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The AIAMC National Initiative:
Improving Patient Care
through Medical Education
PROCEEDINGS OF
NATIONAL INITIATIVE IV
March 2015
New Orleans, LA
TABLE OF CONTENTS
Overview of the National Initiative……………………………………………………..…………..…………………………………2
Project Description Forms and Posters:
• Advocate Lutheran General Hospital……………………………………………………………………..………..…. 6
• Akron General Medical Center………………………………………………………………………………………….. 11
• Atlantic Health System…………………………………………………………………………………………………..…. 15
• Aurora Healthcare…………………………………………………………………………………………………..………… 18
• Bassett Medical Center …………………………………………………………………..………………………………… 24
• Baylor University Medical Center …….……………………………………………………………………………….. 28
• Baystate Medical Center …………………………………………………………………………………………………… 32
• Beaumont Health System …………………………………………………………………………………………………. 35
• Carolinas Medical Center ……………………………………………………………………………………………….…. 38
• Christiana Care Health System …………………………………………………………………………………………. 43
• Crittenton Hospital Medical Center ……………………………………………………………………………….…. 49
• Florida Hospital ………………………………………………………………………………………………………………… 52
• HealthPartners Institute/Regions Hospital ……………………………………………………………………….. 55
• Jersey Shore University Medical Center ……………………………………………………………………………. 60
• JPS Health Network ………………………………………………………………………………………………………….. 64
• Kaiser Permanente Northern California …………………............................................................ 68
• Main Line Health System…………………………………………………………………………………………………... 76
• Maricopa Medical Center ………………………………………………………………………………………...….…… 79
• Marshfield Clinic ……………………………………………………………………………………….……………….……… 81
• Monmouth Medical Center …………………………………………………………………………………..………….. 85
• Ochsner Clinic Foundation …………………………………………………………………………………………..……. 88
• Orlando Health ………………………………………………………………………………………………………..……….. 92
• OSF Saint Francis Medical Center ………………………………………………………..……………………………. 98
• Our Lady of the Lake Regional Medical Center ……………………………………………………….……….. 103
• Riverside Methodist Hospital ……………………………………………………………...……………..….……….. 109
• Saint Francis Care Medical Center……….…………………………………………...………………….………….. 113
• Scott & White Memorial Hospital ………………………………………………………….…………….…..……… 114
• Scottsdale Healthcare …………………………………………………………………..….………………….………….. 117
• Tri Health …………………………………………………………………………….………………………………...………… 121
• University of Utah Health Science Center ……………………………………………….…….…………..…….. 125
• Virginia Mason Medical Center ……………………………………….…………..………………………………….. 128
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OVERVIEW OF THE AIAMC NATIONAL INITIATIVE Why a National Initiative? Both the public and our profession acknowledge that quality and safety efforts are falling short, and many hospitals and healthcare systems are seeking rapid improvements in patient care. Those of us in academic medicine realize that residents play an important role in patient care at teaching institutions; however, residents are generally not visible in safety and quality efforts. The AIAMC recognized that resident quality improvement efforts – shared across multiple programs and systems – had the potential to improve care much more quickly and effectively. Role of the AIAMC The Alliance of Independent Academic Medical Centers was founded in 1989 as a national network of large academic medical centers. Membership in the association is unique in that AIAMC members are affiliated with medical schools but are independent of medical school ownership or governance. Seventy-five major medical centers across the United States are members, representing over 725 senior academic leaders. Fifty-five hospitals and health systems and more than 450 individuals have participated in the AIAMC National Initiatives since 2007 and have driven change that resulted in meaningful and sustainable outcomes which improved the quality and safety of patient care. National Initiative I In early 2007, the Alliance of Independent Academic Medical Centers (AIAMC) launched Improving Patient Care through GME: A National Initiative of Independent Academic Medical Centers. The National Initiative (NI) featured five meetings over the course of 18 months which served as touchstones for ongoing quality improvement in 19 AIAMC participating organizations. These meetings, as well as the monthly collaborative calls held in-between, provided structure, discussion and networking opportunities around specific quality improvement initiatives. This 18-month "NI I" was supported by a grant from the foundation of HealthPartners Institute for Education & Research, an AIAMC member institution located in Minneapolis, Minnesota. As a result of these efforts, we developed initial findings that demonstrated the efficacy of integrating GME into patient safety and quality improvement initiatives. These findings were organized into a series of articles that were published in the December 2009 issue of Academic Medicine. National Initiative II In 2009, we launched the National Initiative II and expanded participation to 35 AIAMC-member teaching hospitals from Seattle to Maine. Each participating hospital developed a quality improvement team led by a resident or faculty member. These teams met on-site four times and participated in monthly conference calls over an 18-month period. Quality improvement projects focused upon one of the following areas: Communication, Hand Offs, Infection Control, Readmissions and Transitions of Care. Results from NI II were published in a variety of publications, including the February 2011 issue of the AAMC Reporter, and in the May/June 2012 special supplement issue of the American Journal of Medical Quality.
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National Initiative III NI III, launched in 2011 with 35 teams, built on the strengths of the first two phases of the AIAMC National Initiative, and moved beyond direct support of local quality improvement teams to the development of teaching leadership and changing organizational culture to support quality improvement initiatives. Graduate medical education and continuing medical education were emphasized as platforms for improving patient care. The focus of NI III was faculty/leadership development. We recognized that part of our responsibility as medical educators was to train the next generation of practicing physicians; thus, residents must be considered as junior faculty and were integral in this effort. Results from NI III were published in a variety of publications, including the Spring 2014 issue of The Ochsner Journal and the Journal of the American College of Surgeons National Initiative IV NI IV: Achieving Mastery of CLER, launched in 2013 with 34 AIAMC-member and – for the first time – non-member teams, focused on navigating the ACGME’s new CLER program. The CLER program was designed to evaluate the level of institutional responsibility for the quality and safety of the learning and patient care environment, and NI IV provided teams the training and guidance necessary to a) identify strengths and weaknesses across the six focus areas, b) prioritize areas for improvement, c) outline, streamline and implement improvement strategies, and, d) significantly and measurably advance the institutional level of preparedness. In addition, three writing groups have been formed to capture the collective work and learning of the initiative. The writing groups are 1) Program Descriptions: focused on describing the purpose, structure, and progress of the overall initiative; 2) Initiative-wide Research: focused on projects that engage the participating institutions or entire initiative as a research project; 3) Resource Materials: focused on scholarly work that can be used as a future resource for others. During National Initiative IV a group of leaders published an article titled “Integrating Quality with Graduate Medical Education: Lessons Learned from the AIAMC National Initiatives in the American Journal of Medical Quality.
For more information on the AIAMC National Initiative, please visit our website at www.aiamc.org or contact Kimberly Pierce-Boggs, Executive Director
via email at [email protected] or phone 312.836.3712.
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NI IV Participating Institutions and Team Leaders
Advocate Lutheran General Team Judi Gravdal, MD [email protected] Akron General Medical Center Cheryl Goliath, PhD [email protected] Atlantic Health System Alan Meltzer, MD [email protected] Aurora Health Care Jeff Stearns, MD [email protected] Bassett Medical Center Jim Dalton, MD [email protected] Baylor University Medical Center at Dallas William Sutker, MD [email protected] Baystate Medical Center Heather Sankey, MD [email protected] Beaumont Health System – Oakland University William Beaumont Jeffrey Devries, MD [email protected] Carolinas Medical Center Eric Anderson, M.Ed. [email protected] Christiana Care Health System Neil Jasani, MD [email protected]
Crittenton Hospital Medical Center / Wayne State University Tsveti Markova, MD [email protected] Florida Hospital Joseph Portoghese, MD [email protected] HealthPartners Institute for Education & Research /Regions Hospital Kelly Frisch, MD [email protected] Jersey Shore University Medical Center David Kountz, MD [email protected] JPS Health Network Josephine Fowler, MD [email protected] Kaiser Permanente Northern California Alex Dummett, MD [email protected] Main Line Health System Joe Greco, MD [email protected] Maricopa Medical Center Michael Grossman, MD [email protected] Marshfield Clinic Matthew Jansen, MD [email protected] Monmouth Medical Center Joe Jaeger, MD [email protected]
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Ochsner Clinic Foundation Ron Amedee, MD [email protected] Orlando Health Kwabena Ayesu, MD [email protected] OSF Saint Francis Medical Center Crystal Coan, MA [email protected] Our Lady of the Lake Regional Medical Center Laurinda Calongne, EdD [email protected] Riverside Methodist Hospital Sara Sukalich, MD [email protected] Saint Francis Care Medical Center Jeri Hepworth, MD [email protected] Scott & White Memorial Hospital Ravi Kallur, MD [email protected] Scottsdale Healthcare Moe Bell, MD [email protected] Tri Health Dave Dhanraj, MD [email protected] University of Utah Health Science Center Alan Smith, MD [email protected] Virginia Mason Medical Center Ananth Shenoy, MD [email protected]
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Team: Advocate Lutheran General Focus Area: Professionalism
I. Team Charter/Objectives
(‘needs statement,’
project requirements,
project assumptions,
stakeholders, etc.; Teams should
identify members and define
responsibility/ purpose)
Our goal was to investigate and improve how the ALGH clinical learning environment promotes and measures professionalism. The literature shows that lapses in professionalism behavior during Medical School have been associated with malpractice actions during practice. What we know about the ‘hidden curriculum’ teaches us that institutional culture is central to the formation of professional identity. Lapses and drifts in physician professionalism lead to deficiencies in safety, quality, associate satisfaction and patient satisfaction. In our institution, concerns about resident and attending professionalism have been raised and managed inconsistently. We have embarked upon a ‘Just Culture’ approach to peer review and desire to have a clear and consistent approach to dealing with concerns in the arena of professionalism as well as to raise-up stories of exemplars in professionalism.
II. Project Description
To finalize our AIM statement and formalize our project, we developed a better understanding of observable and measurable behaviors that define or exemplify professionalism. A review of the literature pointed to a) definitions that tell us what is professionalism; b) observable and measurable behaviors; and c) measurement tools that have been used. We utilized process mapping to investigate our current reporting systems and data repositories in order to identify how we could report and track Physician Professionalism concerns and praises. We determined that the above developmental work was needed prior to attempting a research project.
III. Necessary Resources
(staff, finances, etc.)
Our team had access to the necessary experts and resources which include library services, MIDAS, Online reporting system (RDS), and Crimson.
IV. Measurement/Data Collection Plan
(must partner/match with Milestone
Markers)
We learned about the strengths, flexibility, and limits of tour existing data repositories and tools available to assess and track Physician Professionalism. Educational interventions were developed to communicate how we define and assess Physician Professionalism in our Clinical Learning Environment Tools studied and used by others were reviewed for applicability to our site.
V. Communication Plan
(may be helpful to draft a flow chart of team members
& senior management,
both internal & external)
The following groups were informed and updated on our project: Senior Hospital Leadership, the System CAO, the elected Medical Staff leadership, Department Chairs, Program Directors, members of the GMEC, and one of our Affiliated Medical Schools. Presentations were made at the Medical Executive Committee, the GMEC, Resident Orientation, the semi-annual medical staff meeting.
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VI. Accountability (list of team
members and who is accountable for
what)
Dr. Leo Kelly – as VPMM and DIO was responsible for C-Suite communication and our Clinical Learning Environment and the CLER visit; his previous experience at a nonteaching hospital was invaluable in ‘visioning’ communication with physicians. Dr. Pam Hyziak – as Director of Quality and Patient Safety was responsible for helping us understand and access the available data and connect us with the appropriate personnel familiar with MIDAS. She was also instrumental in assisting with the development and (endless) revisions of our Fishbone Diagram and our Process Map. Cindy Simonsen – as Director of Medical Education ensured communication with the GMEC and the Program Directors and clarified GME processes pertinent to the project.Dr. Judi Gravdal – was accountable for managing the literature, presenting information sessions, communicating with the other Department Chairs, and representing the team on NI IV calls.
VII Potential Challenges
(engagement, budget, time,
skills gaps, etc)
Time and priorities precluded developing and carrying out a formal research project. Competing urgencies prevented team members from attending the NI IV meetings.
VIII. Markers (project phases, progress checks, schedule, etc.;
must partner/match
measurement/data collection plan)
By December 31, 2013 – Our literature review was robust; definitions were reviewed and operationalized. By March 2014 – We had begun to draft our Physician Commitment to Professionalism. We understood the ability of MIDAS to serve as a repository, a source of reports, and for accountability. We identified all the various sources of feedback reporting on physicians. We elected not to pursue a formal study/IRB. By July 2014, the Physician Commitment to Professionalism was finalized for both attending physicians and Residents/Fellows. Approval to use for new appointments immediately and for reappointment in the March 2015 cycle was obtained. By October 2014 the MIDAS flow and FYI letters were finalized.
IX. Vision Statement/Closing
Plan (markers of
success by March 2015)
By March 2015, our team had clearly operationalized components of ‘Physician Professionalism’ for both residents, fellows and attending physicians. Partners and existing tools (our MIDAS database) were identified and tweaked. The Physician Commitment to Professionalism was rolled out. We now have the capability to investigate and improve how our ALGH learning environment promotes and measures physician professionalism at the medical staff level. Our products include: 1- A literature review is in preparation to be submitted for publication 2- Several educational sessions have taken place [Resident Orientation; Family Medicine Faculty Development Session; Medical Staff Semiannual Meeting] and more are planned. 2- A study of Professionalism in our Clinical Learning Environment before and after an intervention was not carried out. 3- The ALGH Physician Commitment to Professionalism has been incorporated into the Appointment, Reappointment and Resident Contract processes. 4- We submitted to the 2015 ACGME conference but were not selected to present 5- Five ‘FYI’ feedback letters were rolled out in Family Medicine and Internal Medicine. Education and spread to the other departments are planned.
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X. Success Factors The most successful component of our work was……….. Collaboration with multiple partners in Quality, Safety and Patient Experience as well as Medical Staff Leadership and GME leadership. We were inspired by……………….. York Wellspan’s “Expectations on Professionalism.” The enthusiastic reception by medical staff leadership and the Department Chairs who urged us to execute more quickly.
XI. Barriers The largest barrier we encountered was…….. We worked to overcome this by…….. Reporting by and about physicians (both attendings and residents) at our hospital is inconsistent and insufficient. Education and the inclusion of reporting exemplary behavior should improve the volume and variety of reports. A telephone hotline was initiated for physicians and residents/fellows to encourage and facilitate reporting. We have not yet identified a tracking mechanism for Residents/Fellows that is standardized across programs.
XII. Lessons Learned The single most important piece of advice to provide another team embarking on a similar initiative would be………… Schedule regular (weekly or biweekly) meetings. Keep an open mind about who needs to be at the table and who has necessary expertise. Make assignments and collaborate to keep the team on track. Follow the monthly assignments Focus on the end goal.
XIII Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10 We had very high expectations but are proud of all we accomplishes
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI III work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact What changes have you observed in your residency program(s), or at your institution, based upon your work? Greater clarity about what we mean by “Physician Professionalism” An expectation that all physicians are expected to meet standards of professionalism that align with the Advocate Behaviors of Excellence
XVI. Next Steps Describe next steps for your project, including plans for sustaining and spreading the changes made. We will next spread this to all clinical departments. We will monitor impact through our Medical Staff Peer Review and Appointment/Reappointment proceses. We will continue to work with GME to assess implementation and impact for residents and fellows. We plan to share our work with the other teaching and nonteaching hospitals in our system.
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Ove
rall
Goa
l/Ab
stra
ct
Phys
ician
Pro
fess
iona
lism
is es
sent
ial to
achi
evin
g Sa
fety,
Qua
lity a
nd S
ervic
e for
ever
y pat
ient e
very
tim
e.
Defin
ing,
teac
hing
, mea
surin
g, an
d re
med
iatin
g pr
ofes
siona
lism
rem
ains a
chall
enge
in m
ost
orga
niza
tions
.
Our g
oal w
as to
inve
stig
ate t
he lit
erat
ure a
nd to
dev
elop
an o
bjec
tive d
efin
ition
of
Phys
ician
Pro
fess
iona
lism
for
the A
LGH
Clin
ical L
earn
ing
Envir
onm
ent .
Defin
ing
and
Com
mitt
ing
to P
hysi
cian
Pro
fess
iona
lism
G
ravd
al J,
Hyz
iak
P, K
elly
L, S
imon
sen
C
Advo
cate
Lut
hera
n G
ener
al H
ospi
tal
Par
k Ri
dge,
IL
Back
grou
nd
AIM
Sta
tem
ent
Mat
eria
ls/M
etho
ds
1- L
itera
ture
revie
w wa
s und
erta
ken
utiliz
ing
Med
line
sear
ch an
d in
terro
gatio
n of
refe
renc
es in
iden
tified
lit
erat
ure.
2- F
ishbo
ne d
iagra
m ai
ded
in id
entif
ying
prob
lems.
3- “A
LGH-
Phys
ician
Com
mitm
ent t
o Pr
ofes
siona
lism
” wa
s cre
ated
whi
ch al
igne
d wi
th S
yste
m B
ehav
iors
of
Exce
llenc
e. --A
ttend
ing
Phys
ician
s sig
n at
App
licat
ion
and
Reap
poin
tmen
t --R
esid
ents
and
Fello
ws si
gn w
ith an
nual
cont
ract
Bibl
iogr
aphy
Barr
iers
Enc
ount
ered
/Lim
itatio
ns-
The l
itera
ture
is ex
tens
ive b
ut n
ot al
ways
appl
icabl
e.
The P
hysic
ian C
omm
itmen
t to
Prof
essio
nalis
m h
as b
een
well a
ccep
ted
but h
as n
ot b
een
in p
lace l
ong
enou
gh to
ev
aluat
e im
pact
.
Resu
lts
Conc
lusi
ons
.
Phys
icia
n Co
mm
itmen
t
Prof
essio
nalis
m in
med
icine
has
had
shift
ing
mea
ning
s ove
r th
e pas
t cen
tury
.
Prob
lems w
ith p
rofe
ssio
nalis
m ar
e well
doc
umen
ted
in th
e lit
erat
ure a
nd ar
e a co
ncer
n of
hos
pita
l and
gra
duat
e med
ical
educ
atio
n lea
ders
hip.
Lap
ses i
n pr
ofes
siona
l beh
avio
r in
med
ical s
choo
l hav
e bee
n as
socia
ted
with
incr
ease
d ra
tes o
f m
alpra
ctice
actio
ns d
urin
g pr
actic
e.
Conc
erns
abou
t res
iden
t and
atte
ndin
g pr
ofes
siona
lism
hav
e be
en ra
ised
at A
LGH
but a
re id
entif
ied an
d m
anag
ed
inco
nsist
ently
and
very
little
has
bee
n do
ne to
iden
tify
exem
plar
s.
•Un
ders
tand
and
oper
atio
naliz
e Med
ical
Prof
essio
nalis
m
•Co
mm
unica
te an
d cr
eate
a co
mm
itmen
t to
Phys
ician
Pr
ofes
siona
lism
Defin
ing
and
mak
ing
expl
icit e
xpec
tatio
ns fo
r Phy
sician
Pr
ofes
siona
lism
is ch
allen
ging
, ong
oing
wor
k whi
ch ca
n an
d sh
ould
be u
nder
take
n.
ALG
H-M
EDIC
AL S
TAFF
CO
MM
ITM
ENT
TO P
ROFE
SSIO
NAL
ISM
AL
GH
and
med
ical
sta
ff ph
ysic
ians
com
mit
to a
par
tner
ship
that
will
pro
vide
Saf
ety,
Qua
lity,
and
Se
rvic
e AL
WAY
S.
As m
embe
rs o
f the
ALG
H m
edic
al s
taff
and
as a
key
par
tner
in th
e AL
GH
team
, I c
omm
it to
the
follo
win
g:
Be S
afe
1- M
ake
safe
ty m
y hi
ghes
t prio
rity
and
repo
rt s
afet
y ev
ents
, nea
r miss
es, a
nd u
nsaf
e co
nditi
ons
2- E
nsur
e co
mpe
tenc
e, a
nd im
prov
e qu
ality
, and
com
mit
to a
n en
viro
nmen
t of l
ife-lo
ng le
arni
ng
3- C
omm
unic
ate
clea
rly a
nd p
rovi
de c
ompl
ete
hand
over
s 4-
Giv
e fu
ll an
d un
divi
ded
atte
ntio
n to
the
task
at h
and
Be R
espo
nsiv
e 1-
Mak
e ey
e co
ntac
t, sa
y he
llo, i
ntro
duce
mys
elf b
y na
me
and
role
, and
exp
lain
wha
t will
hap
pen
2- L
isten
att
entiv
ely
and
addr
ess e
ach
indi
vidu
al’s
nee
ds w
ith k
indn
ess,
pat
ienc
e an
d re
spec
t 3-
Ant
icip
ate
and
resp
ond
to th
e ne
eds a
nd e
xpec
tatio
ns o
f oth
ers
by ti
mel
y co
mm
unic
atio
n an
d do
cum
enta
tion
and
effo
rts
to im
prov
e ac
cess
and
rem
ove
barr
iers
4-
Be
hone
st in
wor
d an
d de
ed
Be R
espe
ctfu
l 1-
Dem
onst
rate
resp
ect f
or a
ll an
d un
ders
tand
ing
of o
ur e
thic
al a
nd le
gal o
blig
atio
ns
2-El
imin
ate
disr
uptiv
e, o
ffens
ive
and
intim
idat
ing
actio
ns
3-Bu
ild tr
ust a
nd re
solv
e co
nflic
ts p
rom
ptly
4
-Mai
ntai
n a
prof
essio
nal s
ettin
g an
d he
alin
g at
mos
pher
e by
redu
cing
noi
se a
nd a
ppro
pria
tely
us
ing
elec
tron
ic d
evic
es.
Be P
rofe
ssio
nal
1-Ac
t with
inte
grity
and
com
pass
ion
in e
very
situ
atio
n 2-
Resp
ect c
onfid
entia
lity
and
priv
acy
in a
ll or
al, w
ritte
n an
d el
ectr
onic
com
mun
icat
ions
, inc
ludi
ng
soci
al m
edia
3-
Crea
te a
pos
itive
firs
t and
last
ing
prof
essio
nal i
mpr
essio
n in
app
eara
nce,
att
ire, p
erso
nal
hygi
ene,
pos
ition
ing
of ID
bad
ge fo
r eas
y vi
sibili
ty, a
nd in
use
of s
ocia
l med
ia
4-Se
t an
exam
ple
and
lead
with
civ
ility
and
altr
uism
Be
Acc
ount
able
1-
Use
reso
urce
s w
isely
seek
ing
just
and
cos
t-ef
fect
ive
dist
ribut
ion
of fi
nite
reso
urce
s 2-
Hono
r and
follo
w th
roug
h on
my
com
mitm
ents
3-
Follo
w e
stab
lishe
d st
anda
rds a
nd p
ract
ices
4-
Cont
ribut
e to
Dep
artm
ent,
Hosp
ital a
nd S
yste
m g
oal a
chie
vem
ent
Be C
olla
bora
tive
1- P
artn
er w
ith o
ther
s in
team
s tha
t pro
vide
exc
eptio
nal c
are
and
serv
ice
2-Co
ntrib
ute
to a
nd p
artic
ipat
e in
an
envi
ronm
ent c
ondu
cive
to le
arni
ng a
nd im
prov
emen
t 3-
Wor
k ac
tivel
y to
see
k th
e in
put o
f oth
ers
4-Ac
cept
and
offe
r coa
chin
g an
d m
ento
ring.
__
____
____
____
____
____
__
__
____
____
____
____
____
____
_
___
____
____
____
____
___
Phys
icia
n
Pres
iden
t of t
he M
edic
al S
taff
ALG
H V
PMM
__
____
____
____
____
____
_
_
____
____
____
____
____
____
__ _
____
____
____
____
____
___
Dat
e
D
ate
D
ate
Succ
ess F
acto
rs a
nd L
esso
ns L
earn
ed
Cam
pbel
l EG
, Reg
an S
, Gru
en R
L, e
t.al.
Prof
essi
onal
ism
in m
edic
ine:
Res
ults
of a
nat
iona
l sur
vey
of p
hysi
cian
s. A
nn In
tern
Med
. 20
07;1
47:7
95-8
02.
Gre
en M
, Zic
k A
and
Mak
oul G
. D
efin
ing
prof
essi
onal
ism
from
the
pers
pect
ive
of p
atie
nts,
phys
icia
ns a
nd n
urse
s. A
cad
Med
. 20
09;8
4:56
6-73
. S
wic
k, H
M.
Tow
ard
a no
rmat
ive
defin
ition
of m
edic
al p
rofe
ssio
nalis
m.
Aca
d M
ed 2
000;
75:6
12-
16.
Wyn
ia M
K, P
apad
akis
MA
, Sul
livan
WM
, et.a
l. M
ore
than
a li
st o
f val
ues a
nd d
esire
d be
havi
ors:
A
foun
datio
nal u
nder
stan
ding
of m
edic
al p
rofe
ssio
nalis
m.
Aca
d M
ed.
2014
;89:
712-
14.
9 of 131
Ove
rall
Goa
l/Ab
stra
ct
Phys
ician
Pro
fess
iona
lism
is o
f utm
ost i
mpo
rtanc
e yet
m
easu
ring
and
prov
idin
g fe
edba
ck fo
r bot
h pr
oblem
atic
and
exem
plar
y has
bee
n ch
allen
ging
.
Our g
oal w
as to
dev
elop
tool
s and
pro
cess
es fo
r do
cum
entin
g an
d pr
ovid
ing
feed
back
to p
hysic
ians a
bout
re
porte
d be
havio
ral la
pses
, drif
ts an
d ex
empl
ars.
Phys
icia
n Pr
ofes
sion
alis
m:
Feed
in a
nd F
eedb
ack
G
ravd
al J,
Hyz
iak
P, K
elly
L,
Sim
onse
n C
Advo
cate
Lut
hera
n G
ener
al H
ospi
tal
Par
k Ri
dge,
IL
Back
grou
nd
AIM
Sta
tem
ent
Mat
eria
ls/M
etho
ds
Bibl
iogr
aphy
•L
esse
r C
S, L
uce
y C
R, E
gen
er B
, et.
al. A
beh
avio
ral a
nd
sys
tem
s vi
ew o
f p
rofe
ssio
nal
ism
. JA
MA
. 20
10;3
04:
2732
-37.
•Lu
cey
C a
nd
Sou
ba W
. T
he
pro
blem
wit
h t
he
pro
blem
of
pro
fess
ion
alis
m.
Aca
d M
ed.
2010
;85:
1018
-24.
•Pap
adak
is M
A, P
aau
w D
S, H
affe
rty
FW
, et.
al.
Th
e ed
uca
tion
com
mu
nit
y m
ust
dev
elop
bes
t p
ract
ices
info
rmed
by
evid
ence
-bas
ed r
esea
rch
to
rem
edia
te la
pse
s of
pro
fess
ion
alis
m.
Aca
d M
ed.
2012
;87:
1694
-98
.
•San
chez
LT
. D
isru
pti
ve b
ehav
iors
am
ong
ph
ysic
ian
s. J
AM
A.
2014
;312
:220
9-10
.
•Ste
rn D
T a
nd
Pap
adak
is M
. Th
e d
evel
opin
g p
hys
icia
n –
bec
omin
g a
pro
fess
ion
al.
N E
ngl
J M
ed.
200
6;35
5:17
94-9
9.
Barr
iers
Enc
ount
ered
/Lim
itatio
ns-
Phys
icia
n an
d De
part
men
t Cha
ir ed
ucat
ion
mus
t be
ongo
ing.
A
pilo
t stu
dy is
und
erw
ay.
Re
side
nt fe
edba
ck p
roce
ss is
bei
ng d
evel
oped
.
Resu
lts
Conc
lusi
ons
•En
gage
men
t of a
wor
king
team
that
inclu
ded
the
VPMM
/Ass
ociat
e DIO
, Dire
ctor
of Q
ualit
y and
Saf
ety a
nd
the D
irect
or o
f Med
ical E
duca
tion
were
cruc
ial to
succ
ess.
•Su
ppor
t and
invo
lvem
ent
from
the C
-Sui
te, Q
ualit
y lea
ders
, Pat
ient S
afet
y, Pa
tient
Exp
erien
ce L
eade
rs .
•Un
ders
tand
ing
and
empl
oyin
g ex
istin
g Qu
ality
Ma
nage
men
t Too
ls (M
IDAS
) was
esse
ntial
to o
ur su
cces
s. •
Early
intro
duct
ion
to, in
put f
rom
and
supp
ort o
f the
elec
ted
Medi
cal S
taff
leade
rshi
p w
as im
porta
nt.
Succ
ess F
acto
rs a
nd L
esso
ns L
earn
ed
Prob
lems w
ith p
rofe
ssio
nalis
m ab
ound
in th
e lite
ratu
re an
d ar
e a co
ncer
n of
hos
pita
l and
GME
lead
ersh
ip. L
apse
s in
prof
essio
nal b
ehav
ior h
ave b
een
asso
ciate
d wi
th in
crea
sed
rate
s of m
alpra
ctice
actio
ns, d
ecre
ased
pat
ient s
atisf
actio
n,
and
decr
ease
d as
socia
te sa
tisfa
ctio
n.
Incid
ents
rega
rdin
g m
edica
l pro
fess
iona
lism
hav
e not
bee
n co
nsist
ently
iden
tified
and
man
aged
. Litt
le ha
s bee
n do
ne to
id
entif
y exe
mpl
ars.
Deve
lop
tool
s and
pro
cess
es fo
r doc
umen
ting
the o
utlie
rs –
both
neg
ative
and
posit
ive –
and
prov
idin
g fe
edba
ck to
ph
ysici
ans.
Proc
esse
s exis
ted
that
coul
d be
use
d fo
r doc
umen
ting
Phys
ician
Pro
fess
iona
lism
. Ph
ysici
ans,
with
few
exce
ptio
ns, w
ere r
ecep
tive t
o th
e fe
edba
ck le
tters
. De
finin
g, m
easu
ring
and
impr
ovin
g a c
ultu
re o
f Phy
sician
Pr
ofes
siona
lism
is ch
allen
ging
, ong
oing
wor
k whi
ch ca
n an
d sh
ould
be u
nder
take
n.
1- P
roce
ss m
appi
ng o
f cur
rent
and
idea
l pro
cess
2- D
evelo
pmen
t an
d pi
lotin
g of
‘Fee
dbac
k Mem
os’
3- E
xplo
ratio
n of
util
izing
MID
AS Q
I sof
twar
e
4- A
lgor
ithm
and
Syst
em fo
r doc
umen
tatio
n of
laps
es in
an
d ex
empl
ars o
f pro
fess
iona
lism
P
HYSI
CIAN
FEE
DBAC
K LE
TTER
TEM
PLAT
ES
EXEM
PLAR
CO
NCER
N
Tim
eline
ss o
f res
pons
e
Doc
umen
tatio
n co
ncer
n
Med
icatio
n er
ror
O
ther
conc
erns
10 of 131
Team: Akron General Medical Center Focus Area: Transitions of Care – Emergency Medicine/Internal Medicine
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams
should identify members and define responsibility/purpose)
Historically, there has been a perception of unnecessary transfers of patients admitted to the floor from the Emergency Department that required transfer to a critical care unit within 24 hours of admission. The objective of this project is to create a quality driven process of standardizing the transitions of care for patients from the Emergency Department to the inpatient setting. This will improve quality of care and patient safety as well as decrease length of stay by ensuring appropriate placement of patients upon admission.
II. Project Description
Our project will focus on the transition of care for patients admitted through the ED to a medical floor that require transfer within 24 hours of admission to a critical care unit. The team will conduct a retrospective chart audit to identify factors related to the transfer and develop a possible intervention to reduce the number of transfers to improve the quality of care, increase patient safety and reduce costs by admitting the patient to the appropriate unit. The team will identify appropriate indicators that can be assessed with measurable outcomes within the scope of the 18 month project timeline.
III. Necessary Resources (staff, finances, etc.)
The team felt nursing representation should be added to the NI IV team to obtain a more global perspective of the transition process. Electronic resources that will enable the team to gather patient transfer information and conduct retrospective chart audit. Resident team members will work with the IRRB for approval of the project and perform the chart audit.
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
The resident team members conducted a retrospective chart audit January – March 2014 to determine the factors that contributed to the patient being transferred to a critical care unit within 24 hours of being admitted to a Medicine floor. Twenty two charts were manually reviewed to determine admitting diagnosis, reason for transfer, time to transfer and final disposition of the patient.
V. Communication Plan (may be helpful to draft a flow chart of team members & senior management,
both internal & external)
Team meetings were difficult to arrange, but team communication was ensured via email. Meetings took place to inform Department leadership and the C-Suite of the project.
VI. Accountability (list of team members and who
is accountable for what)
Titus Sheers, M.D., Co-Team Leader/IM Program Director/DIO Cheryl Goliath, M.D., Co-Team Leader/Executive Director, Medical Education and Research Larry Emmelhainz, PhD, Chief Quality Officer Ankit Anand, M.D., PGY-3 Internal Medicine Resident Zachary Robinson, M.D., PGY-2 Emergency Medicine
11 of 131
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
Identifying transferred patients was difficult because of various record systems within the hospital. The EM resident who started on the team withdrew approximately half-way into the project. A new EM resident had to be identified which took some time. The nursing representation that was added took a position at another hospital and left the project.
VIII. Markers (project phases, progress checks,
schedule, etc.; must partner/match measurement/data collection plan)
Once the focus of the project was identified, it was time consuming finding an electronic resource that could capture the information that was needed to perform the chart audit. At the time the charts were identified, the EM resident on the team withdrew from the project and a new EM resident had to be identified which resulted in a two month delay before the audit could begin.
IX. Vision Statement/Closing Plan (markers of success by March 2015)
Once the chart audit has been completed to determine the factors involved in the patient transfers from the floor to the critical care units within 24 hours, the project team can identify an appropriate intervention to decrease the number of transfers.
X. Success Factors The most successful component of our work was working together with another Department, specifically, Internal Medicine and Emergency Medicine, two Departments that at times approach issues from a different vantage point. Despite early problems with finding a correct reporting mechanism to capture the information needed for the study, we were able to identify a program that produced patient information that previously we had not been able to obtain. Reports from residents of unnecessary transfers within 24 hours from admission seemed to be a somewhat pervasive problem. The study found the opposite to be the case and the number of transfers were much lower than expected.
XI. Barriers The most difficult barrier was finding an electronic mechanism to gather the patient information needed. This process delayed the study. Additionally, there were several changes of the team membership which negatively impacted our momentum. New members had to be identified and this delayed the process as well.
XII. Lessons Learned Schedule regular meetings at the beginning of the project for the duration of the Initiative to ensure ongoing communication. Scheduling as items come up for discussion made it extremely difficult to get members together. If a pre-set meeting is scheduled, it can always be cancelled.
12 of 131
XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI III work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact Based upon our study, we have communicated to the leadership of each Department and the C-Suite the lower than anticipated transfer rate. There is a related study by nursing in the MICU and our findings have been shared with them as well.
XVI. Next Steps Now that an electronic mechanism was identified to gather this information, a more longitudinal study could be beneficial. We would like to create a more structured communication tool to solicit the appropriate information so patients are admitted to the correct unit upon admission.
13 of 131
Ove
rall
Goa
l/Ab
stra
ct
Our
pro
ject
focu
sed
on tr
ansit
ion
of c
are
for p
atie
nts
initi
ally
adm
itted
thro
ugh
the
ED to
a m
edic
al fl
oor
requ
iring
tran
sfer
with
in 2
4 ho
urs o
f adm
issio
n to
a
criti
cal c
are
unit.
We
cond
ucte
d a
retr
ospe
ctiv
e ch
art
audi
t to
iden
tify
fact
ors r
elat
ed to
the
tran
sfer
. W
e fo
und
that
thes
e pa
tient
s wer
e la
rgel
y ap
prop
riate
ly
tria
ged
and
that
, with
onl
y a
few
exc
eptio
ns, t
hey
had
stat
us c
hang
es th
at c
ould
not
hav
e be
en a
ntic
ipat
ed.
Floo
r to
Uni
t Tra
nsfe
rs w
ithin
24
hour
s of A
dmis
sion
fr
om th
e ED
Za
char
y Ro
bins
on, M
D; A
nkit
Anan
d, M
D, C
hery
l Gol
iath
, PhD
;
Titu
s She
ers,
MD;
Lar
ry E
mm
elha
inz,
PhD
Akro
n Ge
nera
l Med
ical
Cen
ter,
Akro
n, O
hio
We
are
an a
ppro
xim
atel
y 50
0-be
d co
mm
unity
hos
pita
l w
ith a
ppro
xim
atel
y 10
3,00
0 ED
visi
ts b
etw
een
four
ED
sites
and
app
roxi
mat
ely
25,0
00 a
nnua
l adm
issio
ns. W
e pe
rfor
med
a c
hart
revi
ew o
f all
tran
sfer
s of a
n ad
mitt
ed
patie
nt to
an
ICU
bed
dur
ing
a 3-
mon
th p
erio
d. W
e at
tem
pted
to a
nsw
er se
vera
l que
stio
ns, n
amel
y w
heth
er
ther
e w
as a
cha
nge
in th
e pa
tient
’s st
atus
, whe
ther
this
stat
us c
hang
e co
uld
have
bee
n an
ticip
ated
, and
whe
ther
th
e in
itial
adm
issio
n un
it w
as a
ppro
pria
te.
Back
grou
nd
Visi
on S
tate
men
t O
nce
the
char
t aud
it ha
s bee
n co
mpl
eted
to d
eter
min
e th
e fa
ctor
s inv
olve
d in
pat
ient
tran
sfer
s fro
m th
e flo
or
to th
e cr
itica
l car
e un
its w
ithin
24
hour
s, th
e pr
ojec
t te
am c
an id
entif
y an
app
ropr
iate
inte
rven
tion
to
decr
ease
the
num
ber o
f tra
nsfe
rs.
Mat
eria
ls/M
etho
ds
A ch
art a
udit
was
per
form
ed o
f adm
issio
ns fr
om 1
/1/1
4 th
roug
h 3/
31/1
4 to
iden
tify
patie
nts w
ho w
ere
tran
sfer
red
to a
n IC
U w
ithin
24
hour
s of a
dmiss
ion.
We
iden
tifie
d 22
pat
ient
s who
met
this
crite
ria. W
e th
en
man
ually
revi
ewed
thes
e ch
arts
to d
eter
min
e ad
mitt
ing
diag
nosis
, rea
son
for t
rans
fer,
time
to tr
ansf
er, a
nd fi
nal
disp
ositi
on o
f the
pat
ient
. Bas
ed o
n th
is da
ta a
nd re
view
of
the
reco
rd, w
e de
term
ined
whe
ther
the
initi
al
plac
emen
t was
app
ropr
iate
and
whe
ther
any
stat
us
chan
ge c
ould
hav
e be
en a
ntic
ipat
ed.
1.Go
ld C
A, M
ayer
SA,
Len
niha
n L,
Cla
asse
n J,
Will
ey JZ
. Unp
lann
ed T
rans
fers
from
Hos
pita
l War
ds to
the
Neu
rolo
gica
l Int
ensiv
e Ca
re U
nit.
Neu
rocr
it Ca
re.
2015
;
2.Re
ese
J, De
akyn
e SJ
, Bla
ncha
rd A
, Baj
aj L.
Rat
e of
pre
vent
able
ear
ly u
npla
nned
inte
nsiv
e ca
re u
nit t
rans
fer f
or d
irect
adm
issio
ns a
nd e
mer
genc
y de
part
men
t adm
issio
ns. H
osp
Pedi
atr.
2015
;5(1
):27-
34.
3.Co
hen
RI, E
icho
rn A
, Mot
schw
iller
C, e
t al.
Med
ical
inte
nsiv
e ca
re u
nit c
onsu
lts o
ccur
ring
with
in 4
8 ho
urs o
f adm
issio
n: A
pro
spec
tive
stud
y. J
Crit
Care
. 20
15;3
0(2)
:363
-8.
4.De
lgad
o M
K, L
iu V
, Pin
es JM
, Kip
nis P
, Gar
dner
MN
, Esc
obar
GJ.
Risk
fact
ors f
or u
npla
nned
tran
sfer
to in
tens
ive
care
with
in 2
4 ho
urs o
f adm
issio
n fro
m th
e em
erge
ncy
depa
rtm
ent i
n an
inte
grat
ed h
ealth
care
syst
em. J
Hos
p M
ed. 2
013;
8(1)
:13-
9.
5.Fl
abou
ris A
, Jey
ados
s J, F
ield
J, S
oulsb
y T.
Dire
ct a
nd d
elay
ed a
dmiss
ion
to a
n in
tens
ive
care
or h
igh
depe
nden
cy u
nit f
ollo
win
g di
scha
rge
from
the
emer
genc
y de
part
men
t: as
soci
ated
pat
ient
cha
ract
erist
ics a
nd h
ospi
tal o
utco
mes
. Crit
Car
e Re
susc
. 201
2;14
(3):1
91-7
.
6.Li
u V,
Kip
nis P
, Rizk
NW
, Esc
obar
GJ.
Adve
rse
outc
omes
ass
ocia
ted
with
del
ayed
inte
nsiv
e ca
re u
nit t
rans
fers
in a
n in
tegr
ated
hea
lthca
re sy
stem
. J H
osp
Med
. 201
2;7(
3):2
24-3
0.
