Quality & Safety Initiatives

Quality Projects

Thomas Jefferson University Hospital (TJUH) enterprise is growing rapidly and becoming one of the main, cutting edge health centers in the United States and certainly in the Tristate area. One of its leading, rapidly expanding divisions is the Cardiovascular Service Line. This service Line includes Jefferson Heart Institute (JHI) (multiple departments including Cardiology, Cardiothoracic Surgery, Cardiovascular Fellowship Program and others), Cardiology Consultants of Philadelphia, Heart Center of Philadelphia and others. The JHI service line is working hard on expanding its level of activity, collaboration and volume. First and foremost, our mission is to take care of our patients and to continuously work on improving the quality of care. This expansion of activity and patient volume allows us to seek, find, and implement different strategies to improve the quality of care on multiple fronts.

Project Titles

• Telemetry monitor timed orders: Dr. John Devine, Hospital Administration, Ms. Lisa Wus, 5W Clinical Nurse Specialist, Ms. Helene Dailey, 5W/NW Nurse Manager, Dr. Yair Lev
• Improving Inpatient / Transition of Care of Patients Suffering from Opioid Abuse. Dr. Edmund Pribitkin, Chief Medical Officer, TJUH, Dr. Yair Lev, Cardiology, Dr. William Jangro, Psychiatry and Director of the TJUH Narcotic Addiction Rehabilitation Program (NARP)
• Improving the quality of patient care based on mortality committee analysis. Drs. Gregary Marhefka, Director of the CCU, Hitoshi Hirose, CVICU, Ms. Kamini Patel
• Reduction of length of stay (LOS) on the 5W Cardiology unit. Ms. Lisa Wus, 5W Clinical Nurse Specialist, Ms. Helene Dailey, 5W/NW Nurse Manager, Drs. Gordon Reeves, Yair Lev
• Postoperative atrial fibrillation (Afib) treatment protocol after cardiac surgery. Drs. Daniel Frisch, Yair Lev, Cardiology, Dr. John Entwistle

Quality Improvement (QI) activities within the Division of Endocrinology, Diabetes & Metabolic Diseases in the past year have primarily focused on developing process improvements addressing clinical outcome measures associated with diabetes. These are identified through our payor contracting, national society measures and HEDIS/National Quality Foundation (NQF).

Project Titles

• A Strategy to Improve Diabetic Control in Our South Philadelphia Diabetic Population
• Interdivision Collaboration: SGLT-2 Inhibitors (Beyond Diabetes)
• Inpatient Endocrine Lab Orders: Hypoglycemia and Adrenal Insufficiency

Quality Improvement in Colonoscopies

In 2018 the department created the direct access colonoscopy program.

This program covers the following:

• Accepts referrals from primary care
• Questionnaire identifies patients appropriate for direct access
• Procedure information provided by specifically trained staff
• Colonoscopy navigator began February 2018, monthly case volume up 42% since then
• Planned Quality Metrics? No show/late cancellation rate

HIV & HCV Testing in ITP Patients

Our aim from this analysis was to make sure standard of care were met and > 90% of patients with ITP diagnosis were checked for HIV and HCV. We had lot of obstacles collecting data from epic using different ICD10 codes to capture the biggest population.

The Division of Hospital Medicine has been implementing robust quality improvement and patient safety projects which led to delivering high quality care at lower costs.

Project Titles

• Outside Hospital Transfer Safety Initiative
• Documentation Improvement Program (cc/mcc)
• Hip Fracture Safety
• Geography unit based multidisciplinary rounds

The Jefferson Infectious Diseases Division receives Ryan White federal funding Parts A and D to provide comprehensive care for those living with HIV. Consequently, we are federally mandated to collect and report quality performance measures as frequently as every two months, depending on the performance measure. The Jefferson HIV Ambulatory Clinic, unlike most care sites in the United States, sees 1:1 ratio of men: women due to our funding and our enhanced capacity to care for women with HIV. We look forward to stratifying our data and assessing for interactions between gender and the independent variables: age group, race, ethnicity, transmission risk factor, insurance type of coverage, insurance status.

Project Title

• HIV/Ryan White Performance Dashboard

Division of Internal Medicine continues to track and improve upon a number of additional quality metrics, with various internal medicine practices using PDSAs cycles to improve upon their numbers.

• Hypertension Control: goal is to get patients with hypertension consistently under 140/90, and we have worked with medical assistants to improve blood pressure measurement
• Depression and falls screening: patients are screened yearly for depression and falls, and a pilot site is now using electronic tablets to record this information while in the waiting room
• Osteoporosis screening: women over 65 with certain fractures need to be screened for osteoporosis, and we have purchased a mobile osteoporosis screen for nurse practitioners to take to patients’ homes
• Statin compliance: patients with diabetes, heart disease and an LDL > 190 need statins, and we are working with providers to identify these.

Project Titles

• Improve rates of recommended care for patients with diabetes
• Improve rates of recommended screening for certain cancers
• Improve rates of immunization
• Perform Medicare Annual Wellness Visits for at least 50% of eligible patients
• Transitions of Care Management
• Chronic Opioid Management

Resident Quality Improvement Projects

In 2019 there were seven resident lead QI projects. All groups submitted an abstract and poster to the House staff Quality and Safety Poster Session which, if accepted, were presented June 6th, 2019.

The projects were as follows:

• Hospital Acquired AKI Severity Reduction
• A Strategy for Noise Reduction to Improve Patient Experiences with Sleep (SNORES)
• Effectiveness of an Educational and Interdisciplinary Intervention in Reducing Continuous Cardiac Monitoring
• Increasing Utilization of the OUD Aftercare Coordinator
• Improving retinal camera use to screen for diabetic retinopathy in the ambulatory setting
• Increasing PA PDMP Enrollment
• Glycemic Control in JHAP

The academic year has been productive with quality improvement initiatives in all aspects of kidney care: acute kidney injury (AKI), chronic kidney disease (CKD) and end stage renal disease (ESRD). All graduating nephrology fellows successfully completed a quality improvement project and presented posters at national/international meetings.

Areas of focus:

• Hypertension
• Anemia
• Inpatient Hemodialysis
• ESRD access care
• Acute Kidney Injury
• Advanced CKD
• Outpatient Hemodialysis
• Kidney/Pancreas Transplantation
• Nephrology Fellow Burnout

The Division of Pulmonary & Critical Care Medicine is highly engaged in improving patient safety and the quality of care across a diverse number of programs that cover the full range of pulmonary and critical care medicine. Furthermore, in addition to projects within the division, faculty serve as leaders for several hospital?based quality and safety initiatives. The following summary includes efforts in hospitalized patients and in the ambulatory arena. At the end, we also include a summary of our efforts to further emphasizing quality improvement within the Institute.

• Promoting Cutting Edge Pulmonary Embolism Care
• Reducing Mortality Index
• Eliminating Central Line Associated Bloodstream Infections (CLASBIs)
• Improving Asthma Control
• Development of the pulmonary dashboard
• Transitions of care
• Epic governance

• Smoking cessation program for patients with Rheumatoid arthritis
• The departmental initiative to improve the process of informed consent for immunosuppression: Biologics in rheumatology
• Documentation of the disease activity measures in systemic lupus and rheumatoid arthritis
• Addressing Bone health in autoimmune diseases