Jonathan Siner, MD, was drawn to medicine because he enjoys problem-solving.
As medical director of the Medical Intensive Care Unit (MICU) at Yale New Haven Hospital, Dr. Siner has brought that problem-solving perspective to the challenge of quality and safety improvement. He has fostered a culture where, instead of hiding problems or pointing fingers, clinicians work collaboratively to find answers, determine how processes can be improved, and add to the overall body of knowledge.
Dr. Siner’s approach has been so successful that he recently was presented with Yale Medicine’s fifth annual Excellence in Quality and Safety Award. The award was established in 2014 to honor Yale Medicine physicians who have made significant contributions by leading quality and safety initiatives, improving quality and safety in patient care, and creating a positive and collaborative culture.
“He has been a superb safety champion,” wrote Aldo J. Peixoto, MD, in his letter nominating Dr. Siner for this year’s award. “His leadership is seen in the way he interacts with his team in the MICU and in the multiple committees where he serves in our organization. His success is measured by the culture of safety that exudes in the MICU. His commitment to growth is realized as he moves on to federally funded research in quality of care.”
Dr. Siner is an associate professor in the Department of Internal Medicine, Section of Pulmonary, Critical Care and Sleep Medicine. He earned his MD from the University of Pittsburgh School of Medicine, and completed a postdoctoral fellowship at Yale. In 2006 he joined the Yale School of Medicine faculty and was selected to serve as medical director of the Medical Step-down Unit at Yale New Haven Hospital, where he began his work in quality and safety improvement.
Reducing Hospital Acquired Blood Stream Infections
But his passion for quality and safety really took off when, in 2009, he was asked to serve as physician leader for a hospital-wide initiative to prevent central line associated blood stream infections (CLABSI). Dr. Siner put his problem-solving skills to work. Working with Francine Lorusso (VP, Heart and Vascular Patient Service and Transplantation, YNHH), the team developed detailed policies and practices for the insertion and maintenance of central lines, implemented a standardized checklist to reinforce best practices, and developed a tracking tool within the electronic medical record.
Dr. Siner and his team recognized that while current federal guidelines and the medical literature focus on CLABSIs related to insertion of the devices, the vast majority at YNHH occurred later in the course of the patient’s care. His team also determined that there was a problem with false positive results related to obtaining blood cultures, in which it appeared that a patient had a blood stream infection when they actually did not.
As a result of the work of Dr. Siner and his team, Yale New Haven Hospital experienced a 50 percent reduction in the number of CLABSIs from 2009 through 2013.
A Culture of Collaboration, Transparency, and Problem-solving
Dr. Siner became medical director of the MICU in 2010, a position in which he and his colleagues have been responsible for a number of improvements in the care of critically ill patients. Under his leadership, the rate of re-admission to the MICU within 48 hours of discharge has been reduced from 4.5 percent to 2 percent. In addition, working with Peter Marshall, MD, and YNHH leadership, Dr. Siner led the development of the Tele-ICU, which uses two-way video and audio technology to provide remote support for the care of critically ill patients across Yale New Haven Health.
One of Dr. Siner’s priorities as medical director of the MICU has been collaborative management with nursing leadership. Working with Jennifer Ghidini, RN (Nursing Director – Medical Critical Care), in 2013 he created a new position for a Patient Safety Nurse in the MICU, which, he says, has made an “enormous difference” in quality and safety improvement by having someone specifically focused on these issues as their primary role. A central outcome of hiring Laura De Vaux, BSN, RN, into this role was the acceleration of the development of a standardized process to understand and address adverse medical events. They instituted a weekly meeting with MICU physicians and nurses, advanced practice providers, pharmacists, and trainees to review all areas of concern from the prior week. These efforts have fostered a culture of transparency, in which team members work collaboratively to identify and analyze systemic problems.
“Medicine has a culture of not acknowledging that there’s a problem,” Dr. Siner says. “We really wanted to change that.” Dr. Siner has worked to encourage transparency by reducing the stigma associated with reporting problems, and providing processes for feedback, discussion, and analysis. As a result, he says, clinicians feel more comfortable reporting adverse medical events “because they know that our job is to help fix problems, not to get people in trouble.”
In fact, one aspect of quality and safety improvement that is often overlooked is the fact that it can often lead to new knowledge, Dr. Siner says. “By saying ‘maybe we can do better,’ we find an opportunity, and from that opportunity we find new knowledge. And that’s what a research institution is all about.”