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Quality Improvement & Patient Safety Section Newsletter - September 2008, Vol 9, #4

Quality Improvement & Patient Safety Section

circle_arrow Chair's Corner
circle_arrow The Malcolm Baldrige National Quality Award
circle_arrow Overcoming Metrics Fatigue
circle_arrow QIPS TIPS 6: The Two Challenge Rule
circle_arrow Quality Indicators for Geriatric Emergency Medicine: Pain management, Care transition and Cognitive assessment
circle_arrow Annual QIPS Section Meeting
circle_arrow Webinar, ACEP Sections: The Power of 100

Newsletter Index

Quality Improvement & Patient Safety Section

Chair's Corner


Robert I. Broida, MD, FACEP

This is the final issue of the QIPS newsletter before the ACEP Scientific Assembly in Boston, and my last as Section Chair. Your Section has been quite busy again this year and has a number of concrete accomplishments to its credit.

I am pleased to announce that the QIPS Section was recently awarded both the Section Newsletter and Service to Section awards by national ACEP. These awards were for the 2007-8 year, and reflect on the leadership of Dickson Cheung, last year's Section Chair, and Elaine Thallner, our Newsletter Editor. Congratulations to both of them and to all who contributed to our success!

I hope you can all attend the QIPS Annual Meeting in Boston (Monday, October 5th, 1-3PM). All QIPS members are welcome. We have a great speaker lined up, and we will hold the annual election of officers. Eric Dickson, MD, MHCM, Professor of Emergency Medicine, University of Massachusetts Medical School, will be our featured speaker. (P.S. Lunch will be served!)

2008-2009 QIPS accomplishments included:

  • HAND-OFFS: Our ED Patient Hand-Off paper was accepted by Annals of Emergency Medicine and should be published any day now. The project leader was Dickson Cheung, MD, MBA, MPH, FACEP, and the project was the recipient of an ACEP Section Grant last year. The project was enthusiastically supported by many QIPS members who contributed countless hours to the final product. There will also be a Research Poster Presentation by Drew Fuller, MD, FACEP, titled "Variation in the Practice of Emergency Department Handoffs," at the ACEP Scientific Assembly in Boston. The Poster presents the findings of last year's pilot survey which was distributed to all attendees at the 2008 ACEP Council Meeting.  Looking forward, Dr. Chris Beach has agreed to take the hand-off project to the next level, leveraging on some of the research opportunities described in the paper.

Anyone interested in contributing should contact Angela Franklin ( We encourage all QIPS members to consider participating in this great opportunity.

  • ED Quality Curriculum: This was another ACEP Section Grant project. Lead by Jack Kelly, DO, FACEP, the project team worked tirelessly throughout the year to develop a comprehensive academic curriculum and reference list specifically focused on ED quality. This curriculum will be used by residency programs and others interested in ED quality resources. The project is now complete and publication is being actively pursued.
  • NEWSLETTER: Continuation of the outstanding QIPS Newsletter tradition by Editor Drew Fuller, MD, FACEP with 4 editions published and posted on the QIPS website. Highlights included two new sections (QIPS TIPS and the member survey), along with timely articles on QI topics, CMS measures, Conference Reviews, Project Updates, Patient Safety and Literature updates.
  • NATIONAL INVOLVEMENT: Several QIPS members were active participants with other ACEP Leaders on the Quality and Performance Committee (QPC). The QPC works with other medical specialties, quality organizations, payers and the various federal agencies to help influence future quality and payment methodologies. Recent QIPS Chairs David John, Jack Kelly, Helmut Meisl, Dickson Cheung and I all sit on this important Committee. In addition, QIPS leadership participated in the National Quality Summit hosted by ACEP in Washington, DC this past April.  

In closing, when I look back at this year, I am amazed by the amount of work done by the many dedicated QIPS members who contributed so much to our success. I am proud to be associated with each of you and grateful for this year as Chair. I know that you will continue your active support for Elaine Thallner, our incoming QIPS Chair for 2009-2010. Special thanks go out to our Section Liaison, Angela Franklin, Esq., for her tireless work in keeping us on track and helping us achieve outstanding results once again. 

