Eisenberg Award Recipients
Congratulations 2024 Eisenberg Awardees
Individual Achievement - Elliott K. Main, MD, Clinical Professor, Obstetrics and Gynecology, Stanford University School of Medicine
Dr. Elliot K. Main is a national leader in maternal quality and safety, directing programs at hospital, health system, state and national levels. His exceptional career has had far-reaching impact for maternal care across the country.
Quality improvement collaboratives: After leading successful hospital and health system efforts to improve obstetric care, in 2006, Dr. Main developed a state-wide quality improvement collaborative, the California Maternal Quality Care Collaborative. During his 16 years as chair of the California Pregnancy-Associated Mortality Review Committee, he took lessons learned from mortality reviews to create highly successful state-wide campaigns to improve clinical care. The California Maternal Quality Care Collaborative became the model for large-scale maternal quality improvement learning collaboratives. At the national level, he co-founded the Alliance for Innovation on Maternal Health, a joint program of the American College of Obstetricians and Gynecologists and the Health Resources and Services Administration. Through these efforts, he has nurtured the development of state perinatal quality collaboratives now underway in 49 states.
Quality measures and transparency: To help drive improvement activities, Dr. Main led the research to establish and obtain consensus-based endorsement for four national perinatal care metrics included in 偶蜜国际传媒’s and Centers for Medicare and Medicaid Services’ (CMS) programs. He has guided transparency efforts via public reporting of obstetrics metrics by 偶蜜国际传媒, the state of California, The LeapFrog Group, and U.S. News & World Report. He also serves as the lead advisor to CMS for their Birthing Friendly initiative that publicly reports select obstetrics measures for every U.S. hospital.
Quality improvement tools: Dr. Main led the development of five widely adopted California Maternal Quality Care Collaborative obstetric quality improvement toolkits and spearheaded the development of national Alliance for Innovation on Maternal Health safety bundles, including hospital bundles on hemorrhage, hypertension, sepsis, cardiac conditions, mental health, substance use and postpartum transitions. Dr. Main served as a maternal quality improvement advisor for the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, CMS, and the World Health Organization.
Quality improvement data systems: Dr. Main led development of a rapid-cycle Maternal Data Center that provides timely outcome and quality measure data with benchmarks, race stratification and multiple features to support the learning collaboratives. He also designed measure analysis tools that assist hospital leaders to identify local quality improvement opportunities and guide hospital interventions. The Maternal Data Center now serves all California hospitals and most hospitals in Oregon and Washington.
The Eisenberg Award panelists:
- Were impressed by his significant contributions to obstetrics quality and his steadfast dedication to improving maternal quality of care, which they perceived as above and beyond.
- Noted, “He has obviously been an innovative transformer of the whole field of maternal health and what he's accomplished at multiple levels—local, state and national—is incredible and has had very high impact and scope… He has undeniably done virtually everything someone could do to advance work in maternal health… He is a testament to the idea that one person can make a change.”
- Said, “Addressing the U.S.'s crisis in maternal morbidity and mortality is of critical importance and Dr. Main has, in many respects, led the charge in this area. The impact of the Alliance for Innovation on Maternal Health has been significant and far-reaching and to establish clear points of intervention that can be replicated in all maternal health settings is paramount to reducing the challenges we face.”
Local Innovation in Patient Safety and Quality - Parkland Health: Identifying and Preventing Missed Opportunities for Diagnosis
Parkland Health developed an innovative approach to address missed opportunities for diagnosis (MODs), a critical patient safety concern affecting 12 million US adults annually. Following a sentinel event, the organization created a comprehensive surveillance program that evolved from tracking delayed imaging findings to managing six high-risk diagnostic scenarios through a centralized Digital Health Center. To do this, a surveillance program was implemented in iterative phases, evolving from basic monitoring to a comprehensive diagnostic safety program. In 2018, Parkland radiologists began flagging delayed imaging surveillance missed opportunities for diagnosis, and nursing staff followed up with patients about their imaging results in between other duties.
To further enhance patient safety, Parkland Health established a Digital Health Center in July 2022, and the surveillance team introduced several key innovations that allowed them to transition from reactive to proactive patient follow up, including:
- A structured workflow to manage the patient trajectory through the diagnostic process.
- An AI language model that achieved 97.2% accuracy in identifying delayed imaging findings (with 99.3% sensitivity and 96.7% specificity).
- A population health management tool in their electronic health record system.
- Bilingual staff trained in motivational interviewing and comprehensive non-medical drivers of health screening.
- Social worker integration to remove barriers, proactively navigate, and coordinate follow up.