7.Ke
nned
y M
, Joy
ce N
, How
ell M
D, L
awre
nce
mot
tley
J, Sh
apiro
NI.
Iden
tifyi
ng in
fect
ed e
mer
genc
y de
part
men
t pat
ient
s ad
mitt
ed to
the
hosp
ital w
ard
at
risk
of c
linic
al d
eter
iora
tion
and
inte
nsiv
e ca
re u
nit t
rans
fer.
Acad
Em
erg
Med
. 201
0;17
(10)
:108
0-5.
8.Hi
llman
KM
, Bris
tow
PJ,
Chey
T, e
t al.
Dura
tion
of li
fe-th
reat
enin
g an
tece
dent
s prio
r to
inte
nsiv
e ca
re a
dmiss
ion.
Inte
nsiv
e Ca
re M
ed. 2
002;
28(1
1):1
629-
34.
9.Pa
rkhe
M, M
yles
PS,
Lea
ch D
S, M
acle
an A
V. O
utco
me
of e
mer
genc
y de
part
men
t pat
ient
s w
ith d
elay
ed a
dmiss
ion
to a
n in
tens
ive
care
uni
t. Em
erg
Med
(F
rem
antle
). 20
02;1
4(1)
:50-
7.
10.
Rapo
port
J, T
eres
D, L
emes
how
S, H
arris
D. T
imin
g of
inte
nsiv
e ca
re u
nit a
dmiss
ion
in re
latio
n to
ICU
out
com
e. C
rit C
are
Med
. 199
0;18
(11)
:123
1-5.
Bibl
iogr
aphy
Barr
iers
Enc
ount
ered
/Lim
itatio
ns
-Id
entif
ying
tran
sfer
red
patie
nts w
as d
iffic
ult b
ecau
se
of th
e re
cord
s sys
tem
use
d in
our
hos
pita
l.
-Du
ring
the
stud
y th
ere
wer
e se
vera
l cha
nges
to th
e te
am m
embe
rshi
p, a
nd m
eetin
gs w
ere
ofte
n di
fficu
lt to
sche
dule
.
Resu
lts
Conc
lusi
ons
Cont
rary
to re
siden
t per
cept
ions
, the
num
ber o
f tr
ansf
ers w
as e
xcee
ding
ly lo
w. I
n co
ntra
st to
the
liter
atur
e, n
one
of th
ese
patie
nts e
xpire
d w
hile
in th
e ho
spita
l, an
d ha
lf of
them
wer
e di
scha
rged
to h
ome.
Am
ong
thes
e tr
ansf
ers,
abo
ut 2
7% w
ere
felt
to b
e du
e to
que
stio
nabl
e in
itial
pla
cem
ent,
how
ever
no
clea
r pa
tter
n of
cau
se w
as id
entif
ied.
50%
of t
he tr
ansf
ers
wer
e du
e to
resp
irato
ry d
ecom
pens
atio
n, id
entif
ying
a
high
-risk
gro
up fo
r ear
ly d
ecom
pens
atio
n, h
owev
er
with
out d
ata
on th
e to
tal n
umbe
r of p
atie
nts a
dmitt
ed
for r
espi
rato
ry d
iagn
oses
, it i
s im
poss
ible
to q
uant
ify th
e ris
k. In
the
futu
re w
e w
ould
like
to e
xplo
re st
anda
rdize
d ha
ndof
fs su
ch a
s I-P
ASS
to h
elp
adm
ittin
g te
ams
antic
ipat
e po
ssib
le st
atus
cha
nges
.
Tota
l tra
nsfe
rs
Tota
l adm
issi
ons
Tran
sfer
rate
22
53
02
0.41
%
Inap
prop
riate
/que
stio
nabl
e in
itial
pla
cem
ent
6/22
(27%
)
Aver
age
time
to tr
ansf
er
11:4
6 hr
Reas
on fo
r Tra
nsfe
r Re
spira
tory
dec
ompe
nsat
ion
11 (5
0%)
Card
iac
(NST
EMI,
arrh
ythm
ia, c
ardi
ogen
ic sh
ock)
7
(32%
) Co
de B
lue
2 (9
%)
Alco
hol w
ithdr
awal
1
(5%
) Pe
rsist
ent b
leed
ing
1 (5
%)
Fina
l Dis
posi
tion
Hom
e 11
(50%
) Ho
spic
e 6
(27%
) SN
F/EC
F 4
(18%
) LT
AC
1 (5
%)
Succ
ess F
acto
rs a
nd L
esso
ns L
earn
ed
-Pa
tient
dec
ompe
nsat
ion
is di
fficu
lt to
pre
dict
-W
e la
rgel
y do
wel
l with
adm
ittin
g pa
tient
s to
the
appr
opria
te le
vel o
f car
e
-An
inte
rdep
artm
enta
l tea
m is
use
ful i
n id
entif
ying
po
ssib
le im
prov
emen
ts to
car
e
14 of 131
Team: Atlantic Health System Focus Area: Transitions of Care
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
On the Goryeb Children’s Hospital-Atlantic Health System’s pediatric inpatient unit, a number of admissions arrive on the floor without formal physician to physician hand-off. Pilot data revealed that hand-offs, especially from the pediatric surgical service, were limited. The purpose of the current study was to develop a streamlined method of communication between multiple disciplines and the inpatient pediatric admitting resident to increase hand-off rate.
II. Project Description
A team comprised of members of the pediatric and general pediatric surgical services will be formed. A new communication tool, a portable telephone to be carried by the admitting pediatric resident 24 hours a day, seven days a week will be introduced. Once the new portable telephone is obtained, instructions, both verbal and written, will be provided to all disciplines that admit to the inpatient unit (i.e., ER, surgical teams, subspecialists and outpatient general pediatricians). Data will be collected for a six-week period examining hand-off rate for pediatric inpatient admissions. After the initial six-week data collection, results will be analyzed and a second PDSA cycle will be performed. Data will be collected for an additional six week period; analyzed and future PDSA cycles will be planned.
III. Necessary Resources (staff, finances, etc.)
New portable telephone, data collection tool, data analyst
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
Percent of admissions to the pediatric unit where a formal hand-off occurred, from what service and by what method. Data will be collected over 6 week periods utilizing a PDSA model of intervention
V. Communication Plan (may be helpful to draft a flow chart of team
members & senior management, both internal & external)
All stakeholders in the admission process to the pediatric unit will be in-serviced via verbal and written communication as to the new process of contacting the admitting pediatric residents via the telephone.
VI. Accountability (list of team members and who
is accountable for what)
Dr Michael Pollaro – resident champion of project and responsible for coordinating data collection Dr Alan Meltzer – pediatric program director and faculty champion Dr Eric Lazar – surgical program director and surgical champion responsible for in-servicing the pediatric surgical services Pediatric and Surgical Chief residents to assist in communication of the new process to their respective residents Kiley Alpert – pediatric residency coordinator to provide administrative and IT support
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc.
Buy-in by the surgeons as to the necessity of formal verbal hand-offs as opposed to a post-op note only method of hand-offs
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
Three phases of project 1. Pilot data collected prior to implementation of phone 2. In-service the medical, surgical and subspecialty faculty as to the
new admission phone for hand-offs 3. Collect data for 6 weeks followed by analysis of results 4. Implement changes to process based on data 5. Collect data for 6 weeks followed by analysis of results
15 of 131
IX. Vision Statement/Closing Plan (markers of success by March 2015)
Increase overall number of hand-offs Eliminate the admission pager which leads to delays in communication Full adoption of the direct line admission phone Enhanced communication to improve patient safety.
X. Success Factors The ED had full adoption of the telephone with 100% of admissions having a formal verbal hand-off via the telephone. Although the medical subspecialists did not use the phone to the extent we had desired, the number hand-offs via other methods of communication by the subspecialists reached 100%.
XI. Barriers Buy in to the process by non-employed surgical subspecialty faculty.
XII. Lessons Learned More frequent meetings with the surgical stakeholders to maintain pressure and focus on the project.
XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI III work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact What changes have you observed in your residency program(s), or at your institution, based upon your work? 100% of ED and subspecialty admissions now have a formal hand-off.
XVI. Next Steps Continue to work on engagement of the surgeons, more specifically the non-employed surgical subspecialist.
16 of 131
Proj
ect A
im
On
our i
nstit
utio
n’s
pedi
atric
inpa
tient
uni
t, a
num
ber o
f ad
miss
ions
arr
ive
on th
e flo
or w
ithou
t for
mal
phy
sicia
n to
phy
sicia
n ha
nd-o
ff. P
ilot d
ata
reve
aled
that
han
d-of
fs,
espe
cial
ly
from
th
e pe
diat
ric
surg
ical
se
rvic
e,
wer
e lim
ited.
The
pur
pose
of t
he c
urre
nt st
udy
was
to d
evel
op
a st
ream
lined
m
etho
d of
co
mm
unic
atio
n be
twee
n m
ultip
le d
iscip
lines
and
the
inpa
tient
ped
iatr
ic a
dmitt
ing
resid
ent t
o in
crea
se h
and-
off r
ate.
Back
grou
nd
Pilo
t Dat
a
Visi
on
•In
crea
se o
vera
ll nu
mbe
r of h
and-
offs
•El
imin
ate
the
adm
issio
n pa
ger w
hich
lead
s to
dela
ys in
co
mm
unic
atio
n
•Ad
opt a
dire
ct li
ne a
dmiss
ion
phon
e
•En
hanc
e co
mm
unic
atio
n to
impr
ove
patie
nt sa
fety
Refe
renc
es
Anto
noff,
M.,
Berd
an, E
., Ki
rchn
er, V
., Kr
osch
, T.,
Holle
y, C.
, Mad
daus
, M.,
et a
l. (2
013)
. Who
’s co
verin
g ou
r
love
d on
es?:
Sur
prisi
ng b
arrie
rs in
the
sign-
out p
roce
ss. T
he A
mer
ican
Jour
nal o
f Sur
gery
, 205
, 77-
84.
Aror
a, V
. & Jo
hnso
n, J.
(200
6). A
mod
el fo
r bui
ldin
g a
stan
dard
ized
hand
-off
prot
ocol
. Jou
rnal
on
Qua
lity
and
Pat
ient
Saf
ety,
32,
646
-655
. Cl
ark,
C.,
Sind
ell S
., &
Koe
hler
, R. (
2010
). Te
mpl
ate
for s
ucce
ss: U
sing
a re
siden
t-de
signe
d sig
n-ou
t tem
plat
e
in
the
hand
over
of p
atie
nt ca
re. J
ourn
al o
f Sur
gica
l Edu
catio
n, 6
8, 5
2-57
. Cr
aig,
S.,
Smith
, H.,
Dow
nen,
A.,
& Y
ost,
J. (2
012)
. Eva
luat
ion
of p
atie
nt h
and-
off m
etho
ds o
n an
inpa
tient
teac
hing
serv
ice.
The
Och
sner
Jour
nal,
12, 3
31-3
37.
Helm
s, A
., Pe
rez,
T., B
altz
, J.,
Dono
witz
, G.,
Hoke
, G.,
Bass
, E.,
et a
l. (2
011)
. Use
of a
n ap
prec
iativ
e in
quiry
a
ppro
ach
to im
prov
e re
siden
t sig
n-ou
t in
an e
ra o
f mul
tiple
shift
cha
nges
. Jou
rnal
of G
ener
al In
tern
al
M
edic
ine,
27,
287
-291
. Ke
ssle
r, C.
, Sha
keel
, F.,
Harn
, G.,
Jone
s, J.
, Com
es, J
., Ku
lstad
, C.,
et a
l. (2
013)
. A su
rvey
of h
and-
off p
ract
ices
in e
mer
genc
y m
edic
ine.
Am
eric
an Jo
urna
l of M
edic
al Q
ualit
y, 2
9, 1
-7.
Barr
iers
and
Lim
itatio
ns
•Ad
optio
n of
pro
cess
by
all a
dmitt
ing
disc
iplin
es
•Em
ploy
ed v
s. n
on-e
mpl
oyed
phy
sicia
n bu
y-in
•Pe
rcei
ved
burd
en b
y/on
the
surg
ical
phy
sicia
ns
•In
abili
ty to
fully
cap
ture
all
adm
issio
ns
Resu
lts
Conc
lusi
ons a
nd F
utur
e Di
rect
ions
Th
e lit
erat
ure
has
show
n th
at t
here
is
a pa
ram
ount
im
port
ance
to
prop
er p
hysic
ian
to p
hysic
ian
hand
-off
(Aro
ra &
Joh
nson
, 20
06;
Clar
k, S
inde
ll, &
Koe
hler
, 20
11; K
essle
r et a
l., 2
013)
. By
stre
amlin
ing
the
proc
ess
and
ensu
ring
that
ad
mitt
ing
resid
ents
ar
e ea
sily
acce
ssib
le,
ther
e sh
ould
be
mor
e en
cour
agem
ent
to
hand
-off
patie
nts w
hen
tran
sfer
ring
or a
dmitt
ing
them
to
the
pedi
atric
floo
r. O
ur d
ata
indi
cate
d an
impr
oved
nu
mbe
r of
han
d-of
fs fr
om th
e su
bspe
cial
ists
alth
ough
th
e us
e th
e ne
w p
hone
was
lim
ited
sugg
estin
g a
halo
ef
fect
of t
he p
roje
ct.
The
surg
ical
team
s ho
wev
er d
id
not
adop
t th
e pr
oces
s.
Futu
re s
teps
will
see
k to
fu
rthe
r eng
age
the
surg
eons
and
mor
e sp
ecifi
cally
the
non-
empl
oyed
sur
gica
l sub
spec
ialis
ts, i
n th
e ha
nd-o
ff pr
oces
s .
How
Sim
ple
Tech
nolo
gy C
an
Impr
ove
Phys
icia
n to
Phy
sici
an
Patie
nt H
and-
off
Mic
hael
Pol
laro
DO
, Ala
n M
eltz
er M
D FA
AP, K
iley
Alpe
rt C
-TAG
ME
Gory
eb C
hild
ren’
s Hos
pita
l-Atla
ntic
Hea
lth S
yste
m
Mor
risto
wn
NJ
M
etho
ds
A te
am c
ompr
ised
of m
embe
rs o
f th
e pe
diat
ric a
nd
gene
ral
pedi
atric
sur
gica
l se
rvic
es w
as f
orm
ed.
A ne
w
com
mun
icat
ion
tool
was
intr
oduc
ed, a
por
tabl
e te
leph
one
to b
e ca
rrie
d by
the
adm
ittin
g pe
diat
ric re
siden
t 24
hour
s a
day,
seve
n da
ys
a w
eek.
O
nce
the
new
po
rtab
le
tele
phon
e w
as o
btai
ned,
ins
truc
tions
, bo
th v
erba
l an
d w
ritte
n, w
ere
prov
ided
to a
ll di
scip
lines
that
adm
it to
the
inpa
tient
uni
t (i.
e., E
R, s
urgi
cal t
eam
s, s
ubsp
ecia
lists
and
ou
tpat
ient
gen
eral
ped
iatr
icia
ns).
Data
was
col
lect
ed fo
r a
six-w
eek
perio
d ex
amin
ing
hand
-off
rate
for
ped
iatr
ic
inpa
tient
ad
miss
ions
. Af
ter
the
initi
al
six-w
eek
data
co
llect
ion,
re
sults
w
ere
anal
yzed
an
d a
seco
nd
inte
rven
tion,
a fe
edba
ck se
ssio
n w
ith th
e ge
nera
l ped
iatr
ic
surg
ical
team
was
per
form
ed. D
ata
was
then
col
lect
ed fo
r an
add
ition
al si
x w
eek
perio
d.
17 of 131
Team: Aurora Health Care Focus Area: Patient Safety
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions,
stakeholders, etc.; Teams should identify members
and define responsibility/purpose)
AIM: To pilot an approach/model that integrates and aligns AHC priorities (Quality & Safety) its existing committees/groups (Quality Committee/Council, CPC) and metrics with ACGME requirements (CLER, Common Requirements) OBJECTIVES
1. Create a Steering Committee responsible for overall project framing and achievement of project aim and objectives.
2. Design the model to integrate key elements including a. Utilize evidence-based approach b. Address Triple Health Care + AHC, Hospital priorities and
Accreditation (ACGME-Common Requirements, Milestones and CLER) requirements
3. Obtain buy in and commitment regarding the model and implementation in additional programs from Resident Council and GMEC
4. Actively engage residents and faculty in 3 programs to pilot the model in Interdisciplinary team approach
5. Disseminate results internally and broadly in peer reviewed scholarly forums.
ACTION PLAN SYNOPSIS: To engage resident council (and thereby residents and programs) in culture change focused on Patient Safety and Quality resulting in curriculum standardization that maximizes resident/fellow engagement. Commission the Resident Council members to engage their peer groups and increase awareness of existing measures in place. Charge three teams to implement a residency program specific safety/quality project using systematic process.
II. Project Description
RESIDENT COUNCIL The resident council is charged with defining and standardizing methodology by which we engage residents in our system. The council will be engaged in resident driven dissemination of data to all residents and will be added trigger for program specific improvement projects and overall GME system change NI-IV TEAMS: Residents/Fellows and faculty from 3 participating programs (FM, Medicine, Ob/Gyn) will be active members their residency’s team. Each team will perform a systematic needs assessment to identify potential project foci, identify project based on its alignment with AHC/Hospital/Clinical quality/safety priorities and ACGME standards and requirements. Project work will include identification of education gaps, opportunities for workplace learning, continuous evaluation based on participant evaluations and care management metrics. Team members will co-author abstract of internal/external dissemination highlighting methodology and key findings to meet, as appropriate, their scholarly project requirements. Each program will utilize proven approaches and tools (e.g., checklists) to address target patient safety and related CLER focal areas (e.g., error reporting, professionalism, transitions in care, quality improvement). Teams will have junior and senior residents, senior faculty, a non-physician health
18 of 131
professional, a quality/safety/operations resource, and education resource. Active involvement of our senior medical education leaders, patient safety, and chief clinical officers will provide content and process expertise to support project initiatives and align with other CLER focus areas for maximal impact.
III. Necessary Resources (staff, finances, etc.)
1. Personnel: Program specific team members, Resident Council, GME C, Academic Affairs and Quality/Safety Leadership in targeted specialty programs, IT/EPIC programmers, consultants as needed.
2. Educational Resources aligned with special project (e.g., IHI modules, GME shared noon conference opportunities).
3. Data: AHC & Hospital Safety Priorities and Metrics, ACGME Faculty/Resident Data
4. Travel: Stipends and time away for team members to attend NI IV meetings
5. Communication: Engage Educational & Quality Leaders to assure continuous, multi-method communication strategies are used to disseminate plans and progress throughout the GME programs, quality/safety leaders, and staff/caregivers.
IV. Measurement/Data Collection Plan
(must partner/match with Milestone Markers)
• AHC Metrics collected through Quality/Safety Committees, NI IV Project Teams, Triple Aims, etc. Steering Committee will review and evaluate progress.
• DIO assessment • ACGME and AHC GME Annual Resident Survey results related to Patient Safety
and QI • Perceptions of GMEC, Faculty, Residents and C-Suite
V. Communication Plan (may be helpful to draft a
flow chart of team members & senior management, both
internal & external)
• Resident Driven Communication – Resident Council members to engage and distribute information discussed to peers at monthly resident program meetings.
• NI IV Steering Committee – communicate with C-Suite, Academic Affairs leadership, GMEC, AHC Quality committee members and NI IV Program Charter teams.
• NI IV Program Teams – communicate with faculty, other program personnel, clinic staff, etc. goals of NI IV Charter projects and CLER focus areas.
• Residents and NI IV Program Teams will communicate results and feedback to the NI IV Steering Committee.
VI. Accountability
(list of team members and who
is accountable for what)
• NI IV STEERING COMMITTEE / C-SUITE: Strategic planning, finance and resources, holding resident council and specialty teams accountable for meeting timelines and completing tasks.
• RESIDENT COUNCIL & THEIR NI IV SUBCOMMITTEE: Reviewing data from quality/safety metrics and generating strategies for resident buy and accountability for improvement. Screening, identifying required IHI and assuring that modules are completed by all GME trainees. Monitor progress on NI IV 3 program teams and seek to generalize model to other programs. Co-design and teach as appropriate in the shared noon conferences and secure resident/fellow attendance. Responsible for providing updates to/from their residency/fellow programs on quality/safety data and NI IV initiatives related to CLER.
19 of 131
• NI IV Program Teams: Attend regularly scheduled AHC Wide NI IV Program Team Meetings to share best practices, barriers and solution strategies across programs. Individual teams are responsible for identification of QI/Safety project that is aligned with AHC priorities using establishing metrics, CLER and RRC specific requirements for quality and safety y curriculum and scholarly activities. Systematically design, implement and evaluate project impact consistent with their RRC requirements for scholarly
VI. Accountability (cont)
activities. Identify curriculum gaps associated with their project and provide education as appropriate to all program residents/faculty. Present their findings in AHC forums (e.g., Resident Council, GMEC, Scientific Day).
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc.)
• Culture change including recognition that quality/safety is truly a team accountability (e.g., willing to question senior faculty)
• Residents/Faculty/Caregivers Perceptions: Apparent lack of interest, time, not a priority among other duties, lack of support
• Project Management: Multiple moving parts to our model (e.g., Resident council, noon shared conferences, 3 different program teams) may be difficult to track and monitor progress; keep projects aligned with AHC priorities and CLER focus areas.
• Limited ability of participants to recognize what you don’t know – attribute problems to others (I always wash my hands; recognition that there is a literature on effective quality/safety to drawn upon).
VIII. Markers (project phases, progress
checks, schedule, etc.; must partner/match
measurement/data collection plan)
• Steering Committee has established a timeline by task grid that was presented to Resident Council for review and revision and then finalized by the AHC NI IV Program Teams. Steering committee and residency council will monitor progress with NI IV/AHC DIO Leader assuming ultimately responsible (i.e., Dr. Stearns).
• All teams have been formed per the timeline and will identify specific project foci by January 1, 2013.
• Steering Committee will design and circulate drafts of program team evaluation tools for finalization and manage data collection, analysis and reporting. Additional data collection will be tasked to each program as they will utilize established AHC metrics for quality/safety as baseline and post project evaluation.
IX. Vision Statement/Closing Plan
(markers of success by March 2015)
At the conclusion of the project, we will have demonstrated the impact of a sustainable 2-component model (Resident Council and Program Specific NI IV Teams) for engaging residents/faculty in quality improvement initiatives, aligned with AHC priorities, CLER and RRC requirements (e.g., curriculum in quality/safety, scholarly activity) to continuously improve our clinical learning environment and assure high quality/safe care for our patients.
20 of 131
X. Success Factors (The most successful
component of our work was; We were inspired by…)
SUCCESS FACTORS PER RESIDENT LEADERS • Active participation by dedicated Interdisciplinary/interprofessional working
groups and providers around specific projects related to quality/safety. Residents report seeing increased provider quality/safety awareness and behavior changes, targeted improvements in patient care, and a “culture change” among residents and staff.
• Ongoing, regular meetings and communication with other professionals. • Recognition about just “How terrifying the safety issue is” along with the need
and ability to identify projects related to specific problems. • Project(s) selected revolved around a common theme/area so that the work
can continue to evolve and benefit patients beyond the duration of any one resident.
• Framework and resources at AHC to support scholarship. XI. Barriers
(The largest barrier we encountered was; We
worked to overcome this by…)
BARRIERS PER RESIDENT LEADERS • Logistics: Getting everyone at same meeting (competing schedules, duty
hours). • EMR: Variability in provider EMR training and competence; limited options for
modifying EMR; multiple and distinct EMR views impacting communication between providers (e.g., RN, Physicians, Pharmacists); difficulty obtaining/accessing EMR data for PDSA rapid cycle improvement.
• Communication: Recognition that communication between providers and staff essential in change process; quickly revised strategy to routinely hold interdisciplinary meetings
• Accountability: Limited accountability if providers choose not to participate; importance of sustained faculty champion(s)
XII. Lessons Learned (The single most important piece of advice to provide
another team embarking on a similar initiative would
be…)
LESSONS LEARNER PER RESIDENT LEADERS • Begin change with yourself; look only at what you can change (focus on the
system process); pilot work with a small engaged group (those with vested interest) before full roll out.
• Have an open mind, persistence and patience when working on an improvement project: o Must understand the difficulties that each caregiver may see in certain
situations and how different the approach might be; o Seek to incorporate all perspectives to yield collaborative final product as
only then will the idea can translate into something that can be applied in the real life patient care situations;
o Understand that assigning team member roles help in the achieving final goals; and
o Be persistent: do not give up, no matter how daunting the project may seem.
• Leadership & Participation: Have a leader and hold frequent, regularly scheduled meetings to ensure meetings yield results and goals are met. o Program director and associate faculty vital to project success. o Must have all key players, departments, disciplines actively involved and
recognized for their involvement to ensure continued dedication. • Never doubt that a small group of thoughtful committed citizens can change
the world; indeed, it's the only thing that ever has." - Margaret Mead XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish?
21 of 131
1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction
On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI III (presume mean NI IV) work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact What changes have you observed in your residency program(s), or at your institution, based upon your work? • L&D Checklists: Tremendous change in the culture and relationships among
L&D caregivers and providers. Improvement in quality of care via checklists and associated smart phrases to standardize care.
• Medication Reconciliation: Increased awareness from all providers regarding importance of having correct medical lists and importance of med-rec work flow has resulted in improved accuracy. Emphasis on medication reconciliation in our clinics by MA/residents and MAs is more uniform: each medication is reviewed compared to the faster alternative of asking "any changes to your medication list." We have carved out specific times to present at monthly resident/faculty meetings and all clinic meetings in order to reinforce the progress that we have made.
• 30-Day Readmission: Awareness of the issue/changes in the discharge process. Earlier mobilization of resources in challenging patients. Increased ability of residents to identify patients at risk.
XVI. Next Steps Describe next steps for your project, including plans for sustaining and spreading the changes made. • L&D CHECKLISTS: To continue applications and improvement in current patient
safety projects to standardize care and improve outcomes by: (1) Educating new upcoming residents and staff into the work flow; (2) Involving medical students into our daily workflow, safety groups, and projects.
• MEDICATION RECONCILIATION: (1) Continue to reinforce steps taken/education already provided through Med Rec discussions at each clinic team meeting. (2) Finalize a "staffing list" for use by attending physicians to ensure that medications and other patient safety metrics are reviewed; (3) Expand our team to include current PGY1 so that we have continuity moving forward next year.
• 30-DAY READMISSION: (1) Complete chart audit and calibrate risk assessment tools to increase accuracy (LACE) followed by implementation of evidence-based interventions in identified high risk patients; (2) Continue early and on-going engagement of our multi-disciplinary work group including program directors/faculty while adding junior physicians (interns, medical students) to help carry on project goals; (3) Reassess project goals to assure alignment with health care system goals/processes.
22 of 131
Ove
rall
Goa
l/Ab
stra
ct
AIM
: To
pilo
t an
appr
oach
/mod
el th
at in
tegr
ates
and
alig
ns A
HC p
riorit
ies (
Qua
lity
&
Safe
ty) i
ts e
xist
ing
com
mitt
ees/
grou
ps (Q
ualit
y Co
mm
ittee
/Cou
ncil,
CPC
) and
met
rics w
ith
ACGM
E re
quire
men
ts (C
LER,
Com
mon
Req
uire
men
ts)
OBJ
ECTI
VES
1.
Crea
te a
Ste
erin
g Co
mm
ittee
resp
onsib
le fo
r ove
rall
proj
ect f
ram
ing
and
achi
evem
ent o
f pr
ojec
t aim
and
obj
ectiv
es.
2.
Desig
n th
e m
odel
to in
tegr
ate
key
elem
ents
incl
udin
g a.
Util
ize e
vide
nce-
base
d ap
proa
ch
b. A
ddre
ss T
riple
Hea
lth C
are
+ AH
C, H
ospi
tal p
riorit
ies
and
Accr
edita
tion
(ACG
ME-
Com
mon
Req
uire
men
ts, M
ilest
ones
and
CLE
R) re
quire
men
ts
3.
Obt
ain
buy
in a
nd c
omm
itmen
t reg
ardi
ng th
e m
odel
and
impl
emen
tatio
n in
add
ition
al
prog
ram
s fro
m R
esid
ent C
ounc
il an
d GM
EC
4.
Activ
ely
enga
ge re
siden
ts a
nd fa
culty
in
3 pr
ogra
ms t
o pi
lot t
he m
odel
in
Inte
rdisc
iplin
ary
team
app
roac
h 5.
Di
ssem
inat
e re
sults
inte
rnal
ly a
nd b
road
ly in
pee
r rev
iew
ed s
chol
arly
foru
ms.
Crea
ting
a Cu
lture
of Q
ualit
y &
Saf
ety
at
Auro
ra H
ealth
Car
e
Back
grou
nd: M
ulti-
Pron
ged
Stra
tegy
TH
REE
RESI
DEN
CY P
ROG
RAM
QUA
LITY
/SAF
ETY
PRO
JECT
S •
Fam
ily M
edic
ine,
Inte
rnal
Med
icin
e, O
b/Gy
n
•Cr
eate
a w
ork
team
that
incl
udes
: res
iden
ts (s
enio
r as l
eade
rs; j
unio
rs fo
r sus
tain
abili
ty) ,
a
seni
or fa
culty
mem
ber i
n th
e pr
ogra
m, a
non
-phy
sicia
n he
alth
pro
fess
iona
l, a
qual
ity/s
afet
y/op
erat
ions
reso
urce
, and
edu
catio
n re
sour
ce
•Ap
poin
t res
iden
t lea
der t
o se
rve
on N
I-IV
Stee
ring
Com
mitt
ee a
nd re
pres
ent p
rogr
am a
t N
I-IV
mee
tings
/act
iviti
es
•Ap
ply
syst
emat
ic P
DSA
proc
ess a
nd re
port
find
ings
ENG
AGE
RESI
DEN
CY C
OU
NCI
L
•Foc
us o
n cu
rric
ulum
stan
dard
izatio
n ac
ross
pro
gram
s to
max
imize
s res
iden
t/fe
llow
en
gage
men
t •R
C m
embe
rs c
omm
unic
ate
and
enga
ge re
siden
ts &
pro
gram
s in
cul
ture
cha
nge
focu
sed
on
Patie
nt S
afet
y an
d Q
ualit
y
•RC
Mem
bers
serv
e as
trig
gers
and
acc
ount
able
for p
rogr
am sp
ecifi
c im
prov
emen
t pro
ject
s an
d ov
eral
l GM
E sy
stem
cha
nge
Visi
on S
tate
men
t VI
SIO
N:
O
ur re
siden
cy p
rogr
ams w
ill b
e m
odel
s for
a
QUA
LITY
AN
D SA
FETY
CU
LTU
RE th
at a
ligns
with
our
he
alth
car
e sy
stem
prio
ritie
s to
plac
e th
e pa
tient
’s he
alth
and
wel
l bei
ng fi
rst a
nd fo
rem
ost.
G
UID
ING
PRI
NCI
PLES
•
Educ
atio
nal i
nitia
tives
will
be
focu
s on:
o
Qua
lity
and
safe
ty p
rinci
ples
o
Delib
erat
e Pr
actic
e ap
plyi
ng p
rinci
ples
to
addr
ess q
ualit
y/sa
fety
gap
s
•Q
ualit
y an
d Sa
fety
pro
ject
s will
be
data
driv
en,
alig
ned
with
pat
ient
nee
ds a
nd h
ealth
car
e sy
stem
pr
iorit
ies,
and
sust
aina
ble
•M
undh
I, S
en L
, Eve
n L
et a
l. U
tiliz
ing
Resid
ent C
ounc
il Le
ader
s to
Impr
ove
Cultu
re o
f Pat
ient
Car
e. A
IAM
C An
nual
Mee
ting.
San
Di
ego,
CA.
Mar
ch 2
7-29
, 201
4.
•Si
mps
on D
, Kno
x K
, Ste
arns
J, B
abus
ukum
ar U
et a
l. C
apita
lizin
g on
Syn
ergi
es in
Qua
lity
and
Safe
ty U
sing
Accr
edita
tion
Stan
dard
s to
Con
nect
the
Dots
. AAM
C In
tegr
atin
g Q
ualit
y An
nual
Mee
ting.
Ros
emon
t, IL
. Jun
e 12
-13,
201
4. A
vaila
ble
on A
AMC
iCol
lobo
rativ
e
•Se
n L,
Sha
nitk
vich
A, S
alvo
N, C
icer
o AK
, et a
l. Ho
w to
ass
ign
role
s on
a te
achi
ng s
ervi
ce.
Amer
ican
Colle
ge o
f Obs
tetr
ics &
Gy
neco
logy
201
4 Di
stric
ts V
I, VI
II, IX
Ann
ual M
eetin
g. N
apa,
CA.
Sep
t 5-7
, 201
4 •
Cain
M, M
undh
I, V
ulca
no J,
et a
l. O
btai
ning
Pat
ient
’s Pe
rspe
ctiv
e on
30-
Day
Read
mit
is an
Exp
onen
tial W
in-W
in.
AAM
C An
nual
M
eetin
g - I
nnov
atio
ns in
Aca
dem
ic M
edic
ine.
Chi
cago
, IL
Nov
8-9
, 201
4
•LO
GIS
TICS
: G
ettin
g ev
eryo
ne a
t sam
e m
eetin
g (c
ompe
ting
sche
dule
s, d
uty
hour
s)
•EM
R: V
aria
bilit
y in
pro
vide
r EM
R tr
aini
ng a
nd co
mpe
tenc
e; li
mite
d op
tions
for m
odify
ing
EMR;
mul
tiple
and
dist
inct
EM
R vi
ews/
com
mun
icat
ion
by p
rovi
der (
e.g.
, RN
, Phy
sicia
ns,
Phar
mac
ists)
; diff
icul
ty o
btai
ning
/acc
essin
g EM
R da
ta fo
r PDS
A ra
pid
cycl
e im
prov
emen
t •
COM
MU
NIC
ATIO
N: R
ecog
nitio
n th
at c
omm
unic
atio
n be
twee
n pr
ovid
ers a
nd st
aff e
ssen
tial i
n ch
ange
pro
cess
; qui
ckly
revi
sed
stra
tegy
to ro
utin
ely
hold
inte
rdisc
iplin
ary
mee
tings
•
ACCO
UN
TABI
LITY
: Li
mite
d ac
coun
tabi
lity
if pr
ovid
ers c
hoos
e no
t to
part
icip
ate;
impo
rtan
ce o
f su
stai
ned
facu
lty c
ham
pion
(s)
•CU
LTU
RE C
HAN
GE:
Res
iden
ts &
Fac
ulty
now
aw
are
of re
quire
men
ts fo
r qua
lity/
safe
ty b
ut
enga
gem
ent i
n te
ams/
com
mitt
ees
to in
itiat
e qu
ality
/saf
ety
an a
rea
for a
dditi
onal
wor
k
Resu
lts (d
ata
gath
ered
bot
h qu
ant &
qua
l.)
Conc
lusi
ons &
Nex
t Ste
ps
THRE
E RE
SIDE
NCY
PRO
GRA
M Q
UALI
TY/S
AFET
Y PR
OJE
CTS
1.Fa
mily
Med
icin
e~M
edic
atio
n Re
conc
iliat
ion
•
Incr
ease
d aw
aren
ess f
rom
all
prov
ider
s reg
ardi
ng im
port
ance
of h
avin
g co
rrec
t med
ical
lis
ts a
nd im
port
ance
of m
ed-r
ec w
ork
flow
has
resu
lted
in im
prov
ed a
ccur
acy.
•
NEX
T: Co
ntin
ue c
urre
nt sa
fety
pro
ject
s to
stan
dard
ize c
are/
impr
ove
outc
omes
by:
o
Rein
forc
e w
orkf
low
thro
ugh
Med
Rec
disc
ussio
ns a
t eac
h cl
inic
team
mee
ting
oFi
naliz
e a
"sta
ffing
list
" for
use
by
atte
ndin
g ph
ysic
ians
to
ensu
re th
at m
edic
atio
ns
and
othe
r pat
ient
safe
ty m
etric
s are
revi
ewed
o
Expa
nd te
am to
incl
ude
curr
ent P
GY1
con
tinui
ty m
ovin
g fo
rwar
d ne
xt y
ear
2.M
edic
ine~
30-D
ay R
ead m
issi
on:
•Aw
aren
ess o
f the
issu
e/ch
ange
s in
the
disc
harg
e pr
oces
s/ea
rlier
mob
iliza
tion
of
reso
urce
s in
chal
leng
ing
patie
nts/
incr
ease
d ab
ility
of r
esid
ents
to id
entif
y pa
tient
s at r
isk
•N
EXT:
Cont
inue
read
miss
ion
focu
s shi
ftin
g to
evi
denc
e dr
iven
inte
rven
tions
to
read
mits
o
Com
plet
e ch
art a
udit
and
calib
rate
risk
ass
essm
ent t
ools
to in
crea
se a
ccur
acy
(LAC
E)
oIm
plem
ent i
nter
vent
ions
in id
entif
ied
high
risk
pat
ient
s;
oCo
ntin
ue e
arly
and
on-
goin
g m
ulti-
disc
iplin
ary
wor
k gr
oup
incl
udin
g pr
ogra
m
dire
ctor
s/fa
culty
and
add
juni
or p
hysic
ians
(int
erns
, med
ical
stud
ents
) o
Reas
sess
pro
ject
goa
ls to
ass
ure
cont
inue
d a
lignm
ent w
ith h
ealth
car
e sy
stem
goa
ls
3.O
b/GY
N ~
L&D
Che
cklis
ts:
•Tr
emen
dous
cha
nge
in th
e cu
lture
and
rela
tions
hips
am
ong
L&
D ca
regi
ver &
pro
vide
rs
•Im
prov
ed c
are
qual
ity v
ia c
heck
lists
& sm
art p
hras
es c
reat
ed to
stan
dard
ize c
are
•
NEX
T: Co
ntin
ue c
urre
nt sa
fety
pro
ject
s to
stan
dard
ize c
are/
impr
ove
outc
omes
by
o
Educ
ate
new
upc
omin
g re
siden
ts a
nd st
aff i
nto
the
wor
k flo
w
oIn
volv
e m
edic
al st
uden
ts in
to o
ur d
aily
wor
kflo
w, sa
fety
gro
ups,
and
pro
ject
s.
RESI
DEN
CY C
OU
NCI
L •
NEX
T: Su
stai
n cu
rren
t rol
es a
nd re
spon
sibili
ties a
s lea
ders
hip
tran
sitio
ns
oRe
vise
cha
rter
and
seek
pro
tect
ed ti
me
for r
esid
ent Q
/S le
ader
ship
role
s o
IHI C
urric
ulum
and
shar
ed n
oon
conf
eren
ce a
s for
um fo
r app
licat
ion
Q/S
prin
cipl
es
oSu
ppor
t NI-V
initi
ativ
e
ALL
NI-I
V: I
nter
nal /
Exte
rnal
Diss
emin
atio
n of
our
impr
ovin
g ca
re “
succ
ess
stor
ies”
Succ
ess F
acto
rs &
Les
sons
Lea
rned
THRE
E RE
SIDE
NCY
PRO
GRA
M Q
UALI
TY/S
AFET
Y PR
OJE
CTS
1. F
amily
Med
icin
e –
Med
icat
ion
Reco
ncili
atio
n in
Prim
ary
Care
Clin
ics
•Fi
shbo
ne a
naly
sis to
iden
tity
and
prio
ritize
cont
ribut
ing
fact
ors t
o er
rors
in M
ed R
ec
•Fo
cus o
n ac
cura
te u
tiliza
tion
of E
HR/E
PIC
feat
ures
by
all p
rovi
ders
•
Crea
tion
of M
ed R
ec P
rovi
der W
orkf
low
•
(Re)
Trai
ning
and
Pre
-Pos
t Qui
z re:
EPI
C an
d W
orkf
low
2.
Inte
rnal
Med
icin
e -
30 d
ay R
eadm
issi
ons
•Li
tera
ture
revi
ew to
iden
tify
and
sele
ct re
adm
issio
n ris
k to
ol (L
ACE)
: RCA
tool
for
read
mitt
ed p
atie
nts ;
Pat
ient
Per
spec
tive
Que
stio
nnai
re (P
PQ)
•Es
tabl
ish W
orkf
low,
dev
elop
trai
ning
mat
eria
ls, tr
aini
ng fo
r tea
m m
embe
rs
•M
id-p
roje
ct su
rvey
rega
rdin
g to
ol u
tiliza
tion
and
perc
eptio
n of
impa
ct +
cha
rt a
udit
3. O
b/Gy
n –
Ope
rativ
e Ch
eckl
ists
in L
&D
•Li
tera
ture
revi
ew to
iden
tify
and
sele
ct c
heck
lists
ass
ocia
ted
with
qua
lity
care
gap
s •
Delin
eate
team
mem
ber r
oles
and
wor
kflo
w
•Tr
aini
ng fa
culty
, res
iden
ts, a
nd st
uden
ts
RESI
DEN
CY C
OU
NCI
L
•De
fine
Resid
ency
Cou
ncil
role
s rel
ated
to Q
ualit
y/Sa
fety
•
Curr
icul
um: R
evie
w IH
I Mod
ules
to id
entif
y co
re re
quire
men
ts fo
r all
inco
min
g re
siden
ts
oRe
com
men
d Sh
ared
Noo
n Co
nfer
ence
s (a
com
mon
core
cur
ricul
um se
ssio
n fo
r all
resid
ents
/fel
low
s) b
e st
ruct
ured
to re
quire
app
licat
ion
of p
rinci
ples
THRE
E RES
IDEN
CY P
ROG
RAM
QUA
LITY
/SAF
ETY
PRO
JECT
S 1.