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The Malcolm Baldrige National Quality Award

Dickson Cheung, MD MBA MPH

Dr. Dickson CheungMy first introduction to the Baldrige award came in business school when we studied Ritz Carlton as a model of service excellence. It wasn't until eight months ago though that a fellow emergency medicine colleague of mine deeply involved in quality encouraged me to apply to be a member of the Board of Examiners for the Baldrige Award. What particularly impressed him was its holistic approach to quality which was a refreshing and rewarding way to look at organizations.

The Malcolm Baldrige National Quality Award is the only award that the U.S. president personally presents himself at an annual dinner ceremony in our nation's capital to high performing organizations in the fields of business, education and now healthcare and charities. The Award was created by Public Law 100-107 and signed into law on August 20, 1987 leading to the creation of a new public-private partnership. Principal support for the program comes from a private foundation.

The Award is named in remembrance of Malcolm Baldrige, who served as Secretary of Commerce from 1981 until his tragic death in a rodeo accident in 1987. Previous winners have come from the fields of business, manufacturing and service and have included Motorola, GE, Ritz Carlton, AT&T and Boeing. In 2002, the Baldrige award expanded to include health care. Since 2005, applicants from the healthcare sector have made up more than half of all Baldrige award applicants.

How is the Baldrige award different than other health care awards, e.g. Eisenberg, AHRQ, Solucient, etc? First, the criterion upon which the award is based is extraordinarily comprehensive: leadership, strategic planning, customer focus, measurement, analysis and knowledge management, workforce focus, process management and results. All the applicants are judged on how well they fulfill the criteria and more importantly how well they integrate the criteria. For example, if a hospital states in its organizational profile that efficiency is a key attribute of their company, then examiners look for a strategic planning process that leverages its resources and position to achieve this aim, workforce processes that support this goal and then specific measures that track progress towards this future state.

The application process is unusually thorough and rewarding for both the examiners and the applicants. A relationship is developed over several months whereby the applicant opens their doors and allows examiners to provide guidance into how to become a better organization according to their own stated objectives. Literally thousands of hours are poured into each application in a consulting role. Award recipients are expected to share their best practices. One of the most rewarding aspects of the application process I look forward to is interacting with organizations that have struggled with and overcame barriers on their journey to becoming one of the most innovative and high performing organizations in their sector.

For most of us who pursue healthcare quality, efforts tend to focus on specific structure, outcome or process measures relating to specific disease states, e.g. door to balloon time in STEMI or specific processes, e.g. decreasing LOS in the ED. While measurement of quality is included in the Baldrige criteria, it is a relatively small part and then only as integrated with the organization's stated vision, mission and goals. In essence, the organization is graded upon how well it "walks its talk."

If you are interested in becoming a member of the Board of Examiners, the open application period is performed online between November and January of each year. Notifications of selected examiners are sent at the end of March. As noted earlier, a one week training session is required each May at its sponsoring organization, The National Institute of Standards and Technology (NIST, think NIH of engineering) in the suburbs of Washington, DC. The application evaluation cycle begins in June which requires roughly enough 60 hours of examiner effort including an independent and group consensus review. High scoring applicants are then paid a site visit in the middle of October which generally consists of 16-18 hour days over a 5 day review to clarify and substantiate claims in the applicant's written application. In the end, the award recipients are chosen by a board of judges and the Secretary of Commerce. 

Interested? You can find more about the Malcolm Baldrige National Quality Award at their website See you at next year's training session!

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Overcoming Metrics Fatigue

E. Thallner, MD, MS

thallnerIncreasing pressure from internal and external agencies is straining the healthcare industry. How can we (personally and organizationally) keep our bearings in an increasingly regulated and stressful environment? In other words, how can we keep on doing our important work without succumbing to burnout by increasing pressures?

Compassion fatigue refers to a gradual lessening of compassion over time and may be a form of burnout. It is also known as secondary traumatic stress disorder and was first recognized in nurses in the 1950's. Affected individuals feel less pleasure, and feel hopeless, stressed, and negative. This leads to lower morale, productivity, and even self-doubt. More recently, the term has been used to describe the behavior of caregivers of dependent people, attorneys who work with trauma victims, and charitable donors in response to the media response to disasters.

