BWH Teams Complete Clinical Process Improvement Course

From left, Roya Ghazinouri, Stuart Pollack, Emily Kadehjian, John Wright, Namrata Patil and Melissa Spinks.

BWH has offered a “Joint Class,” a pre-operative education class for patients undergoing a primary total hip arthroplasty, for more than 10 years. But before this spring, there was no uniform way for patients to find out about the class.

“Some people were told by surgeons about the class, and others were told by schedulers,” said Roya Ghazinouri, PT, DPT, MS. “The timing of the joint class and pre-operative evaluation date rarely coordinated, requiring patients to make two or even three trips to the hospital to complete their pre-op evaluation and education.”

This spring, Ghazinouri and John Wright, MD, set out to change that. They were one of five BWH teams to complete Partners’ Clinical Process Improvement Leadership Program, or CPIP, which is modeled after Intermountain Healthcare’s mini-Advanced Training Program in Salt Lake City.

“The Intermountain course, which is led by Brent James, focuses on ways to engage clinical practitioners in their clinical spaces,” said Jessica Dudley, MD, chief medical officer, Brigham and Women’s Physicians Organization, who completed the Intermountain training program in 2008, along with seven others from the Partners network. “We all found it incredibly useful, but we knew if we wanted to have cultural change in this space, we would do better having our own version of this course.”

Dudley and Michael Gustafson, MD, MBA, senior vice president of the Center for Clinical Excellence, now represent BWH on the CPIP steering committee. After the decision was made to replicate the course for Partners organizations, a second group of Partners clinicians traveled to Salt Lake City, this time with the mission of learning to implement the program in Boston.

“The Brigham has played a unique role in this Partners-level initiative. Michael and Jessica have both been instrumental in raising awareness of the course and designing its curriculum,” said Sandhya Rao, MD, CPIP co-course director, who was among the second group of Partners employees to complete Intermountain’s program.

“The goal of the CPIP is to provide front line clinicians with tools, such as a process mapping and variation analysis, to improve clinical outcomes by addressing the underlying processes of care,” said Rao. “It combines lessons from Intermountain with the Lean methods for process improvement and uses an array of teaching methods, including seminars, expert panels, case examples and small group sessions.”

Participants also complete a team clinical process improvement project during the 12-week course, allowing them to translate theory into action.

Ghazinouri and Wright analyzed the existing work flow and developed a process map to outline how patients are scheduled for their pre-operative activities, including attendance to the educational joint class. They ultimately decided to schedule the class on the same day as the patient’s pre-operative evaluation. They made the class mandatory for all patients, and not only standardized how information about the class is conveyed to patients, but also what information is conveyed. This effort was the first phase of a two phased program on standardizing clinical management of patients undergoing primary total hip arthroplasty at BWH.

Another team, led by Stuart Pollack, MD, and Senior Project Manager Emily Kadehjian, MS, aimed to identify defects in care of blood pressure management and to develop processes to prevent them in real time at the point of care. They set out to implement a fool-proof method to alert the physician or nurse practitioner of a patient’s high blood pressure and hoped to reduce by 50 percent the number of patients with unacknowledged high blood pressure.

Robert Boxer, MD, PhD, and Ellen Clemence, MSN, RN, looked at the issue of variation in discharge planning. Their goal was to provide a structured framework for discharge planning communication; an end result of their project included the creation of a discharge planning checklist that all care team members can view and update.

Namrata Patil, MD, MPH, and Senior Project Manager Melissa Spinks addressed the issue of a lack of objective method or validated tool to assess delirium in a patient. They worked with the BWH Delirium Task Force’s adopted tool, the Confusion Assessment Method, developing guidelines and forms to standardize the assessment process.

And a fifth BWH team consisting of Christopher Baugh, MD, MBA, and Ali Raja, MD, MBA, examined overuse of imaging for patients in the Emergency Department with suspected renal stones. The team worked with Emergency Medicine and Emergency Radiology experts to determine an appropriate goal and method to decrease the number of imaging studies on patients in this demographic.

“All of the project areas had been identified as priorities by leadership,” said Rao. “Each Brigham team was really strong, and as a whole, Jessica and Michael did a great job of selecting individuals with strong leadership capability.”

Rao, a BWH physician and leader of High Performance Medicine Team 5, which sponsored the course, and co-course director Joseph Jacobson, MD, of North Shore Medical Center, are planning the next CPIP session. “It’s a demanding course,” said Rao. “Quality improvement is hard, and this course gives people a taste of the challenge in a very compressed time frame.”

Now that she has completed the course, Ghazinouri says she is using everything she learned. “I thought the course was great,” she said, “The challenge I face now is to promote quality improvement in my department and to continue to show people how important it is.”