All p
rogr
ams h
ave
com
plet
ed >
1 P
DSA
proj
ect c
ycle
2.
All t
eam
s hav
e di
ssem
inat
ed re
sults
: 2 L
ocal
Pos
ters
; 2 S
tate
/Nat
iona
l Pla
tform
s ; 9
St
ate/
Nat
iona
l Pos
ter;
2 AI
AMC
“Pos
ter S
lam
” Aw
ards
Pla
tform
pre
sent
atio
ns
RESI
DEN
CY C
OU
NCI
L 1.
Esta
blish
ed a
Cha
rter
with
role
s/re
spon
sibili
ties f
or Q
&S
– ap
prov
ed b
y GM
EC
2.GM
EC a
ppro
ved
Resid
ency
Cou
ncil
reco
mm
ende
d re
quire
men
t: Re
siden
ts a
nd fa
culty
co
mpl
ete
5 IH
I mod
ules
3.
Co-s
pons
or G
MEC
wid
e Sh
ared
Noo
n Co
nfer
ence
– u
sing
Hand
Hyg
iene
as r
equi
red
qu
ality
/saf
ety
appl
icat
ion
proj
ect;
RC re
ps a
re a
ccou
ntab
le fo
r pro
gram
par
ticip
atio
n .
SUCC
ESS F
ACTO
RS
•RE
COG
NIT
ION
“How
terr
ifyin
g th
e sa
fety
issu
e is”
and
the
abili
ty to
iden
tify
proj
ects
re
late
d to
spec
ific
prob
lem
s in
our f
ield
of w
ork.
•
TEAM
WO
RK: A
ctiv
e pa
rtic
ipat
ion
and
invo
lvem
ent
by d
edic
ated
inte
rpro
fess
iona
l pr
ovid
ers o
n al
l pro
ject
s (m
edic
al st
uden
ts, r
esid
ents
, nur
ses,
pha
rmac
ists)
•
STRU
CTU
RE: O
ngoi
ng, r
egul
ar m
eetin
gs a
nd co
mm
unic
atio
n w
ith o
ther
pro
fess
iona
ls
•PR
OJE
CT(S
) sel
ectio
n ar
ound
a c
omm
on th
eme/
area
so th
at t
he w
ork
can
cont
inue
to
evol
ve a
nd b
enef
it pa
tient
s be
yond
the
dura
tion
of a
ny o
ne re
siden
t LE
SSO
NS L
EARN
ED
•Be
gin
chan
ge w
ith y
ours
elf;
look
onl
y at
wha
t you
can
chan
ge (f
ocus
on
the
syst
em/p
roce
ss );
pilo
t wor
k w
ith a
smal
l eng
aged
gro
up b
efor
e fu
ll ro
ll ou
t •
Have
an
open
min
d, co
mbi
ne p
atie
nce
and
pers
isten
ce
•Le
ader
ship
& P
artic
ipat
ion:
Hav
e a
lead
er a
nd h
old
freq
uent
, reg
ular
ly sc
hedu
led
mee
tings
to e
nsur
e go
als a
re m
et a
nd m
eetin
gs y
ield
resu
lts.
•M
ust h
ave
all k
ey p
laye
rs, d
epar
tmen
ts, d
iscip
lines
act
ivel
y in
volv
ed a
nd re
cogn
ized
Mat
eria
ls/M
etho
ds
Barr
iers
Enc
ount
ered
/Lim
itatio
ns
Lora
s Eve
n DO
, Lili
a Se
n M
D, In
derv
ir M
undh
MD,
Deb
orah
Sim
pson
, PhD
, Tan
ya M
artin
ez, J
effr
ey A
. Ste
arns
, MD,
And
y An
ders
on, M
D Au
rora
Hea
lth C
are
- M
ilwau
kee,
Wisc
onsin
Resu
lts
Bibl
iogr
aphy
23 of 131
Team: Bassett Medical Center Focus Area: Transitions in Care
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
Our goal was to develop a standardized hand-off tool within the electronic medical record for the medical and surgical residency hospital teams. Prior to the project, each of the residency teams had handoff tools that were not HIPAA compliant, that existed outside of the medical record, that were not retrievable and available for quality Improvement, and that were not available to other members of the hospital care teams. We convened a Steering Committee composed of senior administrative leadership in QI/Safety, IT, and Medical Education in order to support the residents and program directors in development of standardized hand off tools to be contained in the EMR. The residents and program directors were the front line developers of the tools and the Steering Committee provided support.
II. Project Description
The Steering Committee met monthly. The residents in Medicine and Surgery met between meetings to develop the tools, using rapid cycle improvement techniques to modify the handoff tools. The resident and program directors met monthly with the Steering Committee with progress reports and requested support where needed.
III. Necessary Resources (staff, finances, etc.)
IT leadership was the most critical support, given the necessity of working with the Epic software.
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
After the tool was developed, the plan was to measure adherence with its use by the residents and its use by faculty and residents as a teaching tool. Secondary goals were to measure the satisfaction with the handoff tool as a communication method by residents and other members of the care teams.
V. Communication Plan (may be helpful to draft a flow chart of
team members & senior management, both internal & external)
Monthly or bimonthly meetings of the Steering Committee with meetings by the residents between. Effort was expected by both Medicine and Surgery teams to develop a tool that worked for them and to incorporate parts of the other’s.
VI. Accountability (list of team members and who
is accountable for what)
Residents and their program directors would report at each Steering committee meeting their progress. Administrative and educational leaders would provide support wherever needed.
24 of 131
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
Time is always a concern, for all members of the team. The residents found it difficult to meet with members of the other resident team with any frequency. Perhaps the biggest challenge was the difference in needs and expectations that faced the Medicine and Surgery resident teams. The handoffs of the Medicine team were all for primary inpatient responsibility, while the handoffs for the Surgery team were both primary inpatient responsibility and consultation – the electronic record made this latter group more difficult to track. The EHR also presented other technical barriers that were not easy to overcome.
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
We set timeline goals in the beginning of the project that had to be modified because of the inability of Epic to modify their software except in a yearly “version” update for some important requirements. We therefore had to extend our timeline beyond the original plan.
IX. Vision Statement/Closing Plan (markers of success by March 2015)
In March of 2015, the Medicine and Surgery residents will have standardized handoff tools that are part of the electronic health record and it will be the expectation that these are used exclusively as the written communication tool at handoff. These will be supplemented by a verbal handoff. The faculty and program directors in each program will be aware of the handoff tools. There will be faculty development around the learning of high quality handoffs.
X. Success Factors The most successful component of our work was the development and implementation of the tools, though still somewhat clumsy for technical reasons and still without 100% adherence. We were inspired by the hard work of the residents in the development process.
XI. Barriers The largest barrier we encountered was the inability of Epic to accommodate the needs of the residents in several areas that would have made the use of the tools less clumsy. We will overcome most of these problems with the next iteration of Epic and have provided feedback to them through our Chief Medical Information Officer, who serves on the Steering Committee.
25 of 131
XII. Lessons Learned The single most important piece of advice to provide another team embarking on a similar initiative would be to spend enough time in the beginning to understand what the needs and requirements are of your care teams that will be developing the transition tools. We did so, but it was an ongoing process and collided with our IT tools in several areas.
XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI III work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact What changes have you observed in your residency program(s), or at your institution, based upon your work? The culture is more attuned to transitions of care and the faculty is starting to see that this is an area where they need to assess the residents’ competence.
XVI. Next Steps Describe next steps for your project, including plans for sustaining and spreading the changes made.
1. We will assess post implementation satisfaction with the handoff tool as a communication device among the residents and among the nurses, who have started to use it.
2. We will modify it when the institution rolls out the next version of Epic.
3. We will create a faculty development program around transitions in order to use these tools and the verbal handoff as educational events
4. After collecting data to support user satisfaction, we will bring non-resident hospital teams and clinic teams into the discussion to spread the use of standardized, EHR based handoff tools. At some point, we will turn the work of this Steering Committee over to the Medical Staff leadership.
26 of 131
Ove
rall
Goa
l/Ab
stra
ct
It is w
ell kn
own t
hat tr
ansit
ions i
n car
e can
crea
te ris
k for
pa
tient
safet
y and
quali
ty ca
re. It
is al
so w
idely
acce
pted t
hat
stand
ardiz
ed to
ols fo
r han
doffs
of pa
tient
care
decre
ase t
he
oppo
rtunit
y for
risk.
Bass
ett M
edica
l Cen
ter ha
s not
had a
sta
ndar
dized
tool
for ha
ndoff
s in t
he ho
spita
l sett
ing.
Admi
nistra
tive a
nd G
ME le
ader
ship
were
seek
ing s
uch a
n ins
trume
nt. T
he Jo
int C
ommi
ssion
and t
he A
CGME
are
enco
urag
ing ho
spita
ls an
d GME
prog
rams
to pu
rsue
stand
ardiz
ed ha
ndoff
tools
. Our
goal
was t
o gath
er
educ
ation
al an
d hos
pital
leade
rship,
alon
g with
resid
ent
leade
rs in
Quali
ty an
d Safe
ty fro
m Me
dicine
and S
urge
ry, an
d to
create
a sta
ndar
dized
tool
for ha
ndoff
s in t
he M
edici
ne an
d Su
rger
y res
ident
hosp
ital te
ams. A St
anda
rdize
d EH
R Ha
ndof
f Too
l for
Med
icin
e an
d Su
rger
y
Edw
ard
Bisc
hof M
D, N
atal
iya
Yukl
yaev
a M
D, Je
ssic
a Ca
rlson
MD,
Dav
id M
orro
w M
D,
Ahm
ad C
haud
hary
MBB
S, D
avid
Bor
gstr
om M
D, R
onet
te W
iley,
Mel
ane
Mul
chy,
Sco
tt
Cohe
n M
D, S
cott
Gro
om, B
ertin
e M
cKen
na, P
hD, O
neeb
Ahm
ad M
BBS,
Jam
es D
alto
n, M
D
Bass
ett M
edic
al C
ente
r, Co
oper
stow
n, N
Y
Back
grou
nd
Bass
ett M
edica
l Cen
ter be
gan u
sing t
he E
pic E
HR in
2012
, with
ful
l dep
loyme
nt in
both
inpati
ent a
nd ou
tpatie
nt ar
eas i
n De
cemb
er 20
13. P
rior t
o tha
t time
, both
Med
icine
and S
urge
ry re
siden
ts us
ed a
(diffe
rent)
Wor
d-ba
sed h
ando
ff too
l that
was
not p
art o
f the E
HR, v
ariab
ly us
ed in
a pr
inted
form
, not
HIPA
A co
mplia
nt, an
d aug
mente
d by a
verb
al sig
n out.
This
proje
ct to
intro
duce
an E
pic-b
ased
, stan
dard
ized e
lectro
nic
hand
off to
ol in
both
Medic
ine an
d Sur
gery
resid
ency
prog
rams
wa
s des
igned
as an
itera
tive q
uality
impr
ovem
ent p
rojec
t.
In the
fall o
f 201
3, we
ass
embl
ed a
stee
ring
com
mitt
ee,
chai
red
by th
e DI
O, a
nd c
ompo
sed
of re
siden
t lea
ders
, pr
ogra
m d
irect
ors ,
the
COO
and
seni
or le
ader
ship
ad
min
istra
tors
in Q
ualit
y an
d Sa
fety
and
IT. T
he g
roup
m
et m
onth
ly w
ith p
rogr
ess r
epor
ts fr
om th
e re
siden
t w
ork
grou
ps, w
hich
wer
e un
der t
he d
irect
ion
of th
eir
resp
ectiv
e pr
ogra
m d
irect
ors,
and
who
se c
hart
er w
as to
de
velo
p st
anda
rdize
d ha
ndof
f too
ls fo
r tra
nsfe
r with
in th
e re
spec
tive
resid
ency
team
s (da
y-ni
ght,
nigh
t-da
y).
Visi
on S
tate
men
t
Our
visi
on w
as to
see
a st
anda
rdize
d ha
ndof
f too
l for
th
e M
edic
ine
and
Surg
ery
resid
ent t
eam
s. O
ur h
ope
was
that
this
wou
ld p
rovi
de im
prov
ed, c
onsis
tent
tr
ansit
ions
of h
ospi
tal c
are
and
wou
ld b
e a
tool
whi
ch
coul
d be
tran
sfer
red
to o
ther
clin
ical
gro
ups i
n th
e ho
spita
l. M
ater
ials
/Met
hods
Barr
iers
Enc
ount
ered
/Lim
itatio
ns-
Our
initi
al p
lan
was
that
the
Hous
esta
ff Q
ualit
y Co
unci
l wou
ld o
vers
ee th
is pr
ojec
t. Th
is di
d no
t ha
ppen
and
was
a m
issed
opp
ortu
nity
.
EHR
(Epi
c) m
odifi
catio
ns a
re sl
ower
and
less
nim
ble
than
they
mig
ht b
e. T
here
is a
n aw
kwar
d in
terf
ace
that
pro
mise
s to
be c
orre
cted
in th
e ne
xt v
ersio
n.
The
Med
icin
e su
rvey
s cou
ld h
ave
been
offe
red
to
Surg
ery.
The
initi
al p
ushb
ack
from
facu
lty h
as le
ssen
ed a
nd w
e be
lieve
the
hosp
italis
ts a
re re
ady
to e
mbr
ace
the
hand
off t
ool.
An au
dit of
med
ical in
patie
nt ch
arts
show
ed 10
0% ad
here
nce b
y the
Me
dicine
resid
ents
in the
use o
f EHR
for s
ign ou
t. Stric
t adh
eren
ce to
the
meth
od pr
escri
bed
in the
prog
ram
was 6
5% -
this l
ower
rate
was
likely
due t
o the
tech
nical
need
of m
oving
infor
matio
n fro
m on
e are
a of
the E
HR to
anoth
er.
The p
erce
ntage
of re
siden
ts wh
o felt
that
the w
ritten
sign
out w
as an
eff
ectiv
e com
munic
ation
devic
e wen
t from
58%
pre E
HR ha
ndoff
tool
to 83
% po
st Re
siden
t sur
veys
reve
aled a
feeli
ng th
at sig
n out
was m
ore
thoro
ugh,
more
accu
rate,
and b
etter
orga
nized
after
imple
menta
tion
of the
hand
off to
ol
Resu
lts (d
ata
gath
ered
bot
h qu
ant &
qua
l.)
Conc
lusi
ons
The
deve
lopm
ent o
f an
EHR-
base
d ha
ndof
f too
l at
BMC
has b
een
a su
cces
sful
pro
ject
that
dem
onst
rate
s th
e im
port
ance
of g
oal a
lignm
ent a
nd te
amw
ork.
Th
ere
is m
ore
to b
e do
ne to
exp
and
this
beyo
nd th
e re
siden
cies
.
The
alig
nmen
t of
goal
s with
the
inst
itutio
n w
as c
ritic
al.
Incl
usio
n of
the
COO
and
PI/
IT le
ader
ship
in
the
St
eerin
g Co
mm
ittee
mad
e se
vera
l hu
rdle
s eas
ier t
o
over
com
e. O
ne o
f the
se w
as a
misc
once
ptio
n by
som
e
of th
e fa
culty
that
hav
ing
sign
out i
n th
e EH
R w
as a
lega
l lia
bilit
y.
Adhe
renc
e w
ith u
se o
f the
tool
by
the
med
ical
and
su
rgic
al re
siden
ts w
as a
succ
ess.
We
are
also
hop
eful
th
at th
eir e
nthu
siasm
for t
he si
gn o
ut to
ol a
nd
reco
gniti
on o
f im
prov
ed c
omm
unic
atio
n w
ill c
ause
it
to b
e em
brac
ed b
y ot
her s
ervi
ces.
Succ
ess F
acto
rs a
nd L
esso
ns
Lear
ned(
Disc
ussi
on)
Your
LOGO
1. W
orkg
roup
s with
in th
e re
siden
cies
cre
ated
and
mod
ified
ha
ndof
f too
ls, u
sing
PDSA
tech
niqu
es.
2. M
onth
ly o
r bim
onth
ly m
eetin
gs o
f the
Ste
erin
g Co
mm
ittee
w
ith th
e re
siden
ts a
nd p
rogr
am d
irect
ors p
rovi
ded
ince
ntiv
e an
d ad
min
istra
tive
supp
ort.
3. T
he M
edic
ine
resid
ency
wor
kgro
up c
reat
ed a
resid
ent s
urve
y pr
e an
d po
st im
plem
enta
tion,
ass
essin
g th
e va
lue
of th
e sig
n ou
t too
l
4. A
dher
ence
to u
se o
f the
sign
out
tool
was
mea
sure
d by
the
Med
icin
e re
siden
ts
27 of 131
Team: Baylor University Medical Center GME Focus Area: Patient Safety
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
This initiative is two-fold: 1) to assess the Internal Medicine Trainee’s comfort level and confidence in various Code Blue scenarios before and after educational interventions including didactic sessions and simulation training, mock codes, dialogue and role play; and 2) to assess the impact of simulation training on the survival rate from code event to discharge for patients undergoing resuscitative efforts. The educational interventions have been determined to be a necessary addition to the Internal Medicine Residency Curriculum. Incorporating simulation training and mechanical and cognitive practices into the Code Blue educational training of the IM residents is essential to ensure ongoing cognitive analysis of resuscitative events and muscle memory of skills required in resuscitation. It is hypothesized that these simulation efforts and interactive educational sessions will allow the trainees to gain the confidence and experience to better analyze and manage resuscitation events, therefore increasing the post-code survival to discharge metric at BUMC. Team members include William L. Sutker, MD, DIO and Chief Patient Safety officer, Cristie Columbus, MD, Assistant Director, GME, Jennifer Duewall, MD, Associate Program Director, Internal Medicine, Adam Mora, MD, Critical Care faculty, Bijas Benjamin, MD, IM Resident Champion, and the internal medicine residents at BUMC.
II. Project Description
This project assesses the impact on simulation training for Code Blue Teams on survival to discharge compared with historical and national data utilizing monthly simulation and educational sessions with the internal medicine resident Code Blue teams using a high fidelity simulation mannequin. Rapid response team nurses, respiratory therapists, other ancillary staff, and physician faculty will participate with the residents in simulated code situations, perform ongoing real-time assessments, provide support and education to the resident code teams in resuscitative techniques including intubation, rhythm recognition, identification of underlying causes of cardiorespiratory arrest, defibrillation, cardioversion, and pharmaceutical intervention. Trainees are required to obtain and maintain Basic and Advanced Life Support Certification throughout their training. The objectives of the simulation sessions include: timely delegation of roles, effective communication, familiarization with code supplies, recognition of rhythm abnormalities and underlying causes of cardiorespiratory arrest, proper use of equipment and administration of treatment.
III. Necessary Resources (staff, finances, etc.)
Resources needed for this project include simulation facilities and simulation equipment, resuscitative equipment and supplies, instructors to teach the didactic sessions and the simulation scenarios, and nursing and ancillary staff to participate as part of the code blue team.
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
Data gathered during the exercises assess both technical and non-technical skills, such as measuring CPR adequacy, the timing of medications, ventilation and intubation skills, and leadership and communication. Feedback on effectiveness of resuscitative efforts and leadership/communication skills will be provided to the residents by faculty in a debriefing session post simulation on observations during the session. Resident comfort levels with resuscitative algorithms and code situations will be assessed by pre and post education survey responses. Satisfactory performance will be linked to milestone performance/graduated levels of responsibility as intern’s progress into
28 of 131
residency and assumption of role as leader of the Code Team. V. Communication Plan
(may be helpful to draft a flow chart of team members & senior management, both
internal & external)
Project was communicated to program director, IM residency, Dr. Michael Emmett. Dr. Benjamin and Duewall communicated with the IM residents at didactic conference and by email apprising the residents of the project and the required code simulation educational sessions on a monthly basis. Dr. Duewall schedules the sessions, coordinates faculty support, and communicates the scheduled sessions to the residents.
VI. Accountability (list of team members and who
is accountable for what)
Cristie Columbus, MD – project design and oversight; assessment of survey results Emma Herio, RN – data collection and reporting Bijas Benjamin, MD – Internal Medicine resident champion; assistance with project design; survey administrator Jennifer Duewall, MD, Adam Mora, MD, Cristie Columbus, MD, physician faculty BUMC Administration/GMEC – William L. Sutker, MD – Administrative Support Program Director and Chief of Department of Internal Medicine – Michael Emmett, MD – Administrative Support Kim Graham, RN – Supervisor, Rapid Response Team, nurse faculty
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
Potential Challenges include accuracy of data collection through the current EHR system verses the paper-based patient chart, communication including disclosure of adverse events, standardization of Code Blue simulation training, engagement of all physicians and nursing staff that are part of the code blue process.
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
Project Phases for this initiative include: Phase 1 includes a resident survey on perceptions of their previous code blue experience, prior training, and comfort level with resuscitation scenarios as relates to knowledge, team management, and difficult situations - completed 9/2013. Phase 2 includes implementation of educational experiences including simulations, mock codes and didactic sessions to improve knowledge and experience with unexpected code situations and complications - didactic session 9/2013; monthly mock code simulation sessions in simulation lab initiated 10/2013; codes moved in-situ to ICU involving ICU nurses/respiratory therapists/medical students 5/2014; to medical-surgical floors involving ICU nurses/nursing students/respiratory therapists 6/2014 - repeat sessions in simulation lab 6/2014 for new interns, ongoing in-situ monthly multidisciplinary training-most recent session 7/21/14. Phase 3 will include post surveys to evaluate resident comfort levels with resuscitative efforts, knowledge, communication and leadership abilities; and assess post-code survival to discharge outcomes, compared with historical and national averages - post-training surveys administered 5/2014; data analysis underway; to date comparative immediate post-code survival and survival to discharge data collected; analysis beginning 8/2014. It is anticipated this project will result in ongoing, continuous monthly interdisciplinary education for all trainees and code team members, expansion of process/model to other programs, floors and Baylor Health Care System facilities, poster presentations at local, state and/or national levels, and potentially the implementation of the model to other academic facilities throughout the nation. Anticipated submission of pre- and post-simulation training survey results to the Society of Critical Care
29 of 131
Medicine's annual meeting. IX. Vision Statement/Closing Plan
(markers of success by March 2015) Vision Statement/Closing Plan – Utilization of simulation training in code situations will 1) Enhance patient safety by increasing post code survival to discharge statistics as compared with historical and national data 2) Increase IM resident resuscitation teams’ comfort and confidence levels in various scenarios 3) Foster interdisciplinary teamwork and communication 4) Provide an innovative model to other training programs
X. Success Factors The most successful components of our work were 1. Comfort level of residents to lead codes 2. Improved post code survival
We were inspired by the cooperation and participation of multi-disciplinary teams.
XI. Barriers The largest barrier we encountered was scheduling mock codes in the ICU and floors in a busy hospital. We worked to overcome this by working with room control to find empty rooms and with clinical managers and nursing leadership to allow the mock codes.
XII. Lessons Learned The single most important piece of advice to provide another team embarking on a similar initiative would be to write the code scenarios before the project begins. It is important to continue to involve and train multi-disciplinary teams rather than just the residents.
XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI IV work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact What changes have you observed in your residency program(s), or at your institution, based upon your work? More comfort leading codes More organization to the code team
XVI. Next Steps Describe next steps for your project, including plans for sustaining and spreading the changes made. Continue to roll out more multi-disciplinary teams.
30 of 131
Pri
ma
ry A
na
lys
is
Resid
en
t T
rain
ing
in
Co
de B
lue E
xecu
tio
n i
n a
Sim
ula
tio
n
La
b I
mp
rov
es
Im
me
dia
te P
os
t-C
od
e S
urv
iva
l B
rad
ley
Ch
ris
ten
se
n,
MS
IV;
Ad
an
Mo
ra J
r.,
MD
FC
CP
; B
ija
s B
en
jam
in,
MD
;
Bri
tto
n B
lou
gh
, M
D;
Je
nn
ife
r D
ue
wa
ll,
MD
; a
nd
Cri
sti
e C
olu
mb
us
, M
D
Dep
artm
ent o
f Int
erna
l Med
icin
e, B
aylo
r Uni
vers
ity M
edic
al C
ente
r, D
alla
s TX
Ab
str
ac
t
Inte
rnal
me
dic
ine r
esid
en
ts a
t te
ach
ing
in
sti
tuti
on
s o
ften
lead
em
erg
en
cy r
esu
scit
ati
on
att
em
pts
(“co
de b
lues”)
wit
ho
ut
form
al
instr
ucti
on
in
th
e p
racti
cal
ele
men
ts o
f
lead
ing
an
d e
xecu
tin
g a
co
de
blu
e i
n t
he h
osp
ital
se
ttin
g.
Sim
ula
tio
n t
rain
ing
has b
een
sh
ow
n t
o i
mp
rove
resid
en
t co
mfo
rt b
ut
mo
rtality
ben
efi
t h
as b
een
esta
blis
he
d o
nly
in
th
e p
ed
iatr
ic p
op
ula
tio
n1
,2.
We
imp
lem
en
ted
a s
imu
lati
on
-ba
sed
co
de b
lue t
rain
ing
pro
gra
m w
ith
a 3
G S
imM
an
at
Baylo
r U
niv
ers
ity M
ed
ical
Cen
ter
inv
olv
ing
21 in
tern
al
med
icin
e r
esid
en
ts o
ver
a
10-m
on
th p
eri
od
. C
om
pari
so
n t
o a
12
-mo
nth
co
ntr
ol
peri
od
reveale
d a
tre
nd
to
wa
rds i
ncre
ased
im
med
iate
po
st-
co
de s
urv
ival th
at
did
no
t tr
an
sla
te t
o s
urv
ival
to
dis
ch
arg
e. In
cre
ased
wit
hd
raw
al
of
life
-su
sta
inin
g c
are
wa
s a
lso
no
ted
. O
ur
resu
lts in
dic
ate
th
at
sim
ula
tio
n-
based
tra
inin
g c
an
im
pro
ve m
ort
ality
in
th
e a
du
lt
po
pu
lati
on
.
Me
tho
ds
Inte
rnal
me
dic
ine r
esid
en
ts a
t B
aylo
r U
niv
ers
ity M
ed
ical
Cen
ter
wh
o r
esp
on
d t
o a
ll i
np
ati
en
t co
de b
lues w
ere
train
ed
fo
r a 1
0-m
on
th p
eri
od
in
a s
imu
lati
on
lab
on
a 3
G
ve
rsio
n S
imM
an
. R
esid
en
ts w
ere
giv
en
lectu
res o
utl
inin
g
role
s/r
esp
on
sib
ilit
ies a
nd
exp
osed
to
pro
gre
ssiv
ely
mo
re c
ha
llen
gin
g c
od
e s
cen
ari
os in
wh
ich
AC
LS
was
imp
lem
en
ted
. In
tern
al
med
icin
e a
nd
cri
tical
care
facu
lty
pro
vid
ed
cri
tical
feed
back a
fter
each
sessio
n w
ith
an
em
ph
asis
on
rap
id E
KG
rh
yth
m i
nte
rpre
tati
on
,
imp
lem
en
tati
on
of
AC
LS
, an
d t
eam
lead
ers
hip
skills
. A
n
inte
rnal
revie
w o
f B
aylo
r U
niv
ers
ity M
ed
ical C
en
ter’
s
co
de b
lue d
ata
was c
on
du
cte
d c
om
pari
ng
co
de
-rela
ted
ou
tco
mes d
uri
ng
th
e
inte
rve
nti
on
peri
od
wit
h a
12
-
mo
nth
his
tori
cal
co
ntr
ol.
Pri
mary
ou
tco
mes m
easu
red
were
im
med
iate
po
st-
co
de s
urv
ival an
d s
urv
ival to
dis
ch
arg
e. S
eco
nd
ary
ou
tco
mes m
easu
red
in
clu
ded
po
st-
co
de
ch
an
ge t
o “
do
no
t re
su
scit
ate
” s
tatu
s a
nd
po
st-
co
de w
ith
dra
wal
of
life
-su
sta
inin
g c
are
.
Re
su
lts
Th
ere
we
re a
to
tal
of
28
7 e
me
rge
nc
y r
es
us
cit
ati
on
att
em
pts
du
rin
g t
he
22
-mo
nth
stu
dy p
eri
od
. T
here
were
107 c
od
es (
8.9
pe
r m
on
th)
du
rin
g t
he
co
ntr
ol
pe
rio
d a
nd
18
0 c
od
es
(1
6.4
pe
r m
on
th)
du
rin
g t
he i
nte
rven
tio
n p
eri
od
. N
o s
tati
sti
cal
sig
nif
ica
nc
e w
as
no
ted
be
twe
en
th
e c
on
tro
l a
nd
in
terv
en
tio
n g
rou
ps
wit
h r
esp
ect
to a
ge,
gen
der,
race, n
um
ber
of
co
de
s a
t n
igh
t, o
r n
um
be
r o
f w
ee
ke
nd
co
de
s. T
he
ho
sp
ita
l c
en
su
s w
as n
ote
d t
o b
e s
tab
le d
uri
ng
th
e e
nti
re 2
2-m
on
th
stu
dy
pe
rio
d.
Th
e M
ort
ality
Pro
ba
bilit
y M
od
el
II (
MP
M I
I),
a t
oo
l th
at
es
tim
ate
s r
isk o
f d
eath
du
rin
g a
ho
sp
italizati
on
us
ing
15
va
ria
ble
s p
res
en
t a
t a
dm
iss
ion
, w
as
ca
lcu
late
d f
or
ev
ery
pa
tien
t in
th
e s
tud
y.
Th
e m
ean
MP
M I
I sco
res f
or
the
co
ntr
ol
an
d in
terv
en
tio
n p
eri
od
s w
ere
.3
23
an
d .3
43
re
sp
ec
tiv
ely
(p
-va
lue .460)3
.
In t
he
pri
ma
ry a
na
lys
is, th
ere
wa
s a
tre
nd
to
wa
rds
in
cre
as
ed
im
me
dia
te p
ost-
co
de s
urv
ival in
th
e in
terv
en
tio
n c
oh
ort
.
Imm
ed
iate
po
st-
co
de
su
rviv
al o
cc
urr
ed
in
72
pa
tie
nts
(6
7.3
%)
in t
he
co
ntr
ol
gro
up
vers
us 1
28 (
71.1
%)
in t
he
inte
rve
nti
on
gro
up
(p
-va
lue
.4
96
). T
his
tre
nd
did
no
t tr
an
sla
te t
o i
nc
reased
su
rviv
al to
dis
ch
arg
e,
wh
ich
occu
rred
in
25
pa
tie
nts
(2
3.4
%)
in t
he
co
ntr
ol
gro
up
an
d 4
0 p
ati
en
ts (
22
.2%
) in
th
e in
terv
en
tio
n g
rou
p (
p-v
alu
e .
823).
Th
e s
eco
nd
ary
an
aly
sis
re
ve
ale
d a
sig
nif
ica
nt
inc
rea
se
(p
-va
lue
.0
13
) in
th
e n
um
be
r o
f p
ati
en
ts i
n w
ho
m l
ife
-su
sta
inin
g c
are
was
wit
hd
raw
n a
fte
r s
uc
ce
ss
ful re
su
sc
ita
tio
n b
etw
ee
n t
he
co
ntr
ol g
rou
p (
29 p
ati
en
ts o
r 40.3
%)
an
d t
he i
nte
rven
tio
n g
rou
p
(75
pa
tie
nts
or
58
.6%
). N
o d
iffe
ren
ce
wa
s f
ou
nd
in
th
e n
um
be
r o
f p
ati
en
ts w
ho
ch
an
ged
th
eir
co
de s
tatu
s t
o “
do
no
t
res
us
cit
ate
” a
fte
r s
uc
ce
ss
ful re
su
sc
ita
tio
n (
p-v
alu
e .5
94
).
Dis
cu
ss
ion
Fo
rmal s
imu
lati
on
-ba
se
d c
od
e t
rain
ing
of
inte
rnal
med
icin
e r
es
ide
nts
wit
h a
3G
Sim
Ma
n m
ay
in
cre
ase
imm
ed
iate
po
st-
co
de s
urv
ival
of
ad
ult
in
pati
en
ts. T
he
imp
rove
me
nt
in o
ur
stu
dy w
as
no
t s
tati
sti
ca
lly
sig
nif
ica
nt,
po
ssib
ly d
ue
to
in
su
ffic
ien
t p
ow
er.
No
imp
rove
me
nt
wa
s s
ee
n in
su
rviv
al to
dis
ch
arg
e,
tho
ug
h t
he
ra
tes s
ee
n in
bo
th g
rou
ps a
re in
th
e t
op
de
cil
e o
f n
ati
on
al h
os
pit
als
an
d m
ay
re
fle
ct
the
ceil
ing
fo
r a
du
lt r
es
us
cit
ati
on
mo
rta
lity
ou
tco
me
s4.
Th
e s
tati
sti
ca
lly
sig
nif
ica
nt
incre
ase
in
po
st-
co
de
wit
hd
raw
al o
f li
fe-s
usta
inin
g c
are
ma
y r
efl
ec
t
incre
ase
d r
es
ide
nt
co
mfo
rt in
dis
cu
ss
ing
en
d-o
f-li
fe
issu
es w
ith
pa
tien
ts’ fa
mily
mem
bers
. T
his
is
su
pp
ort
ed
by
re
sid
en
t re
sp
on
se t
o a
pre
- a
nd
po
st-
inte
rve
nti
on
su
rve
y t
ha
t s
ho
wed
in
cre
ase
d c
om
fort
dis
cu
ss
ing
pa
llia
tiv
e c
are
aft
er
exe
cu
tin
g a
co
de
blu
e5. P
ote
nti
al w
ea
kn
ess
es
of
ou
r s
tud
y in
clu
de
insu
ffic
ien
t p
ow
er,
la
ck
of
mea
su
red
re
su
scit
ati
on
-
cen
tere
d e
nd
po
ints
, n
o s
imu
lati
on
tra
inin
g o
f
an
cil
lary
sta
ff, a
nd
ob
serv
ati
on
al b
ias
.
Re
fere
nc
es
1.C
onlo
n LW
, Rod
gers
DL,
Sho
fer F
S, L
ipsc
hik
GY.
Impa
ct o
f lev
els
of s
imul
atio
n fid
elity
on
train
ing
of in
tern
s in
AC
LS. H
osp
Pra
ct (1
995)
. 201
4 O
ct;4
2(4)
:135
-41.
2.K
nigh
t LJ,
Gab
hart
JM, E
arne
st K
S, L
eong
KM
, Ang
lem
yer A
, Fra
nzon
D. I
mpr
ovin
g co
de te
am p
erfo
rman
ce a
nd s
urvi
val o
utco
mes
: im
plem
enta
tion
of p
edia
tric
resu
scita
tion
team
trai
ning
. Crit
Car
e M
ed. 2
014
Feb;
42(2
):243
-51.
3.Le
mes
how
S, T
eres
D, K
lar J
, Avr
unin
JS
, Geh
lbac
h S
H, R
apop
ort J
. Mor
talit
y Pr
obab
ility
Mod
els
(MP
M II
) bas
ed o
n an
inte
rnat
iona
l coh
ort o
f int
ensi
ve c
are
unit
patie
nts.
JA
MA
. 199
3 N
ov 2
4;27
0(20
):247
8-86
.
4.M
erch
ant R
M, B
erg
RA,
Yan
g L,
Bec
ker L
B, G
roen
evel
d P
W, C
han
PS;
Am
eric
an H
eart
Ass
ocia
tion'
s G
et W
ith th
e G
uide
lines
-Res
usci
tatio
n In
vest
igat
ors.
Hos
pita
l var
iatio
n in
sur
viva
l afte
r in-
hosp
ital c
ardi
ac a
rres
t. J
Am
Hea
rt A
ssoc
. 201
4 Ja
n 31
;3(1
):e00
0400
.
5.M
ora
A, B
enja
min
B, B
loug
h B
, Chr
iste
nsen
BW
, Due
wal
l J, C
olum
bus
C. D
oes
Sim
ulat
ion
Trai
ning
in C
ode
Blu
e S
ituat
ions
Impr
ove
Res
iden
t Com
fort
in C
ode
Blu
es?
Abs
tract
sub
mitt
ed fo
r pub
licat
ion.
Bay
lor U
nive
rsity
Med
ical
Cen
ter;
2015
Fe
brur
ary;
Dal
las,
Tex
as.
Fu
ture
Dir
ec
tio
n
•R
esu
scit
ati
on
sim
ula
tio
n o
n h
osp
ital
flo
ors
/IC
Us t
o
bett
er
ap
pro
xim
ate
tru
e c
od
e s
ett
ing
•O
bserv
ati
on
of
in-h
osp
ital
co
de b
lue a
ttem
pts
in
ord
er
to
assess a
dh
ere
nce t
o A
HA
resu
scit
ati
on
gu
idelin
es
•E
xte
nsio
n o
f sim
ula
tio
n t
rain
ing
to
an
cilla
ry s
taff
67
.30
%
23
.40
%
71
.10
%
22
.20
%
0%10%
20%
30%
40%
50%
60%
70%
80%
Imm
ed
iate
Po
st-
Co
de
Su
rviv
al
Su
rviv
al
to D
isc
ha
rge
Mortality
Pre
-Inte
rven
tion
(%)
Pos
t-Int
erve
ntio
n (%
)
Se
co
nd
ary
An
aly
sis
70
.80
%
40
.30
%
67
.20
%
58
.60
%
0%10%
20%
30%
40%
50%
60%
70%
80%
Ch
an
ge
to
"D
o N
ot
Re
su
sc
ita
te" S
tatu
sW
ith
dra
wa
l o
f L
ife
-S
us
tain
ing
Ca
re
Percent of Surviving Patients
Pre
-Inte
rven
tion
(%)
Pos
t-Int
erve
ntio
n (%
)
31 of 131
Team: Baystate Health Focus Area: Patient Safety
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
Members: Heather Z. Sankey, MD (team leader), Reham Shaaban, DO, Aubrey Rauktys, MD, Satoko Igarashi, MD; Resident Quality Council members The Resident Quality Council identified a persistent problem with being able to quickly and efficiently identify the right person to contact when obtaining a consult outside of the department. Stakeholders: all
II. Project Description There is a known challenge with correctly identifying the physician/provider to call when 1) obtaining a consult 2) following up on a consult after it has been done and 3) with the consultant contacting the care team - especially on nights and weekends when the original consulting physician/provider is not covering. The goal of this project is to assess the extent of the problem, put a solution in place and then measure its effectiveness.
III. Necessary Resources (staff, finances, etc.)
Key players in the solution: Residents Nursing Information services (especially CIS) may be integral to the solution DHQ Medical Staff
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
Need to determine and effective measurement: If we create a survey for residents and nurses regarding their assessment of how often this is a problem, then we can repeat it. In addition, or alternatively, we can perform a real-time measurement on a few nursing units
V. Communication Plan (may be helpful to draft a flow chart of
team members & senior management, both internal & external)
We need to make sure that the hospital knows that this is a problem and that we're fixing it. Consider: 1) present to medical staff (Med Exec) - fairly easy to get on agenda 2) present to Hospital Quality Council - need Evan Benjamin's okay to get on agenda, and may have to be after the solution is found 3) Submit for President's Quality Award - even the submission will get the project noticed
VI. Accountability (list of team members and who
is accountable for what)
Residents Quality Council is developing a set of subgroups to divide up the responsibilities.
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
1. Effective measurement of the problem and the solution 2. If the assessment and/or solution requires resources such as someone to make changes in our electronic health record, then paying for it will be a challenge.
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
1. Pull the team together 2. Need to develop the assessment tool ASAP by Dec 13 3. Gather data through March 14? 4. Work on solutions through Sept 14 5. Remeasure November - December 14 (to match the time of year) 6. Tweak the solution and remeasure? 7. Create posters/ summary, etc. this can be going on simultaneously
IX. Vision Statement/Closing Plan (markers of success by March 2015)
By March 2015, we will have at piloted solutions and gathered data on the success or lack thereof for determining who to communicate with regarding in hospital consults. We will ideally have a new system
32 of 131
in place that works across all specialties. X. Success Factors The most successful component of our work was working with the
Resident Quality Council as a group. They were very effective at giving input and gathering information to bring back to the group. We were able to identify a best practice and able to create a pilot for the best practice method.
XI. Barriers The largest barrier we encountered was scarce resources: on the part of the residents, lack of time was a roadblock. We also did not have funding support to help institute the pilot. We had identified an issue that was not on the hospital radar at all, and were not working with the Department of Healthcare Quality at this time. We worked to overcome this by keeping the pilot small and doing a lot of the work ourselves – but the contact we had in Information Systems left Baystate Health, and so we lost our ability to collect follow-up data.
XII. Lessons Learned The single most important piece of advice to provide another team embarking on a similar initiative would be 1) The Resident Quality Council needs to align goals with the health system goals and work directly with the Department of Healthcare Quality 2) Projects must be doable within a year’s timeframe because members of the council rotate off or graduate and it is difficult for new members to pick up where the others left off.
