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 (Q&S) 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 (QA) Committee and the Quality and Safety Improvement Committee (QSIC).
Quality Assurance Committee
The QA Committee works closely with the 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.
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
- Creation of an FAQ document for patients
- Creation of a Downtime Blood Ordering Packet
Quality and Safety Leadership Team
- Q&S and Medical Simulation Director: May Pian-Smith, MD, MS
- Associate Director and QA Committee Chair: Jeremi Mountjoy, MD
- Senior Q&S Administrative Manager: Allison Doney, MHA
- Advisor: Jeffrey Cooper, PhD
- QSIC Chair: Lia Tron, MD, MPH
- Senior QA Coordinator: Terry Morris, RN, MS
- QA Coordinator: Ellen Blanch, RN
- Senior Q&S Analyst: Kathy Kong, MPH
Resident Quality Assurance Committee
The Resident Quality Assurance (RQA) 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 available for 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, 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 operating room nurses. Bi-weekly simulation sessions offer opportunities for faculty anesthesiologists, faculty surgeons and operating room 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. The program provides a trained peer support team leader to offer help and resources.
Celebrating Safety Champions
Pioneering Patient Safety
Jeffrey Cooper, PhD, anesthesia researcher at Mass General, discusses his vision for safety-centered medical systems that help prevent errors in anesthesia care and how he revolutionized patient safety through the development of one of the first microprocessor-based medical instruments.
Inventing for Safer Anesthesia
Nathaniel Sims, MD, a clinical and translational anesthesia researcher at Mass General, discusses his career in improving patient safety in health care through the development of patient safety devices such as a portable vital sign monitoring system.
Past Award Recognitions
Dr. Cooper received the American Society of Anesthesiologists (ASA) Distinguished Service Award in recognition of his contributions to advancing the safety of anesthesia.
In 2015, Devan Bartels, MD, MPH, Dustin Long, MD, Puneet Sayal, MD, and Crystal Tan, MD, received the Anesthesia Patient Safety Foundation Resident Quality Improvement Award. This award was announced and presented at the ASA meeting in San Diego, California. The winning entry was a video abstract that described a resident-led project to create 3D-printed brackets to hold emergency drugs on all anesthesia machines.
The Jeffrey B. Cooper Award for Patient Safety
The Jeffrey B. Cooper Award for Patient Safety was developed in honor of Dr. Cooper's dedication and contributions to patient safety. The intent of the award is to annually recognize the contributions of one DACCPM member to the provision of safe patient care and to foster a culture of safety among all members of the department.
Past winners include:
- 2021: Michael Andrawes, MD
- 2020: Rebecca Minehart, MD
- 2019: Aalok Agarwala, MD
- 2018: Kenneth Shepherd, MD
- 2017: William Driscoll
- 2016: Wilton Levine, MD
- 2015: Michele Szabo, MD
- 2014: Nancy Wyman, RN
- 2013: Robert Peterfreund, MD, PhD
- 2012: Nathanial Sims, MD
- 2011: John Walsh, MD
- 2010: Scott Streckenbach, MD
- 2009: Warren Sandberg, MD