Diagnostic error is common, morbid, and mortal. IHQSE faculty member, Dr. Katie Raffel, along with Dr. Andrew Auerbach and other experts on diagnostic error, recently published findings from a multicenter retrospective cohort study in which 2500 hospitalized adults who experienced ICU escalation or death were evaluated for diagnostic error. This study adds to a body of literature highlighting the importance of diagnostic safety within hospital medicine. We discussed the larger implications of this study with Dr. Katie Raffel in this edition of 3Q's for QI.
Faced with rising maternal mortality, the first prenatal visit is essential but, in many cases, important topics are missed. An IHQSE small grant supported the redesign of the first visit, dividing it into a nurse-led telemedicine visit and an in-person visit with an obstetric clinician. Clinic no-shows dropped (9.9%-4.2%), the topics covered in the first prenatal visit increased (70.0%-95.6%), and improvements were observed for all key themes. We spoke with Dr. Diane Christopher about her recent publication, Redesigning the First Prenatal Visit: A Quality Improvement Initiative, and her team's work to improve care for expecting mothers.
Few hospitals have created surveillance programs for diagnostic errors. Fewer have programs to translate those opportunities into improvement efforts to prevent future harm. The Achieving Diagnostic Excellence through Prevention and Teamwork (ADEPT) collaborative is a 16 site AHRQ funded project which is developing measurement frameworks for diagnostic safety, and then using these frameworks to aid with implementation of diagnostic excellence programs. We spoke with IHQSE Faculty Dr. Katie Raffel about ADEPT and its potential impact.
IHQSE Faculty Dr. Janet Kukreja is one of the most prolific robotic cystectomists in North America, completing 100+ surgeries a year and leading the way in the field of robotic surgery. Now she is leading pilot project that’s developed a web-based app to help patients choose the urinary diversion that best suits their personal circumstances and preferences, giving them power and choice in an overwhelming situation.
Most patients requiring prolonged mechanical ventilation in Cardiothoracic Intensive Care Units (CTICU) – which treat some of the hospitals’ sickest patients – remain sedated and bedridden for the bulk of their stay. A team of IHQSE Alumni are helping to change that and improve patient outcomes, starting with one strong-willed young woman named Chenille.
A IHQSE team, including Dr. Norman Friedman, engaged clinicians and staff across multiple services to revise the perioperative pathway for children having a T&A. Published in The Laryngoscope, the team found that 75% of children who qualified as “high risk” patients by the American Academy of Otolaryngology’s clinical practice T&A overnight monitoring guideline were off oxygen within 3 hours of surgery.
A team including IHQSE Faculty member Dr. Tyler Anstett engaged clinicians from different specialties to rethink the design of blood transfusion orders in the EHR at University of Colorado Hospital. This project, ultimately aimed at improving adherence with transfusion guidelines, was recently published in the January volume of Applied Clinical Informatics. We caught up with Dr. Brad Morse and Dr. Tyler Anstett to learn more about the motivation behind this project and what it could mean for future EHR design improvements.
A team from the Cardiothoracic Intensive Care Unit that completed the IHQSE Improvement Academy recently launched their SOAR (Sedation Off, Awake, Rehabilitate) initiative which is aimed at weaning patients off deep sedation sooner to mitigate adverse outcomes related to prolonged sedation periods. The intervention allowed the team to mobilize one of its most critical patients on ECMO. We spoke with Dr. Mikita Fuchita, one of the doctors spearheading this initiative to learn more about the SOAR initiative and its impact.
The cycle of workplace violence in healthcare facilities is detrimental to providers as well as patients. IHQSE Faculty Katie Raffel, MD, along with Jenica Cimino, and Lyza Hilton, RN, discuss how trauma-informed transformations may help to reduce violent episodes in hospitals on MedPage Today’s KevinMD.
