Eisenberg Award Recipients
Congratulations 2023 Awardees
This year’s awardees made advancements related to health care teamwork culture and safety, reduced surgical risk and improved post-surgical outcomes for frail patients, and improved radiation use documentation, decreased high-dose radiation exposure, and improved opioid pill prescribing rates for cardiovascular patients. The awardees are listed below. Additional details on the strategies used and improvements implemented by this year’s recognized initiatives can be found within the awardee summaries.
Individual Achievement
Eduardo Salas, PhD – Rice University
Dr. Eduardo Salas was selected in recognition of his body of work across 40 years designing, developing, and evaluating evidence-based principles and tools to help healthcare organizations create a culture of teamwork and safety. Dr. Salas’ decades of work with the Department of the Navy regarding air crew coordination and teamwork, as well as in other high-risk industries, was foundational to establish core competencies specific to healthcare teams. Dr. Salas was instrumental in the design, development, and delivery of TeamSTEPPSTM - Team Strategies & Tools to Enhance Performance & Patient Safety, which has now been adopted by 70% of U.S. hospitals. The Eisenberg Award panel expressed Dr. Salas’ extremely important and tremendous impact, denoting that the TeamSTEPPS approach and framework were pioneering and revolutionary to how team-based care is provided. The Eisenberg Award panel describes Dr. Salas’ work as “visionary,” “trailblazing,” and “incredibly influential.”
National Level Innovation in Patient Safety and Quality
The Surgical Pause - Veterans Health Administration
The Surgical Pause uses routine screening via the Risk Analysis Index (a bedside frailty assessment that can be completed in 30 seconds without disrupting workflow) to identify 5-10% of the highest risk patients who experience disproportionately high rates of postoperative complications, loss of independence, and mortality. For frail patients, a brief “pause” permits further evaluation to review goals of care and optimize treatment plans. For patients who decide to pursue surgery, multidisciplinary care plans can be tailored to mitigate frailty-associated risks prior to surgery through prehabilitative interventions such as nutritional supplementation, preoperative exercise to improve physical condition and respiratory function, and tailored surgical care (i.e., use of narcotic-sparing regional anesthetics during surgery), and systematic delirium assessment during recovery. Prehabilitative interventions shift the paradigm and effort from focusing on rescuing patients with postoperative complications to strengthening frail patients and mitigating potential complications before they happen. The Eisenberg Award panel was impressed by the simplicity and effectiveness of the Risk Analysis Index to permit clinicians to quickly screen patients, and they noted that the Surgical Pause’s overall methodological approach and implementation strategy makes it accessible and replicable by a wide variety of settings and facilities.
Local Level Innovation in Patient Safety and Quality
Creating a culture of quality for cardiovascular care in Michigan – BMC2
BMC2 (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) is a state-wide quality improvement collaborative that develops and administers a portfolio of quality improvement interventions for patients who undergo percutaneous coronary interventions (PCI), vascular surgical procedures, and transcatheter valve procedures in Michigan. Facilities contribute procedural and outcome data to registries, which are aggregated into hospital and physician-level reports and benchmarked to statewide performance. BMC2 is recognized for its improvements in the documentation of radiation use, a decrease in high-dose radiation exposure, and opioid pill prescribing rates. The panel noted that this kind of collaborative, best-practice approach improved outcomes, reduced costs, and could be replicated by other states. The panel was inspired by BMC2’s inclusive scope across so many clinicians, physicians, teams, and sites, acknowledging the collaborative is “working to improve care, at every institution, and for every patient. It's remarkable.”
2023 Eisenberg Award Top Finalists and All Applicants
The Joint Commission and the National Quality Forum also recognize these organizations that were the Top Finalists considered by the award panel for the National and Local categories for 2023 and all organizations that submitted applications.
2022 Award Recipients
This year’s awardees made advancements related to medical errors in health information technology (IT), significantly reduced rates of critical events related to anesthesia, and connected mothers with important postpartum care. They are:
Individual Achievement
Jason S. Adelman, MD, MS, chief patient safety officer and associate chief quality officer; executive director, Center for Patient Safety Research; director, Patient Safety Research Fellowship, Columbia University Irving Medical Center and NewYork-Presbyterian; associate professor of medicine (in biomedical informatics) and vice chair for quality and patient safety, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons
Dr. Jason S. Adelman is a leader and innovator in the medical errors field and has developed novel methods to measure and prevent errors in health IT systems. Among Dr. Adelman’s key accomplishments is the development of the Wrong-Patient Retract-and-Reorder (RAR) Measure that detects wrong patient orders in electronic health record data. The RAR Measure has subsequently facilitated a large body of patient safety research, including medication errors and wrong-patient orders in neonatal intensive care units (NICUs).
As executive director and founder of the Center for Patient Safety Research, a multi-disciplinary collaboration between Columbia University Irving Medical Center, Weill Cornell Medicine, and NewYork-Presbyterian, Dr. Adelman has led several National Institutes of Health (NIH) and AHRQ funded projects to test safety interventions across the interventions’ lifespans. His far-reaching impact has contributed to national and international safety recommendations, including from The Joint Commission and NQF.
