline Hobbs,

M.D., Ph.D.

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COVER STORY

“WE ARE PREPARING THE NEXT GENERATION OF DOCTORS, AND THE EXPECTATION IS THAT THE SKILLS THEY ARE DEVELOPING TODAY IN REGARDS TO QUALITY WILL BE AS NATURAL AND INTEGRAL TO THEIR PRACTICE AS WRITING ADMISSION ORDERS OR LISTENING FOR A HEART MURMUR.”

— Lisa Dixon, M.D.

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A YEAR OF

GREAT CATCHES UF Health Sebastian Ferrero Office of

Clinical Quality and Patient Safety honors Great Catch Award recipients Last year, the UF Health Sebastian Ferrero Office of Clinical Quality and Patient Safety began recognizing staff members who have prevented medical errors. All of the Great Catch Award recipients from the past year were recognized at a dinner during Patient Safety and Quality Week in March. These award winners range from physicians and nurses to professionals in information and supply chain services, and their close attention to their work ensures patient safety and quality care at UF Health Shands hospitals and programs and within UF Health Physicians practices. In this issue of The Q Report, we are highlighting a few of the past year’s winners.

For a complete list of 2014 Great Catch Award winners, visit qreport.health.ufl.edu.

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Michael Slater

To Renae Lang, R.N., B.S.N., CNOR, a UF Health Shands Hospital college leader of neurosurgery and orthopedic spine surgery, it’s better to be good than lucky.

Before a spinal surgery, the surgical team, which included Lang, the surgeon, the anesthesiologist and a surgical technician, was going through its briefing, a process that follows the World Health Organization recommendations to ensure no mistakes are made during a surgery.

The surgeon indicated verbally on which side of the patient’s spine the procedure was going to occur. But the patient’s consent form did not indicate whether the procedure would take place on the patient’s right or left side.

“Rather than potentially do a wrongsided surgery based on the consent, we correlated the patient’s symptoms to the X-rays and verified we could proceed with the correct procedure,” said Lang, who oversees staffing and collaborates with leaders in the operating room department to direct quality in the department.

Lang said the culture of surgical rooms is different from when she started as a nurse 20 years ago.

“The culture is really supportive of anybody stepping up and saying something,” Lang said. “Back then, the saying was it was better being lucky than good. We’re looking for problems before they’re problems so we can prevent that day when you need luck.”

When Michael Slater, R.N., B.S.N., CCRN, first saw his patient in the 94 intermediate care unit/intensive care unit and checked his medication, the staff nurse noted a problem.

The patient appeared to be about the same weight as Slater — about 200 pounds — rather than the 212 kilograms noted on the patient’s chart. A patient who weighed 212 kilograms would weigh in at 467 pounds.

“Nurses form a visual representation of the patient in their minds based on the information they get during the shift change report, and they expect to see that in the room,” Slater said. “In this instance, the patient did not match the image I had imagined, and at that time, I knew there was a problem with the patient’s medication.”

The patient was being administered heparin, a blood thinner, at a rate 2.2 times the amount of medication needed. Slater questioned the dosage, and the patient’s medication was corrected.

“We need to ensure patients are weighed properly so that our weightbased medications are accurate,” Slater said. “I think every person in this hospital should be weighed and measured for height properly so we can treat them with medication as accurately as possible.”

GREAT CATCH

Renae Lang

The equipment finders There are Great Catch Awards that go to nurses, physicians and surgeons, but there are also awards given to employees who work deep behind the scenes.

Mark Gardner, Raymond Williams and Patricia Long — distribution and information manager, operating room materials supervisor and assistant manager of supply logistics, respectively, in Supply Chain Services for UF Health Shands Hospital — each received a Great Catch Award for their work in finding and replacing faulty equipment.

The equipment in question is called a stopcock, a valve used to control the flow of liquids — in this case, medications.

Long notified Gardner that a doctor — Christoph Seubert, M.D., who also received an award for the event — noticed the valve in a stopcock he was using was faulty, and allowed medication to flow freely.

But that didn’t mean the team could replace the lone valve and fix the problem.

“There were 1,405 stopcocks in the hospital from that potentially faulty lot,” Gardner said. “The logistics team, led by Patricia Long and Raymond Williams, had to visit each of the 80 locations that had these stopcocks and pull them off the shelves.”

The faulty stopcocks were all located and sequestered.

— MORGAN SHERBURNE

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The Q Report is the quarterly newsletter of the UF Health Sebastian Ferrero Office of Clinical Quality and Patient Safety, featuring the latest news and initiatives related to quality and improving the patient experience at UF Health. To suggest ideas for content, please email April Frawley, UF Health Communications, at afrawley@ufl.edu.

Q Report Advisory Committee:  Randy Harmatz, Chris Cassisi, Carolyn Holland, Sue Keating, Debbie Lynn, Cristin Owens, Debbie Robins, Michelle Robinson, Kim Rose, Amy Rosenberg, Anne Schentrup, Gail Stahl THE Q REPORT IS PRODUCED BY UFHEALTH COMMUNICATIONS.