XIII. Expectations Versus Results On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI III work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact What changes have you observed in your residency program(s), or at your institution, based upon your work? We do have a new consult order for internal medicine and Ob/gyn, which may actually help to alleviate the problem over time.
XVI. Next Steps Describe next steps for your project, including plans for sustaining and spreading the changes made. The Resident Quality Council is working to increase the number of “near-miss” reports in our SRS system.
33 of 131
Ove
rall
Goa
l/Ab
stra
ct
Resi
dent
Eng
agem
ent i
n Q
ualit
y Th
roug
h an
RQ
C
Aubr
ey R
aukt
ys, M
D, H
eath
er Z
. San
key,
MD,
Sat
oko
Igar
ashi
, MD
Re
ham
Sha
aban
, DO
, Ba
ysta
te M
edic
al C
ente
r, Sp
ringf
ield
, MA
Back
grou
nd
Visi
on S
tate
men
t
Mat
eria
ls/M
etho
ds
Bibl
iogr
aphy
Barr
iers
Enc
ount
ered
/Lim
itatio
ns-
Conc
lusi
ons
Su
cces
s Fac
tors
and
Les
sons
Le
arne
d(Di
scus
sion
)
Ove
rall
Goa
ls:
•En
gage
Res
iden
ts in
iden
tifyi
ng in
terd
isci
plin
ary
qual
ity im
prov
emen
t pr
ojec
ts
•U
tiliz
e th
e R
esid
ent Q
ualit
y co
unci
l to
gath
er d
ata,
iden
tify
barr
iers
, lim
itatio
ns a
nd o
ppor
tuni
ties i
n qu
ality
impr
ovem
ent i
nitia
tives
.
•Id
entif
y on
e in
itiat
ive
that
wou
ld h
ave
a w
ide
impa
ct
Hou
sest
aff o
ffice
rs p
lay
a ke
y ro
le in
pat
ient
car
e at
aca
dem
ic m
edic
al c
ente
rs.
Bei
ng o
n th
e fr
ont l
ine
give
s the
hou
sest
aff
uniq
ue in
sigh
ts in
to p
robl
ems t
hat
occu
r with
in a
hos
pita
l esp
ecia
lly th
ose
that
hav
e th
e bi
gges
t im
pact
on
thei
r dai
ly
wor
k. Y
et, h
ouse
staf
f hav
e no
t tra
ditio
nally
bee
n op
timal
ly in
volv
ed in
effo
rts to
im
prov
e ca
re. F
requ
ently
, hos
pita
l adm
inis
trato
rs, n
urse
s, an
d at
tend
ing
phys
icia
ns
stud
y th
e ou
tcom
es o
f car
e, a
sses
s roo
t cau
ses w
hen
adve
rse
even
ts o
ccur
, and
de
velo
p im
prov
emen
ts a
s nec
essa
ry. R
esid
ent i
nput
may
not
alw
ays b
e in
clud
ed in
po
licy
chan
ges a
nd, a
s a re
sult,
resi
dent
s may
not
be
enga
ged
in a
dopt
ing
thes
e po
licy
chan
ges.
Als
o, th
e ho
uses
taff
conc
erns
do
not o
ften
go h
igh
enou
gh u
p th
e ch
ain
to b
e ab
le to
inf
luen
ce c
hang
es d
espi
te th
e fa
ct th
at th
e AC
GM
E re
quire
s re
side
nts t
o “s
yste
mat
ical
ly a
naly
ze p
ract
ice
usin
g qu
ality
impr
ovem
ent m
etho
ds,
and
impl
emen
t cha
nges
with
the
goal
of p
ract
ice
impr
ovem
ent.”
W
e de
velo
ped
an in
terp
rofe
ssio
nal,
inte
rdis
cipl
inar
y co
unci
l mad
e up
of 1
6 ho
uses
taff
offic
ers
repr
esen
ting
10 re
side
ncie
s and
3 fe
llow
ship
s.
•Im
prov
e pa
tient
car
e an
d sa
fety
by
enga
ging
resi
dent
s in
a cu
lture
of
qual
ity im
prov
emen
t thr
ough
did
actic
s, di
alog
ue a
nd e
xper
ient
ial
lear
ning
.
•Pr
ovid
e a
safe
env
ironm
ent/v
enue
for t
he h
ouse
staf
f to
voic
e th
eir
opin
ions
/con
cern
s abo
ut sy
stem
wid
e or
pat
ient
safe
ty c
once
rns
•En
cour
age
inte
rdis
cipl
inar
y di
alog
ue a
nd c
olla
bora
tion
•A
fter i
nitia
tion
of th
e R
QC
, cou
ncil
mem
bers
iden
tifie
d qu
ality
and
pat
ient
sa
fety
issu
es a
cros
s spe
cial
ties.
Ther
e w
as c
onse
nsus
that
it w
as d
iffic
ult t
o de
term
ine
who
to c
all f
or a
con
sult
in a
dep
artm
ent o
utsi
de o
f one
’s
own.
Thi
s res
ulte
d in
del
ays i
n ca
re b
ecau
se it
was
ofte
n tri
al a
nd e
rror
, with
m
ultip
le e
fforts
to re
ach
the
corr
ect c
onta
ct p
erso
n th
at to
ok p
reci
ous t
ime.
Th
e is
sue
chos
en fo
r the
inau
gura
l pro
ject
was
to d
evel
op a
sim
ple,
st
anda
rdiz
ed m
etho
d fo
r obt
aini
ng a
con
sulta
tion
acro
ss sp
ecia
litie
s.
•O
nce
this
pro
blem
was
iden
tifie
d, th
e pr
oces
s for
obt
aini
ng a
con
sulta
tion
was
sepa
rate
d in
to p
arts
and
key
stak
ehol
ders
in th
e pa
thw
ay w
ere
iden
tifie
d.
Each
repr
esen
tativ
e on
the
coun
cil c
onve
ned
with
thei
r pro
gram
and
out
lined
th
e st
eps t
o ob
tain
a c
onsu
ltant
with
in th
eir i
ndiv
idua
l dep
artm
ents
. The
se
met
hods
wer
e th
en re
view
ed w
ith th
e co
unci
l and
a “
best
pra
ctic
e” w
as
sele
cted
from
the
vario
us p
roce
sses
.
•Th
e gr
oup
was
subd
ivid
ed to
furth
er in
vest
igat
e sp
ecifi
c as
pect
s of t
he
prob
lem
. Gro
up o
ne c
onta
cted
stak
ehol
ders
alo
ng th
e co
nsul
tatio
n pa
thw
ay
incl
udin
g re
side
nts,
unit
cler
ks a
nd se
cret
arie
s and
the
hosp
ital o
pera
tors
to
iden
tify
thei
r met
hod
of a
ctio
n in
con
tact
ing
a co
nsul
ting
serv
ice.
Gro
up tw
o de
velo
ped
poss
ible
out
com
e m
easu
rem
ent t
ools
and
surv
ey o
ptio
ns to
ev
alua
te fu
ture
succ
ess o
f any
cha
nges
impl
emen
ted.
•
The
inte
rdis
cipl
inar
y g
roup
repr
esen
ted
alm
ost a
ll sp
ecia
lties
/sub
spec
ialit
ies
in o
ur in
stitu
tion
sinc
e w
e ha
d a
repr
esen
tativ
e of
eac
h sp
ecia
lty a
nd
resi
dent
s rot
ate
thro
ugh
mos
t su
bspe
cial
ties
•W
e w
ere
able
to id
entif
y an
opp
ortu
nity
for i
mpr
ovem
ent t
hat c
ross
ed
mul
tiple
dis
cipl
ines
and
affe
cted
pat
ient
s on
a da
ily b
asis
but
was
not
on
the
rada
r for
the
inst
itutio
n •
Dat
a ga
ther
ing
wor
ked
wel
l due
to th
e br
oad
repr
esen
tatio
n an
d th
e fa
ct th
at
resi
dent
s wor
k at
the
fron
t lin
es o
f pat
ient
car
e
•Ex
celle
nt o
ppor
tuni
ty fo
r exp
erie
ntia
l lea
rnin
g an
d in
terd
isci
plin
ary
colla
bora
tion
•
Mos
t res
iden
ts a
re n
ot fa
mili
ar w
ith th
e Q
I sys
tem
s an
d pr
oces
ses i
n pl
ace
in th
e in
stitu
tion,
and
may
com
e up
with
solu
tions
that
app
ear d
ecep
tivel
y si
mpl
e to
ena
ct, b
ut
are
actu
ally
com
plic
ated
and
reso
urce
-inte
nsiv
e •
The
pote
ntia
l pro
ject
s ide
ntifi
ed b
y th
e R
QC
may
not
hav
e th
e ne
cess
ary
reso
urce
s to
mak
e ch
ange
s if t
hey
are
not i
n al
ignm
ent w
ith th
e sy
stem
-wid
e go
als.
The
Dep
artm
ent
of H
ealth
care
Qua
lity
was
not
initi
ally
eng
aged
with
the
RQ
C, w
hich
con
tribu
ted
to a
la
ck o
f alig
nmen
t. •
Abs
ence
of p
rote
cted
tim
e an
d ac
cess
to (f
inan
cial
) res
ourc
es fo
r the
RQ
C to
mee
t and
to
wor
k on
a p
roje
ct re
sulte
d in
slow
pro
gres
s tow
ards
impl
emen
tatio
n •
A la
rge
grou
p of
div
erse
peo
ple
(diff
eren
t spe
cial
ities
, at d
iffer
ent s
tage
s of t
rain
ing
and
with
diff
erin
g le
vels
of k
now
ledg
e) m
ade
it di
fficu
lt to
stay
focu
sed
on ta
sk d
urin
g di
scus
sion
s W
e de
scrib
e ou
r exp
erie
nce
with
wor
king
thro
ugh
an in
terd
isci
plin
ary
Res
iden
t Qua
lity
Cou
ncil
to id
entif
y a
patie
nt sa
fety
issu
e, g
athe
r dat
a on
the
exte
nt o
f the
pro
blem
, and
iden
tify
poss
ible
solu
tions
to d
evel
op a
pilo
t pr
ojec
t bas
ed o
n th
e be
st p
ract
ices
iden
tifie
d by
the
grou
p. T
he R
QC
fu
nctio
ned
wel
l in
this
cap
acity
, and
wor
king
with
the
Dep
artm
ent o
f H
ealth
care
Qua
lity
in th
e fu
ture
will
hel
p to
alig
n th
e go
als o
f the
hos
pita
l sy
stem
with
the
proj
ects
cho
sen
by th
e R
QC
. Pr
ovid
ing
prot
ecte
d tim
e an
d sy
stem
reso
urce
s for
resi
dent
s ($)
to e
ngag
e in
mea
ning
ful i
mpr
ovem
ent
proj
ects
will
ben
efit
ever
yone
($$$
$).
Dix
on JL
, et a
l. H
ouse
Sta
ff Q
ualit
y C
ounc
il: O
ne In
stitu
tion'
s Exp
erie
nce
to In
tegr
ate
Res
iden
t Inv
olve
men
t in
Patie
nt C
are
Impr
ovem
ent I
nitia
tives
. Och
sner
J. 2
013
Fall;
13(3
):394
-9.
Flei
schu
t PM
, et a
l. 20
11 Jo
hn M
. Eis
enbe
rg P
atie
nt S
afet
y an
d Q
ualit
y Aw
ards
. The
effe
ct o
f a n
ovel
Hou
sest
aff
Qua
lity
Cou
ncil
on q
ualit
y an
d pa
tient
safe
ty. I
nnov
atio
n in
pat
ient
safe
ty a
nd q
ualit
y at
the
loca
l lev
el. J
t Com
m
J Qua
l Pat
ient
Saf
. 201
2 Ju
l;38(
7):3
11-7
. Pe
ters
on S
, et a
l. Th
e Po
wer
of I
nvol
ving
Hou
se S
taff
in Q
ualit
y Im
prov
emen
t: A
n In
terd
isci
plin
ary
Hou
se S
taff-
Driv
en V
acci
natio
n In
itiat
ive.
Am
J M
ed Q
ual.
2014
May
9.
34 of 131
Team: Beaumont Health System – Group #2 Focus Area: Quality Improvement/Medical Error Reporting
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
To increase Resident/Fellow involvement in Quality Improvement/Patient Safety Projects at Beaumont Health System by identifying Quality Improvement projects through the PQSI process. At the end of this project, all residents/fellows should be comfortable in reporting patient safety concerns and should have reported at least once in the reporting system. The Graduate Medical Education team will work closely with the Quality Improvement Team to assure compliance with this objective.
II. Project Description
The Quality Improvement Team (PSQI staff) will meet with all residency/fellowship programs on an individual basis to describe the PSQI reporting process and follow-up. Every resident/fellow in each program will be requested to identify a perceived patient safety concern and complete a report. For training purposes, these reports will be flagged as part of the Quality Improvement Project Group. PSQI staff will review and discuss these identified patient safety concerns will the individual residents/fellows and give them immediate feedback. This pilot project will begin with our Emergency Medicine residency program.
III. Necessary Resources (staff, finances, etc.)
Quality Improvement/Patient Safety Staff Resident/Fellow Training Program Directors GME Staff
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
After initial Pilot Program, anonymous PSQI reports will be reviewed on a quarterly basis. A minimum number of quality improvement projects will evolve based on Kaizens.
V. Communication Plan (may be helpful to draft a flow chart of team
members & senior management, both internal & external)
Monthly reporting at GMEC Monthly reporting at Resident/Fellow Council
VI. Accountability (list of team members and who
is accountable for what)
Jeffrey Devries – team leader Sharon Wilson – gather data Paula Levesque - Quality Resident Representative – report at Resident/Fellow Council Program Director (s)
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
Scheduling initial meetings with Residency/Fellowship programs and QI Time Follow-up with PSQI reports that are anonymous Residents/Fellows currently not vested in PSQI reporting – how to change the perception
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
PSQI Meetings Quarterly Quality Data Number of new quality projects and what programs and/or individual residents are involved PSQI Projects are linked with scholarly activity
IX. Vision Statement/Closing Plan (markers of success by March 2015)
At the end of this project, the number of residents/fellows actively reporting in the PSQI data system will be 25% and the number of residents/fellows creating Quality Improvement projects related to the data reported in the PSQI will be 10%.
35 of 131
X. Success Factors The most successful component of our work was the engagement of the Quality staff to assist in the timely feedback of the PSQI Reports to encourage the We were inspired by the medical error reports that were completed by the Residents.
XI. Barriers The largest barrier we encountered was the reporting system We worked to overcome this by utilizing Quality staff to manually pull reports. A new system is being purchased in the near future.
XII. Lessons Learned The single most important piece of advice to provide another team embarking on a similar initiative would be to get buy-in from the Quality Department and the Resident Leadership. Both groups need to be totally engaged to make this a success.
XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI IV work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact What changes have you observed in your residency program(s), or at your institution, based upon your work? The project encouraged discussion about medical error reporting and more involvement by residents in Quality committees.
XVI. Next Steps Describe next steps for your project, including plans for sustaining and spreading the changes made. A Medical Error Reporting System that allows for easier and more timely feedback and results.
36 of 131
Goa
ls
Prom
otin
g M
edic
al E
rror
Rep
ortin
g by
Res
iden
ts
Shar
on W
ilson
, MS
and
Jeffr
ey M
. Dev
ries,
MD,
MPH
Beau
mon
t Hea
lth S
yste
m
Roya
l Oak
, Mic
higa
n
Back
grou
nd
Visi
on S
tate
men
t Ba
rrie
rs E
ncou
nter
ed/L
imita
tions
Re
sults
Succ
ess F
acto
rs a
nd L
esso
ns L
earn
ed
•
To in
crea
se R
esid
ent/
Fello
w in
volv
emen
t in
heal
thca
re Q
ualit
y an
d Pa
tient
Saf
ety
initi
ativ
es b
y id
entif
ying
and
repo
rtin
g op
port
uniti
es
for i
mpr
ovem
ent.
•En
hanc
e Re
siden
ts’ a
tten
tion
to q
ualit
y an
d sa
fety
laps
es, w
heth
er
resu
lting
in p
atie
nt h
arm
or “
near
-miss
es”.
•
By th
e en
d of
this
proj
ect,
all r
esid
ents
/fel
low
s sho
uld
be c
omfo
rtab
le
in re
port
ing
patie
nt sa
fety
con
cern
s and
shou
ld h
ave
repo
rted
at l
east
on
ce in
the
repo
rtin
g sy
stem
.
•Pr
omot
e co
llabo
ratio
n GM
E an
d Q
ualit
y/Pa
tient
Saf
ety
pers
onne
l.
•
The
Qua
lity
Impr
ovem
ent T
eam
met
with
all
40 re
siden
cy a
nd
fello
wsh
ip p
rogr
ams i
ndiv
idua
lly to
edu
cate
them
rega
rdin
g th
e Pa
tient
Saf
ety/
Qua
lity
Impr
ovem
ent (
PSQ
I) re
port
ing
proc
ess a
nd
inci
dent
follo
w-u
p.
•Ev
ery
resid
ent/
fello
w in
eac
h pr
ogra
m w
as th
en re
ques
ted
to
iden
tify
a pe
rcei
ved
patie
nt sa
fety
con
cern
and
com
plet
e a
PSQ
I re
port
.
•PS
QI s
taff
revi
ewed
all
subm
itted
repo
rts a
nd p
rovi
ded
feed
back
on
e m
onth
late
r at r
esid
ent m
eetin
gs.
•
Resid
ents
will
act
ivel
y ob
serv
e op
port
uniti
es to
impr
ove
heal
th c
are
qual
ity a
nd p
atie
nt sa
fety
and
be
will
ing
to d
ocum
ent t
hese
ob
serv
atio
ns o
n ou
r sys
tem
-wid
e in
cide
nt re
port
ing
syst
em.
•
This
info
rmat
ion
– w
heth
er re
sulti
ng in
pat
ient
har
m o
r a “
near
-miss
” w
ill b
e us
ed to
info
rm e
ach
Depa
rtm
ent’s
Mor
talit
y an
d M
orbi
dity
co
nfer
ence
s.
•
Resid
ents
will
use
thes
e fin
ding
s to
deve
lop
QI/
PS Im
prov
emen
t Pr
ojec
ts.
•In
coo
pera
tion
with
the
Qua
lity
Impr
ovem
ent T
eam
, cha
nges
wer
e m
ade
to th
e on
-line
PSQ
I Rep
ortin
g Fo
rm to
incl
ude
an o
ptio
nal d
ata
field
iden
tifyi
ng th
e st
atus
of t
he in
divi
dual
subm
ittin
g th
e re
port
(r
esid
ent,
nurs
e, e
tc.)
so th
at e
ven
whe
n re
port
ing
anon
ymou
sly,
resid
ents
can
be id
entif
ied
as re
siden
ts.
•
This
educ
atio
nal i
nter
vent
ion
(one
-hou
r ses
sions
for e
ach
prog
ram
) yi
elde
d a
12-fo
ld in
crea
se in
med
ical
err
or re
port
s sub
mitt
ed b
y th
e Re
siden
ts!
•
The
inte
rest
and
ent
husia
sm in
qua
lity
and
safe
ty is
sues
exp
ress
ed b
y Re
siden
ts in
the
follo
w-u
p se
ssio
ns h
ad n
ot b
een
seen
bef
ore.
•Th
e m
ost s
ucce
ssfu
l com
pone
nt o
f our
wor
k w
as th
e en
gage
men
t of
the
Qua
lity
Impr
ovem
ent T
eam
to p
rovi
ding
tim
ely
feed
back
of t
he
PSQ
I Rep
orts
.
•Ac
hiev
ing
buy-
in fr
om th
e Q
ualit
y De
part
men
t and
the
GME
Lead
ersh
ip w
ere
criti
cal f
acto
rs in
the
succ
ess o
f thi
s pro
ject
.
•
The
larg
est b
arrie
r was
the
repo
rtin
g sy
stem
itse
lf, w
hich
doe
s not
au
tom
atic
ally
pro
vide
feed
back
to th
e su
bmitt
er.
Staf
f mem
bers
from
th
e Q
ualit
y De
part
men
t man
ually
retr
ieve
d th
e re
port
s. A
new
sy
stem
is b
eing
pla
nned
for t
he n
ear f
utur
e.
•Th
ere
is on
ly a
smal
l sta
ff th
at re
view
s the
ove
r 8,0
00 P
SQI R
epor
ts
subm
itted
ann
ually
by
hosp
ital s
taff
(incl
udin
g Re
siden
ts).
•
We
enco
unte
red
inco
nsist
ent r
espo
nses
by
the
Prog
ram
Dire
ctor
s w
hen
rece
ivin
g re
port
s reg
ardi
ng th
eir R
esid
ents
.
•So
me
nurs
es w
ere
perc
eive
d by
Res
iden
ts to
use
the
PSQ
I rep
ortin
g sy
stem
to re
port
wha
t the
y su
bjec
tivel
y de
fined
as u
ndes
irabl
e Re
siden
t beh
avio
r. T
hese
repo
rts w
ere
view
ed a
s pun
itive
by
the
Resid
ents
, esp
ecia
lly w
hen
repo
rts w
ere
subm
itted
ano
nym
ously
, ca
usin
g th
em h
esita
tion
to u
se th
e sy
stem
.
Nex
t Ste
ps
•W
e ha
ve e
ngag
ed th
e Q
I/Pa
tient
Saf
ety
Depa
rtm
ent &
Nur
sing
Serv
ices
to w
ork
with
us i
n an
inte
rdisc
iplin
ary
effo
rt to
:
1) d
evel
op a
mec
hani
sm to
ens
ure
feed
back
Res
iden
t-ge
nera
ted
PS
QI r
epor
ts;
2) e
stab
lish
focu
s gro
ups o
f Nur
ses &
Res
iden
ts to
est
ablis
h
pref
erre
d m
eans
of i
dent
ifyin
g su
bopt
imal
per
form
ance
;
3)
thou
ghtf
ully
det
erm
ine
who
shou
ld b
e co
pied
on
thes
e re
port
s,
to
ens
ure
that
dist
ribut
ion
is lim
ited
to th
ose
who
can
act
on
the
in
form
atio
n;
4)
trai
n Pr
ogra
m D
irect
ors i
n th
e co
nstr
uctiv
e an
d no
n-pu
nitiv
e
man
ner i
n w
hich
thes
e re
port
s sho
uld
be m
anag
ed a
nd
do
cum
ente
d.
37 of 131
Team: Carolinas HealthCare System Focus Area: Patient Safety
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
Residents in Patient Safety at Carolinas HealthCare System: A Collaborative Integrated Program for Enhanced Patient Outcomes
The current and increasingly complex healthcare environment calls for increased attention to achieving high quality safe patient care. The best patient outcomes require that all health care team members work collaboratively to make quality and safety a top priority. The Resident in Patient Safety program will build a culture of safety by integrating proven strategies into the education and training of new doctors, nurses, and advanced practitioners during their respective formal educational programs. The residents will gain expertise in system-based quality improvement and simulation education as applied to patient safety. The program will educate and prepare the next generation of quality improvement innovators and patient safety leaders. Draft Objectives of the 9-month Program include the following. By participating in the Program, all residents in patient safety will:
1. Identify system errors and opportunities for system safety improvement
2. Facilitate education of other healthcare professionals on patient safety goals and system improvements
3. Work collaboratively and actively in hospital committees and teams on safety initiatives
4. Serve as liaison between fellow trainees and CHS Quality & Patient Safety Division
5. Identify and demonstrate critical actions that contribute to error reduction and patient safety
6. Describe and discuss performance improvement methodology as applied to improving patient safety
7. Demonstrate the ability to communicate effectively with all members of a multidisciplinary team to gain buy-in and build consensus for system improvement
8. Facilitate safety training for other providers through organizing and structuring training scenarios via simulation that are aligned to system needs
9. Provide constructive feedback (debriefing) following safety simulation training events
II. Project Description
The Resident in Patient Safety program will be launched in January 2015. The first academic year will be considered a pilot to assess effectiveness as we develop the program. Residents will be current CHS trainees in existing healthcare programs including: Center for Advanced Practice (CAP), Carolinas College of Health Sciences (CCHS), and Graduate Medical Education (GME). A maximum of 6 residents will be recruited for the inaugural pilot year. Trainees will be invited to apply to participate in the 9 month program. Minimum criteria to participate include: trainee in good standing at CHS medical or health sciences program; successful completion of one full year of post-graduate training; letter of recommendation from program director; strong desire to gain further knowledge and experience in patient safety; Strong interpersonal and teaching skills. Completion requirements will include: Average of 20 hours per month dedicated to the Program; Completion of WHO Patient Safety Curriculum
38 of 131
+ orientation to program (virtual and live); Facilitation of small group teaching sessions; Active participation in patient safety teams; Completion of patient safety improvement project. All residents who successfully complete the Program will receive a CHS certificate of completion at graduation.
II. Project Description
The Resident in Patient Safety program will be launched in January 2015. The first academic year will be considered a pilot to assess effectiveness as we develop the program. Residents will be current CHS trainees in existing healthcare programs including: Center for Advanced Practice (CAP), Carolinas College of Health Sciences (CCHS), and Graduate Medical Education (GME). A maximum of 6 residents will be recruited for the inaugural pilot year. Trainees will be invited to apply to participate in the 9 month program. Minimum criteria to participate include: trainee in good standing at CHS medical or health sciences program; successful completion of one full year of post-graduate training; letter of recommendation from program director; strong desire to gain further knowledge and experience in patient safety; Strong interpersonal and teaching skills. Completion requirements will include: Average of 20 hours per month dedicated to the Program; Completion of WHO Patient Safety Curriculum + orientation to program (virtual and live); Facilitation of small group teaching sessions; Active participation in patient safety teams; Completion of patient safety improvement project. All residents who successfully complete the Program will receive a CHS certificate of completion at graduation.
III. Necessary Resources (staff, finances, etc.)
Program Director or Co-Directors (Med Ed + Quality) Patient Safety Resident Mentors Program Coordinator Travel budget for residents to attend national AHRQ patient safety meeting Stipend for Residents (?) Mentors (?) Protected time from educational program to participate Simulation resources (namely space)
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
• CLER outcomes • Patient Safety metrics or composite measure • Resident cohort satisfaction • Engagement of CHS trainees in patient safety • Interprofessional perceptions & teamwork • Patient safety metrics (relative to focus area)
V. Communication Plan (may be helpful to draft a flow chart of team
members & senior management, both internal & external)
Q3 2014: – Nominations and selection of program mentors/advisors. Q4 2014: E-Mail Communication to key stake holders for call for participants/advisees. Interested learners will complete online application. Q1 2015: The committee will review all applications and notify selected participants by February 17, 2015. March 9, 2015 Program Orientation
VI. Accountability (list of team members and who
is accountable for what)
Name/Credentials Proposed Roles
Position/Title
Mary N. Hall, M.D. Role: Senior Lead & Outpatient
DIO, Interim Chief Academic Officer
39 of 131
Liaison Lisa Howley, Ph.D. Role: Project Leader & Program Designer
Associate DIO, Assistant Vice President Medical Education
Eric Anderson, M.Ed. Role: Program Director & Designer
Director, Graduate Medical Education
Vu Nguyen, M.D. Role: Program Director
Program Director – PM&R
Matthew Hanley, M.D. Role: Inpatient Liaison & Chief Medical Officer
Chief Medical Officer Carolinas Medical Center
Suzette Caudle, M.D. Role: Communications & Program Design
Program Director Pediatrics Residency Program
Danelle Higgins Role: Program Director & Designer
Assistant Vice President Patient Safety
Pamela Beckwith Role: Chief Quality Officer
System Vice President Quality
Ellen Sheppard, EdD Role: Nursing, Advanced Practice, Liaison
President, CCHS
Elizabeth Diaz, M.D. Role: Resident Member
Resident, PG1 Pediatrics
Lisa Hebert, PA-C Role: Ambulatory Quality Liaison
Vice President CHS Medical Group, Quality Improvement
Cameron Davis Role: Program Manager
Program Manager, Vascular and Neurosurgery Residency Programs
Mentors: Danelle Higgins Matt Hanley, M.D. Michael Ruhlen, M.D. Lisa Hebert, PA-C
AVP Patient Safety Chief Medical Officer – CMC Chief Medical Officer – CMC-P VP CHSMG – Quality Improvement
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
• Buy-In from Faculty, Residents • Funding • Protection of Time for Mentors & Residents • Coordination of Diverse Trainees as Residents • Integration of Residents into CHS Patient Safety Teams • Simulation Resources
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
Q1 2014: Design Program Pilot Q2 2014 – Ongoing: Design Curriculum Q3 2014: Recruit Mentors Q4 2014: Recruit Pilot Participants Q1 2015: Launch Program Pilot Q1 2015 – Q4 2015: Administer & Assess Program Q4 2015: Graduation of Pilot Residents
IX. Vision Statement/Closing Plan (markers of success by March 2015)
The Resident in Patient Safety program will build a culture of safety by integrating proven strategies into the education and training of new doctors, nurses, and advanced practitioners during their respective
40 of 131
formal educational programs. Successful completion of the project will include:
• Excellent inaugural Resident cohort satisfaction scores • Increased engagement of CHS trainees in patient safety • Improvement in CLER results in patient safety focus area • Enhanced interprofessional perceptions of Residents
Improved patient safety metrics (relative to focus area) X. Success Factors The most successful component of our work was successful recruitment
of the 8 participants in the Pilot Program. We recruited a diverse team that consisted of: 3 residents (OBGYN, Pediatrics, Neurosurgery), 2 nursing students, nurse – simulation center specialist, nurse – patient safety educator, advanced care practionier – trauma/surgical critical care. We were inspired by the energy of these learners and there excitement towards the program and becoming “experts” in patient safety as well as the diversity of the group.
XI. Barriers The largest barrier we encountered was time. While 18 months seems like a long time this will creep up on you quickly. We worked to overcome this by staying organized and setting milestones for our program development.
XII. Lessons Learned The single most important piece of advice to provide another team embarking on a similar initiative would be to put together a strong, diverse team. Our team of experts from Interprofessional areas within our system helped drive the success of our program development. This same group will ensure that our pilot program is successful.
XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI IV work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact What changes have you observed in your residency program(s), or at your institution, based upon your work? – The pilot program will launch on March 9, 2015. We will be able to report out more in the changes and impact in late 2015.
XVI. Next Steps Describe next steps for your project, including plans for sustaining and spreading the changes made. We will be launching the pilot program on March 9, 2015. The next steps are the implantation and evaluation of the impact of the Certificate in Patient Safety program: Time Frame: Months 1 -4 – Orientation, skill building, needs assessments. Months 5 – 9 – Teaching, patient safety project implementation (PDSA) and presentations and program evaluation and assessment.
41 of 131
Ove
rvie
w
The
CH
S C
ertif
icat
e P
rogr
am in
Pat
ient
Saf
ety
will
bui
ld a
cul
ture
of
safe
ty a
nd p
repa
re th
e ne
xt g
ener
atio
n of
pat
ient
saf
ety
lead
ers
by
inte
grat
ing
prov
en s
trat
egie
s in
to th
e ed
ucat
ion
and
trai
ning
of
resi
dent
phy
sici
ans,
nur
ses,
and
adv
ance
d pr
actit
ione
rs. I
n or
der
to
mee
t thi
s go
al, w
e de
sign
ed a
9-m
onth
inte
rpro
fess
iona
l cur
ricul
um
inte
grat
ed w
ithin
exi
stin
g tr
aini
ng p
rogr
ams.
The
pro
gram
was
deve
lope
d ov
er a
n 18
mon
th p
erio
d an
d la
unch
ed M
arch
201
5.
Cer
tifi
cati
on
Pro
gra
m in
Pat
ien
t S
afet
y:
Pla
nn
ing
& C
urr
icu
lum
Des
ign
E
ric
An
der
son
ME
d, L
isa
Ho
wle
y P
hD
, Mar
y H
all M
D, C
amer
on
Dav
is, M
atth
ew H
anle
y M
D, S
uze
tte
Cau
dle
MD
,
Dan
elle
Hig
gin
s, P
amel
a B
eckw
ith
FA
CH
E, E
lizab
eth
Dia
z M
D
Car
olin
as H
ealt
hC
are
Sys
tem
, Ch
arlo
tte,
No
rth
Car
olin
a
Bac
kgro
un
d
T
he c
urre
nt a
nd in
crea
sing
ly c
ompl
ex h
ealth
care
env
ironm
ent c
alls
for
grea
ter
atte
ntio
n to
war
ds th
e ac
hiev
emen
t of q
ualit
y sa
fe p
atie
nt c
are.
The
bes
t pat
ient
outc
omes
are
a r
esul
t of h
ealth
care
team
mem
bers
wor
king
col
labo
rativ
ely
to
mak
e qu
ality
and
pat
ient
saf
ety
a to
p pr
iorit
y.
The
AC
GM
E C
linic
al L
earn
ing
Env
ironm
ent a
s w
ell a
s th
e C
ore
Com
pete
ncie
s
for
Inte
rpro
fess
iona
l Col
labo
rativ
e P
ract
ice
plac
e em
phas
is o
n 6
area
s w
hich
colle
ctiv
ely
requ
ire th
e sp
onso
ring
inst
itutio
n to
pra
ctic
e di
ffere
ntly
and
inte
ntio
nally
tow
ards
the
achi
evem
ent o
f hig
h qu
ality
, saf
e an
d ac
cess
ible
care
.
Inte
rpro
fess
iona
l edu
catio
n is
def
ined
as:
“Wh
en s
tud
ents
fro
m t
wo
or
mo
re p
rofe
ssio
ns
lear
n a
bo
ut,
fro
m a
nd
wit
h e
ach
oth
er t
o e
nab
le e
ffec
tive
colla
bo
rati
on
an
d im
pro
ve h
ealt
h o
utc
om
es”
-WH
O, 2
010
Tim
elin
e
Req
uir
emen
ts
• L
ive
Orie
ntat
ion
+ K
ick
Off
Eve
nt
• A
ctiv
e P
artic
ipat
ion
in In
terp
rofe
ssio
nal P
atie
nt S
afet
y T
rain
ing
Tria
d Te
am
• T
eam
ST
EP
PS
Mas
ter
Tra
iner
Cer
tific
atio
n
• C
ompl
etio
n of
rel
evan
t WH
O P
atie
nt S
afet
y &
Mod
ules
(A
sync
hron
ous,
Sel
f-
Pac
ed)
follo
wed
by
advi
sem
ent f
rom
pat
ient
saf
ety
expe
rt (
tria
d te
ams)
• C
ompl
etio
n of
10
live
web
-bas
ed e
duca
tiona
l ses
sion
s (S
ynch
rono
us, F
lexi
ble
Offe
rings
)
• F
acili
tatio
n of
sm
all g
roup
teac
hing
ses
sion
s (“
Lunc
h-n-
Lear
n”)
• A
ctiv
e su
perv
ised
par
ticip
atio
n in
pat
ient
saf
ety
RC
A te
am
• C
ompl
etio
n of
pat
ient
saf
ety
impr
ovem
ent p
lan
mod
eled
afte
r AH
RQ
Cas
e
• A
vera
ge o
f 10
hour
s pe
r m
onth
ded
icat
ed to
the
prog
ram
(to
tal 9
0 ho
urs
requ
ired)
Bib
liog
rap
hy
Ker
foot
BP,
Con
lin P
R, T
ravi
son
T, M
cMah
on G
T. P
atie
nt s
afet
y kn
owle
dge
and
its d
iscr
imin
ants
in m
edic
al tr
aine
es. J
GIM
2007
; 22(
8): 1
150-
54.
Luet
cht R
M, M
adse
n M
K, T
augh
er M
P, P
ette
rson
BJ.
Ass
essi
ng p
rofe
ssio
nal p
erce
ptio
ns: d
esig
n an
d va
lidat
ion
of a
n
Inte
rdis
cipl
inar
y E
duca
tion
Per
cept
ion
Sca
le.
J A
llied
Hea
lth. 1
990
Spr
ing:
19(
2): 1
81-9
1.
WH
O M
ulti-
prof
essi
onal
Pat
ient
Saf
ety
Cur
ricul
um G
uide
, UR
L ht
tp://
ww
w.in
t/pat
ient
safe
ty/e
duca
tion/
curr
icul
um/e
n.in
dex.
htm
l
Wei
ss K
B, B
agia
n JP
, Nas
ca T
J. T
he C
linic
al L
earn
ing
Env
ironm
ent:
The
Fou
ndat
ion
of G
radu
ate
Med
ical
Edu
catio
n. J
AM
A.
2013
;309
:168
7-16
88.
Wei
ss K
B, W
agne
r R
, Nas
ca T
J. D
evel
opm
ent,
test
ing,
and
impl
emen
tatio
n of
the
AC
GM
E C
linic
al L
earn
ing
Env
ironm
ent
Rev
iew
(C
LER
) pr
ogra
m. J
Gra
d M
ed E
duc.
201
2;4:
396-
398
Mis
sio
n O
bje
ctiv
e
Met
rics
•
CLE
R O
utco
mes
•S
atis
fact
ion
& P
erce
ived
Ben
efits
: Adv
isor
s +
Adv
isee
s +
Exp
ert F
acul
ty
•A
ttend
ance
+ E
valu
atio
n of
Ext
ende
d Le
arne
rs v
ia T
each
ing
Ses
sion
s
•R
eten
tion
& P
rom
otio
n R
ates
of A
dvis
ees
•IP
E P
erce
ptio
ns (
Luec
ht e
t al,
JAH
199
0)
•K
now
ledg
e in
Pat
ient
Saf
ety
(Ker
foot
et a
l, JG
IM 2
007)
Ph
ase
I: F
irst
4 m
on
ths
1.O
rient
atio
n of
Par
ticip
ants
2.S
kill
build
ing:
Pat
ient
Saf
ety
& T
each
ing
3.N
eeds
ass
essm
ent
Ph
ase
II: M
on
ths
5-9
1.Te
achi
ng
2.P
atie
nt S
afet
y P
roje
ct
Impl
emen
tatio
n
3.E
valu
atio
n/ P
rese
ntat
ion
4.G
radu
atio
n
To b
uild
a c
ultu
re o
f saf
ety
by in
tegr
atin
g tr
aini
ng a
nd a
dvis
emen
t int
o th
e
educ
atio
n of
new
doc
tors
, nur
ses,
and
adv
ance
d pr
actit
ione
rs a
nd th
en
enga
ging
thes
e le
arne
rs a
s ag
ents
of
chan
ge.
Ad
mis
sio
n P
roce
ss
Invi
tatio
n to
join
the
prog
ram
was
pro
vide
d to
all
CH
S tr
aine
es in
grad
uate
med
ical
edu
catio
n, n
ursi
ng, a
dvan
ced
clin
ical
pra
ctic
e as
wel
l as
nurs
ing
team
mat
es in
tere
sted
in c
aree
r ad
vanc
emen
t in
patie
nt s
afet
y.
•C
HS
trai
nee
or te
amm
ate
in g
ood
stan
ding
•Le
tter
of s
uppo
rt b
y pr
ogra
m d
irect
or o
r su
perv
isor
•S
tron
g de
sire
for
gain
furt
her
know
ledg
e an
d ex
perie
nce
in p
atie
nt
safe
ty
•S
tron
g in
terp
erso
nal a
nd c
omm
unic
atio
n sk
ills
•C
ompl
etio
n of
sim
ple
8-qu
estio
n on
line
appl
icat
ion
A
dvis
ors
sele
cted
bas
ed o
n
expe
rienc
e in
qua
lity
impr
ovem
ent
and
patie
nt s
afet
y an
d de
sire
to g
ive
back
A
tota
l of 1
7 ad
vise
e ap
plic
atio
ns
rece
ived
R
evie
w c
omm
ittee
cho
se fi
nal 8
advi
sees
A
dvis
ors
assi
gned
two
advi
sees
for
4
tria
ds
Bac
k R
ow
: T
yle
r A
tkin
s, M
D;
Eri
c A
nd
erso
n, M
Ed
; M
iles
Nel
son
; M
ich
ael
Ru
hle
n, M
D.
Mid
dle
Ro
w:
Lis
a H
eber
t, P
A;
Liz
Dia
z, M
D;
Lis
a F
ost
er, R
N;
Cry
stal
Ben
cken
, R
N;
Kal
i E
llis
on; A
shle
y E
skew
, M
D.
Fro
nt
Ro
w:
Car
oli
ne
Dan
a, P
A;
Pam
Bec
kw
ith
, FA
CH
E;
Dan
elle
Hig
gin
s; L
isa
Ho
wle
y, P
hD
Mar
ch -
Jun
e Ju
ly -
Dec
embe
r
IP P
atie
nt
Saf
ety
Tra
inin
g
Tria
d Te
am
Adv
isor
Adv
isee
A
dvis
ee
42 of 131
Team: Christiana Care Focus Area: Patient Safety
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams
should identify members and define responsibility/purpose)
Christiana Care is a Major Teaching hospital which provides a clinical learning environment for more than 270 residents and fellows within 13 residency programs. The willingness of residents to report safety events and participate in forums to prevent adverse events is often shaped by the beliefs, experiences and infrastructure of the organization in which they train. Our approach to teaching patient safety and quality for residents is that the principles of patient safety and team based care will become embedded so deeply that residents instinctively follow these best practices. Our opportunity statement is 100% of our residents will demonstrate that Patient Safety is a part of their job within the next 12 months. We organized a CLER Steer group consisting of our Institutional DIO and VP of Academic Affairs, Program Director of Family & Community Medicine, Associate Patient Safety Officer & Vice Chair of Dept of Medicine, Quality & Safety Education Specialists, and an Administrative Assistant. This group led the design, implementation and evaluation of our initiative. In addition, a NI IV CLER Operations group consisting of Program Directors, Residents, Risk Management, and Quality & Safety convened and provided guidance and feedback during our initial planning stage of the initiative. One/two members of our CLER Steer also participated in monthly AIAMC NI IV group calls and attended four scheduled National Initiative meetings in 2013-2015.
