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Quality Improvement and Patient Safety Section Newsletter - October 2016

Would you Fly on an Airplane if there were 44,000 Crashes a Year?


Letter from the Chair

Jeffrey PothofWhat exactly is reliability? Is it showing up for work on time? Is it making sure the mortgage payment is made every month or that our children have a ride home from school?

Thomas Nolan, senior fellow at the Institute for Healthcare Improvement defined reliability as “failure free operation over time, from the point of view of the patient.”1 For those of you who enjoy formulas, it looks like this:
Number of actions that achieve the desired result

Reliability = _________________________________________________________
                                                                Total number of actions taken

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QIPS Meeting Keynote: CT Utilization and Choosing Wisely

Gregg MillerGregg A Miller, MD, FACEP is the Program Director of Quality and Performance for Emergency Medicine for CEP America. He has served as the Medical Director for the Emergency Departments at San Joaquin Community Hospital and Swedish/Edmonds Hospital and has been involved in the implementation of multiple operational and quality-related initiatives. Dr. Miller also sits on the Washington state ACEP Board of Directors. He completed an Administrative Fellowship with CEP America with a focus on CMS quality-related programs. Dr. Miller attended medical school at the University of California, San Francisco and did his emergency medicine residency at Harbor-UCLA.

Quality Improvement & Patient Safety (QIPS) Section Meeting (12-2:30 pm PT)
Mandalay Bay Convention Center: South Pacific Ballroom A

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Computers, Measures, and Patients

meislWith great interest, I read Dr Susan Nedza’s article in the March 2016 QIPS Newsletter. Since my wife and I have become greater consumers of health care (I do not like the word consumers, let us say patients), we have experienced medicine from the “Other Side.”

What we have observed is a disconnect between the actual treatment of the patient and the adherence to protocols and mandatory documentation. I will give a few examples, granted all subjective. My visit to the ED a few years ago for chest pain brought out the myocardial infarction routine/protocol from nursing, before seeing the ED physician even though the pain was totally atypical for myocardial ischemia. A brief history and physical would have sufficed, and saved costs. Here, 2 words triggered a rigid response and protocol, without thinking about what the patient might actually have.

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Determining Decisional Capacity

A 62-year-old man with a history of DM, HTN, and HL, and previous myocardial infarction presents to your ED with a complaint of 3 hours of chest pain with onset during activity and radiating to his left shoulder. On arrival to the ED, his pain is improved, he appears comfortable, and his vital signs are normal. His ECG demonstrates new t-wave inversions in the inferior leads and his initial troponin is mildly elevated. You share with him the results and express that you would like to admit him to the hospital for serial troponins, cardiology consultation, and likely cardiac catheterization. At that time he reports that he would like to go home and follow up with his primary care doctor in the next day or two. Given the ECG changes, elevated troponin, and clinical history, you feel he should be admitted to the hospital but he is adamant about going home. He acknowledges your concern that his pain could be the sign of a heart attack or impending heart attack. He reports that he came in to find out if he needed a stent “straight away” from the ED like he has in the past. He otherwise provides multiple reasons for wanting to go home, including a dog to take care of and a desire to sleep in his own bed. You begin to wonder if your patient understands his situation…

As physicians we are responsible for making recommendations to our patients based upon our knowledge as health care professionals. In the ED we routinely recommend specific treatments, various tests, and admissions to the hospital versus discharge home. While we often encounter patients who choose not to adopt these recommendations, there are times when this refusal becomes very uncomfortable and we struggle with balancing our desire to help patients with respecting their autonomy.

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Encouraging Residents to Participate in Hospital-Wide Quality Improvement

As I cleared my voice, preparing to open my first council meeting one year ago, doubt crept back into my mind, would they really listen to me? Will people participate? Is everyone here just for the free food? 

I initially became involved in our hospital’s Resident Quality and Safety Council (RQSC) as an intern, interested in a career in emergency medicine administration and motivated to interact with residents across different specialties. While I sat quietly through my first several monthly meetings, I appreciated the different motivations behind resident comments—exasperation that workflows were inefficient, curiosity as to what a fishbone diagram was, worry that a reported near miss could have just as easily lead to an adverse patient outcome. While many members had no formal training in quality improvement, the counsel served as a venue for residents to get involved in improving quality and safety across the institution.

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Letter from the Editor

Brian SharpWow, what a year! This most recent year will simply add to QIPS’ incredible history that was so nicely summarized by Bobby Turelli at last year’s section meeting and in David John’s article in the December newsletter. Thank you all for your contributions this year to the section and the newsletter. The QIPS newsletter is an amazing vehicle to highlight the impressive work being done by section members, to educate about new quality initiatives that affect us all, and to share our voices, wisdom and perspective. I hope that you will all consider submitting content next year.

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Alternative Payment Models: The Emergency Department Canaries Are Beginning to Chirp

nedzaIt was not so long ago that emergency departments (ED) were first identified as the canaries in the coal mine for the health of the community and the healthcare system at large. 

Bird in a cage

Be it lack of access to primary care, lack of mental health services, increased demand driving ED crowding or the recent illicit drug epidemic, our departments continue to be on the frontline and to embrace the responsibility to inform the public and policy makers about issues that affect our patients. It is time to formally recommit to this role as Alternative Payment Models (APM) launched may threaten the safety of our patients.

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QIPS TIPS #31 To Scribe or Not to Scribe

Shari WelchThere is now a growing body of literature surrounding the use of scribes in clinical practice. The deployment of scribes has spread from its origins in the ED to a whole array of clinical settings including urology offices, cardiology clinics and primary care settings. A number of very positive things have been noted regarding the utilization of scribes in medicine: Physician satisfaction is improved, chart completion is expedited, documentation time is reduced and redirected to patient care, and some studies show improvement of the bottom line. One academic site reported that despite a significant increase in volume, the LOS was maintained and LWBS reduced, with RVUs going up after scribe integration into the practice.

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Does Lean Work?

I. History of Lean Healthcare 

Lean strategies are currently being widely applied in hospital systems across the world. Originally conceived by Toyota in the 1950’s, the key principles and tools of lean methodology received much fanfare and spread to other industries, including healthcare. The core ideas of lean involve decreasing waste and increasing value from the customer or patient’s perspective. Early lean adopters in healthcare, such as Virginia Mason Medical Center and ThedaCare, generated enthusiasm for more widespread implementation. Subsequently, many Emergency Departments (EDs) across the US and the world have adopted lean strategies to tackle common ED problems such as overcrowding. In a 2009 survey of US hospitals, 53% reported using lean approaches and 60% of those hospitals had employed lean in the ED.

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