I propose a similar concept I'll call ‘metrics fatigue' which could similarly affect healthcare professionals involved in quality. Our challenge then becomes to identify it as a possibility, name it, and then learn how to avoid it. Receiving data about the quality of care can be frightening and feel threatening, both personally and institutionally. A common response is to dismiss the data out of hand. Unfortunately this common self-protective reaction does not lead to improvement. A more productive response (in terms of actually improving quality and learning from data) is to feel curious about and reflective about the data, and empowered to deal with its implications.

It requires thoughtful attention to becoming a resilient individual (and by extension, a resilient organization). Resilience is capacity of people to positively cope with stress. These individuals have developed an ability to regulate negative emotion. Resilient groups provide meaning, a supportive environment, and a means to engage positively with it. A resilient person (and organization) is able to continually learn, has capacity to keep going, the ability to not feel threatened (or at least manage the perceived threat positively), and has a sense of purpose. Fortunately, resiliency (like helplessness) can be learned by paying attention to it. This works best in the setting of trusting relationships to provide support and accountability. Let's stretch our own leadership goals to try to create such positive, productive work groups.

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4QIPS TIPS 6: The Two Challenge Rule4

Shari Welch, MD, FACEP

Shari WelchMedication errors are the most common type of adverse event in medicine. Dosing unfamiliar drugs or dosages are more likely to result in medication errors. A standardized communication protocol with callbacks and repeat backs is a safety tool worth considering. Many people believe in using three identifiers. So before administering a drug a nurse would say "Dr. Smith, I am giving 5cc of phenergan with codeine elixir by mouth to the 3 month old baby in room 2 named Garcia. Is that correct?" The doctor would say, "No, that is 5cc's of phenergan with codeine elixir by mouth to the three year old toddler in room 4 named Sanchez". Repeat backs and Callbacks are an effective way to prevent medication errors.

Additionally, in Med Teams Training, the staff is taught the "Two Challenge Rule". In this strategy a staff member is taught to question any order that doesn't seem right. Physicians are trained to encourage this as a form of checks and balances and redundancy. For instance the communication might have gone like this "Dr. Smith do you really want me to give phenerghan with codeine to this 3 month old in room 2?" The physician in a hurry and on the fly retorts "Yes, that is my order." The nurse would challenge a second time "Dr. Smith do you REALLY want me to give phenerghan with codeine to a newborn who might stop breathing???" The physician usually is giving his attention now! "No, I want the toddler who is coughing and vomiting in room five to have that medication!!"

According to the Joint Commission the number one cause sentinel events in healthcare is communication error. Given the chaos of our practice environment isn't it time to change our casual ad hoc communication processes to something more standardized, with built in safety mechanisms?.

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Quality Indicators for Geriatric Emergency Medicine:
Pain management, Care transition and Cognitive assessment

Michael P. Phelan, MD
Quality Review Officer, Cleveland Clinic Emergency Services Institute

The Quality of care problems pertaining to the care of older emergency department patients are well documented. Over two years ago The Society for Academic Emergency Medicine Geriatric Task Force in conjunction with representatives from The American College of Emergency Physicians began the process of developing a select set of quality indicators for geriatric emergency care. Three initial topics were chosen based on a consensus of experts in emergency medicine and geriatrics: cognitive assessment, pain management, and transitional care. The results of this initial project were recently published in the May issue of Academic Emergency Medicine (Terrell, K.T., Hustey, F.M., Huang, U., et. al., Quality indicators for geriatric emergency care. Academic Emergency Medicine, 2009; 16(5):441-449).

The methodology for the development of the quality indicators was modeled after a previously successful and well-documented program in geriatric medicine, the Assessing the Care of Vulnerable Elders (ACOVE) project. One of the ACOVE lead investigators served as a co-investigator and consultant for this project. Content experts were identified for each topic, and a preliminary set of indicators was developed based on a comprehensive search of the literature using expert opinion when necessary. These indicators were vetted through a series of experts in emergency medicine and geriatric medicine in several settings and national forums over a 2 year period. Feedback was used to refine the indicators to their final format.

