Berkshire Medical Center (BMC) is a 300-bed community teaching hospital in western Massachusetts. The hospital is faced, like many healthcare organizations, with the challenge of developing a comprehensive and sustainable approach to improving clinical care across multiple conditions. In response to this challenge, the Department of Medicine at BMC developed a set of principles that have guided the development and improvement of a state-of-the-art sustainable clinical quality-improvement program. We focused our efforts on our implementation system. Several important management books have emphasized the importance of effective and disciplined execution in achieving success.1,2 Placing our implementation system at the center of our efforts made sense. Over time, through literature reviews and workshop attendance, we have refined the principles of our system and feel it must:
- be flexible: have the ability to improve the care of multiple patients with multiple conditions;
- be efficient: maximize use of valuable clinician time and obviate the need to create parallel systems for development and implementation;
- use concurrent review and feedback in real time;
- be sustainable over months and years;
- use system redundancy;
- use a multidisciplinary team approach to care;
- use rapid-cycle improvement principles and techniques;
- promote a system-oriented, not blame-oriented, culture;
- integrate housestaff into all clinical quality-improvement activities.
The resulting system is multidisciplinary rounds (MDR), which we have used in the Department of Medicine at BMC continually since 2000 to enhance communication, promote coordination, and meet the 9 principles of quality improvement outlined above.
Our first effort in quality improvement using MDR was the American Heart Association's Get With The Guidelines–Coronary Artery Disease (GWTGs-CAD) program. BMC joined the GWTGs-CAD pilot program in New England in the fall of 2000.3 We have subsequently participated in all GWTGs modules including stroke and heart failure (HF).
The American Heart Association's GWTGs program is modeled after the cardiac hospitalization atherosclerosis management program (CHAMP) developed by Fonarow et al4 at UCLA. It is a collaborative model using interactive workshops to engage and educate multidisciplinary hospital teams. Between workshops, hospitals use rapid-cycle improvement techniques to change and improve their systems of care. Participating institutions share success stories, tools such as critical pathways, order sets, checklists, and discharge instruction sheets at workshops and between them using conference calls and “Webinars”. The program promotes sharing of systems demonstrated to improve provision of the evidence-based interventions. In addition, it includes a Web-based patient management tool developed by Outcome for concurrent data collection, decision support, on-demand reporting, and patient education.5 In this paper, we describe the structure and function of MDR. We focus on how MDR has driven our performance in GWTGs. We describe the improvements in cardiovascular processes of care achieved using this system and the associated improvement in outcomes.
MDR was developed as a collaborative effort between the leadership of the Department of Medicine, nursing, case management, and quality improvement. Figure 1 shows the multiple participants in this system. Participation has evolved over time. Practitioners from pharmacy, the emergency department, documentation improvement, respiratory therapy, nutrition, our visiting nurse association, hospitalists, and others have joined over time. In addition new quality-improvement programs have been integrated into the system. For the GWTGs programs, we integrated GWTGs-CAD when we joined the New England Pilot in 2000, and then added GWTGs-Stroke in 2003 and GWTGs-HF in 2005. As shown in Figure 1, this is truly a patient-centered approach. The fundamental goal of MDR is to enhance communication and coordination between those providing care at the bedside, whether acting as individuals or as members of a multidisciplinary team. The patient is “surrounded” by multiple informed providers focused on improving care.
Concurrent Clinical Management
MDR for Medicine are held 3 times per week for 1 hour in a conference room. All non-ICU medical patients are reviewed every Monday, Wednesday, and Friday.
Patients are succinctly presented by a nurse leader; housestaff and hospitalists then add relevant additional information. A QI professional navigates the electronic medical record, which is projected on screens for all participants to review. Each department representative focuses on key data and interventions relevant to their area. The GWTG performance and quality measures for acute MI, stroke, and HF are addressed in real time for every eligible patient at every meeting. The review includes requests for cardiac rehabilitation. Smoking cessation counseling referrals are reviewed and followed up by respiratory therapy. Other conditions such as pneumonia, and venous thromboembolism (VTE) prophylaxis, are also addressed. Orders for medications are reviewed. The house officer is reminded to enter orders after the session following confirmation with the attending if he or she is not at rounds. When an intervention is contraindicated, the house officer and hospitalist are reminded to clearly document those contraindications. In addition, transitions in care are coordinated through case management and representatives from outpatient programs such as our visiting nurses and HF and diabetes self-management programs (see Fig. 1).
