Author(s): Megan Cabrera, MS, CCC-SLP
Project Manager, Center for Quality, Safety, and Regulatory
UMass Memorial Medical Center

Ellen Felkel-Brennan, DNP, RN, CPHQ
AVP Quality, Safety and Regulatory - UMass Memorial 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 Health System Suicide Steering Committee identified three focused areas for continuous improvement for patients at risk for suicide: incomplete evidence-based suicide risk assessments, inadequate documentation of observation levels, and gaps in environmental checklist documentation. The team implemented enhancements through our EPIC electronic medical system to increase compliance and improve the quality of care provided to at-risk patients. By leveraging the functionalities of EPIC, we streamlined documentation processes and reinforced care standards across our healthcare continuum. These enhancements facilitated an impressive 35% increase in compliance with documentation standards and elevated the overall quality care delivered to our patients. Problem: After the initial launch of a system-wide initiative to improve the care of patients at risk for suicide in 2018, ongoing evaluation by the UMMH Suicide Steering Committee identified three focused workflows requiring improvement: incomplete evidence-based suicide risk assessments, inadequate documentation of observation levels, and gaps in environmental checklist documentation. Measurement: To effectively visualize our progress and outcomes, we utilized a wide range of measurement tools including bar graphs, control charts, dual-axis charts, dashboards, and data extracted from within EPIC to analyze through the tableau platform. Analysis: Our analysis process was comprehensive involving evaluating pre and post data. Comparative analysis of the presence of an evidenced-based suicide assessment, completion of observation checks, and environmental screens according to policy. Reviews were conducted across various service lines to ensure a standardized approach and compliance. Implementation: Throughout the implementation process, we focused on enhancing documentation of the CSSRS-RA, combined observation and environmental checklist documentation into one flowsheet, optimized suicide risk mitigation orders, implemented BPAs, and leveraged Care Everywhere and EpiCare Link. We closely collaborated with informatics colleagues to assist with any obstacles along the way. Results/Discussion Our efforts resulted in an impressive 35% increase in compliance with our documentation across all three focused workflows. To ensure the sustainability of our implementations, we conduct regular system meetings to review data and discuss opportunities. This commitment to monitoring and refinement highlights our dedication to delivering quality patient care.

Evaluation: Complete Poster Evaluation