II. Project Description See diagram for a depiction of our infrastructure at beginning of the initiative, the gaps we aimed to address, and the ideas/ solutions considered.
43 of 131
Project Description Continued…
Reporting data and a safety attitude assessment formed the basis for our effort and focus on the ACGME CLER area of Patient Safety. We found that many observe, few personally report ( <1% of all events reported by electronic form). When events are reported they are communicated through various paths, making it difficult to capture trends and patterns. While reporting safety events was perceived as part of their professional responsibility, the time to report and senior colleagues reporting attitudes influenced decisions to report. Blame and fear were less prominent factors. To increase resident engagement and participation in patient safety, we created a Resident Quality & Safety Council that consisted if faculty-resident dyads for all our residency programs. The Chairs and Programs Directors nominated the faculty –resident dyads participating in the council. The Council serves as a vehicle for enhancing communication between hospital committees and clinical departments, and provides a forum for teaching safety concepts, discussion/disseminating specific system efforts, developing new initiatives, collaboration across departments, participation in safety activities, data review, and providing feedback and solution generation for system level concerns. Illustration below. The council meets monthly for 1.5 hours with between session follow-up activities. Each council session typically includes a didactic portion, discussion of events/event reporting, report outs of dyad driven department Q&S activities/findings, and advisory or consult function for system level initiatives.
44 of 131
III. Necessary Resources
(staff, finances, etc.)
Resources contributing to successful implementation included • Protected time for faculty-resident dyads’
participation in council meetings & organizational committee meetings (time commitment of approximately 2-6 hours month)
• SharePoint Collaboration site to support sharing documents and reference materials
• Administrative support to schedule meetings , organize materials, prepare minutes, keep attendance log and level of participation data
• Faculty for select curricula and educational topics • Toolkits (electronic versions) for RCA, 5 WHYs, Cause
& Effect Diagrams, etc. • Access to data reports - event reports, intuitional
safety performance indicators – No Harm report, safety climate assessment survey results, participation charts
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
Key measures include: • Adverse Event Reporting rates by resident and programs
o Tracking monthly, reported quarterly. 45 of 131
o 2013-forward • Level of participation by residents in RCAs, Debriefs, Case
Conferences, department and system level quality committees/projects
o Chart. CCHS Residents Committee Activity – tracking monthly, reported twice/year
o May 2013-forward • Percent change in resident self-reported attitudes about
Patient Safety o Assessed annually o Baseline Feb-March 2014, re measure Feb 2015
• Formation of a resident safety council/committee (level of participation by dyads)
o Assessed monthly • # Resident led safety improvement initiatives/ activities
implemented o Assessed annually, June 2015
V. Communication Plan (may be helpful to draft a flow chart of team members & senior management,
both internal & external)
The Council receives reports of activities from System level committees (Safety First, Clinical Excellence, Think of Yourself as a Patient, GMEC, Risk Management). In addition, reports from other related committees/forums (e.g., Root Cause Analysis teams, Debriefing teams, VNA Quality & Safety Committee, Clinical Advisory Group, other Program specific committees) A summary of this Council’s activities are presented to the GMEC, Safety First, Chairs Leadership Council annually, as well as any others deemed appropriate.
VI. Accountability (list of team members and who
is accountable for what)
See Resident Quality & Safety Council Committee description.
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
Challenges: • Resident and program leadership engagement,
especially given the challenges of implementing the milestones in the NAS system.
• Resident engagement for creating a resident safety council/committee.
• Fiscal constraints for supporting these activities. • Addressing the skills gap for our faculty who will be
tasked with the implementation and reinforcement of these concepts related to patient safety.
• Time constraints for residents and faculty given the demands of residency training and balancing same with service and educational needs of the programs.
VIII. Markers (project phases, progress checks,
schedule, etc.; must partner/match measurement/data collection plan)
Milestone dates: • AIAMC NI IV Begins – Meeting One – October 2013 • Steer CLER Committee formed – December 2013 • ACGME CLER visit- January 2014
46 of 131
• President Cabinet presentation – January 2014 • Safety attitude assessment – Feb-Mar 2014 • NI IV CLER Operations group convened – February
2014 – concluded April 2014 • New resident orientation (Safety content revised)–
June 2014; • Resident-Faculty dyads nominations received,
approved by Chair – July-August 2014 • Resident Quality & Safety Council formed – August
2014 • GME Committee updates reported– January 2014,
November 2014 • Safety First Committee updates reported– November
2014, January 2015 • Data milestones reflected in measurement plan
above. IX. Vision Statement/Closing Plan
(markers of success by March 2015)
Vision statement. Movement from Current State to Future State where, • PS is NOT considered “extra”, but is considered “core”
regarding resident’s purpose/duty • PS is NOT project driven/not part of culture, but there is a culture of PS in daily work • PS is NOT someone else’s job, but is coordinated PS efforts through system • Recognition that there are unsafe events but gross under-reporting, to events are recognized, reported and new safety practices and system designs emerge and there is obvious faculty role modeling • Lots of great PS initiatives across our system but not coordinated and many do not involve physicians, to a future state that when asked, all residents will be able to confidently speak about PS and acknowledge how it aligns with Christiana Care’s goals During our study period, we were able to demonstrate more than a 2-fold increase in the total number of resident submitted SFLR reports. Safety attitudes remained relatively the same. It is unclear at this time whether quality and safety forums experienced during training shapes future participation and reporting as medical physician leaders. We believe that the culture within our residency programs, amongst our faculty, and within our institution needs to be aligned in order to create the highly reliable environment our patients and community deserves.
47 of 131
Figu
re-4
. Res
iden
t par
ticip
atio
n in
com
mitt
ees/
coun
cils
.
Intr
oduc
tion
Phys
icia
ns in
trai
ning
are
exc
eptio
nally
pos
ition
ed to
cre
ate
a po
sitiv
e sa
fety
cu
lture
whi
ch re
sults
in th
e de
liver
y of
safe
r pat
ient
care
. Will
ingn
ess t
o re
port
sa
fety
eve
nts a
nd p
artic
ipat
e in
foru
ms t
o pr
even
t adv
erse
eve
nts i
s ofte
n sh
aped
by
the
belie
fs, e
xper
ienc
es, a
nd in
fras
truc
ture
of t
he o
rgan
izatio
ns in
w
hich
they
trai
n. C
hrist
iana
Car
e, a
maj
or te
achi
ng h
ospi
tal,
prov
ides
the
clin
ical
lear
ning
env
ironm
ent f
or m
ore
than
270
resid
ents
/fel
low
s with
in 1
3 re
siden
cy p
rogr
ams.
Our
visi
on is
that
all
resid
ents
will
dem
onst
rate
that
pa
tient
safe
ty is
a p
art o
f the
ir pr
ofes
sion.
We
aim
ed to
incr
ease
resid
ent
enga
gem
ent a
nd p
artic
ipat
ion
in p
atie
nt s
afet
y th
roug
h th
e cr
eatio
n of
a
Resid
ent Q
ualit
y &
Saf
ety
Coun
cil t
hat c
onsis
ts o
f fac
ulty
–re
siden
t dya
ds fr
om
all o
ur re
siden
cy p
rogr
ams.
Deve
lopi
ng a
Res
iden
t Qua
lity
& S
afet
y Co
unci
l:
Inte
grat
ing
Repo
rtin
g an
d Im
prov
emen
t Sci
ence
into
Dai
ly W
ork
Li
sa M
axw
ell,
M.D
., N
eil J
asan
i, M
.D.,
Robe
rt D
ress
ler,
M.D
.,
Lore
tta
Cons
iglio
-War
d, M
.S.N
., Ca
rol K
errig
an M
oore
, M.S
. Ch
ristia
na C
are
Heal
th S
yste
m, N
ewar
k-W
ilmin
gton
, Del
awar
e
Met
hods
Re
port
ing
data
, a sa
fety
att
itude
ass
essm
ent1,
2 , a
nd fe
edba
ck fr
om a
n AC
GM
E CL
ER v
isit f
orm
ed th
e ba
sis fo
r our
effo
rt a
nd fo
cus o
n Pa
tient
Saf
ety.
We
foun
d th
at w
hile
man
y re
siden
ts o
bser
ve sa
fety
eve
nts,
few
per
sona
lly
repo
rt th
em (
<1%
of a
ll ev
ents
repo
rted
by
elec
tron
ic fo
rm).
And
, if e
vent
s ar
e re
port
ed, t
hey
are
com
mun
icat
ed th
roug
h va
rious
pat
hs, m
akin
g it
diffi
cult
to c
aptu
re tr
ends
and
pat
tern
s.
To in
crea
se re
siden
t eng
agem
ent a
nd p
artic
ipat
ion
in p
atie
nt sa
fety
, we
crea
ted
a Re
siden
t Qua
lity
& S
afet
y (Q
&S)
Cou
ncil
that
con
sists
of f
acul
ty-
resid
ent d
yads
for a
ll ou
r res
iden
cy p
rogr
ams.
Cha
irs a
nd P
rogr
ams D
irect
ors
nom
inat
ed th
e pa
rtic
ipat
ing
facu
lty–r
esid
ent d
yads
. Th
e Co
unci
l ser
ves a
s a
vehi
cle
for e
nhan
cing
com
mun
icat
ion
betw
een
hosp
ital c
omm
ittee
s and
cl
inic
al d
epar
tmen
ts, a
nd p
rovi
des a
foru
m fo
r tea
chin
g sa
fety
con
cept
s,
disc
ussin
g/di
ssem
inat
ing
spec
ific
syst
em e
ffort
s, d
evel
opin
g ne
w in
itiat
ives
, co
llabo
ratio
n ac
ross
dep
artm
ents
, par
ticip
atio
n in
safe
ty a
ctiv
ities
, dat
a re
view
, and
pro
vidi
ng fe
edba
ck a
nd so
lutio
n ge
nera
tion
for s
yste
m le
vel
conc
erns
(Fig
ure-
1).
The
coun
cil m
eets
mon
thly
for 1
.5 h
ours
with
ass
ignm
ent
of b
etw
een
sess
ion
activ
ities
. Ea
ch se
ssio
n ty
pica
lly in
clud
es d
idac
tics,
di
scus
sion
of e
vent
s/ev
ent r
epor
ting,
repo
rt o
uts o
f dya
d dr
iven
Q&
S ac
tiviti
es/ f
indi
ngs,
and
adv
ice
or c
onsu
ltatio
n on
syst
em le
vel i
nitia
tives
. The
Co
unci
l rep
orts
act
iviti
es to
the
syst
em’s
GM
EC a
nd S
afet
y Co
mm
ittee
s.
Key
mea
sure
s of e
ffect
iven
ess i
nclu
ded
repo
rtin
g cl
imat
e da
ta (#
resid
ent
subm
itted
eve
nts r
epor
ted
sort
ed b
y de
part
men
t), r
esid
ent p
artic
ipat
ion
in
com
mitt
ees/
coun
cils,
and
per
cent
cha
nge
in se
lf-re
port
ed a
ttitu
des a
bout
pa
tient
safe
ty. (
Figu
res 2
-5.) Re
fere
nces
1
O’L
eary
, KJ e
t al.
Hosp
ital Q
ualit
y an
d Pa
tient
Saf
ety
Com
pete
ncie
s: D
evel
opm
ent,
Desc
riptio
n, a
nd
Reco
mm
enda
tions
for U
se. J
ourn
al o
f Hos
pita
l Med
icin
e. 2
011:
0(0)
:1-7
. 2 B
oike
, JR
et a
l. Pa
tient
Saf
ety
Even
t Rep
ortin
g Ex
pect
atio
n: D
oes i
t Inf
luen
ce R
esid
ents
’ Att
itude
s and
Rep
ortin
g Be
havi
ors?
Jour
nal o
f Pat
ient
Saf
ety.
2013
:9(2
): 59
-67.
Conc
lusi
ons
Durin
g ou
r stu
dy p
erio
d, w
e w
ere
able
to d
emon
stra
te m
ore
than
a 2
-fold
incr
ease
in
the
tota
l num
ber o
f res
iden
t sub
mitt
ed S
FLR
repo
rts .
Saf
ety
attit
udes
rem
aine
d re
lativ
ely
the
sam
e. It
is u
ncle
ar a
t thi
s tim
e w
heth
er q
ualit
y an
d sa
fety
foru
ms
expe
rienc
ed d
urin
g tr
aini
ng sh
apes
futu
re p
artic
ipat
ion
and
repo
rtin
g as
med
ical
ph
ysic
ian
lead
ers.
We
belie
ve th
at th
e cu
lture
with
in o
ur re
siden
cy p
rogr
ams,
am
ongs
t our
facu
lty, a
nd w
ithin
our
inst
itutio
n ne
eds t
o be
alig
ned
in o
rder
to
crea
te th
e hi
ghly
relia
ble
envi
ronm
ent o
ur p
atie
nts a
nd c
omm
unity
des
erve
s.
•Fa
culty
- res
iden
t dya
d pa
rtic
ipat
ion
not o
nly
enab
led
effe
ctiv
e d
issem
inat
ion
of
qual
ity a
nd sa
fety
initi
ativ
es w
ithin
and
bet
wee
n pr
ogra
ms b
ut a
lso st
reng
then
ed
men
torin
g re
latio
nshi
ps.
•Pr
ovid
ing
prot
ecte
d tim
e fo
r par
ticip
atio
n in
cou
ncil
mee
tings
and
org
aniza
tiona
l co
mm
ittee
mee
tings
was
crit
ical
.
•Cu
rric
ula
wer
e in
tegr
ated
to a
ddre
ss th
e sk
ills g
ap fo
r im
plem
enta
tion
and
rein
forc
emen
t of f
unda
men
tal p
atie
nt sa
fety
con
cept
s.
•Ac
cess
to d
ata
repo
rts a
nd th
e av
aila
bilit
y of
(ele
ctro
nic)
tool
kits
for R
CA, 5
WHY
s,
Caus
e &
Effe
ct D
iagr
ams s
uppo
rted
val
uabl
e co
unci
l out
put.
•
Enth
usia
sm to
seek
the
Resid
ent Q
ualit
y &
Saf
ety
Coun
cil’s
adv
ice
was
un
expe
cted
, inc
ludi
ng sp
ecifi
c re
ques
ts fr
om C
EO/C
OO
to h
elp
prob
lem
solv
e ex
cess
ive
capa
city
issu
es.
Disc
ussi
on
Resu
lts
Figu
re-1
.
Figu
re-2
. Res
iden
t rep
ortin
g cl
imat
e.
Figu
re-3
. Rep
orts
subm
itted
by
prog
ram
.
Pos
ter p
rinte
d by
Chr
istia
na C
are
Hea
lth S
ervi
ces
2015
03xx
Cont
act:
Lisa
Max
wel
l, M
D -
LMax
wel
l@ch
ristia
naca
re.o
rg ;
Nei
l Jas
ani,
MD
- NJa
sani
@ch
ristia
naca
re.o
rg ;
Ro
bert
Dre
ssle
r, M
D - R
Dres
sler@
chris
tiana
care
.org
; Ca
rol K
. Moo
re, M
S - C
aMoo
re@
chris
tiana
care
.org
;
Lore
tta
Cons
iglio
-War
d, M
SN -
LCo
nsig
lio-W
ard@
chris
tiana
care
.org
# Co
mm
ittee
s#
Resi
dent
sRC
A &
Deb
riefs
4691
Hosp
ital C
omm
itees
2769
Depa
rtm
enta
l Com
mitt
ees
3164
Data
Sou
rce:
GM
E lo
g of
resi
dent
par
ticip
atio
n in
hea
lth s
yste
m fo
rum
s, 0
5/13
-02/
15.
Resi
dent
Par
ticip
atio
n in
Com
mitt
ee/ C
ounc
ils
M1
M2
% C
hang
eDa
ta S
ourc
e/ M
easu
re (M
1, M
2)
RCA
& D
ebrie
fs28
49↑
75%
GME
log
of re
side
nt p
artic
ipat
ion
in h
ealth
sys
tem
foru
ms.
1st m
easu
re (0
6/13
-2/1
4), 2
nd m
easu
re (0
6/14
-02/
15)
# Re
side
nt
Subm
itted
Eve
nts
108
288
↑16
7%Ri
sk M
gt e
vent
repo
rtin
g sy
stem
. 1s
t mea
sure
(01/
2013
-12/
2013
), 2n
d m
easu
re (0
1/20
14-1
2/20
14)
Figu
re-5
. Saf
ety
attit
udes
.
48 of 131
Team: CHMC Focus Area: Transitions of Care
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
To apply the standardization of resident to resident hand-offs across all aspects of patient transfer within the hospital, services, outpatient and discharge. Requirements- OSHE- expanded/developed for each ToC setting Assumption- That OSHE applies across handoff settings (template) Members- residents, patients, attendings, medicare, et. cetera, ROI benefits, social workers, discharge nurses, ACGME regulation bodies
II. Project Description
Using our QI projects, COPD, CHF, we identified that follow up appointments are critical in reducing readmission. This will serve as the topic for applying our template. We are interested in using OSHE to evaluate handoffs for all providers of care. Currently, we evaluate resident to resident handoffs, but other areas of transfer that need to be examined are inter-hospital, rehabilitation, nursing homes, et cetera.
III. Necessary Resources (staff, finances, etc.)
We have a functioning leadership team that consists of GME and hospital and QI leaders. We have resident to resident hand-off development. We need a training program, specific definitions. OSHE- simulation center TOC Task Force support
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
Analyze Resident 2Resident OSHE data first- make recommendations Qualitative data on COPD/CHF discharge instructions and follow up Analyze Qualitative data to identify TOC gaps for each aspect of care and to evaluate fit/utility of template Other data will be generated throughout: ROI data for financial impact Knowledge and impact on education through pre and post surveys Teamwork (SAQ)- to examine impact on the organization Resident satisfaction Clinical data on patient care
V. Communication Plan (may be helpful to draft a flow chart of
team members & senior management, both internal & external)
Residents have focus groups with patients (move to bottom of cell) GME TOC TF Crittenton leaders Hospital Administration/ QI FM QI Patient TY Residents IM CNO
VI. Accountability (list of team members and who
is accountable for what)
TOC TF report out monthly, finish project in 18 months GME-provide project leadership Programs—provide evaluation scenario
49 of 131
Residents for participation VII. Potential Challenges
(engagement, budget, time, skills gaps, etc)
Program engagement and attention to scheduling and debriefing needs. Activity requires dedicated administrative time over the course of the AY for planning, scheduling, and analysis.
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
2013-2014—Pilot was successful. All programs participated. Pre and post OSHE data were collected. Faculty champions debriefed residents. We concluded that a standard setting was needed and would host all programs at Kado Clinical Skills Center. Increased emphasis on resident feedback was noted and attended to for following academic year. 2014-2015—All programs participated and anticipated the activity. GME staff attended a didactic session to review the activity prior to the actual day. More instruction was provided to resident feedback. In addition to the typical duties, faculty champions wanted to edit their cases for the 2015-2016 year. This is in progress. Pre and post changes need to be examined further. Our institution also is looking to link the activity with our need for program monitoring of handoffs.
IX. Vision Statement/Closing Plan (markers of success by March 2015)
We were able to demonstrate that institution-wide Transitions of Care educational interventions were possible and sustainable while accounting for specialty variability.
50 of 131
Ove
rall
Goa
l/Ab
stra
ct
WSU
GM
E se
t out
to c
reat
e an
inst
itutio
nal
inte
rven
tion
on T
rans
ition
s of C
are
(ToC
) edu
catio
n
Form
al e
duca
tion
on d
eliv
erin
g ef
fect
ive
hand
offs
is a
kn
own
need
for r
esid
ency
pro
gram
s
The
use
of a
stan
dard
ized
pro
cess
save
s tim
e an
d pe
rmits
col
labo
ratio
n am
ong
prog
ram
s
Defin
e ToC
Impl
emen
ting
an In
stitu
tiona
l Obj
ectiv
e Si
mul
ated
Ha
ndof
f Eva
luat
ion
(OSH
E) fo
r Ass
essi
ng
Resi
dent
Han
doff
Ski
ll Di
llon,
L, M
arko
va, T
., &
Cot
tichi
a, J.
W
ayne
Sta
te U
nive
rsity
and
Crit
tent
on H
ospi
tal
Med
ical
Cen
ter,
MI
Back
grou
nd
Afte
r the
impl
emen
tatio
n of
our
ToC
inst
itutio
nal
polic
y, T
oC ta
sk fo
rce
mem
bers
iden
tifie
d a
need
for
mon
itorin
g re
side
nt h
ando
ff qu
ality
The
task
forc
e de
velo
ped
a st
anda
rdiz
ed te
mpl
ate
to b
e us
ed b
y al
l pro
gram
s for
writ
ten
hand
offs
For 2
012-
2013
, the
task
forc
e vo
ted
to re
plic
ate
Farn
an
et a
l. by
requ
iring
resi
dent
s to
com
plet
e an
OSH
E
Each
pro
gram
des
igne
d a
case
and
eve
nt th
at ju
nior
re
side
nts w
ould
han
doff
to se
nior
resi
dent
s.
Part
icip
ants
and
Pro
cedu
re
A to
tal o
f 82
resi
dent
s com
plet
ed th
e O
SHE,
whi
ch is
a
91%
par
ticip
atio
n ra
te
Facu
lty c
ham
pion
s hos
ted
dida
ctic
sess
ion
on T
oC,
secu
red
resi
dent
ava
ilabi
lity,
scor
ed th
e w
ritte
n ha
ndof
f, an
d pr
ovid
ed re
side
nt fe
edba
ck
Seni
or re
side
nts s
core
d th
e ve
rbal
han
doff
and
gave
fe
edba
ck
Mat
eria
ls/M
etho
ds
Bibl
iogr
aphy
Barr
iers
Enc
ount
ered
/Lim
itatio
ns-
Col
labo
rate
with
sim
ulat
ion
cent
er e
arly
on
to
esta
blis
h a
stan
dard
ized
pro
cedu
re
Link
OSH
E pe
rfor
man
ce to
dire
ct o
bser
vatio
n of
ha
ndof
fs
Trac
k an
d co
mpa
re re
side
nt p
erfo
rman
ce o
ver t
ime
Shap
e ca
ses o
ver t
ime
to a
ccom
mod
ate
chan
ging
pr
ogra
m n
eeds
Resu
lts (d
ata
gath
ered
bot
h qu
ant &
qua
l.)
Conc
lusi
ons
Inst
itutio
nal e
duca
tiona
l int
erve
ntio
ns a
ccom
plis
h se
vera
l obj
ectiv
es si
mul
tane
ousl
y. It
is a
de
mon
stra
tion
of G
ME
enga
gem
ent,
perm
its p
olic
y m
onito
ring
that
doe
s not
det
ract
from
its e
duca
tiona
l fo
cus
OSH
E is
a si
mpl
e, b
ut e
ffect
ive
tool
for s
ampl
ing
ho
w fa
culty
and
resi
dent
s del
iver
han
doffs
and
pr
ovid
e an
ong
oing
opp
ortu
nity
to re
fine
hand
off
educ
atio
n
Facu
lty e
ngag
emen
t fro
m a
ll pr
ogra
ms t
hrou
gh a
n
inst
itutio
nal t
ask
forc
e pr
ovid
ed p
latfo
rm fo
r OSH
E
impl
emen
tatio
n w
as k
ey
OSH
E ha
s bec
ome
an a
nnua
l mon
itorin
g to
ol fo
r pr
ogra
m c
ompl
ianc
e w
ith th
e in
stitu
tiona
l ToC
pol
icy
Seni
or re
side
nts r
epor
ted
diffi
culty
in g
ivin
g
feed
back
to a
fello
w re
side
nt. A
s a re
sult,
feed
back
ex
pect
atio
ns w
ere
adde
d to
the
dida
ctic
com
pone
nt
Succ
ess F
acto
rs a
nd L
esso
ns L
earn
ed
Farn
an, J
. M.,
Paro
, J. A
., R
odrig
uez,
R. M
., R
eddy
, S. T
., H
orw
itz, L
. I.,
John
son,
J. K
., &
Aro
ra, V
. M.
(201
0). H
and-
off e
duca
tion
and
eval
uatio
n: p
ilotin
g th
e ob
serv
ed si
mul
ated
han
d-of
f exp
erie
nce
(OSH
E). J
ourn
al o
f gen
eral
inte
rnal
med
icin
e, 2
5(2)
, 129
-134
G
ordo
n, M
, Fin
dley
, R. E
duca
tiona
l int
erve
ntio
ns to
impr
ove
hand
over
in h
ealth
car
e: A
syst
emat
ic
revi
ew. M
ed E
duc.
201
1; 4
5(11
):108
1-10
89.
Hor
witz
, L. I
., D
ombr
oski
, J.,
Mur
phy,
T. E
., Fa
rnan
, J. M
., Jo
hnso
n, J.
K.,
& A
rora
, V. M
. (20
13).
Valid
atio
n of
a h
ando
ff as
sess
men
t too
l: th
e H
ando
ff C
EX. J
ourn
al o
f clin
ical
nur
sing
, 22(
9-10
), 14
77-
1486
. H
orw
itz L
I, K
rum
holz
HM
, Gre
en M
L, H
uot S
J. Tr
ansf
ers o
f pat
ient
car
e be
twee
n ho
use
staf
f on
the
inte
rnal
med
icin
e w
ards
: A n
atio
nal s
urve
y. A
rch
Inte
rn M
ed. 2
006;
166:
1173
–7.
Lang
dale
L, S
chaa
d D
, Wip
f J, M
arsh
all S
, Von
tver
L, S
cott
CS.
Pre
parin
g gr
adua
tes
for t
he fi
rst y
ear
of re
side
ncy:
are
med
ical
scho
ols m
eetin
g th
e ne
ed? A
cad
Med
. 200
3;78
(1):3
9–44
.
Figu
re 1
. O
utlin
es a
ll as
pect
s of t
he
proc
edur
e fo
llow
ed
Surv
ey re
sults
indi
cate
d re
side
nt c
onfid
ence
in p
icki
ng u
p a
new
serv
ice
sign
ifica
ntly
incr
ease
d (,
t = 2
.12,
(63)
, p <
.05.
), al
ong
with
impr
oved
ab
ility
to m
ake
cont
inge
ncy
plan
s, t =
2.0
0, (6
3), p
< .0
6, h
ow to
per
form
a
read
bac
k, t
= 2.
08, (
63),
p <
.05,
and
whe
n to
per
form
a re
ad-b
ack,
t =
2.78
, (63
), p
< .0
1. W
ritte
n te
mpl
ate
scor
es, v
arie
d by
pro
gram
(bel
ow).
51 of 131
Team: Florida Hospital Focus Area: Patient Safety
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams
should identify members and define responsibility/purpose)
The main focus of our project was to develop an effective patient safety curriculum for faculty and residents using as a framework a collaboration between the Graduate Medical Education and the Performance Improvement Department based on a comprehensive Mortality Learning Program for the Hospital.
II. Project Description
Residents assigned to participate on a Morbidity and Mortality presentation for their program were included in this project. The curriculum was divided on four phases: 1) Three modules on the study of medical errors, the science of human error and principles of high reliability. 2) Review of training charts using a clinical triggers methodology. 3) Review of the real case using the tools and format of the Florida Hospital Mortality review Program 4) M & M presentation to Resident Group.
III. Necessary Resources (staff, finances, etc.)
The Florida Hospital Mortality Review Program is funded by the Performance Improvement Department. Graduate Medical Education contributes with 0.25 FTE Faculty Support for expert review of cases as needed by the clinical analyst team and to support resident education related to M&M discussion and patient safety training.
IV. Measurement/Data Collection Plan The measurements are divided on process measures in terms of number of residents completing the patient safety curriculum, and outcomes measures directed at evaluating changes in behavior such as reporting of safety events and quality improvement projects in this area.
V. Communication Plan (may be helpful to draft a flow chart of team members & senior management,
both internal & external)
The structure of the project involves communication between senior leadership and faculty and residents on both the performance improvement department and graduate medical education. Dissemination of information for faculty and residents uses traditional methods. A description of the curriculum was presented as part of the faculty development series.
VI. Accountability (list of team members and who
is accountable for what)
Performance Improvement Clinical Analysts: Support operational needs of the mortality review program and provide feedback to rotating residents on the application of the clinical trigger methodology. Medical Director of the Program: 0.25 Faculty FTE . Support operational needs of the program. Supervise and guide rotating residents. Delivery of curriculum.
52 of 131
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
Get buy in from participating residents on the importance of a patient safety curriculum Time constraints created by competing responsibilities for faculty and residents
VIII. Markers The project and curriculum was divided on four phases: 1) Three modules on the study of medical errors, the science of human error and principles of high reliability. 2) Review of training charts using a clinical triggers methodology. 3) Review of the real case using the tools and format of the Florida Hospital Mortality review Program 4) M & M presentation to Resident Group.
IX. Vision Statement/Closing Plan
Residents at Florida hospital will participate on a patient safety curriculum that engages them on a culture of high reliability and system redesign approach to the mitigation of medical errors.
X. Success Factors The most successful component of our work was………..Engaging Faculty and residents on a patient safety curriculum We were inspired by………………..Institutional commitment to advancing a culture of patient safety and high reliability.
XI. Barriers The largest barrier we encountered was, lack of familiarity with the implications of patient safety for the medical profession. We worked to overcome this by: Discussing implications of Patient Safety not only at the patient level but also for the healthcare system and individual doctor practice.
XII. Lessons Learned The single most important piece of advice to provide another team embarking on a similar initiative would be: Importance of institution support, getting buy in from residents and faculty.
XIII. Expectations Versus Results 8
XIV. Satisfaction 8
XV. Project Impact Increased competencies related to curriculum development in patient safety. Promotion of a high reliability culture that moves from a punitive to a system redesign focus when thinking about patient safety events.
XVI. Next Steps The initial focus has been the IM residency program. We plan to expand curriculum to other residency program and support their M&M presentations.
53 of 131
Ove
rall
Goa
l/Ab
stra
ct
This
proj
ect d
escr
ibes
the
deve
lopm
ent a
nd
impl
emen
tatio
n of
an
stru
ctur
ed p
atie
nt
safe
ty c
urric
ulum
in g
radu
ate
med
ical
ed
ucat
ion
base
d on
the
Flor
ida
Hosp
ital
Mor
talit
y Le
arni
ng P
rogr
am.
ADVA
NCI
NG
PAT
IEN
T SA
FETY
EDU
CATI
ON
TH
ROU
GH
A SY
STEM
ATIC
MO
RTAL
ITY
LEAR
NIN
G P
ROG
RAM
Vi
ctor
Her
rera
, MD,
Jose
ph P
orto
ghes
e,M
D, D
epar
tmen
t of G
radu
ate
Med
ical
Edu
catio
n, F
lorid
a Ho
spita
l, O
rland
o, F
lorid
a
Flor
ida
Hosp
ital,
Orla
ndo
/ Fl
orid
a
Back
grou
nd
Ther
e is
a ne
ed to
impr
ove
the
teac
hing
of
Patie
nt S
afet
y in
Gra
duat
e M
edic
al E
duca
tion.
Tr
aditi
onal
form
ats s
uch
as le
ctur
es h
ave
not
been
effe
ctiv
e on
eng
agin
g re
siden
ts o
n a
patie
nt sa
fety
cul
ture
. Cas
e ba
sed
and
expe
rient
ial l
earn
ing
have
dem
onst
rate
d to
ad
vanc
e sk
ills a
nd c
hang
e be
havi
ors.
Visi
on S
tate
men
t
Resid
ents
will
acq
uire
the
skill
s, k
now
ledg
e an
d a
ttitu
des n
eces
sary
to b
ecom
e le
ader
s in
the
deve
lopm
ent a
nd im
plem
enta
tion
of
initi
ativ
es th
at m
itiga
te p
atie
nt h
arm
and
ad
vanc
e a
cultu
re o
f hig
h re
liabi
lity
in
heal
thca
re.
Mat
eria
ls/M
etho
ds/R
esul
ts
An
stru
ctur
ed c
urric
ulum
usin
g ca
se b
ased
ex
erci
ses a
nd in
tera
ctiv
e de
liver
y of
con
tent
w
as d
evel
oped
usin
g as
a fr
amew
ork
the
Flor
ida
Hosp
ital M
orta
lity
Lear
ning
Pro
gram
. Res
iden
ts
assig
ned
to p
lan
a M
orta
lity
and
Mor
bidi
ty
pres
enta
tion
part
icip
ated
on
a tw
o ph
ases
tr
aini
ng u
nder
facu
lty su
perv
ision
, with
em
phas
is on
pat
ient
safe
ty e
duca
tion
and
lear
ning
of t
he IH
I Glo
bal T
igge
r Met
hodo
logy
as
it re
late
s to
Mor
talit
y Re
view
s.
Bibl
iogr
aphy
w
ww
.ihi.o
rg
ww
w.a
cgm
e.or
g/cl
er/
Heal
th A
ffairs
, 30,
no.
4 (2
011)
:581
-589
.
Can
J Sur
g. F
eb 2
005;
48(
1): 3
9–44
.
Succ
ess F
acto
rs
Resid
ent e
ngag
emen
t was
facil
itated
by us
ing re
al mo
rbidi
ty an
d mor
tality
case
s
An st
ructu
red e
viden
ce-b
ased
meth
odolo
gy ba
sed o
n the
ho
spita
l mor
tality
revie
w pr
ogra
m pr
ovide
d an e
ffecti
ve
frame
work
to tea
ch pa
tient
safet
y
Co
nclu
sion
s
Mor
talit
y Re
view
Pro
gram
s offe
r an
oppo
rtun
ity to
tr
ain
resid
ents
on
prin
cipl
es o
f pat
ient
safe
ty a
nd
high
relia
bilit
y. A
n ad
vers
e ev
ent m
easu
ring
and
trac
king
clin
ical
trig
gers
met
hodo
logy
pro
vide
s a
fram
ewor
k to
del
iver
the
cont
ent u
sing
a ca
se b
ased
an
d in
tera
ctiv
e fo
rmat
.
.
54 of 131
Team: Regions Hospital/HealthPartners Focus Area: Quality Improvement /Patient Safety
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
A video explaining NI IV and CLER was created and sent to team members prior to the first meeting on December 5, 2013. Team Members: Kelly Frisch – Project Co-Leader, Assistant DIO Josh Peltier – Project Co-Leader, G2 Emergency Medicine Resident Julie Cole – GME Accreditation Manager Felix Ankel - DIO Jen Augustson – Sr. Director Ed Administration Brad Gordon – Med Informatics Beth Heinz – VP Operations, Chief Quality Officer Julibeth Lauren – Dir. of Nursing Practice/Education/Research Willie Braziel – GME Manager of Operations Heidi Conrad – CFO, Regions Scott Oakman – Psychiatry Program Director Terry Crowson – Assoc. Med Director, HP Deb Friend – Director, Patient Safety/Corporate Compliance Michelle Island – Pt. Safety Program Manager
II. Project Description
Regions Hospital and the Institute for Education and Research conducted a gap analysis to identify innovative solutions to be fully prepared for a CLER visit. The vision is to align operations with Graduate Medical Education. The team decided to focus on two areas: Error Reporting and Integrating Residents into Hospital Quality Initiatives.
III. Necessary Resources (staff, finances, etc.)
Financial resources are available to cover NI expenses: AIAMC fee, meeting registration fees, travel expenses, etc. Team meets face-to-face nearly every other month. The team collaborated with HP Institute for Education and Research E-Learning Team to develop “Good Catch” Video.
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
Not applicable at this stage in the project
V. Communication Plan (may be helpful to draft a flow chart of team
members & senior management, both internal & external)
Almost all communication for these projects was done via email or during in-person meetings. No major plan was necessary for the project team itself. Communication to the residents was done via GME office emails or at presentations at GMEC. The Good Catch Reporting video is the main communication tool used to inform residents of the process. The QI integration project was primarily done through hospital leadership and GME program leadership. Two quality summits were created to bring the stakeholders to the table. Additional communication was sent via email.
VI. Accountability (list of team members and who
is accountable for what)
Error Reporting: Hospital Leadership (Patient Safety, Informatics, etc) – Responsible for changes to the error reporting tool and process. Provide reporting data to inform the team. Create video content via script writing; participate on camera in the video. GME Leadership – Develop processes to relay video and other communications to all trainees at Regions Hospital. Work with Program Directors and Coordinators to ensure they are making it a priority with their trainees. Create video content via script writing; participate on camera in the video. Quality Integration: Hospital Leadership – Update Quality web site to include new QI training curriculum and create and update a QI project registry.
55 of 131
GME Leadership – Understand hospital QI process, resources, etc. Help establish a process for residents (and faculty assisting residents) to follow when creating a new project or participating in an existing project and utilizing hospital QI resources.
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
We feel we have the right expertise and talent. Time commitment is always an issue in every organization, but we’ll work on making this project a priority and mitigating any potential engagement challenges. The team leaders created a video and sent it to team members prior to the first meeting. This was intended to motivate them and obtain their support.
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
Error Reporting: • Determine new method of reporting errors - COMPLETE • Develop teaching tool and communication plan • New reporting available in EPIC – called Good Catch - COMPLETE • Training tool to be a video (collaborating with the E-Learning
team) - COMPLETE • Write script, assign video roles, film video - COMPLETE • Develop survey to send to trainees pre and post-video -
COMPLETE • Determine how to send out video – to RGHP trainees and
affiliates - COMPLETE • Send out pre-video survey - COMPLETE • Send out video - COMPLETE • Send out post-video survey - COMPLETE
Aligning Residents with Hospital Quality Initiatives: • Work with hospital Performance Improvement Coordinator on
the development of training modules and a QI project database, and other tools to align hospital quality initiatives with training programs. – COMPLETE
• Quality officer new member of GMEC - May 2014 - COMPLETE • Quality Summit – November 2, 2014 – QI curriculum and
updated database now available online - COMPLETE • Quality Summit – February 9, 2015 – Determined need for
program or resident-initiated QI project database. This database is currently in creation and will be added as a separate link on the QI registry web site. Additionally, faculty mentors were named as resources for program faculty who work with trainee projects.
IX. Vision Statement/Closing Plan (markers of success by March 2015)
By March 2015- • Video has been released, surveys indicate increase in awareness
and error reporting. Roll out to faculty and other members of the health care team.
• Database of hospital and resident quality improvement projects created, training modules developed and available, QI resources (statistician) available to residents leading to increased resident involvement in hospital QI initiatives. GME leaders will also present resident QI statistics at quarterly hospital leadership meetings.
Upon completion of the NI IV project, this project team will merged into Learning Environment Committee – to assess CLER focus areas in an ongoing manner. Both of these projects will be monitored under this new committee.
56 of 131
X. Success Factors The most successful component of our work was achieving full collaboration with our hospital operations partners. This project allowed each party to benefit from the results; it wasn’t just a GME project with hospital operations members participating. We were inspired by how willing every individual was to carry this out. And how willing they are to continue participating by joining our Learning Environment Committee.
XI. Barriers The largest barrier we encountered was engaging our affiliate residents. They make up two-thirds of the trainees at our institution and may only spend one or two months at our hospital. We worked to overcome this by engaging the site coordinators, site directors and by working with their sponsoring institution to help increase awareness.
XII. Lessons Learned The single most important piece of advice to provide another team embarking on a similar initiative would be to engage hospital leadership early, prior to the project starting. Our DIO and Assistant DIO did a lot of work to ensure that GME was on the radar of hospital leaders, to ensure that GME leaders were at the table with hospital leadership. In this project, GME leadership also made it a point of listening to ideas, incorporating ideas and making sure everyone invited to the table feels like this is going to benefit their patients, institution and organization in one way or another. This all helped pave the way for collaboration on this project (and will help for future projects as well).
XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10 Ultimately, learning tools for error reporting were created and QI resources and databases are now in place. Resident results are still ongoing and we cannot yet say how effective we were.
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI III work? 1 2 3 4 5 6 7 8 9 10 We were able to create a solid infrastructure for GME and Hospital Operations alignment that will continue well beyond this project.
XV. Project Impact Our NI IV projects were successful in their attempt to align GME with Hospital Operations and now, nearing the end, there is still a lot of energy around this type of work. Therefore, it will continue through a new, ongoing committee called the “Learning Environment Committee.” This committee will include many of the same individuals, but will open up membership to more trainees and more program representatives. We have also seen greater resident interest in participating in institution-wide projects. The resident participants for the Learning Environment Committee have increased from the number on the Good Catch Project. Additionally, the Performance Improvement team from the hospital will now list resident QI projects next to their QI database to ensure that both educators and hospital administrators have an understanding of the full extent of QI scholarly work at our institution. GME Leadership will now present resident scholarly work at quarterly hospital leadership meetings.
