"Until 2002, all CF patients were admitted to pediatrics, no matter what their age, and adult hospitals were not used to CF patients and their regimens," explains Cohen. "It all came to a head with Christina. That's when we realized that it's not the fault of one or two people who just don't understand, but that we need a new way of doing things."
Letting the frontlines lead
LIJ Medical Center embarked on a process to explore how to improve the in-hospital delivery of daily medications to CF patients. It is led by Jaffrey, who was part of the inaugural class of the Dartmouth–Hitchcock Leadership Preventive Medicine Residency, and who is pursuing a master's in healthcare delivery science at the Dartmouth Institute for Health Policy and Clinical Practice.
In February 2009, Jaffrey began coaching an interdisciplinary team of all the frontline caregivers, including Cohen, and a respiratory therapist, dietician, nurse, pharmacist, CF social worker, and Christina's father, in how to apply the methods of improvement science to improving CF care. The team focused on how it could support and empower the patient while still meeting regulatory requirements. "The goal," says Jaffrey, was to go from "a system of care that wasn't deeply connected to patients' experiences to one that is incredibly connected."
That summer the team began meeting for an hour every week to engage in activities that ranged from brainstorming to generating aims statements with numeric goals, creating measures to know that they were moving in the right direction, tracking measures using statistical process controls, and using the plan-do-study-act process to rapidly test change. Jaffrey also met with the team for two hours each month to educate members about healthcare quality improvement systems and how to use the Dartmouth program's five p's—patients, professionals, processes, patterns, and purpose—to assess their work. In addition, she coached team members so that they could report the team's findings to the hospital's leadership on a monthly basis.