Electronic Medical Record
Our electronic medical record includes laboratory data, physician orders, current medications, past history, allergies, imaging, and nursing documentation, including vital signs, echocardiographic results, etc. The MDR team is able to make real-time recommendations to improve care and ensure optimum documentation of that care in large part because of the electronic medical record. The team is able to review approximately 40–60 patients in 1 hour through a highly structured approach.
Coordination With Inpatient Programs
Integration with existing multidisciplinary inpatient programs has been essential to our success. Two examples stand out.
In the fall of 2000, we recruited an NP stroke coordinator who was charged with developing a comprehensive multidisciplinary approach to stroke care. Her program identifies all stroke patients in the institution, has developed a stroke unit with extensive nursing training, and is closely integrated with our neurologists and neurosurgeons. The Stoke Treatment and Recovery Team (START) and a rapid-response team for t-PA-eligible patients are closely aligned with MDR. The START team includes the stroke coordinator and stroke unit charge nurse, a neurologist, physiatrist, physical and occupational therapist, speech therapist, dietician, case manager, social worker, and quality-improvement specialist. The team makes rounds 2 times per week, Tuesdays and Thursdays, on all stroke patients. Thus, between the START team and MDR, every stroke patient is reviewed using the same evidence 5 times per week. The team develops and implements a comprehensive plan for inpatient management and transitions in level of care. The stroke coordinator attends MDR on a regular basis, updating the group in real time on stroke patients, coordinating START team recommendations and MDR, and assuring adherence to the performance and quality measures of GWTGs-Stroke. The congruent designs of MDR and the START team, including a multidisciplinary, redundant, evidence- and data-driven approach, are obvious and intended.
For several years, we have had a comprehensive outpatient HF program. As we joined GWTGs-HF, we realized we had an opportunity to improve HF care, particularly in the area of discharge instructions, patient education, and care coordination across the continuum. We thus kept our outpatient program but brought its nurse practitioner leader in house to assist in management of acute care issues and coordinate seamlessly with outpatient services. The NP for the HF program attends MDR and makes recommendations to the housestaff and attending physicians about care. She also coordinates discharges, holding time outs (as used in wrong-site surgery projects), and assures smooth transitions for HF patients.
The group is always aware of current performance as shown in the upper left corner of Figure 1. Our QI professional continually updates the entire group on GWTGs performance, public reporting, and pay-for-performance activities. These retrospective analyses complement our concurrent clinical management activities.
Coordination With Task Forces
The lower left corner of Figure 1 depicts the continual interaction of our disease-oriented task forces (which develop policies and order sets, pathways, and other tools) and MDR. When one of our task forces makes policy recommendations or develops tools, they are immediately brought to MDR for implementation. We have significant overlap between task force and MDR membership to assure coordination.
Links to the Continuum of Care
As shown in the lower right corner of Figure 1, MDR has a direct link from the inpatient to the outpatient areas. We have representation from the HF program, our visiting nurse association, and other key departments and organizations. Thus, MDR in the Department of Medicine has served as a vehicle to promote not only improved acute inpatient care but also cross-continuum communication and optimal management of patient transitions.
MDR also serves as a teaching venue, presenting and discussing the latest evidence, including new articles, presentations at national meetings, and the latest guidelines and measures. For example, when new AHA/ACC guidelines are released they are immediately presented and discussed with all members of MDR. In addition, after attending a GWTGs workshop, new tools or approaches can be immediately presented to the MDR group and integrated into care. For example, the idea of time outs for HF patients came from a GWTGs workshop presentation by Vassar Brothers Hospital in New York. We were able to integrate this idea into care through MDR in 2 days. MDR is also an essential teaching experience for our housestaff. Residents always attend MDR and present all their cases after a brief nursing synopsis. MDR teaches and reinforces in an ongoing experiential way all 6 of the core competencies of the ACGME.6 These include medical knowledge, practice-based learning and improvement, systems-based learning, patient care, interpersonal and communication skills, and professionalism. Housestaff are continually reminded of the latest in evidence-based care for AMI, stroke, and HF, in addition to the many other conditions addressed by MDR. They thus have continual feedback on best practice and their practices driving self-improvement. MDR emphasizes team coordination across the continuum and collaboration with multiple providers. The importance of communication and handoffs is continually reinforced. Finally, professionalism is a constant theme. Thus, we do not just rely on lectures to teach, reinforce, and measure the 6 core competencies. We focus on them 3 days per week throughout the entire year.