XVI. Next Steps Error Reporting: We plan to incorporate the Good Catch video into New Resident Orientation from now on. Also, we will work with our GME
57 of 131
partners across the region to develop Twin-Cities-wide curriculum around error reporting focusing on what types of events constitute a report. Quality Integration: Faculty QI leaders have been assigned to assist program directors and faculty mentors on managing trainees’ QI projects. Additionally, a database of hospital QI projects and a resident QI database will be established to inform mentors/residents/faculty of the possible available projects/support.
58 of 131
“Goo
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tch”
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t Rep
ortin
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Josh
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tier M
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lly F
risch
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el M
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egio
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mer
genc
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edic
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Paul
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ealth
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lts
Refe
renc
es
1.W
eiss
KB,
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ner R
, Nas
ca T
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stin
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plem
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ram
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rad
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c. 2
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-398
. 2.
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ss K
B, W
agne
r R, B
agia
n JP
, New
ton
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atow
CA,
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ca T
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vanc
es in
the
ACGM
E Cl
inic
al L
earn
ing
Envi
ronm
ent R
evie
w (C
LER)
Pr
ogra
m. J
Gra
d M
ed E
duc.
201
3;5(
4):7
18-7
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nclu
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Resu
lts
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s cite
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re
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re 1
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re 2
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re 3
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59 of 131
Team: Jersey Shore University Medical Center, Neptune, NJ Focus Area: Quality Improvement
I. Team Charter/Objecti
ves (‘needs
statement,’ project
requirements, project
assumptions, stakeholders, etc.; Teams
should identify members and
define responsibility/
purpose)
Needs Statement: All categorical residents at Jersey Shore University Medical Center (JSUMC: Jersey Shore) need to participate in formal training in Quality Improvement (QI) as well as take on a practical experience to be prepared for the healthcare environment of the future. Project Requirements and Assumptions: These objectives need to be met through a combination of on-line learning and engagement with process improvement and clinical mentors who can offer guidance as they design and lead their own hands-on QI project. Stakeholders: All residency training programs sponsored by Jersey Shore, Outcomes Management, and Clinical Effectiveness Team Members and Responsibilities: David Kountz, MD – DIO; overall project oversight Andrew Blechman, MD – Program Director, Ob Gyn – project implementation in Obstetrics and Gynecology Mayer Ezer, MD – Program Director, Internal Medicine – project implementation in Internal Medicine Paul Schwartzberg, DO – Program Director, Pediatrics – project implementation in Pediatrics Rachael Polis, DO – Resident, Ob Gyn – resident perspective and liaison with JSUMC residents to support project implementation Brenda Capuano – Outcomes Management – identify potential teams for residents to join and identify individual projects; assist in identifying clinical mentors Carol Russell – Medical Management – coordination of PI Projects; delivery of the didactic curriculum
II. Project
Description
In 2012-2013 Dr. Blechman, in conjunction with a coach from Medical Management, championed a pilot PI course for selected residents at JSUMC (“Agent of Change”) which included didactic sessions and participation in a PI project. Our team will evaluate this pilot experience (written feedback; interviewers with participating residents and mentors), as well as best practices from other institutions, to generalize the program to meet the needs of the entire resident community at Jersey Shore.
III. Necessary Resources
(staff, finances, etc.)
1. Administrative staff to support meeting coordination
2. Mentors/coaches/facilitators for PI curriculum and didactic sessions
3. Classrooms and laptops with AV capabilities
Subscription to IHI Open School to monitor resident completion of modules
IV. Measurement/Data Collection
Plan (must
partner/match with Milestone
Markers)
Data Collection Plan Task Source(s) Steps to Accomplish Schedule Review PI Pilot PI Faculty, residents 1. Set up meeting
2. Review evaluations
3. Conduct resident interviews
Q3 2013 Q1 2014
Create 2014 Curriculum Project Team, Medical Management
1. Review pilot and other PI Curricula
2. Develop JSUMC Curriculum
3. Identify Projects/Mentors
Q2 2014 Q3 2014
Monitor Curriculum Project Team 1. Match mentors Q3 2014
60 of 131
with Start of New Academic Year
or projects with residents
2. Create schedule for didactic sessions
3. Finalize policies for non-completers
Q4 2014 Q1 2015
V. Communication Plan
(may be helpful to draft a flow chart of team members &
senior management,
both internal & external)
Communications Plan Communication Type
Objective Medium Frequency Audience Owner Deliverable
Kickoff Meeting Review Project Objectives
Face to Face
Once Project Team
Project Leader
Agenda; Meeting Minutes
Project Team Meetings
Review Status of Project
Face to Face
Q6 weeks Project Team
Project Leader
Agenda; Meeting Minutes
GME Update Review Status of Project
Face to Face
Quarterly GME Committee
Project Leader or Team Member
Meeting Minutes
Project Summary at Research Day, June 2015
Inform of Project
Face to Face
Once at Project Conclusion
Graduating Residents and Faculty
Project Leader
Written summary in Research Day proceedings
VI. Accountability (list of team
members and who
is accountable for what)
See section I above re: stakeholders
VII. Potential Challenges
(engagement, budget, time,
skills gaps, etc)
1. Competing priorities of potential mentors 2. Identifying enough mentors for all categorical residents 3. Time challenges adding residents to existing PI/QI teams 4. Disciplinary steps if a resident/fellow fails to complete the project requirements 5. Resident inertia to complete projects given intensity of clinical rotations, on-call, etc
VIII. Markers (project phases,
progress checks,
schedule, etc.; must
partner/match measurement/d
ata collection plan)
Timeline Q3 2013 Q42 013 Q1 2014 Q2 2014 Q3 2014 Q4 2014 Q1 20 Complete Pilot
XXXX
Analyze Pilot XXXX XXXX Develop PI Curriculum
XXXX XXXX
Identify Mentors
XXXX XXXX
Monitor Resident Engagement and Outcomes of Projects
XXXX XXXX
Report to GME
XXXX XXXX XXXX XXXX XXXX XXXX XXXX
61 of 131
Committee
IX. Vision Statement/Closi
ng Plan (markers of success by
March 2015)
Every categorical resident at Jersey Shore understands the principles of performance improvement, and has or is working on a project to improve some aspect of the care that they see around them. They will be confident in making meaningful contributions to their fellowship program or practice to improve patient safety and quality.
X. Success Factors The most successful component of our work was the enthusiasm of our resident champion and PI/QI leader who drove the process at our institution. They were constant cheerleaders for the importance of the project. It was also gratifying to share our project with our site visitors during our CLER visit this fall. We were inspired by the growing recognition of near-misses and safety events, and the need to not just assign blame but work through processes to understand what happened and how to prevent it in the future. I am confident that our residents will be effective change agents for both safety and quality/process improvement issues in the future.
XI. Barriers The largest barrier we encountered was limited engagement and involvement by several of our Program Directors which limited the residents’ participation in those programs. We worked to overcome this by significant engagement with senior/chief residents who were passionate about the project.
XII. Lessons Learned The single most important piece of advice to provide another team embarking on a similar initiative would be to have explicit expectations of the responsibilities of all members of the project team, and hold them accountable to their original commitment!
XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI III work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact One of our other needs in e program was for more mentors for residents involved in the curriculum. Based on this observation as well as the residents’ satisfaction with the IHI Open School classes, we hope to make completion of IHI modules a faculty expectation in 2015. I doubt that we would have seen this step taken by our C-Suite without participation in the Initiative.
XVI. Next Steps We have a final post-test and report out from the resident teams in March/April. We are writing a poster for our Resident Research Day in June 2015 to highlight the program as well.
62 of 131
Ove
rall
Goa
l/Ab
stra
ct
Pro
cess
Impr
ovem
ent (
PI) c
urric
ulum
invo
lvin
g di
dact
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ssio
ns, i
ndep
ende
nt o
nlin
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arni
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nd
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iplin
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now
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to th
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actic
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mpr
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l L P
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ol R
usse
ll, M
S, B
rend
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N,
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han
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tigan
, DO
, Dav
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ntz,
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ualit
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ME)
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ualit
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ram
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ffect
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nge
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etho
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incl
udes
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itute
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ealth
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ent (
IHI)
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n Sc
hool
(Pat
ient
Sa
fety
& Im
prov
emen
t mod
ules
) •
8 cl
assr
oom
sess
ions
ove
r six
mon
ths
•Te
am/in
divi
dual
coa
chin
g,
•Gr
oup/
inde
pend
ent a
ctiv
ities
to d
evel
op P
I pro
ject
s
•Im
plem
ente
d in
Obs
tetr
ics &
Gyn
ecol
ogy
and
Pedi
atric
re
siden
cy p
rogr
ams i
n fa
ll te
rm o
f 201
4 •
QAI
C To
olki
t 12
ques
tion
pre-
test
to m
easu
re se
lf pe
rcep
tion
of 1
2 co
re P
I/Q
I ski
lls (O
yer 2
010)
ad
min
ister
ed
•Tw
o sc
orin
g m
odel
s util
ized
for b
ench
mar
king
/con
trol
gr
oups
: •
Oye
r fro
m U
nive
rsity
of C
hica
go (2
010)
•
ON
eill
from
Nor
thw
este
rn U
nive
rsity
Fei
nber
g Sc
hool
of M
edic
ine
(201
3)
•At
com
plet
ion
of tr
aini
ng p
rogr
am (
April
201
5) Q
AIC
Tool
kit p
ost-
test
will
be
adm
inist
ered
; re
sults
ana
lyze
d
Wor
k Ci
ted:
1) O
’Nei
ll S,
Hen
sche
n B,
Ung
er E
, Jan
sson
P, U
nti K
, Bor
tole
tto
P, G
leas
on K
, Woo
ds D
, Eva
ns D
(201
3). E
duca
ting
futu
re p
hysic
ians
to tr
ack
heal
th ca
re q
ualit
y: f
easib
ility
and
per
ceiv
ed im
pact
of a
hea
lth ca
re q
ualit
y re
port
card
for m
edic
al st
uden
ts.
Acad
emic
Med
icin
e; V
ol 8
8, N
o. 1
0. 2
) Qua
lity
Asse
ssm
ent a
nd
Impr
ovem
ent C
urric
ulum
(QAI
C) T
oolk
it –
Oyl
er, J
. Vin
ci, L
. Joh
nson
, J. ,
Aro
ra, V
., U
nive
rsity
of C
hica
go M
edic
al C
ente
r 3) V
inci
LM
, Oyl
er J,
John
son
JK, A
rora
VM
(201
0).
Effe
ct o
f a q
ualit
y im
prov
emen
t cur
ricul
um o
n re
siden
t kno
wle
dge
and
skill
s in
impr
ovem
ent.
Qua
l Saf
Hea
lth C
are;
19(
4): 3
51-4
.
Barr
iers
Enc
ount
ered
/Lim
itatio
ns
Pre-
Test
Res
ults
Conc
lusi
ons/
Nex
t Ste
ps
•A
stru
ctur
ed P
I tra
inin
g pr
ogra
m b
uilt
into
resid
ent
educ
atio
n:
•In
crea
ses c
omfo
rt w
ith P
I met
hodo
logy
/too
ls •
Faci
litat
es a
war
enes
s and
invo
lvem
ent i
n fu
ture
PI i
nitia
tives
•N
ext S
tep:
Res
iden
t qua
lity
impr
ovem
ent c
ounc
il fo
r tra
inin
g an
d pr
ojec
t ove
rsig
ht
Succ
ess F
acto
rs/L
esso
ns L
earn
ed
•Re
siden
t ses
sion
atte
ndan
ce li
mite
d se
cond
ary
to
off-s
ite ro
tatio
ns, v
acat
ion,
pos
t-ca
ll or
hav
ing
othe
r clin
ical
resp
onsib
ilitie
s •
Diffi
cult
to e
ngag
e en
ough
dep
artm
ent c
linic
al
cham
pion
s with
mul
tiple
sim
ulta
neou
s pro
ject
s •
Grou
p vs
. ind
ivid
ual p
roje
cts l
imits
han
ds-o
n ex
perie
nce
and
proj
ect o
wne
rshi
p
•JS
UM
C an
d O
Nei
ll de
mon
stra
te si
mila
r bas
elin
e se
lf-as
sess
men
t of 1
2 co
re Q
I ski
lls
•JS
UM
C de
mon
stra
ted
a hi
gher
com
fort
leve
l in
11
of 1
2 Q
I ski
lls w
hen
com
pare
d to
Oye
r. •
Pre-
test
resu
lts in
dica
te re
siden
ts p
osse
ss o
nly
slig
ht to
mod
erat
e co
mfo
rt w
ith Q
I ski
lls w
ith th
e lo
wes
t com
fort
ass
esse
d in
PDC
A m
etho
dolo
gy
Tabl
e 1:
Pre
-tes
t Res
ults
Com
pare
d Co
ntro
l Gro
ups
QI L
EARN
ING
OBJ
ECTI
VE
UCh
icag
o Sc
orin
g:
% >
“sli
ghtly
com
fort
able
” N
W F
einb
erg
Scor
ing:
M
ean
(1-5
com
fort
sca
le)
JSU
MC
Pr
e-te
st %
U
C Pr
e-te
st %
JS
UM
C Pr
e-te
st M
ean
NW
Pre
-tes
t M
ean
Writ
e a
clea
r aim
44
71
2.
5 2.
5 Ap
ply
the
best
pro
fess
iona
l kno
wle
dge
56
53
2.5
2.3
Use
mea
sure
men
t to
impr
ove
44
41
2.4
2.3
Stud
y th
e pr
oces
s 50
21
2.
4 2.
2 M
ake
chan
ges i
n a
syst
em
60
24
2 2
Iden
tify
if a
chan
ge le
ads t
o im
prov
emen
t 56
32
2.
6 2.
2 U
se sm
all c
ycle
s of c
hang
e 40
11
2.
3 2
Iden
tify
best
pra
ctic
e/ c
ompa
re lo
cal p
ract
ice
53
44
2.7
2.2
Impl
emen
t str
uctu
red
plan
to te
st a
cha
nge
19
18
1.8
2.1
Use
PDS
A cy
cle
19
9 1.
9 1.
5 Id
entif
y ho
w d
ata
is lin
ked
to p
roce
sses
19
18
2
2 Bu
ild n
ext i
mpr
ovem
ent
60
26
2.2
2.2
•Co
mm
itmen
t fro
m d
epar
tmen
t lea
ders
to
impl
emen
t PI p
rogr
am in
to e
duca
tiona
l cur
ricul
um
•Cu
rric
ulum
tria
led
prev
ious
ly b
y De
part
men
t of
Pedi
atric
s Phy
sicia
ns
•O
n-sit
e PI
exp
ert/
coac
h
63 of 131
Team: JPS Health Network Focus Area: Quality and Patient Safety Education
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
The team will collaborate with the quality and patient safety experts to create an institutional program that engages residents and faculty in experiential and interprofessional education. Assumption: (1) Faculty have limited involvement in PI, quality and patient safety initiates and have had limited training. (2) Residents and Faculty lag behind in initial training begun on the institutional level (3) Interprofessional Education is limited in the institution.
II. Project Description
The overall goal of this project is to increase quality and patient safety in GME through experiential learning with program directors, faculty, and residents. Our team recognizes that a major barrier to moving forward is limited knowledge of standardized process methods among residents and faculty. The preliminary stages of this project include identifying the best method for training residents and faculty given the time constraints and mandates of programs and participants. the aim of the investigators is to develop a sustainable program that is systems-based.
III. Necessary Resources (Staff, finances, etc.)
Faculty- quality, patient safety, metrics, academic faculty Finances to hold meeting – covers meals, any literature reproduction, honorariums for speakers Administrative support Research staff to assist with projects
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
Program Evaluation Metrics: Attendance Trends Increasing Number of faculty participants Increasing number of interprofessional activities Pre and Post surveys # attendants participating in PI, Quality and Patient Safety initiatives # imitative completed # projects leading to transformation or improvement # Barriers addressed Impact factor ** All metrics selected for projects are aligned with nation al or hospital benchmarks
V. Communication Plan (may be helpful to draft a flow chart of
team members & senior management, both internal & external)
Information regarding AIAMC projects and activities are discussed at each GMEC and discussed with individual departments involved. Reports are given to Medical Executive Team, C-Suite as a part of annual reports and Board sub-committee reports.
VI. Accountability (list of team members and who
is accountable for what)
J. Fowler Team Lead- Coordinate lead team as we develop curriculum materials, identify faculty, and approving funding from general academic budgets Lead Team members- responsible for all curriculum and faculty selection for training programs related to project as a collective voice. T. Sanders- VP of Patient Care Services,metrics, recruitment of nursing participants, survey development B. Estment- Resident recruitment to team ( Dr. Estment left our institution in January) L. Hadley- resident recruitment and oversight of fellows on project A. Augustus- Sr. VP of Quality- select and recommend faculty from quality and patient safety team for course Resident team members- recruit other residents and attendees to
64 of 131
educational activities- assist with IRB, initiate resident run projects ( experiential learning) – ambassadors to C-suite and GMEC to discuss project Rick Edwards – Welcome clinic expert- (no longer at institution )– many of the individual projects were about transition of care from hospitalization to primary care Reporting- all are responsible for meeting attendance and assisting with reports
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
Time management is a challenge with so many people changing schedules often. Working in a clinical environment, there is a lot of impromptu meetings and unplanned cancellations. Engagement of residents- Residents are engaged but are met with much conflict due to clinical responsibilities and duty hour requirements.
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
Abbreviated courses: First attempt was to meet educational gals at orientation, resident lectures, and individual course. [Surveys were collected during course or course evaluation sent after meeting]Attendance and professional demographics of attendees were collected. Recommendations for Department level courses stemmed from comments in first phase. Department Pilot training – The largest residency program was determined to be the pilot department with 7 sessions developed by the quality team for learning. Moderate Sedation Training: Participants and nursing who had been trained in the abbreviated learning reported a risk with residents performing Moderate Sedation in the clinical setting. Prior training had been internal online training. Marker- 100% of residents doing rotations that require moderate sedation must complete live course and do testing followed by Anesthesia sign-off. Quality and Patient Safety Institute – Improve Quality and Patient Safety in the Clinical Environment through Interprofessional Education and Initiatives.
IX. Vision Statement/Closing Plan (markers of success by March 2015)
The aims of this project are (1) to identify the best method for training residents and faculty in performance improvement, quality and patient in an interprofessional learning forum; (2) To introduce a sustainable program that is integrated into the clinical learning environment; and (3) to identify barriers and competing assignments that impact participation of residents and faculty in institutional and program initiatives that promote interprofessional problem solving and education. The closing plan is to measure impact of this training on transformation and change in the institution that results in improved quality and patient safety.
65 of 131
X. Success Factors The most successful component of our work was……….. We were inspired by……………….. In this program demonstration project attendance is more positively affected when a certificate is awarded at the end of training or the course is required to perform a service. Increasing the number of programs resulting in more learners educated. Interdepartmental and interprofessional courses appear to increase feedback and interaction. The full day course appears to provide a greater opportunity for team building and problem solving. Interprofessional education improved the understanding of roles and how the health care team can function collaboratively. We were inspired by the apparent desire to be involved in hospital issues expressed in our sessions. Feedback from residents and providers was helpful in identifying provider issues and also in helping us to leverage their role on the team.
XI. Barriers The largest barrier we encountered was multiple small sessions outside of program lecture days or time. Competing schedules and responsibilities impacted attracting a broader audience. We worked to overcome this by following the recommendation of resident and nurse training. They stated it was better to have an all-day event and have small groups and rotate cohorts. The services would support missing one or two people every 90 days. Unexpected challenges (and solutions)
• Timing of training - Solution: decided on a Full day event/ 2 sessions 90 days apart
XII. Lessons Learned The single most important piece of advice to provide another team embarking on a similar initiative would be………… Be flexible and build upon challenges and identified needs. If the project/ course is to impact the institution, then use the organization as the lab.
XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI III work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact What changes have you observed in your residency program(s), or at your institution, based upon your work? Increase in the interest in Quality and Patient Safety training and projects
XVI. Next Steps Describe next steps for your project, including plans for sustaining and spreading the changes made. Continue building Quality and Patient Safety Institute; Improving project management and establish a means to showcase resident and faculty involvement. Get the program officially certified, e.g. an official certificate program.
66 of 131
Ove
rall
Go
al/A
bst
ract
Th
e over
all
goa
l of
this
pro
ject
is
to t
each
per
form
an
ce i
mp
rovem
ent,
qu
ali
ty,
an
d p
ati
ent
safe
ty i
n G
ME
th
rou
gh
exp
erie
nti
al
learn
ing w
ith
pro
gra
m d
irec
tors
, fa
cult
y, a
nd
res
iden
ts a
nd
oth
er p
rofe
ssio
nals
on
th
e
hea
lth
care
tea
m. O
ur
team
rec
ogn
izes
th
at
a m
ajo
r b
arr
ier
to m
ovin
g
forw
ard
is
lim
ited
kn
ow
led
ge
of
stan
dard
ized
pro
cess
met
hod
s am
on
g
lead
ers,
res
iden
ts, fa
cult
y a
nd
oth
er h
ealt
h c
are
tea
m m
emb
ers
in t
he
con
text
of
inte
rpro
fess
ion
al
edu
cati
on
an
d p
art
icip
ati
on
.
Tea
chin
g P
roce
ss I
mpro
vem
ent,
Qual
ity
and P
atie
nt
Saf
ety t
o A
dult
Lea
rner
s in
GM
EJ.
Fo
wle
r, M
D M
Sc;
B. E
stm
ent
MD
, T
. S
ander
s R
N P
HD
; L
. H
adle
y, M
D;
A. A
ugu
stu
s, R
N;
R. E
dw
ards
MD
; A
. P
edd
le, M
D;
Z. M
erch
ant,
MD
JPS
Hea
lth
Net
wo
rk, F
ort
Wo
rth
, TX
Bac
kgro
un
dT
radit
ional
Med
ical
Educa
tion c
urr
iculu
m p
rovid
es l
imit
ed t
rain
ing i
n
qual
ity,
per
form
ance
im
pro
vem
ent
and p
atie
nt
safe
ty.
In 2
009,
the
Worl
d
Hea
lth O
rgan
izat
ion (
WH
O)
intr
oduce
d a
nd e
val
uat
ed m
edic
al s
chool
curr
iculu
m f
or
teac
hin
g o
n p
atie
nt
safe
ty a
cross
nin
e co
untr
ies
and s
ix
WH
O r
egio
ns.
By 2
010, w
ithin
18 m
onth
s of
rele
ase,
the
curr
iculu
m h
ad
bee
n t
aught
acro
ss t
he
worl
d a
nd p
arti
cipan
ts r
eport
ed t
hat
the
info
rmat
ion
would
be
use
ful
in t
he
futu
re.
Fac
ult
y r
eport
ed t
hat
the
tool
was
hel
pfu
l an
d
would
be
use
d i
n t
hei
r in
stit
uti
on.
Subse
quen
tly,
man
y U
S o
rgan
izat
ions
and a
cadem
ic i
nst
ituti
ons
hav
e dev
elo
ped
curr
iculu
m t
ools
to i
mpro
ve
pat
ient
safe
ty a
nd t
he
qual
ity o
f hea
lth
care
. T
he
goal
of
this
pro
ject
is
to
incr
ease
know
ledge
in q
ual
ity,
per
form
ance
im
pro
vem
ent
and p
atie
nt
safe
ty
in G
ME
thro
ugh e
xper
ienti
al l
earn
ing
intr
oduci
ng r
esid
ents
and f
acult
y t
o
inte
rdep
artm
enta
l an
d i
nte
rpro
fess
ional
educa
tion. W
hen
dis
cuss
ing q
ual
ity
and p
atie
nt
safe
ty w
ith n
ew r
esid
ents
, 100%
rep
ort
ed t
hey
had
no p
rior
trai
nin
g i
n t
his
subje
ct a
rea.
R
esid
ents
wer
e in
tere
sted
in e
xpan
din
g t
he
bas
ic t
rain
ing g
iven
duri
ng o
rien
tati
on.
In t
he
init
ial
nee
ds
asse
ssm
ent
sess
ion d
one
wit
h n
ew r
esid
ents
, th
ey r
eport
ed a
des
ire
to p
arti
cipat
e in
pro
ject
s but
stat
ed t
hey
would
nee
d g
uid
ance
on t
he
logis
tics
of
dev
elopin
g
pro
ject
s an
d i
nit
iati
ves
giv
en t
he
work
req
uir
emen
ts a
nd t
ime
const
rain
ts.
Furt
her
rep
ort
s fr
om
acc
redit
atio
n v
isit
s al
so r
eport
ed a
nee
d t
o d
evel
op t
his
area
for
trai
nee
s an
d f
acult
y e
mpow
erin
g t
hem
to l
ead t
eam
in i
mpro
vin
g
qual
ity a
nd p
atie
nt
safe
ty.
The
WH
O a
nd a
ccre
dit
ing a
gen
cies
als
o a
dvis
e
on t
he
nee
d f
or
inte
rpro
fess
ional
educa
tion.
Vis
ion
Sta
tem
en
tT
he
aim
s of
this
pro
ject
are
(1)
to i
den
tify
the
bes
t m
ethod f
or
trai
nin
g
resi
den
ts a
nd f
acult
y i
n p
erfo
rman
ce i
mpro
vem
ent,
qual
ity a
nd p
atie
nt
in
an i
nte
rpro
fess
ional
lea
rnin
g f
oru
m;
(2)
To i
ntr
oduce
a s
ust
ainab
le p
rogra
m
that
is
inte
gra
ted i
nto
the
clin
ical
lea
rnin
g e
nvir
onm
ent;
and (
3)
to i
den
tify
bar
rier
s an
d c
om
pet
ing a
ssig
nm
ents
that
im
pac
t par
tici
pat
ion o
f re
siden
ts
and f
acult
y i
n i
nst
ituti
onal
and p
rogra
m i
nit
iati
ves
that
pro
mote
inte
rpro
fess
ional
pro
ble
m s
olv
ing a
nd e
duca
tion.
Mat
eri
als/
Met
ho
ds
In t
he
abbre
via
ted v
ersi
on,
the
targ
eted
par
tici
pan
ts w
ere
new
res
iden
ts.
The
inves
tigat
ive
team
chose
to u
se a
pre
and p
ost
inte
rven
tion
eval
uat
ion m
ethod f
or
asse
ssm
ent
of
the
qual
ity o
f th
e tr
ainin
g a
nd t
he
asse
ssm
ent
of
the
pro
ject
s of
the
trai
nee
s. D
uri
ng t
he
ori
enta
tion s
essi
on,
74 p
arti
cipan
ts a
tten
ded
a 2
-hour
work
shop o
n q
ual
ity m
etri
cs,
an
over
vie
w o
f th
e P
lan
-Do-S
tudy-A
ct m
ethod (
PD
SA
), a
nd i
nfo
rmat
ion
about
the
import
ance
of
this
tra
inin
g t
o l
ong
-ter
m p
erfo
rman
ce
impro
vem
ent
and p
atie
nt
safe
ty.
In t
he
Qual
ity a
nd P
atie
nt
Saf
ety
Inst
itute
(QP
SI)
, 30 p
arti
cipan
ts w
ere
set
as m
axim
um
att
endan
ce t
o
fost
er i
nte
ract
ive
feed
bac
k a
nd d
iscu
ssio
n. 15 p
arti
cipan
ts w
ere
nom
inat
ed t
o a
tten
d a
nd e
nro
ll b
y t
hei
r pro
gra
m d
irec
tors
or
dep
artm
ent
lead
er.
The
cours
e co
nsi
sted
of
2 f
ull
day
s ,
90 d
ays
apar
t. T
en f
ocu
sed
area
s w
ere
chose
n b
ased
on C
LE
R o
r Q
ual
ity r
equir
emen
ts.
Fac
ult
y
consi
sted
of
mem
ber
s of
the
facu
lty,
inst
ituti
onal
lea
der
s, q
ual
ity a
nd
pat
ient
safe
ty l
eader
s. A
t th
e en
d o
f th
e pro
gra
m,
each
par
tici
pan
t w
as
giv
en a
ssig
nm
ents
to c
om
ple
te b
ased
on t
he
QP
SI
sess
ions.
The
FM
pro
gra
m d
irec
ted s
essi
ons
wer
e co
ord
inat
ed a
nd g
iven
by a
mem
ber
for
the
qual
ity t
eam
. S
essi
ons
wer
e giv
en d
uri
ng t
hei
r w
eekly
confe
rence
tim
e. T
he
rem
ainin
g t
rain
ings
wer
e co
ver
ed a
t var
ious
foru
ms
incl
udin
g
Tea
ch t
he
teac
her
, fa
cult
y d
evel
opm
ent,
res
iden
t co
re s
essi
ons
and
spec
ial
sched
ule
d e
duca
tional
ses
sions.
Fac
ult
y i
ncl
uded
spec
iali
st
trai
ned
in t
he
topic
giv
en.
Bib
liogr
aph
y1.
CL
ER
Eval
uat
ion C
om
mit
tee.
CL
ER
path
ways
to e
xcel
lence
. E
xpec
tati
ons
for
an
opti
mal
clin
ical
learn
ing e
nvi
ronm
ent
to a
chie
ve s
afe
and h
igh q
uali
ty p
ati
ent
care
.
AC
GM
E 2
014.
2.
Pat
rici
a A
Cuff
, R
eport
eur.
Inte
rpro
fess
iona
l E
duca
tion f
or
Coll
abora
tion:
Lea
rnin
g
How
to I
mpro
ve H
ealt
h f
rom
Inte
rpro
fess
iona
l M
odel
s acr
oss
the
Conti
nuum
of
Educa
tion t
o P
ract
ice–
Work
shop S
um
mar
y. I
nst
itute
of
Med
icin
e, M
ay 2
013.
Bar
rie
rs E
nco
un
tere
d/L
imit
atio
ns-
Res
iden
t B
arr
iers
•V
aria
ble
Sch
edu
les
•D
uty
Ho
ur
Lim
itat
ion
s
Fa
cult
y B
arr
iers
•C
lin
ical
Res
po
nsi
bil
itie
s
•V
aria
ble
Sch
edu
les
•M
ult
iple
Pra
ctic
e S
ites
Inst
itu
tio
na
l B
arr
iers
•L
oca
tio
n o
f T
rain
ing
•S
elec
tio
n p
roce
ss f
or
no
n-G
ME
par
tici
pan
ts
•L
imit
ed n
um
ber
of
Fac
ult
y
par
tici
pat
e in
PI,
Qu
alit
y a
nd
Pat
ien
t
Saf
ety
in
itia
tiv
es
Un
exp
ecte
d c
ha
llen
ges
(a
nd
solu
tio
ns)
•T
imin
g o
f tr
ain
ing
-
So
luti
on
:
dec
ided
on
a F
ull
day
ev
ent/
2
sess
ion
s 9
0 d
ays
apar
t
•M
eeti
ng
sp
ace
log
isti
cs
Lim
ita
tio
ns
•C
ou
rse
stan
dar
diz
atio
n i
n p
roce
ss
•G
ME
an
d I
nst
itu
tio
nal
im
pac
t
met
rics
to
o p
reli
min
ary
Pro
gra
m T
yp
eD
ura
tio
n#
Par
tici
pan
tsIn
terp
rofe
ssio
nal
Lea
rnin
g
Att
end
ance
Rat
e
rate
Ab
bre
via
ted
Ver
sio
n
2 h
rs.
74
No
10
0%
Inst
itu
te
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inin
g
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hrs
.
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ay c
ou
rse
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urs
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esA
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end
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o7
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ite
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urs
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on
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Inte
rdep
artm
enta
lan
din
terp
rofe
ssio
nal
edu
cati
on
is
un
der
uti
lize
din
the
med
ical
edu
cati
on
curr
icu
lum
and
hea
lth
care
sett
ing.
Inte
gra
tin
gin
terp
rofe
ssio
nal
edu
cati
on
into
GM
Eis
nec
essa
ryto
imp
rov
ing
hea
lth
care
qu
alit
yan
dp
atie
nt
safe
ty.T
his
mo
de
of
edu
cati
on
isco
reto
teac
hin
gco
mm
un
icat
ion
skil
lsan
dte
amw
ork
inth
e
hea
lth
care
sett
ing.
Inal
ign
men
tw
ith
the
go
ver
nin
gb
od
ies
and
accr
edit
ing
agen
cies
,in
terp
rofe
ssio
nal
and
inte
rdep
artm
enta
l
edu
cati
on
can
assi
stw
ith
rem
ov
ing
bar
rier
s.O
ver
all,
the
trai
nin
gh
asa
po
siti
ve
ou
tco
me
on
mo
tiv
atin
gp
rog
ram
sto
init
iate
qu
alit
yan
dp
atie
nt
safe
tyed
uca
tio
nin
toth
ecu
rric
ulu
min
am
ore
exp
and
edfa
shio
n.T
he
2n
dco
ho
rto
fth
eQ
PS
Iis
sch
edu
led
in2
01
5w
ith
pla
ns
for
off
erin
g
mo
rein
teri
min
dep
thed
uca
tio
nal
op
po
rtu
nit
ies
thro
ug
ho
ut
the
yea
r.
In t
his
pro
gra
m d
emo
nst
rati
on
pro
ject
att
end
ance
is
mo
re p
osi
tiv
ely
aff
ecte
d
when
a c
erti
fica
te i
s aw
ard
ed a
t th
e en
d o
f tr
ain
ing
or
the
cou
rse
is r
equ
ired
to
per
form
a s
erv
ice.
In
crea
sin
g t
he
nu
mb
er o
f p
rog
ram
s re
sult
ing
in
mo
re
lear
ner
s ed
uca
ted
. In
terd
epar
tmen
tal
and
in
terp
rofe
ssio
nal
co
urs
es a
pp
ear
to
incr
ease
fee
db
ack
an
d i
nte
ract
ion
. T
he
full
day
co
urs
e ap
pea
rs t
o p
rov
ide
a
gre
ater
op
po
rtu
nit
y f
or
team
bu
ild
ing
an
d p
rob
lem
so
lvin
g. In
terp
rofe
ssio
nal
edu
cati
on
im
pro
ved
th
e u
nd
erst
and
ing
of
role
s an
d h
ow
th
e h
ealt
h c
are
team
can
fu
nct
ion
co
llab
ora
tiv
ely.
Succ
ess
Fac
tors
an
d L
ess
on
s Le
arn
ed
(D
iscu
ssio
n)
67 of 131
Team: Kaiser Permanente Northern California Focus Area: Performance Improvement: eVisual Board
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions,
stakeholders, etc.; Teams should identify members
and define responsibility/purpose)
Needs statement, improve awareness and accelerated involvement in Quality and Process Improvement at local hospitals. Standardize the process wherein institution’s teaching sites actively involve residents in PI and QI and reporting. Project requirements local and regional buy-in to adapt the current variable QI/ PI process to increase resident involvement. Residents were marginalized from the current process due to lack of awareness of need for resident involvement. Provide a standardized way for residents to contribute to the QI/PI process, while also increasing the visibility of GME and the accreditation requirements (CLER). Project assumptions Time constraints for everyone involved Physical space to conduct QI/PI sessions, leading to development of an electronic QI/PI platform Resident’s limited prior knowledge of QI/PI process and ongoing projects Cross collaboration between multiple departments Collective situational awareness and process ownership, reducing individual need to drive all initiatives Foster peer collaboration Residency uniquely need to balance service with education, thereby initiatives must have academic value Stakeholders - Local Quality and administration PI leadership, Local GME leadership, Regional leadership, Residents Support staff
II. Project Description The eVisual Board is a single shared scalable platform the residents can use to contribute, learn, and disseminate, QI/ PI projects.
III. Necessary Resources (staff, finances, etc.)
Staff and Technology Time of dedicated staff at local and regional level to implement and manage the eVisual Board Technology use was Microsoft SharePoint institutional license to collaborate in a electronically secure, HIPAA compliant online tool, accessible securely anytime anywhere. Allows for page specific user obfuscation of ongoing projects allowing it to be a program management and document repository with patient PHI on the same platform. (all other commercial tools including our residency management suite MEDHUB lacked the functionality)
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Financial commitment of technology is unknown since electronic tools are part of an institutional license And the human capital was pulled from existing roles from patient safety fellow, faculty, and GME admins.
IV. Measurement/Data Collection Plan
(must partner/match with Milestone Markers)
1. Pre Assessment of residents knowledge of QI/PI and concepts going to be taught through the use of eVisual Board Project
2. Volume of ideas suggested and worked on ○ Total Number and % of submissions in CLER
Categories ○ Total number and % of ideas Suggested, Completed
and Sustained ○ Qualitative is residents perception
3. Space for Results of Mock CLER Visit March 13th
V. Communication Plan (may be helpful to draft a
flow chart of team members & senior
management, both internal & external)
● C suite ● Institutional Graduate Medical Education Committee ● The Permanente Medical Group Board of Directors ● Quality Oversight Committee
○ Regional Quality Leadership ● Local Hospital Administration Leadership ● Local Improvement Advisors ● Program Committees
○ Program Directors Obstetrics Gynecology ○ Program Directors Internal Medicine
● Program Directors from KP sponsored residency programs ○ Cardiovascular Disease ○ Internal Medicine ○ ObGyn ○ Otolaryngology ○ Pediatrics ○ Podiatry ○ Family Medicine
VI. Accountability (list of team members and
who is accountable for what)
Team Lead Alex Dummett, MD, CPPS
Primary Driver of the project, Developed conceptual framework and implementation of of multiple iterations of eVisual board
Associate Institutional Director (DIO) Theresa Azevedo
Developed conceptual framework communicated plan and overall authorized and supported using eVisual board as one vessel to involve residents in QI/PI
Lead Improvement Advisor Consultant Kimber Brown
Advising QI/PI ongoing projects once identified
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Project Manager Michelle Loaiza
Develop and ongoing support of the the eVisual board using SharePoint maintaining master access to different functionality
Area Quality Director Darshan Grewal
Permission and provided local Quality projects and committees
Former GME Coordinator Atlantis Cooper
Purchased and organized physical visual board and then developed with input from Alex the original eVisual board using Google Sheets
Research Project Manager EJ Song
Lead role in developing KP SCL Resident SharePoint Research site that is now serving as a template and the next version of the eVisual board for QI/PI projects
Program Director Danny Sam, MD
Overall approval and oversight of SCL residents
Associate Program Director Ryan Kneuppel, MD
Final approval of residents at SCL QI/PI projects and supervision of QI/PI process at SCL Approval of concurrent QI/PI projects including charting lecture series and holds residents accountable for being part of QI/PI at SCL
Resident Representative Emilie Muelly, MD
Enthusiastic early supporter and user of eVisual Board for testing and vetting from end user perspective
Chief Residents, Jennifer Nissly, MD; Roopam Sirohi, MD
Assisted residents with QI/PI when applicable to residency personal, and IT issues
Director of Office and Strategy Management Debra Ruckert
Overall approval for QI/PI locally at SCL
VII. Potential Challenges (engagement,
budget, time,
skills gaps, etc)
Engagement - resident involvement and active meaningful participation QI/PI projects ● Process - develop pathways for consistent reporting ● Budget - allocating Quality and GME staff time for QI/PI work ● Capacity: Time
○ GME to develop and maintain the infrastructure ○ Faculty to support and teach QI PI principles ○ Quality leaders to include residents into the process ○ Resident time to improve the suggested QI/PI areas
● Capability: Skills gap ○ Training on Sharepoint for the administrators
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○ access to Sharpoint site inside kaiser and outside ○ Physician faculty does not have the training that
quality and PI QI leads have
VIII. Markers (project phases, progress
checks, schedule, etc.; must partner/match
measurement/data collection plan)
Discovery - Idea generation discovering local Bright spots of QIPI process. Came across a Visual Board at both Walnut Creek and Santa Teresa.
1. Planning 2. Consensus building 3. Implementation 4. Adaptation
a. physical visual board b. Google c. Evitask d. SharePoint
5. Spread
IX. Vision Statement / Closing Plan
(markers of success by March 2015)
Standardize the solicitation of resident improvement ideas and aid and embed them into the facilities QI/PI process, using HIPAA compliant institution-supported resources. Also, huddle frequently to discuss current progress and explore new projects.
X. Success Factors Top success factors of the NI-IV KP project: ● Soliciting ideas for overall improvement ● Identifying opportunities for improvement and/or change
within a current process (i.e . Improve discharge workflow) ● empowerment of individuals resolving non-PI issues that
were burdensome (IT, ergonomics, resident wellness concerns)
● Improve inter-departmental communication by housing resources in one location
● Providing the opportunity for open communication between residents and local administration
● Observant about identify safety issues in their daily workflow: ○ Identified inconsistencies with ordering blood labs
and what was reported ○ Identified safety concerns about change in mental
status not being escalated for non-stroke patients ○ medication delay in administration impacting care ○ inconsistent am CXR requiring repeat
● improved resident wellness by improving their space fostering buy in and appreciation
We were inspired by: ● Inspiration by residents eagerness to share ideas ● Wanting to make a difference ● Residents commitment to safety (i.e. OTO residents
collaborating to find a solution which allows for non-ENT to
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provide necessary care for airway management after hours)
XI. Barriers Barriers we encountered were: ● Identifying Technology for our needs
○ Security ○ Scalability ○ Functionality
● Resident, faculty and hospital administration acceptance ● Resident and faculty time for meetings and implementation ● Alignment of institutional initiatives and priorities ● The time it takes to get the approval necessary to complete a
project from a resident time frame is sometimes incompatible with the amount of time they have. Specifically any changes to Health Connect.
