Our mission is to learn from our successes and failures, continuously improve the quality of care we provide, commit to a culture of safety that protects our patients and colleagues, and to inspire and develop the next generation of quality and safety leaders.
The mission of the Quality and Safety Program in the Department of Anesthesia, Critical Care and Pain Medicine (DACCPM) at Massachusetts General Hospital is supported by coordinated and complementary work of the Quality Assurance Committees (QA) and the Quality and Safety Improvement Committee (QSIC).
Quality Assurance Committee
The QA Committee works closely with the Quality and Safety Improvement Committee (QSIC), a process improvement group responsible for the implementation of recommendations from the QA Committee and suggestions shared by department clinicians. Its members include faculty anesthesiologists, fellows, residents, CRNAs, nurses and administrative staff. It is very common to have device inventors, pharmacists and health information technology experts attend our meetings as well, for input and collaboration. An editorial published in the February 2014 issue of Anesthesiology explains our philosophy on the integration of quality assurance and quality improvement activities. Read the article (PubMed login required)
Some of the QSIC’s improvement efforts have included:
- Implementation of a standardized pre-procedure “time-out” prior to invasive procedures performed by the anesthesia care team
- Improvement of communication processes for transport of our most critically ill patients between the operating room and intensive care units
- Introduction of Emergency Manuals to provide guidelines that help clinicians with crisis management in specific situations of uncommon but life-threatening emergencies
- Standardization of handoff processes and workflows whenever a change in anesthesia provider occurs
- Standardization of operating room anesthesia tray set up and turnover processes between cases
Quality and Safety Leadership Team
- Director: May Pian-Smith, MD, MS
- Associate Director: Aalok Agarwala, MD, MBA
- Administrative Manager: Allison Doney, MHA
- Advisor: Jeffrey Cooper, PhD
- QA Committee Chair: May C. Pian-Smith, MD
- QSIC Chair: Jeremi Mountjoy, MD
- Director of Medical Simulation: May C. Pian-Smith, MD
- Q&S Administrative Manager: Allison Doney, MHA
- Program Manager: Vanessa Kurzweil, PhD
- Senior QA Coordinator: Terry Morris, RN, MS
- QA Coordinator: Ellen Blanch, RN
- Q&S Analyst: Kathy Kong, MPH
Resident Quality Assurance Committee
The Resident Quality Assurance (QA) Committee works closely with both the QA Committee and the QSIC. This committee is exclusively made up of residents and is open to all departmental residents. Meetings provide a forum to discuss patient safety events and suggestions for how they could improve the process and prevent similar events in the future. The committee sponsors resident M&M presentations to the whole department as well as relevant presentations and workshops. For example, a recent communication workshop focused on helping residents facilitate difficult conversations and mutual understanding through nonverbal communication, advocacy-inquiry, and reframing techniques. The committee also works on quality initiatives such as improving transfusion practices and preventing perioperative eye injuries.
Our department is home to Jeffrey Cooper, PhD, internationally renowned patient safety advocate and co-founder of the Anesthesia Patient Safety Foundation, and founder of the Center for Medical Simulation. Dr. Cooper is a long-standing member of the QA and QSIC committees and serves as Advisor to the DACCPM Quality and Safety Leadership Team.
Simulation training and facilitated debriefings are an important aspect of experiential learning for faculty and trainees at Mass General. In addition to team training at the Center for Medical Simulation, deliberate practice of procedural skills occurs within the department and on campus at the Mass General Learning Lab. Unique offerings on Mass General’s main campus include fully immersive interdisciplinary crisis management training: weekly sessions allow anesthesiology residents and CRNAs to manage simulated emergencies with surgery residents and OR nurses. Bi-weekly simulation sessions offer opportunities for faculty anesthesiologists, faculty surgeons and OR nurses to manage simulated critical events. Creating shared learning experiences is at the foundation of our safety culture.
Evidence informs us that adverse events or medical errors can have a significant impact on the clinicians involved. Clinicians involved in these types of event are at higher risk for distress in the wake of the event and burn out in the longer term. Therefore, in 2014 the Peer Support Program was developed to assist clinicians who have been involved in adverse events or medical errors by providing a trained Peer Support Team Leader to offer help and resources.
Physician satisfaction and wellness are increasingly frequent topics of discussion in both the media and in academic publications. The Clinician Wellness Committee is made up of staff, residents, CRNA’s and administration. This committee is focused on promoting health, well-being and job satisfaction among department clinicians.
Celebrating Safety Champions
Recent Award Recognition
Dr. Jeffrey Cooper, received the American Society of Anesthesiologist’ Distinguished Service Award in recognition of his contributions to advancing the safety of anesthesia. Drs. Devan Bartels, Dustin Long, Puneet Sayal and Crystal Tan received the Anesthesia Patient Safety Foundation Resident Quality Improvement Award for 2015. This award was announced and presented at the ASA meeting in San Diego, California. The winning entry (video abstract) describes a resident-led project to create 3D-printed brackets to hold emergency drugs on all anesthesia machines. Watch video
Drs. Susan Vassallo and Adrian Ionescu were nominated for the McGovern Award. This award recognizes physicians who are focused on patients care; are viewed by colleagues as the “go-to” person in their area of practice; make compassion and kindness the cornerstone of their practice; make an extra effort to ensure patient needs are met; and are often the “unsung hero” whose contributions make the MGH a better place to work and receive care.
The Jeffrey B Cooper Award for Patient Safety
The annual Jeffrey B. Cooper Award for Patient Safety honors the dedication and contributions of Dr. Jeffrey B. Cooper to patient safety. Dr. Cooper is a Professor of Anesthesia, Harvard Medical School, and the Executive Director of the Center for Medical Simulation. The intent of the award is to annually recognize the contributions of an individual member of the department to the provision of safe patient care and to foster a culture of safety among the members of the department.
Past winners include:
- Warren Sandberg, MD – 2009
- Scott Streckenbach, MD – 2010
- John Walsh, MD – 2011
- Nathanial Sims, MD – 2012
- Robert Peterfreund, MD – 2013
- Nancy Wyman, RN – 2014
- Michele Szabo, MD – 2015