Education is obviously not limited to housestaff and other physicians. On a daily basis, explanations and evidence for recommendations are provided to all participants at MDR. Relevant articles are reviewed with all participants, not just physicians.
Clinical Decision Aids and Tools
MDR also represents an opportunity to remind providers to use the many clinical decision aids and tools developed to improve clinical care. We have checklists based upon AHA/ACC recommendations, pocket cards, preprinted orders now integrated into our computerized physician entry system (CPOE), and pathways to coordinate nursing care. MDR also provides immediate feedback on the quality and usability of our tools.
MDR is a catalyst for rapid-cycle improvement. On a daily basis, the team critically appraises our current care and makes suggestions not only for interventions to apply to an eligible patient but also how to improve our systems of care. Multiple improvements in care, including the addition of key providers to MDR, improved communication strategies, improved pharmacy utilization, etc, have come directly from discussions at MDR.
Below, we have scripted a typical interaction from MDR. This is obviously a more complicated case than many and thus would take more time than the average patient. However, all appropriate issues could be covered in about 90 seconds when properly facilitated. The review and recommendations are based upon the ACC/AHA “Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult.”7
Nurse: Mr J. in room 422-1 is a 62-year-old with CAD, S/P AMI admitted for HF 2 days ago.
Resident: Mr J. has systolic failure, with a depressed EF. He has been diuresed and now has a normal JVP, no S3, and clear lungs.
The performance improvement professional has entered the patient's electronic medical record, which is projected on a screen visible to all MDR participants. In rapid sequence, the entire group views:
- Hematology showing normal H/H and normal platelet count.
- Laboratory showing K of 4.2 mmol/L, creatinine of 1.1 mg/dL, glucose of 105 mg/dL, normal LFTs and serial troponins, a normal CPK, and an admission LDL of 122 mg/dL.
- Echo report from yesterday showing EF of 25% and no significant valvular heart disease.
- List of previous diagnoses from past 5 years, confirming CAD coded 4 times, AMI coded twice, and HF coded 4 times.
- Pneumococcal and influenza vaccinations are up to date.
- Nursing documentation shows a pulse of 75 bpm and BP of 135/80 and documents that the patient is a current smoker. Patient has diuresed 4.2 L and lost 9 lbs since admission.
- Current medication list includes:.
- ASA (admission drug)
- Heparin 5000 units tid (DVT prophylaxis) (added at admission)
- Lisinopril 40 mg per day (admission drug)
- Lasix 40 mg q 12 hours
- Atorvastatin 80 mg q day (increased from admission dose of 40 mg)
- Other prn medications
- The resident comments: We are starting Carvedilol today.
- The pharmacist suggests adding spironolactone with the patient's normal potassium and creatinine.
- The resident turns to the hospitalist, who agrees with these suggestions, and reminds nursing that a new order to ambulate the patient in the hall has just been entered through CPOE.
- The chair of medicine suggests consideration of an AICD and resynchronization therapy and asks the respiratory therapist if he has counseled the patient on smoking cessation.
- The hospitalist states the consulting cardiologist will be asked to address device therapy.
- The resident notes the patient should be discharged tomorrow morning after team review.
- The HF specialist reminds the hospitalist and resident to hold a HF “time out” with her in the morning to review the discharge plan, patient education, and medication reconciliation. She reminds the resident to dictate the discharge summary before the patient leaves, utilizing the reconciled patient-friendly medication list, and include follow-up physician and laboratory appointments since both a β-blocker and spironolactone have been added. She confirms she has arranged follow-up with the outpatient HF program and cardiac rehabilitation.
- Next case.
