Author(s): Laura Innarelli, MS, CPHQ
Quality, Safety, Regulatory Project Manager - UMass Memorial Medical Center
Innarelli is a Quality, Safety, Regulatory Project Manager in the Center for Quality and Safety at UMass Memorial Medical Center in Worcester, MA. She has been working in healthcare quality improvement since 2017 and became a Certified Professional in Healthcare Quality in 2023. Additionally, she is trained in lean methodologies for process improvement.

Ellen Felkel-Brennan, DNP, RN, CPHQ
AVP Quality, Safety and Regulatory - UmassMemorial Medical Center
I am the AVP of Quality, Safety and Regulatory at UMass Memorial Medical Center, a large Academic MC in Massachusetts. I have held several positions within Nursing and Operations focusing on Quality, Safety and Regulatory (QSR) and am an Assistant Professor at UMass GSN. I lead a team of QSR staff that focus on activities to support the commitment to Zero Harm. This includes targeting high risk priorities related to, Falls, Pressure Injuries, Mortality, and Infection Control and also ensures ongoing compliance with external agencies.Holds a Black Belt in Lean Methodology and is active in coaching belt candidates. Ellen led Systemwide Lean initiative focused on Suicide Risk and process redesign. Initiative involved several Kaizen events, process redesign and PDSA cycles. Resulting in greater than 90% utilization of an EB suicide screen and assessment coupled with activation of standing orders and mitigation plans aligned to the patients stratified risk level.

Competency Domain: Patient Safety

Description: UMass Memorial Medical Center (UMMMC) identified a gap in an effective system to identify, plan, and coordinate care for pediatric behavioral health patients who board in the hospital, as they have complex needs behaviorally and/or socially. These patients experience an increased length of stay (LOS), which ultimately has resulted in patients, caregivers, and families experiencing harm and/or negative outcomes. During this project, representatives from all pediatric care areas within UMMMC addressed some of the challenges associated with delivery of care for the identified population, with the goal to ultimately decrease patient length of stay and improve patient and staff safety. Problem: UMMMC experiences an influx of pediatric behavioral health patients >4 and <19 years old, who board in the hospital for >5 days after medical clearance due to their complex behavioral and/or social needs. The organization lacks an effective system to address the challenges associated with caring for this vulnerable population. Measurement: By the end of FY2024, goals include reducing:-the average LOS for population by 20%-the average number of caregiver harm incidents related to patient aggression by 20%-the average number of patient incidents of harm/aggression by 10%An electronic Pediatric Behavioral Health Dashboard was created to monitor goal progress. Analysis: Average LOS, average caregiver harm incidents, and average number of patient harm/aggression incidents for FY2023 were compared to the same data during the implementation process. The results measurement will continue through the end of FY2024.Implementation:Key representatives from all major pediatric care areas determined the following interventions: a screening tool to earlier identify patients at risk for long LOS, creation of patient specific de-escalation/safety plans accessible across care areas, implementing a trauma informed care model, and building a pediatric behavioral health rapid response team (PBHRRT).Results/DiscussionUMMMC created a long LOS screening tool in the medical record. A subsequent de-escalation/safety plan is completed, and a patients' individualized plan is accessible regardless of patient location. Trauma informed care curriculum is being rolled out across pediatric care areas. The PBHRRT is anticipated to be live starting 3/2024.

Evaluation: Complete Poster Evaluation