From 2018 to present, the program has addressed six high-risk scenarios:
- Radiology findings which require additional imaging follow-up
- Abnormal tumor marker lab results in patients who have not been evaluated by cancer specialists
- Abnormal mammograms in patients without primary care physicians
- Critical abdominal aortic aneurysm findings
- Suspicious lung lesions requiring rapid evaluation
- New cancer diagnoses in patients who have not been seen by cancer specialists
Parkland Health’s efforts lead to measurable improvements:
- 91% of patients with an abnormal imaging study had completion of the recommended follow-up studies in this program--with 4.3% of completed cases being found to have cancer, and 3.1% requiring surgical intervention. These follow-ups resulted in potentially life-saving findings that may have otherwise been delayed or missed. The improvement from baseline was greater than 54% improvement in obtaining follow-up specialty care for patients with new cancer diagnoses.
- Delayed imaging surveillance findings overdue with no follow up was reduced from 17% at baseline in 2018 to 9% by 2022.
- Follow-up rates for abnormal mammograms improved from 83% to 87%.
- Abnormal tumor marker follow-up gaps decreased by 27%.
The award panel noted that this work successfully addresses a very common system problem in diagnostic errors: the failure to adequately support patients throughout their diagnostic trajectory. Panel feedback included:
- One panelist said, “Arranging follow up and tracking patients coming and going within health systems has been a deeply problematic challenge for many healthcare systems… It is assumed that when a test is ordered that magically it's going to happen, and without visibility or follow through, people can get lost.”
- One panelist said that this initiative was quite innovative and comprehensive in how it combined informatics, such as natural language processing and population management tools, but also integrated navigators and social workers, and considered social determinants that impact patient follow up.
- The panel was also impressed that Parkland Health applied these interventions and achieved improvements across a range of conditions, which illustrated their ability to replicate their success.
National Level Innovation in Patient Safety and Quality - CommonSpirit Health: Innovative Approach to Achieving and Sustaining Clinical Excellence
CommonSpirit Health uses a benchmarking database to identify opportunities for improvement in many quality and patient safety measures which are prioritized using robust criteria. CommonSpirit Health identified and prioritized three areas for improvement:
- Heart failure: CommonSpirit Health identified an opportunity to implement the American College of Cardiology/American Heart Association guidelines to lower risk鈥恆djusted observed-to-expected (O:E) mortality rate.
- Maternal hypertension bundle: CommonSpirit Health sought to address disparities in adherence to the use of evidence-based practices for maternal hypertension in its rural hospitals as compared to its urban hospitals.
- Catheter-associated urinary tract infections: CommonSpirit Health focused on implementing a bladder management protocol, including the use of indwelling catheter alternatives and bladder scanners.
CommonSpirit Health’s efforts to address these improvement targets included:
- Eight-step quality improvement model: Systemwide, CommonSpirit Health developed and implemented an eight鈥恠tep quality improvement model that incorporated:
- Internal and external scans for priorities
- Establishment of cascaded targets and goals
- Clinical governance for all initiatives
- Evidence-based standards
- Comprehensive toolkits, resources and educational opportunities
- Performance improvement cycles of change
- Performance feedback and reporting at the system, region, entity and provider level
- Engagement and accountability
- Technology suite: Technical components that support its work include a clinical quality data repository and technology suite to collect and normalize clinical data from more than 40 sources and 17 electronic health record configurations. Additionally, its online health equity dashboard includes demographic data (e.g., ethnicity, race, gender, age, and language), providing information on disparities across acute and ambulatory measures to enable targeted improvements.
- CommonSpirit Health’s virtually integrated care model provides supplemental support. This model embeds a virtual nurse into the care team many of its hospital locations. The virtual nurse mentors new staff, reduces workload, manages care transitions, and cultivates collaborative patient care. Each patient room under the virtually integrated care model has in-room technology, including a touchscreen computer, a pan鈥恡ilt鈥恴oom camera, a speaker and microphone, a patient鈥恌acing virtual nurse call bell, hardware status indicators, and text communication capabilities enabling virtual nurse connection to each patient room.
These efforts led to measurable improvements:
- Reduction in risk-adjusted hospital mortality from 0.93 in 2021 to 0.64 YTD 2024 across all 99 of CommonSpirit Health’s acute care hospitals nationwide.
- A 42% reduction in heart failure mortality in the same period.
- An 18% performance gap between heart failure patients with high and low social vulnerability indices was reduced to 5% at fiscal year-end.
- Nursing turnover for virtually integrated care units is down 62% on average, and patient length of stay is down 13% in virtually integrated care units.
- Collectively, these efforts represent improved care for over 409,130 patients over a three-year period and the prevention of over 2,700 harm events, including CAUTI.
The award panel:
- Commended the innovative virtual nurse component and use of technology as workforce extenders, noting these were likely instrumental to unlocking CommonSpirit Health’s success.
- Was impressed with CommonSpirit Health’s comprehensive data regarding its adverse event reduction across multiple diagnoses.
- Applauded the concentrated effort to focus on difficult healthcare outcome disparities in high-risk conditions which are not easy to improve.
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 偶蜜国际传媒 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
偶蜜国际传媒 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, 偶蜜国际传媒.
偶蜜国际传媒 and NQF have awarded Mark R. Chassin, MD, FACP, MPP, MPH, former president and CEO of 偶蜜国际传媒 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.”