Thus, in the brief MDR review evidence-based interventions for which this patient may be eligible have been addressed. The group has either confirmed that an intervention has been provided (and its safety) or recommended additional interventions in all the following for this patient with CAD and HF:
- LVF assessment
- ACE/ARB use for LVEF less than 40%
- ASA for CAD
- β-Blocker for CAD and HF
- Aldosterone antagonist
- Lipid measurement on admission
- Lipid treatment
- Smoking cessation counseling
- HF device therapy
- Pneumococcal and influenza vaccinations
- Discharge instructions, including medication reconciliation
- Follow-up in appropriate programs, including cardiac rehabilitation and our outpatient HF program
The case emphasizes the importance of a team approach to care, with multiple professionals providing input to optimize patient care. A clinical system of care consists of informed professionals and multiple tools. We have used the airline model to be sure that redundancy is built into our system and reinforced in MDR. From this case, we have assembled a list of the informed professionals (knowledgeable of the latest evidence and able to apply that evidence in a patient-centered way). The informed professionals caring for this patient include:
- ED MD
- House officers
- Clinical leaders (nurse managers)
- Midlevel providers (HF specialist)
- QI professionals
- Documentation specialists
- Case manager
The tools available to help manage this patient include:
- CPOE with evidence-based order sets
- The EMR
- Pocket guides
- Patient pathways
- HF discharge checklist
- Time out before discharge
These tools and professionals are coordinated by the in-patient HF team and MDR.
Multidisciplinary Performance Improvement (MDPI)
The pace of MDR does not permit an in-depth discussion of problems with detailed dissection of issues and comprehensive planning of improvement strategies. The members of MDR recognized this shortcoming and recommended a weekly addition to MDR called MDPI.
The upper right-hand corner of Figure 1 demonstrates the direct connection with MDPI. This conference is a direct outgrowth and extension of MDR. The Department of Medicine has a formal physician oriented M&M conference held on a monthly basis. This traditional conference is not multidisciplinary and is focused on physician issues rather than systems issues. MDPI, however, involves all the members of MDR (see Fig. 1) plus other departments, depending upon the specific issues of the case. One or occasionally 2 cases (with a similar theme) are presented in a 1-hour session led by our medicine chief residents. A resident presents a recent case (usually still in the hospital), emphasizing those areas in which problems arose and a clear timeline. The entire group then participates in a formal sequence of steps:
- Clarification of the events of the case.
- Identification of quality issues in the case, with a focus on systems issues and teamwork, not individual performance.
- Suggestions for improving performance in each identified area (brainstorming and then focusing).
- Identification of next steps to improve care (often have 2–8 tangible actions).
- Identification of person(s) responsible for each recommendation.
- Timeframes for follow-up, including immediate, intermediate, and long term actions.
- Identification of data required and their source to assess progress.
- Date for follow-up in MDPI (eg, 2 weeks from now).
- Integration of recommendations into clinical care and monitoring at MDR.
- Every month, the team holds a review session to assess progress and further refine improvement plans as required.
Improved Processes of Care
MDR has driven performance in all 3 GWTGs modules, CAD, stroke and HF. Figure 2 summarizes our performance over the past 6 years in the American Heart Association's GWTGs-CAD. The figure demonstrates the percent of eligible patients without contraindications, receiving specific evidence-based interventions from 2000, our baseline year, through year 6 (2006). Figure 2 also shows our defect-free score (percentage of patients who receive all interventions for which they are eligible) from 2005 through 2006. Figure 2 reflects rapid and sustained improvement over a 6-year timeframe, with perfect performance in the last year.
Figure 3 demonstrates our performance in GWTGs-Stroke. Although we formally joined GWTGs-Stroke in 2004, we were managing and measuring many of the same evidence-based processes since 2000, when we developed and implemented our stroke program.
Our performance with GWTGs HF is shown in Figure 4. We collected baseline data for HF in Q4 04 and initiated our program in Q1 05. Figure 4 also demonstrates our defect-free score for HF.
Berkshire Medical Center, through its MDR, has received more awards from the American Heart Association's GWTGs programs than any other hospital in the country. The GWTGs program awards performance achievement awards for >85% adherence to all performance measures for a given time period for a specific condition. Each condition (CAD, HF and stroke) has 5 to 7 performance measures. BMC is the only hospital to receive 6 consecutive American Heart Association performance achievement awards in coronary artery disease and the first, and only, hospital to receive 3 consecutive performance achievement awards for stroke. In addition, BMC was the first hospital in the country to win the GWTGs Heart Failure Annual Performance Achievement Award.
BMC has carefully applied the QI principle of focus and spread. While maintaining our focus on GWTGs modules, we have successfully spread our efforts in MDR to improve performance for multiple noncardiac conditions. We have applied many of the lessons learned from the AHA's GWTGs program to multiple conditions. BMC is in the top decile in the Premier/CMS HQID Project in Pneumonia. We have improved our VTE prophylaxis rate from 65% at baseline in May of 2006 to 97% in December 2006 and January 2007, using lessons learned from DVT prophylaxis in stroke patients (Fig. 5).
