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Spotlight: Brigham and Women’s Faulkner Hospital’s Quality, Safety, Risk, Compliance and Infection Control team

Newly reorganized under the leadership of Chief Medical Officer and Vice President of Medical Affairs Scott Schissel, MD, PhD, Brigham and Women’s Faulkner Hospital’s Quality, Safety, Risk, Compliance and Infection Control team can be divided into three distinct, yet interconnected, groups: Hospital Quality; Infection Control, Clinical Compliance and Patient Safety; and Risk Management.

Hospital Quality

Caitlin Manca, MPH, is the Director of Hospital Quality where she oversees data reporting and quality improvement work associated with CMS, TJC, MassHealth, Get With the Guidelines and National Surgery Quality Improvement Program measures completed by the Quality team. She also completes our annual Leapfrog survey. Reporting to Manca are three Quality Analysts. “The majority of my team’s time is spent looking at our quality measures and trying to find areas of improvement within those quality measures,” she says. “Quality improvement requires engagement from a multidisciplinary group of stakeholders. Recently, we have seen improvement in our sepsis measure from 37 percent (2020) to 46 percent (2021) because of the collaborative work from our Sepsis Workgroup which includes representation from ED and ICU nursing leadership, nursing professional development, ED clinicians, med/surg clinicians, the lab, the pharmacy and informatics.”

Infection Control, Clinical Compliance and Patient Safety

Andrea Shellman, MHSA, CPPS, is the Director of Infection Control, Clinical Compliance and Patient Safety where she manages the hospital’s Joint Commission readiness, supports the prevention and tracking of infections and addresses all manner of patient safety concerns. Her team currently consists of the Associate Hospital Epidemiologist, a Project Manager for Infection Control and Clinical Compliance and a Project Manager for Patient Safety. “Ultimately, we collaborate across BWFH to ensure safety for both our patients and staff. My team ensures that we have a culture that mitigates, discusses and learns from errors, prevent the spread of infection and are compliant with regulatory bodies such as The Joint Commission,” she says.

Risk Management

Beth Uhl-Israel, MBA, CPHRM, CPHQ, is the Director of Risk Management. Her department is charged with identifying risks and responding to them in order to promote both staff and patient safety. Working collaboratively with Uhl-Israel is Risk Manager Cat Pepe. “When you think of risk, you want to think about any occurrence that is not consistent with the routine operation of the hospital or routine patient care,” Uhl-Israel says. “Even issues that don’t result in harm to a patient should be reported. Every report is reviewed. If staff have entered a safety report in the past, but the safety problem persists, they should continue to report using the RL Solutions application. Some events unfortunately result in harm to a patient and those may require external reporting to regulatory agencies. After an event occurs, we value the insight provided by the clinical team. They have the best ideas for improvement. Risk Management is also available to consult in those times when we need to apologize to a patient or their family after an event occurs. The best way we can support staff is to think about how to prevent events from occurring.”

All three directors report to Dr. Schissel. “The functions of the subdepartments are distinct, but there is a lot of interplay between the three directors,” he says. “The thread that runs throughout this department is our commitment to safe and optimal care for our patients. Whether it’s monitoring quality, assessing risk or ensuring we are complaint with the various regulations, the ultimate goal is to provide high-quality, safe patient care.”

To ensure they are meeting their common goals, the directors meet weekly and work together daily. If you or your patient has a concern related to the care being provided, they stress that you can reach out to any of them as a lot of concerns don’t fall into one clean bucket. “There is a new synergy around how the work gets done,” says Dr. Schissel. “We now have three strong leaders who are looking at things with a fresh set of eyes. Their distributed perspectives on each of their domains allows them to focus on their area of expertise but also interact with their co-directors in new and innovative ways.”

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