We overcame barriers by:
● Persistence ○ trying multiple tools from physical board to different
non kaiser to kaiser approved programs ending up with sharepoint
○ Worked with local IT support to establish a secure file sharing server/database that will be utilized across all programs and facilities.
● Region wide push to shed light and educate about QI/PI and residents are now much more aware of the problem and the Kaiser process and are more willing to get engaged.
● Resident/faculty acceptance is a work in progress. Our newest system using sharepoint is still in development and has not been implemented yet.
XII. Lessons Learned
The two most important pieces of advice to provide another team embarking on a similar initiative would be
1. Persistence ○ residents will treat the any opportunity to air their
grievances. They may be residency specific like ran out of coffee cups, or profound like EHR functionality that faculty take for granted is not available to the residents.
○ Start with small easy projects, ensure they get done and provide ample support. As the small wins snowball and the you make process more ideas will be generated, the process will be accepted, and the projects scope will increase. This only happens with shorter frequent huddles discussing identified problems rather than monthly long meetings
2. Ok to change technology mid stream just focus on the
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process. We suggest a Wiki like functionality so many people can edit and add to the site rather than on single point of entry. a single point of updating and entry = a single point of failure and missing the opportunity for collaboration. Ideas are generated on the fly in the midst of work on the go, at any time day or night. Having to wait until morning to jot down the idea or worse yet when the person is physically in their presence misses countless opportunities.
XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NIV work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact What changes have you observed in your residency program(s), or at your institution, based upon your work? Heightened awareness and eagerness to point out QI/PI Closer involvement and communication with Quality Departments GME initiated projects changed the awareness culture
XVI. Next Steps Describe next steps for your project, including plans for sustaining and spreading the changes made. Step 1: Scale visual board project to other KP-sponsored residency program sites (Oakland, San Francisco, and Vallejo). Step 2: Scale visual board project to KP teaching sites who receive affiliate sponsored residents (additional 16 KP medical centers in Northern California.
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Suggested workflow Residents suggest issues
74 of 131
Ove
rall
Goa
l/Ab
stra
ct
Impr
ove
QI/
PI a
war
enes
s, st
anda
rdize
the
proc
ess f
or
PI/Q
I ide
a ge
nera
tion
and
part
icip
atio
n.
Alig
nmen
t of G
ME
and
Qua
lity
in Q
I/PI
. Pr
ovid
e re
sour
ces a
nd te
mpl
ates
to a
id in
QI/
PI.
Prep
arat
ion
for C
LER.
Ga
ps id
entif
ied
wer
e re
siden
ts li
mite
d pr
ior k
now
ledg
e of
QI/
PI, l
ack
of in
tere
st, a
nd c
ompe
ting
prio
ritie
s.
Patie
nt S
afet
y, P
erfo
rman
ce &
Q
ualit
y Im
prov
emen
t Al
ex D
umm
ett,
MD,
The
resa
Aze
vedo
, Mic
helle
Loa
iza
Kaise
r Per
man
ente
Nor
ther
n Ca
lifor
nia
Back
grou
nd
We
wan
ted
to d
evel
op a
con
siste
nt p
roce
ss fo
r id
entif
ying
QI/
PI p
roje
cts a
s wel
l as s
hare
pro
gres
s.
Assu
mpt
ions
: Lac
k of
tim
e, la
ck o
f des
igna
ted
spac
e,
need
for c
ross
col
labo
ratio
n, fo
ster
pee
r col
labo
ratio
n,
limite
d pr
ior k
now
ledg
e in
pra
ctic
al a
pplic
atio
ns o
f QI/
PI.
The
eVisu
al B
oard
is a
sing
le sh
ared
scal
able
pla
tform
the
resid
ents
can
use
to c
ontr
ibut
e, le
arn,
and
diss
emin
ate,
Q
ualit
y an
d Pe
rfor
man
ce Im
prov
emen
t pro
ject
s. C
oupl
ed
with
freq
uent
shor
t hud
dles
, the
eVi
sual
Boa
rd im
prov
es
visib
ility
of r
esid
ent a
nd fa
cilit
y im
prov
emen
t goa
ls.
Visi
on S
tate
men
t St
anda
rdize
the
solic
itatio
n of
resid
ent i
mpr
ovem
ent
idea
s and
aid
and
em
bed
them
into
the
faci
litie
s QI/
PI
proc
ess u
sing
HIPA
A co
mpl
iant
inst
itutio
n-su
ppor
ted
reso
urce
s. A
lso, h
uddl
e fr
eque
ntly
to d
iscus
s cur
rent
pr
ogre
ss a
nd e
xplo
re n
ew p
roje
cts.
Mat
eria
ls/M
etho
ds
Bibl
iogr
aphy
1.
Cha
ng, B
. K. (
2013
). En
gagi
ng R
esid
ents
in Q
ualit
y &
Pat
ient
Saf
ety
(pp.
1–7
). R
etrie
ved
from
http
://cb
pps.o
rg/re
certi
ficat
ion/
2.O
grin
c, G
., N
iere
nber
g, D
. W.,
& B
atal
den,
P. B
. (20
11).
Bui
ldin
g ex
perie
ntia
l lea
rnin
g ab
out
qual
ity im
prov
emen
t int
o a
med
ical
scho
ol c
urric
ulum
: the
Dar
tmou
th e
xper
ienc
e. H
ealth
Af
fair
s (Pr
ojec
t Hop
e), 3
0(4)
, 716
–22.
doi
:10.
1377
/hlth
aff.2
011.
0072
3.H
erne
r, S.
, & R
awlin
gs, J
. (20
14).
Gla
d W
e C
augh
t Tha
t ! T
he Im
porta
nce
of C
lose
Cal
ls, 1
–49
.
4.C
raw
ford
, B.,
Skea
th, M
., &
Whi
ppy,
A. (
2013
). M
ultif
ocal
Clin
ical
Per
form
ance
Im
prov
emen
t acr
oss 2
1 H
ospi
tals
. Jou
rnal
for H
ealth
care
Qua
lity :
Offi
cial
Pub
licat
ion
of th
e N
atio
nal A
ssoc
iatio
n fo
r Hea
lthca
re Q
ualit
y, 0
0(00
), 1–
8. d
oi:1
0.11
11/jh
q.12
039
5.K
ohn,
L. T
., C
orrig
an, J
. M.,
& M
olla
, S. (
2000
). To
Err
Is H
uman
, Bui
ldin
g a
Safe
r Hea
lth
Syst
em (p
. 312
). N
atio
nal A
cade
mie
s Pre
ss. R
etrie
ved
from
ht
tp://
ww
w.na
p.ed
u/ca
talo
g/97
28.h
tml
6.W
eiss
, K. B
. (20
14).
Patie
nt S
afet
y an
d ob
serv
atio
ns fr
om th
e AC
GM
E C
linic
al L
earn
ing
Envi
ronm
ent R
evie
w (
CLE
R )
Prog
ram
.
7.En
visi
onin
g D
iabl
o as
the
Best
at G
ettin
g Be
tter.
(201
3).
8.Fr
ush,
K.,
& G
rayd
on-b
aker
, E. (
n.d.
). R
isk
Iden
tific
atio
n an
d A
naly
sis
Kar
en F
rush
,.
Barr
iers
Enc
ount
ered
/Lim
itatio
ns
Wha
t cou
ld y
ou h
ave
done
diff
eren
tly?
Opp
ortu
nitie
s fo
r im
prov
emen
t? G
ettin
g bu
y in
and
acc
epta
nce
to
the
proc
ess.
Une
xpec
ted
chal
leng
es (a
nd so
lutio
ns)?
Iden
tifyi
ng
tech
nolo
gy, t
ime
of re
siden
t fac
ulty
and
ad
min
istra
tion.
Less
ons l
earn
ed p
ersis
tenc
e an
d ad
apta
bilit
y
Resu
lts a
nd E
xam
ples
Conc
lusi
ons
Heig
hten
ed a
war
enes
s and
eng
agem
ent t
o po
int o
ut
QI/
PI p
roje
cts.
Clo
ser e
ngag
emen
t with
qua
lity
depa
rtm
ent.
GME
driv
en p
roje
cted
cha
nged
the
awar
enes
s cul
ture
.
Wor
k st
ill n
eeds
to b
e do
ne to
hav
e a
stab
le
stan
dard
ized
tech
nica
l sol
utio
n in
Sha
rePo
int t
hat
faci
lity
shar
ehol
ders
refe
renc
e w
hen
look
ing
for
resid
ent i
nvol
vem
ent i
n Q
I/PI
. Im
prov
e th
e fe
edba
ck.
Succ
ess F
acto
rs a
nd L
esso
ns L
earn
ed
(Dis
cuss
ion)
Cultu
ral-
We
succ
essf
ully
solic
ited
man
y im
prov
emen
t ide
as a
nd
empo
wer
ing
resi
dent
s to
esca
late
and
reso
lve
thei
r ow
n pr
oble
ms
thro
ugh
use
of e
stab
lishe
d pa
thw
ays.
ie, I
T, e
rgon
omic
s, re
side
nt
wel
lnes
s con
cern
s. S
ocia
l - W
e im
prov
ed th
e co
mm
unic
atio
n of
in
stitu
tiona
l goa
ls b
y st
reng
then
colla
bora
tion
betw
een
resi
dent
s and
Q
I/PI
pro
ject
lead
s.
Tech
nica
l - W
e id
entif
ied
that
pat
ient
safe
ty e
vent
repo
rtin
g w
as
unde
rutil
ized
so w
e cr
eate
d a
path
way
for b
ette
r fee
dbac
k w
hile
m
aint
ain
anon
ymity
, ie
Res
iden
cy e
RRF.
Aft
er m
any
itera
tions
, we
iden
tifie
d a
nd c
usto
mize
d a
secu
re y
et w
idel
y ac
cess
ible
, eVi
sual
Bo
ard
in M
icro
soft
Sha
rePo
int.
Ch
arac
teris
tics–
docu
men
t and
tem
plat
e re
posi
tory
, QI/
PI re
sour
ce to
ge
t ide
as fr
om b
oth
inte
rnal
and
ext
erna
l pro
ject
s. Id
ea ca
ptur
e fo
r Q
I/PI
opp
ortu
nitie
s tha
t can
be
shar
ed in
terd
epar
tmen
tally
and
inte
r fa
cilit
y, a
nd h
as p
roje
ct m
anag
emen
t cap
abili
ties
Alig
ning
Qua
lity
with
CLE
R
75 of 131
Team: Main Line Health System Focus Area: Patient Safety
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
1. Improve the culture of Patient Safety at Main Line Health System
2. Better Train qualified physician leaders in Patient Safety Competencies.
3. Provide an interface between residents and administration surrounding Patient Safety concerns
4. Identify and close the gaps between system level and residency/fellowship program level patient safety initiatives.
5. Provide a forum for interdisciplinary collaboration among residencies and fellowships
6. Create a standing Core Curriculum series at the institutional and program level which is both informational and hands on for the trainees.
II. Project Description
Main Line Health System will establish a Resident Patient Safety Council. The council will be comprised of a resident or Fellow member from each program in the system. Residents currently encounter and often solve patient safety concerns on a local level but would benefit from system level collaboration to identify problems and provide practical solutions. The council will participate in development of core curriculum and a “Walk the Talk” for Patient Safety Event. The council will facilitate the six charter/objectives listed above.
III. Necessary Resources (staff, finances, etc.)
Protected time for Steering Committee, Resident Council and Core Lecture Series Administration support financially for NI IV tuition and offsite collaborative meetings. Administrative liaisons for Patient Safety and Quality Initiatives.
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
Needs analysis (knowledge of trainees and faculty ) in Patient Safety Language, Event Recognition and Reporting Tracking of resident and program Patient Safety Initiatives and Scholarly activity Creation of “Great Catch” Award restricted to resident/fellow recipient. Pre and Post Culture of Patient Safety Survey Responses Pre and Post “Walk the Talk” Resident Surveys
V. Communication Plan (may be helpful to draft a flow chart of
team members & senior management, both internal & external)
National Initiative IV project description and goals are presented at local GMEC meetings, program faculty meetings, at system level GME Steering Committee and at the Research and Education Committee. Updates will follow on meeting agendas in an ongoing fashion. The project will be present verbally and in written format to the Medical Executive Committee during annual GME report. Chair (resident or fellow) of the Resident Patient Safety Council will sit on system Patient Safety and Quality Committee. Chief Academic Officer, both DIOs, the Chief Medical Officer and the VP of Quality and Patient Safety will serve as liaisons to the resident council.
VI. Accountability (list of team members and who
is accountable for what)
Dr. Greco and Sharon Iannucci will take the lead on overall project Resident Patient Safety Council Chair (TBD) will Chair meetings and coordinate resident pt safety initiatives. Drs. Greco, Burke and Mann will serve as mentors to resident council
76 of 131
and to communicate needs and accomplishments to administration Denise Murphy/Laura Thompson and Dr. Norton will refine team goals and secure resources to further align missions of GME and the Hospital Administration. Judy Spahr, Lankenau Institute of Medical Research will head the scholarly writing subgroup.
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
Two geographically distinct campuses make gathering residents across the system a logistical challenge. Faculty Development Needed Time must be protected for Dr. Greco and Sharon Iannucci, for local work, conference calls and regional collaborative meetings. Resident turnover (graduation) and keeping momentum
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
Completion of resident/faculty needs assessment. Monthly Meetings of the Resident Patient Safety Council Resident/Fellow involvement in the “Walk the Talk” event Fall 2014 Resident and Fellow membership on the System Patient Safety and Quality Committee Connecting one Resident Patient Safety Council driven Patient Safety Project to the system level Patient Safety and Quality Committee
IX. Vision Statement/Closing Plan (markers of success by March 2015)
Senior Management and Residents/Fellows with the support of GME mentoring and interfacing will align initiatives and resources to improve the Patient Safety Culture at Main Line Health System. Ongoing projects will stimulate Faculty/Trainee engagement in event recognition and reporting as well as improved standardized curricula elements for Patient Safety. Scholarly activities surrounding Patient Safety will occur at local, regional and national forums.
77 of 131
Ove
rall
Goa
l To
inte
grat
e re
siden
ts in
to th
e M
ain
Line
Hea
lth
(MLH
) cul
ture
of P
atie
nt S
afet
y w
ith th
e go
al o
f le
arni
ng E
rror
Pre
vent
ion
Tool
s and
teac
hing
th
ese
tool
s to
othe
rs.
Wal
k th
e Ta
lk fo
r Pat
ient
Saf
ety:
In
tegr
atin
g Re
side
nts i
n th
e O
rgan
izatio
n’s P
atie
nt S
afet
y Cu
lture
Jo
seph
A. G
reco
, MD;
Jad
Sfei
r , M
D; A
llen
Dim
ino,
MD;
Sha
ron
Iann
ucci
; Jud
y Sp
ahr
Mai
n Li
ne H
ealth
Sys
tem
, Wyn
new
ood,
PA
Back
grou
nd
Visi
on
Sta
ffing
the
WTT
boo
ths p
rovi
ded
an
oppo
rtun
ity fo
r res
iden
ts to
teac
h ot
her
resid
ents
and
att
ende
es a
bout
err
or re
port
ing
proc
esse
s and
pro
cedu
res.
Thi
s act
ivity
was
de
signe
d to
cre
ated
visi
bilit
y fo
r res
iden
ts a
s ac
tive
part
icip
ants
in p
atie
nt sa
fety
lead
ersh
ip
whi
le c
ompe
lling
resid
ents
to b
ecom
e co
mpl
etel
y fa
mili
ar w
ith th
e la
ngua
ge o
f pa
tient
safe
ty a
nd th
e M
LH p
atie
nt sa
fety
st
ruct
ure.
Mat
eria
ls/M
etho
ds
Ch
alle
nges
/Rec
omm
enda
tions
Re
siden
t sch
edul
es a
nd m
ultip
le ca
mpu
s site
s cr
eate
d ch
alle
nges
for s
ched
ulin
g an
d at
tend
ing
th
e ev
ent.
Early
invo
lvem
ent w
ith th
e in
terd
iscip
linar
y W
TT
Plan
ning
Com
mitt
ee li
kely
wou
ld fa
cilit
ate
resid
ent
invo
lvem
ent a
nd p
rovi
de m
ore
mea
ning
ful
lead
ersh
ip ro
les.
A b
ooth
at t
he e
vent
conc
eive
d by
the
resid
ents
w
ould
furt
her e
nhan
ce te
achi
ng a
nd G
ME
visib
ility
in
Mai
n Li
ne H
ealth
’s Pa
tient
Saf
ety
Cultu
re.
Re
sults
Conc
lusi
ons
Both
taki
ng a
lead
ersh
ip ro
le a
nd a
tten
ding
WTT
for
Patie
nt S
afet
y le
d to
incr
ease
d kn
owle
dge
of
patie
nt sa
fety
topi
cs a
nd d
emon
stra
ted
that
re
siden
ts a
re in
volv
ed in
the
patie
nt sa
fety
cul
ture
of
MLH
.
In a
dditi
on, t
he e
vent
pro
vide
d an
enj
oyab
le a
nd
ente
rtai
ning
exp
erie
nce
for a
ll at
tend
ees.
Succ
ess F
acto
rs
Resid
ents
wer
e in
vite
d to
staf
f the
boo
ths a
t thi
s yea
r’s W
TT e
vent
at o
ur m
ajor
te
achi
ng h
ospi
tal,
Lank
enau
Med
ical
Cen
ter.
Erro
r Pre
vent
ion
Tool
s in
clud
ed:
Patie
nt sa
fety
trai
ning
at M
LH h
as e
volv
ed o
ver
time.
Err
or p
reve
ntio
n to
ols n
ow fo
cus o
n ve
rbal
co
mm
unic
atio
n to
ols t
hat e
nhan
ce b
est s
afet
y be
havi
ors.
Mai
n Li
ne H
ealth
cre
ated
“W
alk
the
Talk
(WTT
) for
Pat
ient
Saf
ety”
. Th
is ev
ent p
rom
oted
pat
ient
safe
ty le
arni
ng
thro
ugh
hand
s-on
, eng
agin
g ac
tiviti
es w
ith
carn
ival
-like
boo
ths t
each
ing
patie
nt sa
fety
goa
ls,
tool
s, a
nd p
roce
dure
s.
In a
dditi
on, t
he C
LER
visit
had
hig
hlig
hted
the
need
for m
edic
al re
siden
ts a
t MLH
to b
oth
lear
n an
d be
com
e in
tegr
ated
in th
e cu
lture
of p
atie
nt
safe
ty a
t thi
s org
aniza
tion.
Resid
ents
show
ed st
atist
ical
ly s
igni
fican
t im
prov
emen
t in
thei
r kno
wle
dge
of p
atie
nt sa
fety
tool
s fr
om p
re- t
o po
st- i
nter
vent
ion.
The
y st
atist
ical
ly s
igni
fican
tly fe
lt co
nfid
ent t
hat t
hey
knew
the
MLH
err
or p
reve
ntio
n to
ols p
ost-
inte
rven
tion,
and
agr
eed
that
WTT
was
a
good
way
to le
arn
abou
t pat
ient
safe
ty.
Adm
inist
ratio
n w
as e
xcite
d to
hav
e re
siden
t in
volv
emen
t and
is e
ager
to a
ctiv
ely
incl
ude
GM
E in
pl
anni
ng fu
ture
sim
ilar e
vent
s.
Re
siden
ts w
ere
aske
d to
com
plet
e an
ano
nym
ous q
uest
ionn
aire
to
asse
ss
know
ledg
e ab
out p
atie
nt sa
fety
and
opi
nion
s ab
out W
TT b
efor
e an
d af
ter
the
WTT
eve
nt.
Erro
r Pre
vent
ion
Tool
Pu
rpos
e
“STA
R”
(Sto
p –
Thin
k –
Act –
Rev
iew
) fo
cuse
s on
atte
ntio
n to
det
ail
“SBA
R”
(Situ
atio
n –
Back
grou
nd –
Ass
essm
ent –
Re
com
men
datio
n)
prom
otes
effe
ctiv
e ha
ndof
fs
“ARC
C” (
Ask
a qu
estio
n --
mak
e a
Requ
est -
- voi
ce a
Con
cern
) an
d “S
top
the
Line
”
empo
wer
s tho
se lo
wer
in th
e po
wer
gr
adie
nt to
spe
ak u
p fo
r saf
ety
“Got
you
r Bac
k”
Enco
urag
es a
ppro
pria
tely
che
ckin
g an
d co
achi
ng p
eers
“
3-w
ay re
peat
bac
k an
d re
ad b
ack”
en
cour
ages
cle
ar c
omm
unic
atio
n
62.7
%
88.2
%
37.3
%
11.8
%
pre
WTT
post
WTT
inco
rrec
tco
rrec
t
Nam
e 3
Erro
r Pre
vent
ion
Tool
s us
ed a
t MLH
(p=0
.002
)
28.0
0%
48.5
0%
post
WTT
pr
e W
TT
Stro
ngly
agr
ee: W
TT is
a g
ood
way
to
lear
n ab
out p
atie
nt sa
fety
tool
s (p
=0.0
13)
43.5
%
8.9%
post
WTT
Disa
gree
: I fe
el c
onfid
ent t
hat I
kno
w w
hat t
he
MLH
Err
or P
reve
ntio
n To
ols a
re (p
<0.0
001)
pre
WTT
78 of 131
Team: Maricopa Integrated Health System Focus Area: Quality education and resident participation
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
To identify those areas that have created significant gaps in knowledge and lack of participation of both our residents and many faculty
II. Project Description Using the REPORT from our CLER visit we were able to identify a critical lack of information dissemination leading to demonstration of gaps in knowledge and performance in Quality and Patient Safety initiatives
III. Necessary Resources (staff, finances, etc.)
Ability to gain access to adverse event reporting, cooperation with Quality and Safety departments and other patient care oriented departments as identified
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
Determine level of knowledge and level of engagement of our residents in these two areas by direct quiz or encounter. utilizing educational conferences determine the preferred method of learning Likewise establish bench mark of attending physician involvement Use of PDCA cycle to test educational tools that lead to most improved performance Document resident adverse event reporting before educational intervention Record resident reporting these events post education anticipating 50% increase
% Communication Plan (may be helpful to draft a flow chart of team
members & senior management, both internal & external)
Direct contact with principles, contact via existing hospital wide committees Resident communication via resident leadership council, program directors , GMEC
VI. Accountability (list of team members and who
is accountable for what)
Major weak spot as ownership of this project dwindled precipitously due to significant external hospital driven processes. Original volunteer members included 4 faculty from 3 programs, the CMO and the director of GME along with one program director and the V.P. Academic Affairs Attrition lowered these numbers to the program director, Director of GME and VPAA The DGME and PD established and implemented the institutional curriculum
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
Budget constraints, time and other work demands
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
Project did get underway and as we progressed we discovered outside markers which have significant potential impact on present learning and future educational and experiential required activities the Adverse event recording exceeded expectations by significant percentage
IX. Vision Statement/Closing Plan (markers of success by March 2015)
To develop a systematic educational and evaluation process to assure all residents understood institutional Quality and patient safety initiatives leading to their full engagement in the processes. We envisioned the adoption of quality and safety parameters measuring continuous improvement in performance or knowledge gaps
79 of 131
X. Success Factors The most successful component of our work was the willing collaboration of several independent departments to design and test educational modalities and track outcomes of education as well as identifiable resident responses…….. We were inspired by…the ability of these teams to work within the frame of our developing institutional curriculum and how this team interacted with our residents……………..
XI. Barriers The largest barrier we encountered was…difficulty to find otherwise committed individuals with adequate time and resources to work with us….. We worked to overcome this by probably pure luck. The departments who did cooperate were thorough and dedicated to developing meaningful data and measurable performance outcomes……..
XII. Lessons Learned The single most important piece of advice to provide another team embarking on a similar initiative would be to have clarity in your expectations and recruit your associates carefully recognizing their other demands……
XIII. Expectations Versus Results On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI III work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact What changes have you observed in your residency program(s), or at your institution, based upon your work? Residents now clearly understand and can identify an adverse event , including the concept of a “near miss” Likewise they are now more prone to report these events through our reporting system (Kronos) Thirdly we have identified and tested the more efficient tools and processes for teaching and demonstrating the didactic portions of our curriculum.
XVI. Next Steps Describe next steps for your project, including plans for sustaining and spreading the changes made. There remains more and in depth development for more involvement by the residents in our quality and safety initiatives WE need to assure that the program is sustainable and productive by continuously measuring the quality outcomes Ultimately we are hopeful that the resident adopt these measures as their own processes Finally we need to improve the timeliness and follow up of feed- back to residents to complete loop of their MIDAS ( event) Reporting
80 of 131
Team: Marshfield Clinic Focus Area: Quality Improvement “My Health Care Team” Pictorial
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
• Team charter and project goal: to enhance effective communications between provider and patient as well as fellow providers. Subsequent review of the current listing of related projects with the Medical Director for Accreditations and Standards (Lisa Benson) did not identify another project that met this need.
• Intended to benefit patient care and quality improvement among the internal medicine resident medical ward teams; further expansion to be determined by project success
• Project requirements: pictorial development including scheduling, photos; pictorial distribution with program coordinator, volunteer services and internal medicine resident ward teams; data collection
II. Project Description
• Creation of “My Health Care Team” pictorials by internal medicine program coordinator (Nicole Kumm) at the first of the month.
• Volunteer services distribute these documents to a main floor of the hospital.
• Internal medicine resident teams then distribute these pictorials to patients admitted to their service ideally within 24 hours of admission.
• Referenced by the patient, nurses and consultants for coordination of care.
III. Necessary Resources (staff, finances, etc.)
• Internal medicine resident, attending physician, and medical student photos.
• Time of program coordinator and volunteer services for document creation and distribution of pictorials
• Resources related to printing of the pictorials IV. Measurement/Data Collection Plan
(must partner/match with Milestone Markers)
• Review of HCAHPS data regarding patient satisfaction • Pictorial creation and distribution; study design • Cohort study of internal medicine resident ward team patients
chart review and subsequent survey performed by project leader • Exclusion criteria: documented altered mental status or delirium;
failure of orientation questions; positive CAM score. • Data collected: patient age; confirmation of orientation/CAM;
admitting diagnosis; recall of provider names; pictorial receipt – given to patients if not received; thoughts on pictorial; understanding of care plan; overall satisfaction score (1-5)
• Initial data analysis • Future considerations, new study design, project expansion
V. Communication Plan (may be helpful to draft a flow chart of
team members & senior management, both internal & external)
• Discussion of project leader with program coordinator and director of ward team scheduling and subsequent pictorial creation
• Program coordinator facilitates pictorial distribution with volunteer services
• Program leadership and project leader encourages residents to distribute pictorials to patients on their teams
• Project leader discusses project progress with program director on a periodic basis
• Project leader analyzes initial data along with team members to
81 of 131
be presented to the internal medicine residency program and subsequently the NI IV group.
• Communication with the Director of Graduate Medical Education (Matthew Jansen, MD) for future considerations and project expansion
VI. Accountability (list of team members and who
is accountable for what)
• This has been discussed in previous sections.
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
• Project scope: is it too large or narrow? • Do we receive benefit? • How do we get internal medicine residents to buy in? • Identification of point(s) of contact at various steps along the
way. • Who would be the distributor at the point of care (likely the
intern)? • Data collection of patient satisfaction • Keeping it up to date. Project fatigue plays a role.
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
• Prior patient satisfaction survey results review • Pictorial creation and development • Enlist participants/team members • Discussion with Dr. Remeika, Internal Medicine Residency
Director, project pioneer • Data collection survey (see above) • Initial data analysis • Future considerations and expansion of project
IX. Vision Statement/Closing Plan (markers of success by March 2015)
• Our vision is that the “My Health Care Team” pictorial will provide a more positive patient experience by aiding in the identification of providers and coordination of care.
• As the project continues, we plan to obtain additional data – including randomization of patients - and expand the project to other departments.
X. Success Factors • The creation of a user-friendly team pictorial and subsequent distribution system to the hospital wards is achievable with the right support system.
• All patients reported positive impressions of the pictorial. Allied providers also anecdotally agree that it is a helpful tool.
• There was an observed trend towards improved name recall, patient satisfaction and care plan understanding.
XI. Barriers • Distribution process and points of contact. Lack of compliance of pictorial distribution by the ward teams.
• Data collection: we would like more patients and more data to achieve statistical significance. Patients were selected retrospectively and not randomized. Official data from other members of the care team has yet to be gathered.
• Project scope likely too narrow. The plan is to include other programs in the future.
• As a jointly sponsored residency program (Marshfield Clinic and Ministry Saint Joseph’s Hospital), there is no seamless approach in
82 of 131
terms of project management since both institutions – while merged as a training program – operate independently from one another.
XII. Lessons Learned The single most important piece of advice to provide another team embarking on a similar initiative would be………… • Ensuring a good support system and project team that can fulfill
all roles as defined by said project. Education of all team members is very important. Identification of key contacts is critical.
XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI III work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact What changes have you observed in your residency program(s), or at your institution, based upon your work? • No immediate changes have been observed with our program.
The patients that received the pictorial found it helpful.
XVI. Next Steps Describe next steps for your project, including plans for sustaining and spreading the changes made. • Identification of a new project leader from the internal medicine
residency program is ongoing. As noted, we plan to include other residency programs with this project. In addition, we are looking into ways to provide incentives to the residents in distributing these pictorials in order to provide a culture of provider identification with patients.
83 of 131
Back
grou
nd
•Pa
tient
satis
fact
ion
data
from
Hos
pita
l Con
sum
er
Asse
ssm
ent o
f Hea
lthca
re P
rovi
ders
and
Sys
tem
s (H
CAHP
S) re
veal
ed p
oor p
erfo
rman
ce b
y in
tern
al
med
icin
e re
siden
ts.
•Tw
o re
cent
pro
spec
tive,
coho
rt st
udie
s sho
wed
im
prov
emen
t in
prov
ider
iden
tific
atio
n w
ith ‘f
ace
shee
ts’ o
r ‘fa
ce c
ards
’ and
a tr
end
tow
ards
impr
oved
pa
tient
satis
fact
ion
but n
o st
atist
ical
sign
ifica
nce.
Deliv
erin
g a
Posi
tive
Patie
nt E
xper
ienc
e:
Inte
rnal
Med
icin
e Re
side
ncy
Prov
ider
Pic
toria
l M
atth
ew D
’Cos
ta, M
D, M
atth
ew Ja
nsen
, MD,
Lisa
Ben
son,
MD,
Lor
i Rem
eika
, M
D, M
icha
el R
oher
ty, N
icol
e Ku
mm
M
arsh
field
Clin
ic, M
arsh
field
, Wisc
onsin
Proj
ect D
escr
iptio
n •
Crea
tion
of “
My
Heal
th C
are
Team
” pi
ctor
ials
is pe
rfor
med
by
inte
rnal
med
icin
e pr
ogra
m c
oord
inat
or
at th
e fir
st o
f the
mon
th.
•Vo
lunt
eer s
ervi
ces d
istrib
ute
thes
e do
cum
ents
to a
m
ain
floor
of t
he h
ospi
tal.
•In
tern
al m
edic
ine
resid
ent t
eam
s the
n di
strib
ute
thes
e pi
ctor
ials
to p
atie
nts a
dmitt
ed to
thei
r ser
vice
idea
lly
with
in 2
4 ho
urs o
f adm
issio
n.
•Th
ese
pict
oria
ls a
re th
en re
fere
nced
by
the
patie
nt,
nurs
es a
nd c
onsu
ltant
s for
coo
rdin
atio
n of
car
e.
Visi
on S
tate
men
t •
Our
hyp
othe
sis is
that
kno
wle
dge
of p
rovi
der n
ames
an
d th
eir r
oles
via
team
pic
toria
ls w
ill im
prov
e p
atie
nt
satis
fact
ion
scor
es b
y en
hanc
ing
effe
ctiv
e co
mm
unic
atio
n be
twee
n pa
tient
s and
pro
vide
rs a
s w
ell a
s am
ong
othe
r mem
bers
of t
he c
are
team
.
Mat
eria
ls/M
etho
ds
•
Coho
rt st
udy
of in
tern
al m
edic
ine
resid
ent w
ard
team
pa
tient
s, c
hart
revi
ew a
nd su
bseq
uent
surv
ey
perf
orm
ed b
y pr
ojec
t lea
der.
• Ex
clu
sio
n c
rite
ria:
do
cum
ente
d a
lter
ed m
enta
l sta
tus
or
de
liriu
m; d
isorie
ntat
ion;
pos
itive
Con
fusio
n As
sess
men
t M
etho
d (C
AM) s
core
. •
Dat
a co
llect
ed: 2
5 p
atie
nts
wer
e su
rvey
ed a
fter
40
ch
art
revi
ews p
erfo
rmed
; pat
ient
age
; con
firm
atio
n of
or
ient
atio
n/CA
M; a
dmitt
ing
diag
nosis
; rec
all o
f pro
vide
r na
mes
; pic
toria
l rec
eipt
– g
iven
to p
atie
nts i
f not
re
ceiv
ed; t
houg
hts o
n pi
ctor
ial;
unde
rsta
ndin
g of
car
e pl
an; o
vera
ll sa
tisfa
ctio
n sc
ore
(1-5
).
Bibl
iogr
aphy
Si
mm
on
s et
al.
“Eff
ect
of
a fa
ce s
hee
t to
ol o
n m
edic
al
pro
vid
er id
enti
fica
tio
n a
nd
fam
ily s
atis
fact
ion
.” 2
01
4 J
. H
osp
. Med
., 9
: 13
7–1
41
. do
i: 1
0.1
00
2/j
hm
.21
00
Una
ka e
t al “
The
impa
ct o
f fac
ecar
ds o
n pa
tient
s’
know
ledg
e, sa
tisfa
ctio
n, tr
ust a
nd a
gree
men
t with
hos
pita
l p
hys
icia
ns:
a p
ilot
stu
dy”
20
14
J.
Ho
sp. M
ed.,
9: 1
86
–18
8.
do
i: 1
0.1
00
2/j
hm
.21
14
Barr
iers
Enc
ount
ered
/Lim
itatio
ns
• D
istr
ibu
tio
n p
roce
ss a
nd
po
ints
of
con
tact
. •
Lack
of c
ompl
ianc
e of
pic
toria
l dist
ribut
ion
by th
e
w
ard
team
s.
•D
ata
colle
ctio
n -
need
for m
ore
patie
nts a
nd m
ore
data
to a
chie
ve st
atist
ical
sign
ifica
nce.
Pat
ient
s w
ere
sele
cted
retr
ospe
ctiv
ely
and
not r
ando
mize
d.
Offi
cial
dat
a fr
om o
ther
mem
bers
of t
he c
are
team
ha
s yet
to b
e ga
ther
ed.
•Pr
ojec
t sco
pe –
the
plan
is to
incl
ude
othe
r
prog
ram
s in
the
futu
re.
Pict
orial
Su
rvey
Co
mpl
iance
Aver
age A
ge
Nam
e Re
call
Unde
rsta
ndin
g of
Car
e Plan
Av
erag
e Sa
tisfa
ctio
n Sc
ore
Rece
ived
(4/25
) 65
.75
2/4 or
50%
4/4
or 10
0%
5.0
Did n
ot re
ceive
(2
1/25)
64.19
5/2
1 or
23.8%
19
/21 or
90
.47%
4.5
7
Initi
al R
esul
ts
Conc
lusi
ons
•Cr
eatio
n of
a p
icto
rial f
or p
rovi
der i
dent
ifica
tion
is ac
hiev
able
with
the
right
supp
ort s
yste
m.
•Te
am p
icto
rials
are
wel
l rec
eive
d by
pat
ient
s and
ot
her m
embe
rs o
f the
car
e te
am.
•D
istr
ibu
tio
n b
y w
ard
tea
ms
is a
maj
or
chal
len
ge;
pote
ntia
l rem
edie
s are
in th
e pl
anni
ng st
ages
.
•Fu
rthe
r dat
a co
llect
ion
and
patie
nt ra
ndom
izatio
n al
on
g w
ith
exp
ansi
on
to
oth
er d
epar
tmen
ts m
ay
prov
ide
mor
e in
sight
. Su
cces
s Fac
tors
and
Les
sons
Lea
rned
•Th
e cr
eatio
n of
a u
ser-
frie
ndly
team
pic
toria
l and
su
bseq
uent
dist
ribut
ion
syst
em to
the
hosp
ital w
ards
. •
All p
atie
nts r
epor
ted
posit
ive
impr
essio
ns o
f the
pi
ctor
ial.
Allie
d pr
ovid
ers a
lso a
necd
otal
ly a
gree
that
it
is a
help
ful t
ool.
•O
bser
ved
tren
d to
war
ds im
prov
ed n
ame
reca
ll,
patie
nt sa
tisfa
ctio
n an
d ca
re p
lan
unde
rsta
ndin
g.
84 of 131
Team: Monmouth Medical Center Focus Area: Error reporting
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
• ACGME CLER site visit revealed issues with patient safety, quality, and health disparities.
• Core curriculum development team to include Joseph Jaeger, DrPH; Beth Baratz, MS, MPH, CCLS; Alex Puma, BA.
• Key stakeholders include (1) Program directors; (2) Residents; (3) Faculty; (4) Community/Patients; (5) C-Suite; (6) Payors.
II. Project Description • Project to improve patient safety reporting and education, performance and quality improvement practices, health disparities interventions, and cultural competency.
• Goal was to infuse the CLE with public health principles and practices.
• Delivered a comprehensive public health curriculum for GME. • Identified and addressed barriers to patient safety reporting.
III. Necessary Resources
(staff, finances, etc.) • Preceptor • Public health intern • Assessment specialist • Performance Improvement/Quality Improvement
representative • Program directors
IV. Measurement/Data Collection Plan
(must partner/match with Milestone Markers)
• Outcome: curriculum and resource list applicable to professionalism, practice based learning and improvement, and systems based practice competencies across all specialties.
V. Communication Plan
(may be helpful to draft a flow chart of team members & senior management, both
internal & external)
• Kick off/announcement to program directors and C-Suite by DIO
• Regular meetings with GMEC (bimonthly) • Regular meetings with public health intern (x1 weekly)
VI. Accountability
(list of team members and who is accountable for what)
• Team leader (DIO) – responsible for overall direction and vision; public health expertise.
• Public health intern – conduct needs assessment, identify public health educational resources, draft public health GME curriculum, present to GMEC.
• Assessment specialist – review public health GME curriculum, develop scholarly products (poster), develop implementation plan
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
• Curriculum development demands new skills. • Developing public health curriculum champions: Who will
teach? • Incorporating curricular materials into already full graduate
medical education programs. VIII. Markers
(project phases, progress checks, schedule, etc.; must partner/match
measurement/data collection plan)
• Phase 1 (Completed) : Development/kick off • Phase 2 (Completed) : Needs assessment, includes literature
review and program director interviews • Phase 3 (Completed) : Curriculum development • Phase 4 (Completed) : Assessment by GMEC
85 of 131
• Phase 5 (Ongoing) : Implementation IX. Vision Statement/Closing Plan
(markers of success by March 2015)
• Monmouth Medical Center will provide its medical staff and students with a clinical learning environment that prioritizes quality-driven, safe, and responsive health care services.
• Future efforts should target the translation of knowledge to physician strategy, physician performance, and improved patient outcomes.
X. Success Factors • Needs assessment helped staff and students recognize opportunities for learning.
• Dedicated person prepared to search for and provide resources for learning.
• Peer review encouraged staff and students to provide feedback on translational potential.
XI. Barriers • “The way we do things”: Challenging institutional and program culture.
XII. Lessons Learned • The single most important piece of advice to provide another team embarking on a similar initiative would be to engage its learners in the full scope of curriculum development.
XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish?
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI III work? 8
XV. Project Impact • Increased awareness regarding public health, disparities and inequities.
• Greater awareness of patient safety and error reporting.
XVI. Next Steps • Develop implementation plan to incorporate new curricular elements into each residency’s standard curriculum.
86 of 131
•Pr
ojec
t to
impr
ove
patie
nt sa
fety
repo
rtin
g an
d ed
ucat
ion,
per
form
ance
and
qua
lity
impr
ovem
ent
prac
tices
, hea
lth d
ispar
ities
inte
rven
tions
, and
cul
tura
l co
mpe
tenc
y.
•Go
al w
as to
infu
se th
e cl
inic
al le
arni
ng e
nviro
nmen
t (C
LE) w
ith p
ublic
hea
lth p
rinci
ples
and
pra
ctic
es.
•De
liver
ed a
com
preh
ensiv
e pu
blic
hea
lth c
urric
ulum
fo
r gra
duat
e m
edic
al e
duca
tion
(GM
E).
•Id
entif
ied
and
addr
esse
d ba
rrie
rs to
pat
ient
safe
ty
repo
rtin
g.
A Ho
spita
l Pub
lic H
ealth
Res
pons
e to
CLE
R Be
th B
arat
z, M
S, M
PH, C
CLS;
Ale
x Pu
ma,
BA;
Jose
ph Ja
eger
, DrP
H, M
PH
Mon
mou
th M
edic
al C
ente
r, Lo
ng B
ranc
h, N
ew Je
rsey
Visi
on S
tate
men
t M
onm
outh
Med
ical
Cen
ter w
ill p
rovi
de i
ts m
edic
al st
aff
and
stud
ents
with
a c
linic
al le
arni
ng e
nviro
nmen
t tha
t pr
iorit
izes q
ualit
y-dr
iven
, saf
e, a
nd re
spon
sive
heal
th ca
re
serv
ices
.