National Level Innovation in Patient Safety and Quality
Anesthesia Risk Alerts Program – North American Partners in Anesthesia (NAPA)
North American Partners in Anesthesia is honored for its Anesthesia Risk Alerts Program, which was implemented across 500 hospitals and ambulatory surgery centers (ASCs) in March 2019. The program implemented specific mitigation strategies targeting five high-risk clinical scenarios: known or suspected difficult airway, a body mass index (BMI) greater than or equal to 45, pulmonary hypertension, American Society of Anesthesiologists (ASA) status 4 or 5, and operating room (OR) fire risk. Each patient is assessed by the anesthesia clinician, and if a risk is identified, the specific mitigation strategy for that scenario is advised to prevent harm.
After implementation of the program, which reached greater than 95% compliance, the incidence rate of relevant critical adverse events for patients with a BMI greater than or equal to 45 and under general anesthesia decreased significantly.
Local Level Innovation in Patient Safety and Quality
Improving Maternal Safety and Quality Through Extending Maternal Care After Pregnancy in Dallas County – Parkland Health
Parkland Health is recognized for its Extending Maternal Care After Pregnancy (eMCAP) program in Dallas County, initiated in October 2020. The eMCAP program provides postpartum access to care for 12 months after birth for women with the highest social needs and limited access to physician clinic locations, mostly minority women. The program utilizes advance practice providers, community health workers, nurse home visits, virtual visits, and a mobile van deployed to locations in Dallas County to address patient health concerns including hypertension, diabetes, and behavioral health.
Compared to matched controls:
- Attendance for eMCAP patients with chronic hypertension was significantly better up to 12 months after birth.
- Up to three months after birth, patients with diabetes management had significantly better follow up, resulting in significantly lower HbA1c values.
- Patients with abnormal mental health screening scores were successfully referred for behavioral therapy, completed sessions with licensed mental health counselors, and accepted therapeutic intervention.
Launched in 2002, the awards honor the late John M. Eisenberg, MD, MBA, former administrator of the Agency for Healthcare Research and Quality (AHRQ). An impassioned advocate for healthcare quality improvement, Dr. Eisenberg was a founding member of NQF’s board of directors.
Additional details on the strategies used and improvements implemented by this year’s recognized initiatives can be found within the awardee summaries.
2021 Award Recipients
The Joint Commission and National Quality Forum (NQF) are pleased to recognize the recipients of the 20th John M. Eisenberg Patient Safety and Quality Awards. The Eisenberg Awards recognize major achievements by individuals and organizations to improve patient safety and healthcare quality.
This year’s recipients improved diagnostic safety and the safety of health information technology, addressed social determinants of health to improve patient outcomes and created advanced patient monitoring systems and alerts that have saved patients’ lives. The 2021 awardees are listed below.
Additional information about these initiatives and individuals are available within:
Individual Achievement Awardee
Hardeep Singh, MD, MPH
Chief of the Health Policy, Quality & Informatics Program in the Center for Innovations in Quality, Effectiveness and Safety at Michael E. DeBakey VA Medical Center and professor at Baylor College of Medicine
Dr. Singh is recognized for his expansive, pioneering career in diagnostic safety and health IT safety. He has succeeded in translating his research into pragmatic tools, strategies and innovations for improving patient safety.
National Level Innovation in Patient Safety and Quality
Prime Healthcare Services, Improving and Promoting Social Determinants of Health at a System Level
Prime Healthcare Services is commended for establishing a program to address social determinants of health (SDOH). The initiative, “Improving and Promoting Social Determinants of Health at a System Level,” aims to help providers more effectively deliver patient care and reduce healthcare disparities. After implementing a new screening tool, community partnerships and bidirectional communications flow, Prime Healthcare Services observed improvements in all-cause hospital-wide readmission rates.
Local Level Innovation in Patient Safety and Quality
Kaiser Permanente Northern California, Advance Alert Monitor – Automated Early Warning System of Adults at Risk
Kaiser Permanente Northern California is honored for its life-saving initiative, “Advance Alert Monitor – Automated Early Warning System of Adults at Risk.” Kaiser Permanente developed a predictive analytic system called Advance Alert Monitor (AAM) that proactively identifies patients with a high risk of mortality or transfer to the ICU. Evaluation of the program showed statistically significant decreases in mortality with between 550 to 3,020 lives saved over four years. Data also indicated improvements in ICU admission rates, length of hospital stay, in-hospital morbidity and mortality within 30 days of an alert.
Honorary Eisenberg Lifetime Achievement Award
Mark R. Chassin, MD, FACP, MPP, MPH, President Emeritus, The Joint Commission.
The Joint Commission and NQF have awarded Mark R. Chassin, MD, FACP, MPP, MPH, former president and CEO of The Joint Commission and current president emeritus, with an Honorary Lifetime Achievement Award. During his 14 years as president, Dr. Chassin oversaw the activities of the nation’s predominant standards-setting and accrediting body in healthcare. He introduced profound changes to Joint Commission accreditation and certification programs during that time. Under his leadership, accreditation shifted away from simply citing deficiencies to helping to drive improvement, as summarized in the motto, “Evaluate, educate and inspire.”