The final set of indicators represent floor measures of geriatric emergency care – that is they are absolute minimum standards below which care would be considered substandard in these areas. The detection and management of older emergency patients with altered mental status has been repeatedly shown to be substandard[1-8]. Emergency physicians routinely miss delirium in older patients and discharge many delirious patients home inappropriately. These patients are at risk for increased morbidity and mortality. One study found that that patients who are discharged home with unrecognized delirium are more than three times as likely to suffer short-term mortality than counterparts in whom delirium is recognized[4]. There are similar serious quality issues in the areas of care transitions and pain management. Poor communication during care transitions between nursing homes and emergency departments is well documented. Such communication deficits can lead to inadequate evaluations, unnecessary or insufficient testing, and poor outcomes[9-13].

The quality indicators developed in this study were designed to be monitored using administrative data. Future steps include testing the feasibility of monitoring these indicators, and determining whether these indicators are related to better outcomes for patients. In addition, the newly created Society for Academic Emergency Medicine Academy for Geriatric Emergency Medicine (formerly the Task Force) is continuing its work in developing a second set of indicators on a separate group of topics. We hope that these efforts will ultimately play a part in fostering higher quality care for our older patients.

  1. Elie, M., et al., Prevalence and detection of delirium in elderly emergency department patients. CMAJ Canadian Medical Association Journal, 2000. 163(8): p. 977-81.
  2. Hustey, F.M. and S.W. Meldon, The prevalence and documentation of impaired mental status in elderly emergency department patients.[see comment]. Annals of Emergency Medicine, 2002. 39(3): p. 248-53.
  3. Hustey, F.M., et al., The effect of mental status screening on the care of elderly emergency department patients. Annals of Emergency Medicine, 2003. 41(5): p. 678-84.
  4. Kakuma, R., et al., Delirium in older emergency department patients discharged home: effect on survival. Journal of the American Geriatrics Society, 2003. 51(4): p. 443-50.
  5. Lewis, L.M., et al., Unrecognized delirium in ED geriatric patients. American Journal of Emergency Medicine, 1995. 13(2): p. 142-5.
  6. Miller, D.K., et al., Controlled trial of a geriatric case-finding and liaison service in an emergency department.[see comment]. Journal of the American Geriatrics Society, 1996. 44(5): p. 513-20.
  7. Naughton, B.J., et al., Delirium and other cognitive impairment in older adults in an emergency department. Annals of Emergency Medicine, 1995. 25(6): p. 751-5.
  8. Sanders, A.B., Missed delirium in older emergency department patients: a quality-of-care problem.[comment]. Annals of Emergency Medicine, 2002. 39(3): p. 338-41.
  9. Kripalani, S., et al., Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA, 2007. 297(8): p. 831-41.
  10. Madden, C., J. Garrett, and J. Busby-Whitehead, The interface between nursing homes and emergency departments: a community effort to improve transfer of information. Academic Emergency Medicine, 1998. 5(11): p. 1123-6.
  11. Propp, D.A., Emergency care transitions.[comment]. Academic Emergency Medicine, 2003. 10(10): p. 1143; author reply 1143-4.
  12. Terrell, K.M., et al., An extended care facility-to-emergency department transfer form improves communication.[see comment]. Academic Emergency Medicine, 2005. 12(2): p. 114-8.
  13. Terrell, K.M. and D.K. Miller, Challenges in transitional care between nursing homes and emergency departments. Journal of the American Medical Directors Association, 2006. 7(8): p. 499-505.

Fredrick Hustey, MD

ED geriatric quality metrics like the geriatric measures vetted by the SAEM geriatric academy alert us to problems with how we evaluate and care for the ever increasing older segment of our patient population. Previous quality issues like missed myocardial infarction, unstable abdominal aortic aneurysms, ectopic pregnancy and pulmonary embolus cause us to search endlessly for theses potentially life threatening illnesses usually with high tech solutions like imaging, serology, or by implementing clinical guidelines. Other quality issues like managing patients with acute myocardial infarction or pneumonia increasingly rely on clinical guidelines to devise process metrics to measure and benchmark.

