Quality Improvement and Patient Safety

The Department of Medicine at SUNY: Upstate Medical University 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.

Our fundamentals are based on Upstate’s core values:

  • Excellence in effective and timely patient care
  • Teamwork and collaboration
  • Respect and collegiality
  • Innovation and research in healthcare
  • Efficient and equitable care
  • Patient- and family-centered care

Patient- and family-centered care incorporates a significant focus on patient safety. Patient safety is based on a culture of learning, reporting and communication, and just culture.

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Our Quality Improvement Team

The Department of Medicine’s quality improvement team is comprised of the following:

  • Chair of medicine
  • Clinical chief for Department of Medicine for University of Community General Hospital
  • Vice chair for quality improvement and patient safety (team leader)
  • Departmental quality and divisional quality officers
  • Quality chief resident
  • Quality lead fellow
  • Quality coordinators
  • Core and fellowship program directors
  • Divisional chief

The vice chair for quality improvement and patient safety leads this program in the Department of Medicine, plus the core and fellowship programs, and oversees/supervises the quality programs for each division. The departmental quality and divisional quality officers collaborate to address quality issues across all department and divisions at Upstate.

The quality chief resident mentors and supervises residents for the quality improvement and patient safety programs, under the mentorship of the program director and vice chair for quality.

The quality coordinators assigned to the Department of Medicine help in quality data collection, analysis, and projects. The core and fellowship program directors serve as mentors for their respective trainees and ensure robust participation in the department’s quality endeavors.

Goals

1. Inpatient Mortality (O/E)

Develop a process to review all mortalities by inpatient admitting services in the Department of Medicine, recognize learning opportunities, and develop quality initiatives based on trends.

2. Sepsis Mortality (O/E)

Continue education and awareness for early recognition of sepsis and appropriate medical care. Monitor the usage of sepsis order sets and procedure notes when sepsis is recognized in patients.

3. Patient Experience

Collaborate with patient experience champions and chief patient experience officer to develop a process to share HCAPS, Press Ganey scores, and patient comments with providers within the Department of Medicine.

4. Cardiovascular Quality Initiatives

Create a cardiovascular quality committee to improve quality of care and patient safety by developing quality, process, and outcome measures.

5. Ambulatory Quality Initiatives

Define ambulatory quality metrics.

6. Educational Quality Initiatives

Education and engagement of trainees to develop a process of faculty development in the quality improvement and patient safety (QIPS) program by:

  • Completing IHI basic certification course in quality improvement and patient safety
  • Attending Department of Medicine quality improvement meetings, resident quality council, and morbidity and mortality conferences

Significant Accomplishments

  • Creation of the great catch award program
  • Creation of pulmonary embolism response team (PERT)
  • Creation of awards to provide positive enforcement, for example, sepsis champion, the best mortality and morbidity presentation award
  • Implementation of sepsis campaign for education and awareness of sepsis, and to reduce observed and expected mortality
  • Creation and collaboration of interdisciplinary teams with emergency department and trauma in order to share cases that improve quality of care and service to our patients
  • Creation of departmental multidisciplinary quality and patient safety conferences
  • Creation of a physician code team leader for the hospital code/rapid response team
  • Creation of a physician sign-out tool that is embedded in the hospital EMR
  • Creation of admission, progress note, and discharge note templates for internal medicine residents that optimize accurate documentation
  • Creation of multidisciplinary rounds with case management, physical therapy, nutrition, nursing, and physicians to facilitate patient-centered care and hospital throughput
  • Creation and implementation for hospital discharge workflow process to ensure patient safety, improve accuracy of medication reconciliation, and ensure a safe transition to outpatient care

Quality and Patient Safety Publications

  1. Gambhir HS, Dhamoon Amit, Goodrich Samantha, Kaul Viren. Impact of structured and scheduled family meetings on satisfaction in patients admitted to hospitalist service. Journal of Patient Experience. March 2021. DOI: 10.1177/23743735211002748.
  2. Sean Byrnes, Rao Suman, Banerjee Sanchari, Paularaj Shweta, Shah Siddharth, Raj Vijay, Singh Avneet. Clinical utility of transesophageal echocardiograms in the workup of acute ischemic stroke. The American Society of Echocardiography. June 2021.
  3. Paularaj Shweta, Raj Vijay, Ohja Niranjan, Sean Byrnes, Prashant Kumar Ashok, Singh Avneet. Impact of a quality initiative to reduce inappropriate ordering of transthoracic echocardiography in a university hospital. The American Society of Echocardiography. June 2021.
  4. Billal Mohmand, Naqvi Abeeha, Durland Justin, Sruti Akula, Raj Vijay, Shah Siddharth, Singh Avneet. Can it wait? Transthoracic echocardiograms prior to discharge. The American Society of Echocardiography. June 2021.
  5. Kudaravalli P, Doobay R, Carvounis C, Toomey C, Dhamoon A. Initiatives to reduce the inappropriate use of proton pump inhibitors in an outpatient primary care clinic. Ann Pharm Fr. 2020 May 30:S0003-4509(20)30069-9. doi: 10.1016/j.pharma.2020.05.002.

If you have questions or would like to know more about the quality improvement and patient safety program at the Department of Medicine at SUNY: Upstate Medical University, contact us by sending an email to DeptMedicine@upstate.edu.

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