2014 Quality Improvement Initiatives

The following are three examples of the numerous quality improvement initiatives that Fletcher Allen staff engaged in during 2013. For more information on these or other QI initiatives, contact the James M. Jeffords Institute for Quality & Operational Effectiveness at Fletcher Allen at 802-847-0554.

  1. Choosing Wisely Vermont: Implementing Change via Education and EMR Modification to Reduce Daily Chest X-Rays in the Adult Medical Intensive Care Unit
  2. Advancing Patient Safety in Clinical Oncology Through Simulation-Based Team Training
  3. 2013 Employee Wellness Campaign: Know Your Numbers, Know Your Score 

Choosing Wisely Vermont: Implementing Change via Education and EMR Modification to Reduce Daily Chest X-Rays in the Adult Medical Intensive Care Unit

Time Frame:  July 2013-March 2014

Description/Problem

Traditional intensive care unit (ICU) practice includes daily chest X-rays (CXRs) on all mechanically ventilated patients for confirmation of airway tubes and venous catheters. Recent data suggest that “the diagnostic yield and therapeutic consequences of daily routine CXRs are very low.” In one study, less than 5 percent of daily CXRs led to any changes in treatment in the ICU. 

At Fletcher Allen Health Care in the Medical ICU (MICU), pre-implementation data (collected between December 2012 and June 2013) showed that 901 CXRs were obtained on 1,111 census days that were not associated with the first day of endotracheal/breathing tube placement or another procedure that would justify a CXR (or 81.1% of the total). 

Runaway healthcare costs dictate that medical communities shift to a paradigm of efficiency in value. Because ICU care contributes to a disproportionate amount of this cost, efficiency in value must be swiftly adopted in this arena.

Project Goals  

  • Fewer unnecessary chest X-rays in the ICU  
  • Fewer disruptions in patient comfort 
  • Reduced patient and caregiver exposure to radiation
  • Reduced cost of ICU care   

Interventions

A project team was assembled: Two MICU leaders, a quality improvement consultant, electronic medical records, radiology staff and a third-year Medicine resident set out to implement the reduction of unnecessary CXRs with the following planned interventions:  

  • Education of the MICU staff and residents (utilizing medicine grand rounds and daily resident huddles)
  • Removal of automated adult “daily CXR” order in electronic medical records
  • Addition of a daily query to the ICU rounding checklist to determine whether a CXR is clinically indicated the next day to assure that patients who did require a CXR the next day were not overlooked 

An examination of this culture-driven practice, with open skepticism of the rationale that “this is how it has always been done,” was instrumental in identifying a potentially rewarding target for improving “efficiency in value.” 

And staff engagement was critical in:

  • Analyzing current practice 
  • Generating solutions
  • Facilitating organizational “buy-in” for change 

Results 

Since completion of education and implementation of the changes within the EMR, the number of daily chest x-rays on non-ventilator placement and/or non-procedure day has dramatically decreased in the MICU down to 31% in the month of March 2014.  


Advancing Patient Safety in Clinical Oncology Through Simulation-Based Team Training

Time Frame:  July 2013-Present

Description/Problem 

Data demonstrates that clinical outcomes and quality are optimized in patients who are treated by high-functioning teams. Most health care teams do not receive opportunities to formally work on enhancing teamwork and collaborative practice skills. 

Project Goals

The aim of this project is to enhance teamwork, collaboration and communication among members of inter-professional health care teams in order to optimize patient safety and clinical outcomes.

Interventions

  • Arranged time for the hematology-oncology nurses and fellows to meet informally and get to know one another 
  • Piloted simulation team training program with hematology-oncology nurses and fellows
  • Developed a series of oncology in-patient clinical care scenarios and conducted the scenarios with pairs of nurses and fellows in the simulation lab
  • Debriefing session following simulation where team performance was reviewed and team members exchanged viewpoints and perceptions

Results

  • Simulation-based team training scenarios were successfully implemented in a novel interprofessional curriculum for hematology-oncology nurses and fellows. 
  • Team training program was highly rated by all participants. (90 percent rating on feedback).
  • Participants valued the experience and indicated that they acquired new knowledge, skills and attitudes to enhance interprofessional collaborative practice. 
  • Principles of interprofessional collaboration are effectively conveyed through simulation team-training and improve team performance in the clinical setting. 
  • Team identified further areas for communication and collaborative training which have been implemented.
  • Preliminary observation of improved clinical collaboration on the unit

2013 Employee Wellness Campaign: Know Your Numbers, Know Your Score 

Time Frame:  June – December 2013

Description/Problem 

The Employee Wellness Program launched its campaign, “Know Your Number, Know Your Score,” to increase the health awareness of Fletcher Allen employees. 

Project Goals  

The 2013 “Know Your Numbers, Know Your Score” campaign focused on obtaining baseline measurements of health and lifestyle choices. This data would allow the Employee Wellness Program to focus its program efforts on the health needs and interests of the employees. 

Interventions

The “Know Your Numbers, Know Your Scores” campaign kicked off in June 2013. 

The program included:

  • A testimonial campaign that included experts, leaders and employees who had made significant lifestyle changes.
  • Employees received a $25 gift card for their participation in a biometric screening.
  • Screenings took place at over 25 satellite locations, 24 hours a day, seven days a week.
  • Employees received a $25 payout in their paycheck for completing an online health assessment created in partnership with BlueCross and BlueShield of Vermont.
  • Employees received an online score and summary of their current health status and behavior risks.
  • Upon completion of the assessment, employees could enroll in online health classes and receive information through the Employee Wellness portal.

Results 

Thirty-four percent of Fletcher Allen employees participated in the “Know Your Numbers, Know Your Score” biometric screening and online assessment. Baseline health data gathered through completion of a biometric screening and an online health assessment gave a better understanding of the employee’s strengths and areas needing improvement. A one-on-one meeting with a Wellness Health Coach allowed the employee to create lifestyle change goals.

The Employee Wellness Program evaluated participation rates among employee groups across the organization. These rates were broken down by job category and compared to the total number of employees in those job categories.

  • The groups with the lowest participation rates in the online assessment tended to be those with less access to computers in their work day.
  • The groups with the lowest participation rates in the biometric screenings tended to be clinical employees.
  • Exceeded participation rate goals for both biometric screening and online health assessment completion
  • Formed a Wellness Steering Team representative of key stakeholders