Current Quality Improvement Projects

 

Processes

Discharge Planning

Information Management

Medical Education

Patient Satisfaction

Telemetry Utilization

 

Conditions

Alcohol Withdrawal | Delirium

Falls | Foley Catheter Safety

Glycemic Control | HIV Screening

Infection | Osteoporosis | Pneumonia |

Syncope | VTE

 

Three pillars of Hospital Medicine at UCSD: excellent patient care, effective teaching, QI/research.

Process Improvement


Discharge Planning

Discharge documentation

Dr. Brian Clay
  • Continuous enhancement of discharge instructions and discharge summary templating to conform to evidence based and consensus based best practices to ensure appropriate transitions of care.

Improving the hospital discharge process

Dr. Gregory Maynard, Dr. Jennifer Quartarolo, Dr. Brian Clay, Dr. Bryan Huang,
Dr. Weijen Chang
and Dr. Daniel Bouland
  • Multi-pronged project examining the discharge process, with the aim of improving discharge education, communication with referring physicians, and optimizing information systems. Implementation of a hospital-wide standardized patient information and provider communication module for inpatient discharges. Monitoring compliance of process; updating standards associated with the process to meet additional needs based on patient and provider feedback. Initial implementation complete. Experience used to guide mentoring efforts of Dr. Maynard in Project BOOST, the Society of Hospital Medicine collaborative to improve transitions of care.

Medication reconciliation

Dr. Brian Clay
  • Implementation of an enterprise-wide standard process for a Joint Commission National Patient Safety Goal for Medication Reconciliation. Monitoring compliance of process and measuring outcomes associated with successful implementation.

Optimization and standardization of the signout/handoff process

Dr. Weijen Chang
  • Examination of signout/handoff processes and preferences, with the goal of establishing a standard for patient signout/handoff.

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Information Management

Inpatient documentation and billing - optimizing

Dr. Diana Childers, Dr. John Bell, Division Administrator Gregory Vervoort, and Dr. Brian Clay
  • Using focused feedback and audits to improve the accuracy and aggressiveness of documentation and billing. Enhancing EPIC-based note templates to support appropriate billing elements. Investigating options to enhance EPIC billing with PQRS reporting.

Inpatient systems and online order entry, informatics - ongoing enhancements

Dr. Brian Clay
  • Dr. Clay is the Chief Medical Informatics Officer for UC San Diego Health System and has a formal role in electronic medical records (EMR) and computerized physician order entry (CPOE) deployment. He is involved in many improvement efforts for the Hospital Medicine division and for all UCSD clinical services.

SHM-sponsored Web 2.0 Initiative

Dr. Weijen Chang
  • Participation in a Society of Hospital Medicine-sponsored group examining the use of Web 2.0 technologies in hospital medicine collaboration and communication.

Who to call

Dr. Ian Jenkins, Dr. Brian Clay and Dr. Gregory Seymann
  • Design and implementation of a medical center-wide strategy for accurately designating the right doctor to call. Measures include resident and nursing surveys outlining satisfaction with the process, time to reach correct provider, and number of calls received that should have been triaged to others. Translated into EPIC as “Treatment Teams” applicable to all services.

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Medical Education

CQI in Action

Dr. Gregory Seymann, curriculum developer and lecture series leader
  • CQI in Action is a lecture series for faculty and housestaff to highlight principles of CQI. The target audience is medical residents, though attendance by Hospital Medicine faculty is also frequent. The lectures teach about common issues in medical management where gaps in performance exist. Discussion of the evidence is followed by illustration of how QI efforts have affected outcomes locally and nationally. The lectures serve to educate about topics in medicine as well as principles in QI, and highlight the work done by the Division of Hospital Medicine to improve patient care. Lectures are given by a rotating series of Hospital Medicine faculty. Evaluations indicate the lecture series is extremely well received by attendees.

Evidence-based medicine web training/resources

Dr. Michele DeKorte
  • Improving the EBM skills of residents, students and hospitalists, with integration into Morning Teaching Conference. Development of a web-based curriculum, repository of past questions, searches, and summaries.

Hospital Medicine Teaching Curriculum

Dr. Sarah Horman, Dr. Meghan Sebasky and Dr. Ian Jenkins
  • Creation and compilation of a set of core curriculum topics in Hospital Medicine that can be used for teaching on the wards. Organization of the topics into brief 1-2 page teaching handouts that are accessible to all faculty for quick references to support on-the-fly teaching in the hospital.

