Background: Hospital-acquired delirium is serious, leading to increased falls, pressure ulcers, length of stay, cost, patient institutionalization, and patient and caregiver distress. In addition, it is associated with mortality rates as high as 35-40% within one year in older patients who develop delirium. Programs targeted at delirium prevention and treatment may affect these outcomes. We [...]

Background: Hospital-acquired delirium is serious, leading to increased falls, pressure ulcers, length of stay, cost, patient institutionalization, and patient and caregiver distress. In addition, it is associated with mortality rates as high as 35-40% within one year in older patients who develop delirium. Programs targeted at delirium prevention and treatment may affect these outcomes. We [...]

Background: Stony Brook University Hospital (SBUH) identified an opportunity to develop and implement prevention strategies to reduce hospital onset C. difficile infections (CDI). Hospital Onset (HO) CDI are included in National Healthcare Safety Network (NHSN) reporting and included with other hospital-acquired infections as publically reported data. CDI contribute to prolonged hospital stays, inappropriate antimicrobial use, [...]

Background: Endoscopies are commonly performed in the inpatient setting, and successful completion frequently requires close coordination among nurses, hospitalists, gastroenterologists, and anesthesiologists. Given the complexity of this multidisciplinary involvement, as well as variability in patient factors like clinical stability and presentation, endoscopies are prone to delays. These delays may cause frustration amongst care providers and [...]

Background: Excessive daily routine laboratory testing for hospitalized patients is a contributor to poor hospital sleep, iatrogenic anemia, and excessive costs. Recommendations from the Choosing Wisely™ campaign specifically state to avoid sleep interruptions for routine care (American Academy of Nursing) and to avoid routine labs for stable patients (Society of Hospital Medicine). The purpose of [...]

Background: Third International Consensus Definitions for Sepsis and Septic Shock (SEP-3) defines Sepsis as life-threatening organ dysfunction due to a dysregulated host response to infection. In United States about 1.5 million Americans are diagnosed with Sepsis each year and about 250,000 of them die each year. It is also the costliest single diagnosis to treat [...]

Background: Joint Commission has identified “communication” as the third most frequent root cause of sentinel events.1 Alpha-numeric pagers are common for communication among healthcare professionals. Pagers are not HIPAA compliant and communication through pagers often lacks sufficient information for effective communication.2 Because pager communication is one-way, closed loop communication requires a return telephone call, disrupting [...]

Background: Developing effective tools which enhance patient-physician communication is crucial to improving the patient experience. Existing research has shown that there are several components which are central to effective communication, including creating a good interpersonal relationship, facilitating exchange of information, and including patients in decision making. Based on our experience at an underserved community hospital [...]

Background: At the University of Colorado, we developed the ‘Health Innovations Scholars Program’ (HISP), a 5-week intensive training program for pre-clinical medical students who seek to lead innovative transformation of the healthcare system. The program focuses on quality improvement, patient safety, leadership skills, design-thinking, and change management delivered through didactic sessions and applied to an [...]

Background: The ACGME has developed competencies for systems-based practice and problem-based learning and improvement to encourage trainees to integrate quality and safety into their everyday practice. Furthermore, the AAMC has a call to action for US Medical schools and teaching hospitals to successfully align clinical and education missions in order to have quality improvement and [...]