In October 2006, we expanded the Department of Medicine model for MDR to our Department of Surgery. Preliminary results suggest a significant improvement in our Surgical Care Improvement Project (SCIP) performance. The VTE prophylaxis rates shown in Figure 5 reflect performance in surgery and medicine.
The improvements in processes of care driven by our MDR have been associated with improvements in clinical outcomes. Figure 6 demonstrates our AMI in-hospital mortality rates from 2003 through 2006. Actual and expected mortality rates are provided by Premier, one of our data vendors. Expected mortality is derived comparing our severity-adjusted mortality to that of the entire Premier data base. MassCHIPS8 data are reported by the state of Massachusetts on a yearly basis. Using death certificate information, the state reports cause-specific mortality for the entire state and county by county. We use Berkshire County data and compare it to statewide data to assess our progress in improving our community's health. BMC provides about 80% of all acute care in Berkshire County. Thus county mortality rates are a reasonable reflection of BMC's impact. Data are reported in raw form and age-adjusted for comparison purposes. Figure 7 shows unadjusted stroke mortality from 1998 through 2004 (the latest year of reporting). We use 1999 as our baseline year, since in 2000 we started MDR and integrated it into our comprehensive stroke program. There has been a decline in stroke deaths during this period, associated with MDR and our stroke program. Finally, Figure 8 shows the age-adjusted mortality changes from 1999 to 2004. Berkshire County is represented in gray, Massachusetts in black, and the country in white. National data are courtesy of the AHA.9 In all cardiovascular measures, Berkshire County has shown a greater reduction in mortality than the rest of Massachusetts or the country.
We believe that MDR has had a significant impact on the quality of care delivered at BMC over the past 6 years. The quantitative improvements in adherence to evidence-based interventions for patients with CAD, stroke and HF seem clear. The more subtle impact has been on our culture. In 2000, when leaders presented quality-improvement information, the benchmark for BMC's projects was average performance. This attitude has fundamentally changed. Today, if BMC is not the best-performing hospital in national programs such as GWTGs, providers are deeply disturbed. Of greatest importance, if a single patient does not receive an intervention for which they are eligible, all providers mobilize to prevent a recurrence. An advantage of our program is that with MDR, most patients only miss an intervention for about 1 day, not weeks or months. MDR has driven providers to genuinely embrace 4 cultural themes:
- It's personal.
- “The passionate pursuit of perfection” (Lexus).
- A systems-oriented not blame-oriented approach to clinical improvement.
All organizations strive to implement programs that promote teamwork and communication. MDR has been the vehicle through which enhanced communication between all caregivers has been institutionalized. Many of the participants in MDR have met together 3 times per week, 1 hour per session, for almost 7 years.
MDR in Other Settings
In general, MDR has been used by other institutions in ICUs and specialized settings. Dutton and colleagues10 demonstrated sustained improved patient flow in a trauma unit with a 36% increase in volume and a 15% decrease in length of stay. Multidisciplinary teams included physicians, nurses, physical therapists, and discharge planners and focused on enhanced communication. Vazirani et al11 reported improved satisfaction with care for physicians, nurses, and patients using MDR in an acute care medical unit. The authors noted that MDR resulted in better communication and collaboration among providers. A major contributor to our MDR efficiency and effectiveness has been the incorporation of information technology. A systematic review of information tool use in various types of MDR found patient-centric information (eg, the chart) and decision-support tools (eg, clinical pathways) helpful in improving information organization and communication.12 We have a large portion of the “chart” available electronically and viewed by all members of the MDR team. Although we do not have pathways available for review (they are at this time only available on paper), we do have orders, order sets, checklists, and other patient-centric tools available in electronic format. In addition, this review found that process-oriented tools such as the rounding lists we use were helpful in facilitating communication.12
We believe that MDR has improved the outcomes of patients in the Berkshires and has been associated with the reduction of cardiovascular mortality in our community. BMC provides care for almost 80% of the residents of Berkshire County. We believe our focus in MDR on acute interventions, including ED care, improved in-hospital clinical outcomes, reflected in decreased inpatient mortality. This decrease in inpatient mortality and the focus of GWTGs on secondary prevention for patients with CAD, stroke, and HF have combined to decrease overall C-V mortality in our community.