Journal club/Topics in Hospital Medicine

Dr. Diana Childers
  • Quarterly Journal Club to review and discuss scholarly topics pertinent to academic hospital medicine. Meetings also include presentations by UCSD hospitalists to present their current QI projects and spur development of new projects.

Nocturnist Teaching Curriculum

Dr. Jay Varughese
  • This project, similar to the one below, addresses the lack of a set curriculum or format for teaching on the Night Float rotation. It is an attempt to enhance the formal educational value of this rotation for the housestaff.
  • Creation and compilation of a set of core curriculum topics and Hospital Medicine that can be used for teaching on the night rotation. Organization of the topics into brief 1-2 page teaching handouts that are accessible to all faculty for quick references to support on –the-fly teaching at night.

Teaching at the Bedside

Dr. Alina Popa
  • In partnership with Internal Medicine leadership, teaching faculty in Hospital Medicine underwent additional training in a formal process to re-introduce bedside rounding on the teaching service, without compromising the mission of efficient and safe patient care. Efforts to standardize the rounding process to include regular bedside teaching sessions are in progress.

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Patient Satisfaction

Improving patients’ ability to identify their providers

Dr. Greg Seymann
  • In collaboration with nursing unit leadership, a pilot project which entails posting of the attending hospitalist’s photo and name in the patients’ room was implemented on one of the medicine units. Early data shows improvement in resultant patient satisfaction scores.
  • Further monitoring of the effect is needed, with potential for future application of the intervention to the entire hospital.

Telemetry Utilization

Appropriate use of inpatient telemetry monitoring

Dr. Remus Popa and Dr. Brian Clay
  • Collaborative effort between Hospital Medicine, Nursing, and Cardiology to reduce the inappropriate utilization of telemetry monitoring on the inpatient medicine service. Indications for telemetry orders will be required and tracked. Baseline data collection is complete.
  • Future efforts will include interventions to safely reduce the length of time that patients remain on telemetry after the initial appropriate indications have been addressed.
  • The project has potential implications on patient flow and ED throughput.

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Condition Management

Alcohol Withdrawal Management

Diagnosis and management of alcohol withdrawal and delirium tremens

Dr. Ian Jenkins
  • Design and implement protocol for the appropriate integration of a CIWA-based protocol for the management of patients with high risk for alcohol withdrawal and delirium tremens.

Delirium Detection and Management

Early detection and management of patients with delirium

Dr. Bryan Huang, Dr. Gregory Maynard and Dr. Jennifer Quartarolo
  • Screening using the confusion assessment method (CAM) for delirium to identify patients early on. For those identified as having delirium, start a physician/nursing/pharmacy-driven protocol to reduce potentially inappropriate medications, start antipsychotics when indicated, and also behavioral interventions by nursing staff to reorient the patient. The outcome will be a reduced number of CAM-positive patient-days compared to baseline after the protocol is in place.

Falls, Prevention and Risk Assessment

Reducing falls and assessing risk of falls among inpatients

Dr. Bryan Huang and Dr. Leslie Martin
  • Multidisciplinary effort to reduce falls among inpatients and to monitor use of medical/behavioral restraints. The team has been assessing several new fall risk assessment tools for institution-wide implementation.

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Foley Catheter Safety

Reducing unnecessary use of Foley catheters

Dr. Ian Jenkins and Dr. Leslie Martin
  • This project is to design and implement a computerized order-entry protocol and screen for urinary Foley catheters to ensure justification as well as prompt removal. It will attempt to track Foley use in the hospital. The goal is to reduce unnecessary Foley catheter use and reduce avoidable urinary tract infections and subsequent complications.

Glycemic Control

Glycemic control and iatrogenic hypoglycemia

Dr. Gregory Maynard, Dr. Pedro Ramos, Dr. Diana Childers and Dr. Daniel Bouland
  • Multidisciplinary approach has tackled virtually all aspects of inpatient glycemic control, contributing to local and national efforts, with heavy contributions to the Society of Hospital Medicine (SHM) Glycemic Control Resource Room and several peer-reviewed articles in the literature. UCSD experience also being used to contribute to the SHM Glycemic Control Mentored Implementation Collaborative.

Glycemic evaluations/consults

Dr. Daniel Bouland
  • Evaluations triggered by daily reports on hyper- and hypoglycemic values, spurring earlier adherence to UCSD protocols, and appropriate changes in therapy. Intervention and data collection launched November, 2008. Pilot data collection to end March 2009.

