1. Volume 5, Issue 8
August 31, 2013
I N S I D E T H I S I S S U E :
Atrius Health Quality
and Safety Newsletter
Quality & Safety Updates
Welcome to the August 2013 Issue of the Quality and Safety Newsletter. In
this issue:
 We celebrate how the Cambridge Dermatology department’s safety
reporting helped improve workflow and patient care
 Linda Oliver, Director of ACO Development, provides a one page summary
of recommendations for falls risk screening, prevention & communication
 Mary Quilty, Senior Project Manager ACO (HVMA), opens our
conversation around Shared Decision Making, and we invite YOUR stories
 Marianne Lee, Co-Director of Clinical Pharmacy, rounds out the summer
with a refresher on Vitamin D and Falls
 We welcome Kelly Bitters to the Safety and Risk Management Team
As always, we share the most recent Top Tier results…with a shout out to
Chelmsford, the first practice to achieve the Triple Crown —1st
place and at
stretch goal on all 3 key chronic disease outcome metric. What a great way to
close out the summer! Hats off to everyone.
-- Anita Ung, MD MPH, Department of Quality & Patient Safety
July 2013 Safety Champion 1
Helping to Reduce the Risk of
Falls
2
Shared Decision-Making 3
Vitamin D and Fall Prevention 4
Welcome to Kelly Bitters! 4
Top Tier Metrics: July 2013 6
July 2013 Safety Champion: Cambridge Dermatology
The Harvard Vanguard Cambridge (CAM) practice is making great strides toward a culture of safety, and
helping lead the way is their Dermatology department. The Patient Safety & Risk Management team would
like to award the Cambridge Dermatology department, supervised by Eric Scaduto, with the July 2013 Safety
Champion Award for their continued efforts to report and review safety events from a systems perspective.
The department consists of Laura Houk, MD, Christy Flory, NP, Patricia Morris, LPN, Natacha Figaro, LPN,
and Tina Soares, MA.
CAM Medical Specialties accounts for 23% of the events reported by CAM. Of those 23% events, 18%
originated from the Dermatology department. All Dermatology team members report events, and the events
are reviewed with a focus on systems-related issues. Reviewing events from this perspective has resulted in
numerous work flow changes, creation of new standard work, and process redesign. Some examples include:
 The site where the biopsy was performed was listed erroneously on the pathology form, as a result of a
process in which the pathology form was completed separately from the EPIC order and the specimen jar.
Based on their event review, a few process changes were implemented to prevent this from happening
again. A question was added to the Dermatology surgical Time Out process: “Have you completed the
pathology sheet?”, as well as an extra check point in which the Epic order is compared with both the
specimen jar and pathology sheet prior to bring them to the lab. These changes will ensure that the
pathology form, Epic order and specimen jar contain the same patient and site information.
 Another trend observed by the Cambridge Dermatology was a delay in communicating pathology results
to patients within an appropriate timeframe. The Dermatology department developed a new policy in
which pathology results are communicated to the patient within 10 days of specimen collection.
We would like to thank the Cambridge Dermatology department for focusing on safety event reporting this
year and tracking their safety metrics on their site MDI board. There are many site based efforts and initiatives
focusing on the importance of reporting and increasing reporting among all levels of staff.
— Contributed by Erica Ribeiro, Department of Patient Safety & Risk Management