Goals & Accomplishments

The Department of Medicine (DOM) has a robust and expanding Quality Improvement and Patient Safety program that is committed to delivering high-quality, safe, equitable, efficient, and patient and family-centered care to our patients and community. The DOM fundamentals are based on Upstate's core values: excellence in effective and timely patient care, efficient and equitable care, and patient and family-centered care. Patient and family-centered care incorporates a significant focus on patient safety. Patient safety is based on the culture of learning, reporting, communication, and just culture.

Main Goals

  1. Inpatient Mortality: Develop a process to review all mortalities by inpatient admitting services in the DOM, recognize learning opportunities, and develop quality initiatives based on trends.
  2. Sepsis Mortality: Continue education and awareness for early recognition of sepsis and appropriate medical care. Monitor the usage of sepsis order set and procedure notes when sepsis is recognized in patients.
  3. Patient Experience: Collaborate with Patient Experience Champions and Chief Patient Experience Officer to improve patient satisfaction and develop a process to share HCAPS, Press Ganey scores, and patient comments with provers within the DOM.
  4. Cardiovascular Quality Initiatives: develop a process to review all mortalities, procedures, and processes in Division of Cardiology to improve the quality of care and service. Create a Cardiovascular Quality committee to improve the quality of care and patient safety by developing quality, process, and outcome measures.
  5. Ambulatory Quality Initiatives: Define ambulatory quality metrics to develop a process to implement quality initiatives for the Division of Primary Care to improve efficiency and improve diabetic care and preventive medicine.
  6. Educational Quality Initiatives: Education and engagement of trainees to develop a process of faculty development in Quality Improvement and Patient Safety Program (QIPS) by:
    • Completing IHI basic certification course in Quality Improvement and Patient Safety.
    • Attending DOM Quality Meetings, Resident Quality Council, and Morbidity and Mortality Conferences.

Significant Accomplishments

  1. Creation of Medical ICU Quality Council to identify opportunities for improvement and patient safety.
  2. Creation of platforms to improve communication with patients and nursing teams through the Internal Medicine Residency program.
  3. Creation of quality dashboards for Cardiac Critical care & Primary Care Clinic to identify areas of opportunities.
  4. Creation of Outpatient Quality: Primary Care Initiatives.
  5. Monthly Quality and Sepsis Rounds on the medicine and ICU Floors in the Department of Medicine to engage with the frontline team to share about quality initiatives and also get feedback.
  6. Creation of Quickstarter: A platform to pitch Quality Projects in the DOM.
  7. Creation of the great catch award program.
  8. Creation of Cardiology Quality Council to develop quality initiatives and metrics.
  9. Creation of pulmonary embolism response team (PERT).
  10. Creation of awards to provide positive enforcement, for example, Sepsis Champion, The Best Mortality and Morbidity Presentation award.
  11. Implementation of a Sepsis campaign for education and awareness of sepsis, and to reduce observed and expected mortality.
  12. Creation and collaboration of interdisciplinary teams with the emergency department and trauma to share cases that improve the quality of care and service to our patients.
  13. Creation of departmental multidisciplinary quality and patient safety conferences.
  14. Creation of physician code team leader for the hospital code/rapid response team.
  15. Creation of a physician sign-out tool that is embedded in the hospital EMR.
  16. Creation of admission, process note, and discharge note templates for internal medicine residents that optimize accurate documentation.
  17. Creation of multidisciplinary rounds with case management, physical therapy, nutrition, nursing, and physicians to facilitate patient-centered care and hospital throughput.
  18. Creation and implementation for the hospital discharge workflow process to ensure patient safety, improve accuracy of medication reconciliation, and ensure a safe transition to outpatient care.