Recognizing there is a problem is the first step. The next step is to determine if there are interventions that can be implemented that are feasible, reliable and can show outcome difference. For instance regarding geriatric cognitive assessment; Is the problem limited to poor documentation or is it truly lack of recognition? Studies seem to point to the latter. If we are not recognizing the problem does routine cognitive assessment of patients 65 years and older need to be included as another "vital sign"? If so, then this must be relatively easy to implement, administer and feasible to track and report using administrative data. Perhaps we need to re-evaluate the triage process and similar to pain assessments or falls risks, devise a means to routinely identify these patients with cognitive difficulty. However, screening alone is pointless unless there are interventions available that can be implemented in the ED to improve outcomes. These are areas in need of further study.

Regarding transitions of care, the fact we are often not given enough of the right kind of information when patients arrive in the ED has been well documented. However, information gaps also exist when patients are transitioned back to nursing homes. Many emergency departments use health information technology systems to generate standard discharge instructions for patients on a variety of conditions. These are typically designed for ambulatory patients, and are not always sufficient for residents in long term or rehabilitative care. These information gaps are likely a sign of a dysfunctional system. Few could argue that serious quality problems do not exist in these systems that have the potential to contribute to adverse outcomes. The proposed quality indicators targeting communication gaps are the first step in what is likely to be a much longer process towards process improvement in this realm. Better organizing the two way flow of information is important.

Adequate managing pain in emergency department patients has been a high profile issue for years. This is particularly problematic in the older patient. Physicians may be hesitant to use narcotics in older patient for fear of unwanted side effects. However, narcotics are indicated for many painful conditions in the elderly, give better pain control when used appropriately, and often carry less risk than longer term NSAID use. There are obvious reasons why ED physician's underutilizes pain medications over all, not withstanding being cautious with administering potent narcotics to the elderly. The quality indicators proposed by the SAEM Geriatric Academy set a minimum standard for pain management in these patients. However, in order to monitor adherence to these indicators and their effect on patient outcomes we need mechanisms for tracking and reporting this type of data. In addition, adverse events like such as unintentional narcotic overdoses, subsequent falls, and issues with associated constipation need to be reported and tracked as well. This is much easier said than done. However I am confident as more hospitals shift to EMR this data may be easier to track and report.

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Annual QIPS Section Meeting

You are invited to attend ACEP's 2009 Scientific Assembly, October 5-8, in the historic city of Boston. Please plan to join us for the QIPS Section Annual Meeting and luncheon:

Date: Monday, October 5th
Time: 1:30 to 3:00 pm
Location: Room 151
Boston Convention and Exhibition Center (BCEC)
415 Summer Street
Boston, MA 02210

Agenda Items:

  • Chairs, Councilors Report
  • Annual Election
  • Educational offerings: Eric Dickson MD FACEP, Dennis Beck, MD FACEP

The meeting will feature a luncheon courtesy of EA Health, a corporation that focuses on providing on call specialists to EDs. EA Health has provided healthcare solutions since 1992 and has been the leading innovator of on call compensation programs ever since.

The meeting will also include the election of Section Officers for the 2009-2010 cycle. Our current officers are:


Chair/Alternate Councilor: Robert I. Broida, MD, FACEP
Chair-Elect: Elaine A. Thallner, MD, FACEP
Immediate Past Chair/Councilor: Dickson S. Cheung, MD
Secretary/Newsletter Editor: Drew C. Fuller, MD


Nominations are open for a new Chair-Elect and Secretary/Newsletter Editor!

Nominations will be offered by the Nominating Committee, and nominations from the floor will be accepted at the meeting. Officers will be elected by a majority vote of the Section members present and voting at the meeting. For more information on the responsibilities of each office, please review the Operational Guidelines on the Section website.

Please contact our staff liaison Angela Franklin ( with nominations, questions, or to indicate your interest in seeking office.

Register now at:!

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Webinar, ACEP Sections: The Power of 100


Listen in to section veteran and ACEP Board member, Dr. Andy Bern in the Webinar, ACEP Sections: The Power of 100.

As another section year begins, this presentation is a good overview for new and returning section leaders and involved section members. (Please note that there is a brief interruption about 19 minutes into the recording, please feel free to skip to the 23 minute mark.)


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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.

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