Transitions from infusion to subcutaneous insulin

Dr. Pedro Ramos,  Dr. Diana Childers and Dr. Gregory Maynard
  • A collaborative pharmacist-hospitalist study using a protocol to transition patients from infusion to subcutaneous insulin, funded by the American Society of Health-System Pharmacists (ASHP). Patients in the Hillcrest MICU and SICU were transitioned using this protocol and their glycemic control was followed 48 hours after transition. Glycemic control was significantly better in those following the protocol than not. Data is still being evaluated. The project is being prepared for presentation. We are hoping to expand the protocol to other units and eventually automate the process.

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HIV Screening in the Inpatient Setting

Assessment of patient and physician perceptions
of opt-out HIV testing in the inpatient setting

Dr. Jennifer Quartarolo
  • A survey project involving patients and physicians regarding their experiences with the new opt-out testing program in place at Hillcrest. We plan to evaluate the efficacy and limitations of the current program, in order to reveal specific steps in the screening process that can be improved upon to increase the rates of testing.

Infection Prevention and Control

Appropriate implementation of contact precautions

Dr. Greg Seymann and Dr. Meghan Sebasky
  • Initial audits of the frequency with which dedicated sterile equipment, gowns, gloves and gel were readily available to clinicians for patients on contact precautions showed room for improvement. Through collaborative work with nursing leadership, processes to increase utilization of dedicated stethoscopes and flashlights in such rooms have been implemented.
  • Post-intervention data to assess the impact of the current changes is forthcoming, with further efforts to follow if needed.

Clostridium difficile-associated diarrhea (CDAD)

Dr. Pedro Ramos and Dr. Kent Smitherman
  • A project studying the results of implementing C. difficile medication and contact precautions order sets (through computerized physician order entry) on the incidence of C. difficile colitis in the medical center, and trying to improve the effectiveness of these CDAD prevention efforts.


Handwashing

Dr. Greg Seymann and Dr. Reid Sasaki
  • Baseline service specific data for handwashing compliance on the medicine service was collected and will be shared with the division. Improvement strategies will be discussed and implemented, and continuous quality improvement will be assured via repeat audits and “PDSA” cycles.

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Osteoporosis Management

Osteoporosis – early recognition and appropriate triage and treatment for inpatients

Dr. Gregory Maynard and Dr. Leslie Martin
  • Multidisciplinary effort with Heather Hofflich, DO, of Internal Medicine, Endocrinology, Orthopedics, and Geriatrics, to identify and appropriately document diagnosis of osteopenia/osteoporosis, and initiate protocol-driven evaluation, treatment, and follow up.

Pneumonia Management

Improving the care of patients with pneumonia

Dr. Gregory Seymann,Dr. Bryan Huang and Dr. Michele DeKorte
  • CQI project in conjunction with the Performance Improvement and Patient Safety (PIPS) department to monitor and improve performance on ORYX core measures for inpatient pneumonia. Initial areas of focus have been partnering with information systems to integrate ordersets to improve compliance with targeted processes of care. Successes have been realized in improving time to initial antibiotic and improving rates of discharge vaccinations. Focus has shifted to improving appropriate initial antibiotic selection for community-acquired pneumonia (CAP) as well as health care-acquired pneumonia (HCAP), which is not currently monitored as a core measure. Revised ordersets are in place, and ongoing monitoring of orderset utilization and outcomes is planned.

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Syncope Evaluation and Management

Syncope Protocol

Dr. Remus Popa
  • Collaborative effort between Hospital Medicine, Emergency Medicine, Cardiology and Neurology leadership to develop and implement an evidence-based protocol for the evaluation and management of patients admitted to the hospital for syncope. Baseline utilization data has been collected and the protocol has been implemented. Post-intervention data collection is in process to assess the impact on quality, outcomes, and utilization patterns.

VTE Prevention and Management

VTE management and anticoagulation

Dr. Gregory Maynard, Dr. Ian Jenkins, Dr. Brian Clay and Dr. Michael Montazeri
  • Another collaborative, multidisciplinary effort, funded in part with a grant from the American Society of Health-System Pharmacists (ASHP). Goals are to optimize management of VTE via protocol-driven care, and to fully comply with Joint Commission National Patient Safety Goal 3E. Protocols/policies have all been formulated and passed, revised computerized physician order entry (CPOE) order sets are in development, and efforts to trigger the protocol use via brief consultative evaluations are underway.

VTE prevention

Dr. Gregory Maynard and Dr. Ian Jenkins