It is thus reasonable to associate improved performance at BMC through MDR and GWTGs with improved community outcomes, although cause and effect cannot be demonstrated. In Figure 8, we compare changes in cardiovascular mortality to the state of Massachusetts and the United States. Figure 8 shows that the age-adjusted decrease in major cardiovascular disease deaths and the components of that measure, including CHD, AMI, HF, and stroke deaths, have been greater in Berkshire County than in the state of Massachusetts or the United States. Although the most recent data are only through 2004, those areas on which we have focused, including stroke, AMI, and HF, demonstrate large decreases in age-adjusted mortality. AMI mortality in Berkshire County has decreased 44.4% since 1999 compared with a 27.2% decrease for Massachusetts and a 28.3% decrease for the United States. Berkshire County had a 33.9% decrease in stroke mortality compared with a 15.7% decrease for the state and an 18.8% decrease in the United States. HF mortality decreased 33.9% in the Berkshires compared with a 5.1% decrease in the state and 5.9% decrease in the United States. These components of major C-V mortality contributed to an overall 26.3% decrease compared with 17.3% for the state and 17.8% for the country. We believe these improvements have been at least in part driven by improved acute and secondary prevention care facilitated by MDR.
We have presented MDR in multiple regional and national programs and have seen replication of our approach in multiple organizations throughout the Northeast. Large organizations can take MDR and apply it on individual units to groups of 30 to 60 patients. For example, MDR could be applied to patients on a cardiology step-down unit or a neurology stroke unit. Smaller organizations have directly applied MDR to their entire inpatient population. We believe that this approach of assembling all the critical caregivers in one place at one time, empowered by the electronic medical record (if available), is an opportunity for any organization to institutionalize the principles of teamwork, concurrent review and feedback, flexibility, sustainability, redundancy, and rapid-cycle improvement.
Our MDR-centered implementation system meets all our principles for quality improvement. It is likely that many, if not all, of these principles underlie the improvement efforts of other organizations. In our experience MDR is:
- Flexible. We have successfully applied it to multiple patients with multiple conditions while maintaining performance in longer-term initiatives. For example, we have maintained our performance in GWTGs-CAD for 6 years while adding GWTGs-Stroke, GWTGs-HF, pneumonia, DVT prophylaxis, etc.
- Efficient. Despite the addition of multiple new conditions, we are still able to review 40–60 patients per 1-hour session.
- An excellent approach to concurrent review and concurrent feedback to providers. This we believe has been essential to our success.
- Designed for sustained performance in many clinical conditions but in particular the GWTGs modules: our 6 consecutive performance achievement awards for GWTGs-CAD and 3 consecutive performance achievement awards for GWTGs-Stroke support the sustainability of the MDR model.
- A foundation to ensure redundancy. We believe we have achieved a balance of redundancy and efficiency, but each time we add a new tool or provider to the system (eg, CPOE), we explicitly consider removing something.
- A mechanism to reinforce a multidisciplinary team approach to care and care improvement. MDR is not just a structural but also a cultural change.
- A key driver of rapid-cycle improvement. Many ideas from GWTGs workshops such as “time outs” for HF patients have been immediately integrated into MDR and frontline care. Since the group meets 3 times per week and is continually tracking data, measurement of the impact of a change and refinement of that change are relatively easy.
- A catalyst for changing the culture of an organization. We believe that bringing together the clinical leaders from multiple departments 3 times per week and collaborating to improve care over almost 7 years has helped drive our cultural shift from a blame-oriented to system-oriented culture. Our MDPI conference, through its in-depth analysis of problems and organized approach to improvement, has reinforced the importance of systems for clinical improvement.
- An effective approach to integrating housestaff into improvement efforts. Their integration has been seamless and their contributions to clinical improvement have been significant. The educational value of MDR in teaching and reinforcing the 6 ACGME core competencies is obvious.
In summary, MDR is the centerpiece of the clinical improvement efforts of the Department of Medicine at BMC. We believe that much of our sustained improvement in evidence-based processes of care and clinical outcomes has been a direct result of the enhanced communication and coordination facilitated by MDR. MDR is now used by the Department of Surgery at BMC and has been implemented in other hospitals. It fulfills 9 principles of clinical care and care improvement. This system can be adapted to any healthcare organization and demonstrates the value of a clear focus on implementation to improve the care of our patients.