IHQSE Alum Candice Kmetz-Parkinson was recently featured on Colorado's 9NEWS discussing UCHealth's new Virtual Respiratory Therapist program that is helping to streamline workflow and get patients off ventilators sooner.
Studies find that most patients undergoing cancer treatment receive little to no information on the possible effects that treatment may have on their sexual well-being. In this US News & World Report article, IHQSE Faculty member, Dr. Sarah Tevis, discusses the need for providers to give honest information to patients about these side effects early in the treatment process.
IHQSE Alumni Dr. Jennifer Kemp and Sherry Knott, NMTCB, have been asked to present their work, ‘Adding Friction to the Electronic Health Record to improve adherence with best practices for diagnostic testing across multiple hospital system intensive care units,’ at the Scientific Assembly and Annual Meeting of the Radiological Society of North America in November 2022.
IHQSE Alumni Drs. Laura Leonard, Danielle Abbitt, Edward Jones, Andrew Berry and nurses Emily Englehaupt and Sara Davidson presented their work, ‘post-operative readmissions in an aging veteran population,’ which won the award for the Best PRO/Patient Centeredness abstract at the American College of Surgeons 2022 Quality and Patient Safety Conference.
IHQSE Lead Physician Informaticist, Moksha Patel, MD, gave an inspirational talk about mental health awareness and overcoming adversity, discussing his own journey with severe OCD as a template, at the Matiya World Cultural Convention.
The Institute for Healthcare Quality, Safety and Efficiency was launched in 2012 with the aim of developing leaders and transforming processes to create lasting organization-level change and fundamentally improve patient care. In March 2022, the IHQSE celebrates 10 years of work and nearly 2000 individuals trained.
The COVID-19 pandemic has created numerous challenges across all clinical specialties. One set of challenges for residency programs is finding balance between the elevated clinical needs in hospitals and the educational needs of residents. In this article from The Hospitalist, IHQSE faculty member Dr. Emily Gottenborg speaks about the willingness of CU residents to meet challenges head-on and adapt to change, caring for high volumes of critically ill patients while still maintaining a focus on education.
Working with a team of clinicians and informaticists, IHQSE Director Dr. Jeff Glasheen helped create and implement an EHR-driven tool that accurately predicts inpatient mortality. A recent feature by EHR Intelligence highlights how the team leveraged EHR data and multiple models to create this highly predictive tool in just one month. Tested on over 80,000 patients, the tool was developed to aid decision making in scare resource situations, such as COVID-19 ventilator shortages.
Two recent publications, one from TJC and the other from the CDC highlight Certificate Training Program graduates Drs. Sarah Parker, Jason Child and Christine MacBrayne’s innovative ‘handshake stewardship’ program. Developed during of their time in the Certificate Training Program, the program does not rely on traditional stewardship policies such as preauthorization of antimicrobials.
Certificate Training Program graduates were recognized for significant improvements in pancreas surgery outcomes. The team highlighted the importance of “building relationships, identifying stakeholders, creating a business case--important work that we didn’t know how to do before IHQSE” as well as the need to enhance communication and build care pathways.
In an interview with the University of School of Medicine, Dr. Read Pierce, IHQSE faculty member noted the importance of robust data systems, clinician engagement and creating a sense of urgency in driving improved outcomes in sepsis.
IHQSE is proud to announce the Children’s Colorado Hospital Ortho Spine Team was presented with the Excellence in Quality & Patient Safety Award at Children’s Hospital medical Staff dinner on April 21, 2016.
The Society of Hospital Medicine awarded IHQSE the Innovation Award for their work in developing the program. The program, selected from a over 100 innovation presentations was recognized for developing high-functioning clinical teams that are trained, resourced and aligned with broader organizational goals in order to improve the value of the care provided.
The IHQSE Certificate Training Program helped set the path to creating a Comprehensive Unit-based Safety Program for the program’s 2014 Esophageal Surgery Team. After achieving their primary goal of standardizing care, they decide to set another goal in reducing the average length of stay by one day.