Barr
iers
Enc
ount
ered
/Lim
itatio
ns
•Cu
rric
ulum
dev
elop
men
t dem
ands
new
skill
s.
•De
velo
ping
pub
lic h
ealth
cur
ricul
um c
ham
pion
s:
Who
will
teac
h?
•In
corp
orat
ing
cur
ricul
ar m
ater
ials
into
alre
ady
full
grad
uate
med
ical
edu
catio
n pr
ogra
ms.
Resu
lts
Succ
ess F
acto
rs a
nd L
esso
ns L
earn
ed
•M
etho
ds in
clud
ed a
lite
ratu
re se
arch
, a n
eeds
as
sess
men
t of
prog
ram
dire
ctor
s and
resid
ents
, a
curr
icul
ar a
udit,
pre
sent
atio
n, a
nd p
eer r
evie
w.
•In
tend
ed c
hang
es in
clud
ed th
e de
sign
of a
pub
lic h
ealth
cu
rric
ulum
.
•Su
cces
s dep
ende
nt u
pon
the
appr
oval
or r
ejec
tion
issue
d by
Mon
mou
th M
edic
al C
ente
r’s G
radu
ate
Med
ical
Ed
ucat
ion
Com
mitt
ee (G
MEC
).
Back
grou
nd
•AC
GME
CLER
site
visi
t rev
eale
d iss
ues w
ith p
atie
nt
safe
ty, q
ualit
y, a
nd h
ealth
disp
ariti
es.
•Th
e O
ffice
of A
cade
mic
Affa
irs a
nd a
n M
PH c
andi
date
de
velo
ped
a pu
blic
hea
lth c
urric
ulum
for r
esid
ency
pr
ogra
ms.
•De
sired
out
com
es in
clud
ed th
e id
entif
icat
ion
and
redu
ctio
n of
pub
lic h
ealth
rela
ted
know
ledg
e ga
ps.
Ove
rall
Goa
l/Ab
stra
ct
Mat
eria
ls/M
etho
ds
•Pu
blic
Hea
lth C
urric
ulum
for G
radu
ate
Med
ical
Ed
ucat
ion
Prog
ram
at M
onm
outh
Med
ical
Cen
ter
com
plet
ed o
n tim
e an
d w
ithin
pro
ject
bud
get.
•GM
EC c
omm
ittee
app
rove
d. A
dopt
ed b
y pr
ogra
m
dire
ctor
s.
•Co
re c
urric
ulum
add
ress
es p
atie
nt sa
fety
, hea
lth c
are
impr
ovem
ent,
erro
r rep
ortin
g, a
nd h
ealth
disp
ariti
es.
•Pr
ogra
m-s
peci
fic c
urric
ulum
foun
d to
be
resp
onsiv
e to
th
e ne
eds o
f sev
en re
siden
cy p
rogr
ams.
•Nee
ds a
sses
smen
t hel
ped
staf
f and
stud
ents
reco
gnize
op
port
uniti
es fo
r lea
rnin
g.
•Ded
icat
ed p
erso
n pr
epar
ed to
sear
ch fo
r and
pro
vide
re
sour
ces f
or le
arni
ng.
•Pee
r rev
iew
enc
oura
ged
staf
f and
stud
ents
to p
rovi
de
feed
back
on
tran
slatio
nal p
oten
tial.
Conc
lusi
ons
•M
onm
outh
Med
ical
Cen
ter a
ppre
ciat
es a
pub
lic
heal
th c
urric
ulum
’s po
tent
ial t
o en
gend
er c
linic
al
exce
llenc
e.
•Ed
ucat
ors a
nd tr
aine
es n
ow h
ave
acce
ss to
a
com
plet
e se
t of c
once
pts,
term
s, a
nd a
ctiv
ities
th
at m
ake
up th
e pu
blic
hea
lth d
omai
n.
•Fu
ture
effo
rts s
houl
d ta
rget
the
tran
slatio
n of
kn
owle
dge
to p
hysic
ian
stra
tegy
, phy
sicia
n pe
rfor
man
ce, a
nd im
prov
ed p
atie
nt o
utco
mes
.
Sele
cted
Bib
liogr
aphy
•Ac
cred
itatio
n Co
unci
l for
Gra
duat
e M
edic
al E
duca
tion
[ACG
ME]
(201
4). A
ccre
dita
tion
Coun
cil f
or
Grad
uate
Med
ical
Edu
catio
n. R
etrie
ved
from
: htt
ps:/
/ww
w.a
cgm
e.or
g/ac
gmew
eb/.
•Ar
mst
rong
, G.,
Head
rick,
L.,
Mad
igos
ky, W
., &
Ogr
inc,
G. (
2012
). De
signi
ng e
duca
tion
to im
prov
e ca
re.
The
Join
t Com
miss
ion
Jour
nal o
n Q
ualit
y an
d Pa
tient
Saf
ety,
38(
1): 5
-14.
•N
asca
, T.J.
, Phi
liber
t, I.,
Brig
ham
, T.,
& F
lynn
, T.C
. (20
12).
The
next
GM
E ac
cred
itatio
n sy
stem
–
Ratio
nale
and
ben
efits
. The
New
Eng
land
Jour
nal o
f Med
icin
e, 3
66(1
1): 1
051-
1056
.
•W
eiss
, K.B
., Ba
gian
, J.P
., &
Nas
ca, T
.J. (2
013)
. The
clin
ical
lear
ning
env
ironm
ent:
The
foun
datio
n of
gr
adua
te m
edic
al e
duca
tion.
Jour
nal o
f the
Am
eric
an M
edic
al A
ssoc
iatio
n, 3
09(1
6): 1
687-
1688
.
•W
eiss
, K.B
., W
agne
r, R.
, & N
asca
, T.J.
(201
2). D
evel
opm
ent,
test
ing,
and
impl
emen
tatio
n of
the
ACGM
E cl
inic
al le
arni
ng e
nviro
nmen
t rev
iew
[CLE
R] p
rogr
am. J
ourn
al o
f Gra
duat
e M
edic
al E
duca
tion,
Se
ptem
ber:
396-
398.
87 of 131
Team: Ochsner Clinic Foundation : NI IV Focus Area: Transitions of Care
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
I. Needs Statement: Based on findings from internal and external, formal and informal, clinical and operational metrics, we have identified a significant need to formalize a process for transitions of care between inpatient care settings, hospital based and primary care as well as hospital based and external care providers( i.e. SNF, Rehab, LTC, and Home Health). The results of this lack of continuity are found in patient safety metrics ( medication and treatment compliance ) readmissions and patients lost to follow up with unknown outcomes. Based on these findings the focus of transitions of care was identified as a primary area of focus for this project.
II. Team Charter: implement a standardized approach to transitions of care at Ochsner based on a integrated multidisciplinary approach to care .
III. Objectives: a) Identify and engage key stakeholders and champions to
include executive sponsorship, clinical dyads, IT and decision support, program directors and key house staff.
b) Explore and define best practices for implementation c) Hardwire solutions to assure sustainability of efforts d) Overall improvement of defined metrics. e)
IV. Project Assumptions a) Team and Institutional commitment to the Proposed
Outcome b) There will be support from clinical and operational leaders c) Solutions will be “hardwired” for sustainability
V. Team: a) Ron Amedee, MD DIO b) Rob Wolterman , CEO, OMC c) Robin Stedman, MD , PD Anesthesiology d) Janice Piazza, AVP , GME e) Roneshia McClendon Alexander, MD CA-2 President of OMC
House Staff Association f) Jacob Breaux, MD PGY-2 Internal Medicine
II. Project Description
I. Initial Assessment of the tools, practices and policies currently in use to facilitate Transitions in Care ( TOC) [P]
II. Determine best practices currently in place internally as well as assessment of the literature for demonstrated best practices.[P]( add lean)
III. Assess EMR ( EPIC ) functionality that could support defined practice(s)[P]
IV. Identify metrics ( measures of success) and available date sources [P]
V. Identify Pilot areas for initial assessment of best practice [D]
VI. Review Outcomes of Pilot / impact on defined metrics [S] VII. Refine metrics and data collection VIII. Define accountabilities for implementation [P] IX. Implement education plan, go live with EMR support,
implement metric performance reporting process [D]…………
88 of 131
Develop plan to spread and sustain - December 2014
III. Necessary Resources (staff, finances, etc.)
I. Time and commitment II. Survey III. Literature search IV. Funding allocated IT development V. Decision Support to establishment metric reporting
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
Initial Survey assessment completed Follow up survey : September 15-30, 2014 Observation data ( how long / # of observations Quality data tie in ? – LOS / adverse events / Inter-professional integration - who else will use Bundle development/ customization
V. Communication Plan (may be helpful to draft a flow chart of team
members & senior management, both internal & external)
To faculty : PD meeting(s) To House Staff: presentations to individual programs July / August 2014 Continue through Quality Council / quarterly To Patient Safety Executive Committee with quarterly follow starting in August 2014 To Executive Team: July 30th during Operating Review
VI. Accountability (list of team members and who
is accountable for what)
Shared – we each do what needs to be done at the time the issue presents itself RA / RS– Communication and education of faculty JP – operational logistics Residents: Scholarly production, peer support for implementation
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
IT resource availability for development and optimization Team Time for appropriate implementation, follow up and monitoring Integration into practice Faculty support for mentoring component
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
Initial Survey completion Repeat Survey completion Initial Observation Data Analysis Ongoing Observation Data Analysis : Frequency Like to Quality data ( CAUTI, CLABSI, LOS, Adverse Pt Outcomes Interprofessional Integration
IX. Vision Statement/Closing Plan (markers of success by March 2015)
By March of 2015 a standardized tool and process for facilitating TOC will be in use throughout OMC in an effort to ensure quality patient care in the safest of environments
X. Success Factors The most successful component of our work was……….was the level of institutional support provided in the form of unlimited assistance/ dedication from GME and department heads. Also significant buy – in and support from Health Information management team, IS security and technical staff, EPIC developers and executive administration. We were inspired by………………..Our CLER visit and an evident need to formalize a process that have become an instrumental aspect of healthcare
89 of 131
XI. Barriers The largest barrier we encountered was……..buy-in from individual residents and overcoming historical perspective and tendencies We worked to overcome this by…….. holding interactive sessions describing not only the process, but also the research supporting the essential nature of such an endeavor . Additionally, we employed resident and faculty champions to assist in dissemination of the process and help drive the change in culture we will need to have continued success
XII. Lessons Learned The single most important piece of advice to provide another team embarking on a similar initiative would be………… 1. Plan and anticipate 2. Maintain flexibility in all aspects of the process 3. Be realistic in determining attainable measures , with consideration
of the timeframe and scope of the project – think small cycles of change
4. Start the project with the end in mind 5. Solicit feedback early in the process from key stakeholders to
anticipate problems / issues that can slow implementation / publication
6. Be aware of tools / systems currently in place that can facilitate the process.
7. Create and early abstract / draft of the project to serve as a guide and foundation for milestone and final paper publication
8. Utilization of PDSA cycles throughout implementation , can serve as basis for publications
XIII. Expectations Versus Results On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI IV work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact What changes have you observed in your residency program(s), or at your institution, based upon your work? There have been cultural shifts and practice based shifts toward more efficient and effective patient safety practices in the form of standardized handoffs. The original scope of the project was to facilitate the resident to resident handoff process, however in the later stages of the project we have observed increase interest and utilization by staff in some sub- specialties as well as well as the engagement of advanced practice clinicians and utilization of the tool for transitions between levels of care.
XVI. Next Steps Describe next steps for your project, including plans for sustaining and spreading the changes made. Next steps will include :
1) Modification of the tool for greater utility across specialty disciplines
2) Further integration to procedural specialties 3) Adaptation of the tool to support discharge planning 4) Continue to evaluate and track meaningful metrics to further
document the impact of this improvement 5) Engage the next resident team to begin Phase 2
90 of 131
Overall Goa
l/Ab
stract
Dut
y ho
ur re
stric
tions
impo
sed
upon
trai
ning
phy
sicia
ns h
ave
led
to in
crea
sed
hand
offs
and
the
pote
ntia
l for
disc
ontin
uity
in
patie
nt c
are.
The
refo
re, i
t is n
o su
rpris
e th
at g
roup
s gov
erni
ng
med
ical
pra
ctic
es h
ave
reco
mm
ende
d th
e m
easu
rem
ent a
nd
guar
ante
e of
pat
ient
safe
ty, w
ith a
key
em
phas
is on
han
doff
com
mun
icat
ion
stand
ardi
zatio
n. (1
,2) A
t our
insti
tutio
n, w
e id
entifi
ed a
sign
ifica
nt n
eed
to fo
rmal
ize
a pr
oces
s for
tran
sitio
ns
of c
are
betw
een
inpa
tient
setti
ngs.
Spe
cific
ally
, we
focu
sed
our
effo
rts o
n cr
eatin
g, im
plem
entin
g, a
nd e
valu
atin
g a
stand
ardi
zed
appr
oach
to tr
ansit
ions
of c
are
at O
chsn
er C
linic
Fou
ndat
ion.
Th
roug
h th
e im
plem
enta
tion
of a
stan
dard
ized
han
doff
proc
ess a
t ou
r ins
titut
ion
we
aim
to im
prov
e re
siden
t con
fiden
ce a
nd
com
pete
ncy
in th
is ar
ea w
hile
also
impr
ovin
g ac
cura
cy o
f in
form
atio
n re
sulti
ng in
a sa
fer e
nviro
nmen
t for
our
pat
ient
s.
Implem
en4n
g a Stan
dardized
and
Sustainab
le Residen
t
Sign-‐Out Process at O
chsner Clin
ic Fou
nda4
on:
An AIAM
C Na4
onal In
i4a4
ve IV
Project
Backgrou
nd
Vision
Statemen
t By
Mar
ch o
f 201
5 a
stand
ardi
zed
tool
and
pro
cess
for f
acili
tatin
g tra
nsiti
ons o
f car
e w
ill b
e in
use
thro
ugho
ut O
chsn
er M
edic
al
Cent
er in
an
effo
rt to
ens
ure
qual
ity p
atie
nt c
are
in th
e sa
fest
of
envi
ronm
ents
1. R
iebs
chle
ger M
, Phi
liber
t I.
New
Sta
ndar
ds F
or T
rans
ition
s of C
are:
Disc
ussio
n an
d Ju
stific
atio
n. A
vaila
ble
at: h
ttp://
ww
w.ac
gme.
org/
acgm
eweb
/Por
tals/
0/PD
Fs/
jgm
e-11
-00-
57-5
9[1]
2.
The
Join
t Com
miss
ion
anno
unce
s the
200
9 N
atio
nal P
atie
nt S
afet
y G
oals
and
requ
irem
ents.
Jt C
omm
Per
spec
t. 20
08 Ju
l;28(
7):1
,11-
15.
3. C
hu E
S, R
eid
M, S
chul
z T, e
t al.
A str
uctu
red
hand
off p
rogr
am fo
r int
erns
. Aca
d M
ed.
2009
Mar
;84(
3):3
47-3
52.
4. V
idya
rthi A
R, A
rora
V, S
chni
pper
JL, W
all S
D, W
acht
er R
M. M
anag
ing
disc
ontin
uity
in
aca
dem
ic m
edic
al c
ente
rs: s
trate
gies
for a
safe
and
effe
ctiv
e re
siden
t sig
n-ou
t. J
Hos
p M
ed. 2
006
Jul;1
(4):2
57-2
66.
5. A
boum
atar
H, A
lliso
n RD
, Fel
dman
L, W
oods
K, T
hom
as P
, Wie
ner C
. Foc
us o
n tra
nsiti
ons o
f car
e: d
escr
iptio
n an
d ev
alua
tion
of a
n ed
ucat
iona
l int
erve
ntio
n fo
r in
tern
al m
edic
ine
resid
ents.
Am
J M
ed Q
ual.
Epub
201
3 N
ov 1
. 6.
Sta
rmer
AJ,
O’T
oole
JK, R
osen
blut
h G
, et a
l. D
evel
opm
ent,
impl
emen
tatio
n, a
nd
diss
emin
atio
n of
the
I-PA
SS h
ando
ff cu
rricu
lum
: a m
ultis
ite e
duca
tiona
l in
terv
entio
n to
impr
ove
patie
nt h
ando
ffs. A
cad
Med
. 201
4 Ju
n;89
(6):8
76-8
84.
7. H
orw
itz L
I, M
oin
T, G
reen
ML.
Dev
elop
men
t and
impl
emen
tatio
n of
an
oral
sign
-out
sk
ills c
urric
ulum
. J G
en In
tern
Med
. 200
7 O
ct;2
2(10
):147
0-14
74.
8. A
rora
V, J
ohns
on J.
A m
odel
for b
uild
ing
a sta
ndar
dize
d ha
nd-o
ff pr
otoc
ol. J
t Com
m J
Q
ual P
atie
nt S
af. 2
006
Nov
;32(
11):6
46-6
55.
9. G
akha
r B, S
penc
er A
L. U
sing
dire
ct o
bser
vatio
n, fo
rmal
eva
luat
ion,
and
an
inte
ract
ive
curri
culu
m to
impr
ove
the
sign-
out p
ract
ices
of i
nter
nal m
edic
ine
inte
rns.
Acad
M
ed. 2
010
Jul;8
5(7)
:118
2-11
88.
Bibliograp
hy
Barriers Encou
ntered
/Limita
4ons
• Th
e m
ost s
igni
fican
t bar
rier e
ncou
nter
ed w
as
gain
ing
acce
ptan
ce a
nd b
uy-in
from
indi
vidu
al
resid
ents
and
facu
lty a
s wel
l as o
verc
omin
g hi
storic
al p
ersp
ectiv
es a
nd te
nden
cies
. •
A se
cond
bar
rier w
as th
e ac
cess
to d
ata
to
esta
blish
succ
ess a
nd im
pact
of t
he p
roje
ct
thro
ugh
all p
hase
s, to
incl
ude
plan
ning
, im
plem
entin
g an
d ev
alua
ting
post
impl
emen
tatio
n im
pact
.
Results
Disc
ussio
n Fu
eled
by
an o
ppor
tuni
ty to
opt
imiz
e re
siden
t tra
inin
g an
d pa
tient
safe
ty, w
e de
velo
ped
a pl
an to
stan
dard
ize,
im
plem
ent,
and
eval
uate
han
doff
syste
ms w
ithin
our
sy
stem
. We
adm
inist
ered
a su
rvey
prio
r to
and
afte
r the
di
ssem
inat
ion
of th
e ha
ndof
f mod
el to
com
pare
per
ceiv
ed
perfo
rman
ce w
ith h
ando
ffs. R
esul
ts in
dica
ted
a m
odes
t in
crea
se in
feed
back
with
resp
ect t
o an
d su
perv
ision
of
hand
offs
. As w
e pr
ogre
ss w
ith sy
stem
-wid
e im
plem
enta
tion,
we
plan
to in
corp
orat
e ob
ject
ive
met
rics
such
as n
umbe
rs o
f lab
orat
ory
tests
ord
ered
by
resid
ents,
ch
ange
s in
hosp
ital l
engt
h of
stay
, and
med
icat
ion
occu
rrenc
es. T
hese
par
amet
ers c
ompl
emen
t sub
ject
ive
data
from
obs
erve
r eva
luat
ions
and
surv
ey re
sults
.
10/13%
1/14%
4/14%
7/14%
9/14%
12/14%
3/15%
S"
D
S"
A
Pre("Interven
-on""
Data"Collec-on""
Project"Design"&""
Developmen
t""
Implemen
ta-on""
Post"In
terven
-on""
Data"Collec-on""
P"
D"
S"
A"
Work%Plan%Tim
eline%Transi8ons%of%Care%%%
! Gap%Analysis:%R
eview%tools,%prac8ces,%policies%curren
tly%in%place%to%
%%%Facilitate%transi8ons%of%care%%%
! %%Literature%Review%to%iden
8fy%best%prac8ces%%
! %Faculty%&%House%Staff%survey%to%determine%curren
t%%
%%%understanding%/%opinions%%
! %Assess%EM
R%(%EPIC)%func8onality%that%could%support%%
%%%%defi
ned
%best%prac8ces%%
! %%Build%Tool,%Iden
8fy%m
etrics%and%available%data%sources%
! Im
plemen
ta8on%in%Internal%M
edicine%with%%
%%%Residen
t%Cham
pions%%
! %Pre%im
plemen
ta8on%educa8on%/%training%%
! %Roll%out%to%all%program
s%%
! %Rep
eat%Survey%and%collect%feedback%
! %M
inor%modifica8ons%to%form
s%%
! Be
gin%next%cycle%:%focus%
%men
toring%and%faculty%developmen
t%%
! %Publish%
1%
• Pr
ojec
t rev
iew
ed b
y th
e O
chsn
er In
stitu
tiona
l Rev
iew
Boa
rd a
nd re
ceiv
ed a
qua
lifyi
ng e
xem
ptio
n
• A
sses
sed
the
tool
s, pr
actic
es, a
nd p
olic
ies c
urre
ntly
in u
se to
faci
litat
e tra
nsiti
ons o
f car
e at
our
in
stitu
tion
• D
istrib
uted
surv
ey to
resid
ents
and
facu
lty in
ord
er to
ass
ess c
urre
nt p
erce
ptio
ns a
nd p
ract
ices
su
rroun
ding
tran
sitio
ns o
f car
e. (3
, 6, 9
)
• M
et w
ith p
rogr
am d
irect
ors a
nd re
siden
ts fro
m m
ultip
le sp
ecia
lties
to re
view
the
publ
ished
impo
rtanc
e of
sign
-out
stan
dard
izat
ion
and
our g
oals
at th
e in
stitu
tiona
l lev
el
• D
esig
ned
writ
ten
sign-
out t
empl
ate
utili
zing
ele
men
ts fro
m th
e pn
eum
onic
AN
TICi
pate
•
Prog
ram
med
the
writ
ten
docu
men
t with
in th
e EM
R; p
ilote
d as
a st
anda
rdiz
ed a
nd u
p-to
-dat
e sig
n-ou
t to
ol a
cces
sible
via
com
pute
rs a
nd i
Pads
Resid
ent%H
ando
ff Prim
ary%T
eam%Te
am%X
Ro
om%Num
ber:%6W
Date%of%B
irth%1/
01/1964
Al
lergie
s:%NK
DA
Age:
%60
Admit%Da
te:%07/21
/201
4
Sex:
F
BMI:%32
Code
%Status:%Full
Illness%level%(%current%clinica
l%status%)%:%W
ATCH
ER%
Reason
%for%a
dmiss
ion:%Ovaria
n%carcinom
a
Brief
%HPI%(%pe
r:ne
nt%PM
H%an
d%diagno
sis%or%d
ifferen
:al%diag
nosis
%)%:%
60%yo
%F%with%ovaria
n%carcinom
a%and
%large%p
elvic%mass,%recent%bilateral%LE%D
VTs
Hospita
l%Cou
rse(%U
pdated
%brie
f%assessm
ent%b
y%system%or%p
roblem
,%sign
ificant%ev
ents)
%%
POD%#1%s/
p%TA
H%an
d%BS
O%with%tu
mor%deb
ulkin
g%and
%lymph
%nod
e%diss
ec:o
n,%IV
C%filte
r%plac
emen
t.%Pa
:ent%had
%an%EB
L%of%2
300%m
l%and
%is%%
s/p%5%u
nits%PR
BCs/2%F
FP.%C
urrently%he
mod
ynam
ically%stab
le%
Tasks%%(sp
ecific,%using%if%,%th
en%statem
ents%):%
If%pa
:ent%becom
es%hypoten
sive%(
SBP%<
100)%or%u
rine%o
utpu
t%decreases,%p
lease%bolus%pa:
ent%w
ith%normal%salin
e.%Obtain
%repe
at%Hgb%an
d%Hc
t%to%en
sure%th
ere%h
as%been%an
%adeq
uate%re
spon
se%to
%tran
sfusio
n%
Con:
ngen
cy%Plan
%(%%%spe
cial%circ
umsta
nces%an
:cipated
%and%plan
%)%
Plan
:%Currently%ho
lding%loven
ox,%w
ill%discuss%w
ith%te
am%an
d%consider%re
star:ng%on%PO
D%#2%%
%
Repe
at su
rvey
resu
lts w
ere
obta
ined
from
45
facu
lty a
nd 6
3 re
siden
ts re
pres
entin
g m
ultip
le sp
ecia
lties
. Co
mpa
ring
the
initi
al re
sults
to th
e re
peat
surv
ey, t
here
rem
aine
d va
riabi
lity
in p
roce
ss p
erce
ptio
n.
Seve
nty-
two
perc
ent o
f fac
ulty
repo
rted
at le
ast o
nce
iden
tifyi
ng a
pat
ient
safe
ty is
sue
occu
rring
as a
re
sult
of th
e ha
ndof
f pro
cess
, whi
ch w
as c
onsis
tent
with
the
initi
al su
rvey
resu
lts. T
here
was
an
incr
ease
fro
m 8
2% to
86%
of f
acul
ty re
porti
ng su
perv
ision
of t
he h
ando
ff pr
oces
s. In
the
initi
al su
rvey
80%
of
resid
ents
repo
rted
som
etim
es o
r nev
er re
ceiv
ing
feed
back
on
thei
r han
doffs
, and
that
num
ber d
ecre
ased
to
70%
in th
e re
peat
surv
ey. T
here
was
also
an
incr
ease
in th
e pe
rcen
tage
of r
esid
ents
repo
rting
use
of a
sta
ndar
dize
d pr
oces
s for
han
doffs
.
Discussion
• D
efine
d a
verb
al si
gn-o
ut m
odel
ed a
fter t
he p
neum
onic
I-P
ASS
, whi
ch w
as d
evel
oped
at B
osto
n Ch
ildre
n’s
Hos
pita
l (9)
• Pr
inte
d ta
bles
for b
oth
the
writ
ten
and
verb
al h
ando
ff pr
oces
s on
note
car
ds a
nd d
istrib
uted
to a
ll sta
ff an
d re
siden
ts w
ithin
our
insti
tutio
n •
Hel
d in
tera
ctiv
e di
dact
ic se
ssio
ns in
trodu
cing
the
docu
men
ts an
d tra
inin
g in
thei
r use
• Fa
cilit
ated
fee
dbac
k an
d di
scus
sion
surro
undi
ng
spec
ialty
spec
ific
requ
irem
ents
and
cons
ider
atio
ns fo
r th
e ha
nd-o
ff pr
oces
s •
Repe
ated
surv
ey to
qua
ntify
impr
ovem
ent;
plan
late
r su
rvey
to e
valu
ate
susta
inab
ility
• Id
entifi
ed st
akeh
olde
rs to
ens
ure
susta
inab
ility
of t
he
proj
ect a
nd c
ontin
ued
impr
ovem
ent
Materials/M
etho
ds
Faculty
Survey
Jacob Breaux, M
D, Ron
eisha McLen
don, M
D, Rob
in Stedm
an, M
D, N
avita
Gup
ta, M
D, Kelly Shu
m, M
D,
Mannan Kh
an, M
D, Elizabeth Ellent, M
D, Ron
ald Am
edee, M
D, Janice Piazza, M
SN, M
BA, R
obert W
olterm
an, M
HA
We
use
a st
anda
rdiz
ed h
and
over
pro
cess
on
my
serv
ice
Most of the Time
Always
0.0%
$
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91 of 131
Team: Orlando Health Focus Area: Patient Safety – Improving Hand-Hygiene Compliance to Reduce Healthcare Associated Infections
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
• A baseline evaluation of hand hygiene compliance at ORMC revealed that the Department of Internal Medicine performed hand hygiene techniques 8% and 12% of the time for Attendings and Residents, respectively.
• Data from the Infection Control Department at ORMC showed that 45% of individuals washed their hands with soap and water after leaving a patient’s room, which has a sign identifying C. difficile isolation. Statistics also showed 72% individuals entering a C. difficile isolation room wore gowns and 45% of them washed their hands after exiting the room.
• With these startling numbers, the need to delve into investigating the overall HH compliance rate and figuring out the best strategy for positive change within our institution became self-evident.
II. Project Description • Our aim is to develop an innovative and feasible approach to impact hand hygiene that will help align the GME and institutional goals, which will in turn help reduce healthcare associated infections.
• To re-evaluate hand hygiene (HH) compliance at Orlando Health (OH) after education and demonstration of proper hand hygiene
III. Necessary Resources (staff, finances, etc.)
• IHI Hand Hygiene Expedition Webinar • Team leader and members • Staff – residents, medical students, nurses, attendings • Patients • Department of Infection Prevention and Control • Succinct power points teaching about hand hygiene • Hand washing demonstration tools (Black light, gloves, timer)
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
• Collect data of the opportunities for handwashing on Internal Medicine Residency Program teams via secret selected member of the team; in this case medical students
• Approach Infection prevention and control department for secret observers to evaluate all GME programs
V. Communication Plan (may be helpful to draft a flow chart of team
members & senior management, both internal & external)
• Plans will be communicated to team members through short team meetings and emails
• Short meetings with medical students on Internal Medicine Residency program teams explaining surveillance process
• Short meeting with Infection Prevention and Control Department • Discuss and provide planned interventions to the resident quality
advisory committee and obtain feedback VI. Accountability
(list of team members and who is accountable for what)
Dr. Madruga – DIO Dr. Clark – Chief Quality Officer of OHPG Dr. Kelley– Chief Quality Officer for Hospital Division/Advisor Dr. Ayesu – Team Leader Drs. Agard and Toms – Project Coordinators
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
• Time management as residents have obligations and time consuming schedules
• Limited resources for monitoring handwashing opportunities (Secret Observers)
• Discordance between the interventions occurring by infection control and GME
• Decline in enthusiasm to receive education and facilitate hand hygiene tools
92 of 131
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
• Short PDSA cycles (August- December 2014) • Provide education on hand hygiene with power points (August –
September 2014) • Distribute power points to other GME programs and encourage
teaching (September 2014- December 2014) • Meet with representative from Infection Prevention and Control
Department to discuss interventions (November- December 2014) • Collect comprehensive data via surveillance of handwashing
opportunities (January 2015) IX. Vision Statement/Closing Plan
(markers of success by March 2015)
• Improve hand hygiene compliance to 50% compared to baseline for the Internal Medicine Program (Attendings, Residents, Medical Students) in 6 months, then distribute effective strategies to all GME programs
X. Success Factors • Continued collaboration with the Department of Infection Prevention and Control as well as the Chief Quality Officer
• Continuing to engage the C-suite • Residents are more conscientious of performing hand hygiene
XI. Barriers • Difficulty in gathering HH compliance data from all GME programs due to limitation of monitoring resources
• Discordance between the interventions occurring by infection control and GME
• Decline in enthusiasm to receive education and facilitate hand hygiene tools
• Surveillance was performed by medical student present on Internal Medicine teams
XII. Lessons Learned • The most important part of the process is to form a good relationship with Infection control at the institution with open communication so that efforts are collaborated creating a bigger impact.
• Establishing champions is key to continual education and promotion of proper practice
XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI III work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact • Improved hand hygiene compliance in the Internal Medicine Residency Program from baseline after education and demonstrations
XVI. Next Steps • Involve the patients and their families in the practice and
encouragement of proper hand hygiene to further improve compliance, therefore decreasing HAI
93 of 131
Ove
rall
Go
al/A
bst
ract
•T
o e
val
uat
e han
d h
yg
ien
e (H
H)
com
pli
ance
at
Orl
and
o
Hea
lth
(O
H)
afte
r ed
uca
tio
n a
nd
dem
on
stra
tion
of
pro
per
han
d h
yg
ien
e
•To
dev
elo
p a
n i
nn
ov
ativ
e an
d f
easi
ble
app
roac
h t
o i
mpac
t
HH
com
pli
ance
an
d r
edu
ce h
osp
ital
acq
uir
ed i
nfe
ctio
n
Ha
nd
Hy
gie
ne
Co
mp
lia
nce
at
Orl
an
do
Hea
lth
Mali
sa A
gard
MD
, M
art
ha T
om
s M
D, C
aro
lin
e N
gu
yen
-Min
MD
, K
wab
ena A
yes
u M
D
Orl
an
do H
ealt
h, O
rlan
do F
L
A
uth
ors
, In
stit
uti
on
, Cit
y /
Stat
e
Bac
kgro
un
d
Han
d h
ygie
ne
is a
n e
ssen
tial
hum
an b
ehav
ior
that
can
hel
p r
educe
hea
lth
care
acq
uir
ed i
nfe
ctio
ns
(HA
I).
HA
I
pro
lon
gs
hosp
ital
sta
y, i
ncr
ease
res
ista
nce
of
mic
roorg
anis
ms
to a
nti
mic
rob
ials
, ad
dit
ion
al f
inan
cial
bu
rden
, an
d e
xce
ss d
eath
s. T
he
risk
of
HA
I is
un
iver
sal
and
the
glo
bal
bu
rden
is
un
kn
ow
n s
eco
nd
ary t
o t
he
dif
ficu
lty
of
gat
her
ing
rel
iab
le d
ata.
The
CD
C e
stim
ates
that
eac
h y
ear
nea
rly
2 m
illi
on
pat
ien
ts i
n t
he
US
get
s an
infe
ctio
n i
n h
osp
ital
s, a
nd
abou
t 90,0
00
of
thes
e pat
ients
die
as
a re
sult
of
thei
r in
fect
ion
. H
ere
at O
rlan
do
Hea
lth
, th
e D
irec
tor
of
Infe
ctio
n
Pre
ven
tio
n a
nd
Co
ntr
ol
has
pro
vid
ed t
hou
gh
t pro
vo
kin
g
stat
isti
cs w
hic
h s
ho
wed
th
at 7
2%
indiv
idual
s en
teri
ng a
C.
dif
fici
le i
sola
tio
n r
oo
m w
ore
gow
ns
and 4
5%
of
them
was
hed
thei
r h
and
s af
ter
exit
ing t
he
room
. W
ith
thes
e
star
tlin
g n
um
ber
s, t
he
nee
d t
o d
elve
into
inves
tig
atin
g t
he
ov
eral
l H
H c
om
pli
ance
rat
e an
d f
igu
rin
g o
ut
the
bes
t
stra
teg
y f
or
po
siti
ve
chan
ge
wit
hin
ou
r in
stit
uti
on
bec
ame
self
evid
ent.
Vis
ion
Sta
tem
en
t •
To i
mp
rov
e H
H c
om
pli
ance
to a
t le
ast
50%
in
6 m
onth
s
at O
rlan
do
Hea
lth
Mat
eri
als/
Met
ho
ds
•D
evel
op
su
ccin
ct p
ow
er p
oin
ts t
o t
each
ab
ou
t h
and
hy
gie
ne
imp
ort
ance
an
d t
ech
niq
ues
th
at t
ake
no
lon
ger
th
an 5
min
ute
s to
co
mm
un
icat
e
•A
dm
inis
ter
pow
er p
oin
ts t
o r
esid
ents
in I
nte
rnal
Med
icin
e R
esid
ency
Pro
gra
m
•R
e-ev
alu
ate
HH
co
mp
lian
ce w
ith
in I
nte
rnal
Med
icin
e P
rog
ram
(A
tten
din
gs,
Res
iden
ts, M
edic
al
Stu
den
ts)
Bib
liogr
aph
y •
CD
C. (2
00
3).
Hand
Hyg
ien
e in
Hea
lthca
re S
etti
ngs
Sli
de-
Set
.
•IH
I E
xped
itio
n. (2
013
). I
mpact
ing
Hand H
ygie
ne
at
the
Fro
nt
Lin
e.
Bar
rie
rs E
nco
un
tere
d/L
imit
atio
ns
•D
iffi
cult
y i
n g
ather
ing H
H c
om
pli
ance
dat
a fr
om
all
GM
E p
rog
ram
s du
e to
lim
itat
ion
of
monit
ori
ng
reso
urc
es
•D
isco
rdan
ce b
etw
een t
he
inte
rven
tio
ns
occ
urr
ing b
y
infe
ctio
n c
on
tro
l an
d G
ME
•D
ecli
ne
in e
nth
usi
asm
to r
ecei
ve
edu
cati
on
and
faci
lita
te h
and h
yg
ien
e to
ols
•S
urv
eill
ance
was
per
form
ed b
y m
edic
al s
tud
ents
pre
sent
on I
nte
rnal
Med
icin
e te
ams
Re
sult
s
Co
ncl
usi
on
s •
Han
d h
ygie
ne
rem
ains
the
sing
le m
ost
eff
ecti
ve
mea
sure
to p
reven
t hea
lth
care
acq
uir
ed i
nfe
ctio
ns
•O
ur
study
rev
eale
d t
hat
thro
ugh
tea
chin
gs
wit
h
succ
inct
pow
er p
oin
ts t
o p
rom
ote
aw
aren
ess
and
han
d w
ash
ing
dem
on
stra
tion
s, c
om
pli
ance
im
pro
ves
•A
ltho
ug
h c
om
pli
ance
has
im
pro
ved
, to
opti
miz
e
safe
ty i
t is
nec
essa
ry t
o i
ncl
ud
e th
e pat
ien
t in
the
pra
ctic
e
•R
esid
ents
are
more
co
nsc
ien
tio
us
of
per
form
ing
pro
per
han
d h
ygie
ne
resu
ltin
g i
n i
mpro
ved
co
mp
lian
ce
•C
onti
nu
ed c
oll
abora
tion
wit
h t
he
Dep
artm
ent
of
Infe
ctio
n P
reven
tion
and
Contr
ol
as w
ell
as t
he
Chie
f Q
ual
ity O
ffic
er
•C
onti
nu
ing
to e
ngag
e th
e C
-su
ite
Succ
ess
Fac
tors
80
%
8%
8%
4
%
Inte
rn
al
Me
dic
ine
Ba
se
lin
e
Ha
nd
Hy
gie
ne
Co
mp
lia
nc
e R
ate
Mis
sed
Att
end
ing
PG
Y 1
PG
Y 2
-3
0%
10%
20
%
30
%
40
%
50
%
60
%
70
%
80
%
90
%
100
%
Att
end
ing
sS
enio
rIn
tern
Med
ica
lS
tud
ent
Fel
low
81%
93
%
100
%
100
%
88
%
100
%
100
%
100
%
100
%
83
%
Fo
am
In
Fo
am
Ou
t
Inte
rnal
Med
icin
e H
an
d H
yg
ien
e C
om
pli
an
ce
Rea
sses
smen
t
94 of 131
Team: Orlando Health Focus Area: Patient Safety- Resident QI Core Curriculum Development Revisited
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
• Following the landmark report “ To Err is Human” many institutions incorporated QI into GME curriculum. However formal training was lacking, therefore a curriculum using IHI Open School Modules was developed to enhance the resident’s ability to effectively carry out their quality improvement projects.
• With more than a year passed, a reassessment of the residents QI knowledge since completing formal training was prudent
II. Project Description • Evaluate the retention of the knowledge obtained from the curriculum developed previously in National Initiative III after completion of formal training
• Evaluate effectiveness of the QI core curriculum and possible need for continued training
III. Necessary Resources (staff, finances, etc.)
• Residents and Team Leader • Clinical coordinators and Chief Residents of the GME programs at
Orlando Health (IM, General Surgery, Orthopedic surgery, Pediatrics, Pathology, OB/GYN)
• Literature survey to identify available questionnaires • Creation of a baseline questionnaire • IHI QI training provided • Post-test assessment results to compare with maintenance
results IV. Measurement/Data Collection Plan
(must partner/match with Milestone Markers)
• Administer questionnaire/surveys provided on IHI website to all the GME residency programs
• Aim will be to have baseline measurement of the knowledge retained to evaluate effectiveness of the developed curriculum
V. Communication Plan (may be helpful to draft a flow chart of
team members & senior management, both internal & external)
• Plans will be communicated to clinical coordinators/secretaries and chief residents of the residency programs through emails and short meetings
• Will deliver the surveys to the designated representative of each program that will administer it
• Inform and evaluate the Resident Quality Advisory Council (collaboration of champions of the different GME programs) of the plans to evaluate the need for maintenance of QI knowledge
VI. Accountability (list of team members and who
is accountable for what)
Dr. Madruga – DIO Dr. Clark- Chief Quality Advisor Dr. Kwabena Ayesu- Team Leader Dr. Malisa Agard and Dr. Caroline Nguyen- Project coordinators
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
• Time management especially with the resident’s busy schedule • Ensuring proper administration of the surveys
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
• Obtain IHI questionnaire/survey and eliminate unnecessary parts • Administer Maintenance questionnaire/survey to Resident
Quality Advisory Council champions (September 2014) • Collect comprehensive data (January 2015)
IX. Vision Statement/Closing Plan (markers of success by March 2015)
• To maintain a QI Curriculum that is simple, yet effective and adaptable to all GME programs at Orlando Health that will help residents better facilitate QI Projects
95 of 131
X. Success Factors • The most successful component of our work was we were able to collaborate with all the other GME programs representatives to administer the questionnaire/survey to the residents. Now we have an idea of how much the residents are retaining from the developed curriculum
• We were inspired by the level of retention (percentage) as illustrated in the data collected to find ways to ensure that resident education of Quality improvement core concepts is more effective as well as sustainable.
XI. Barrier • The largest barrier we encountered was resistance and lack of eagerness to participate.
• Time management is another issue most related to the busy schedules and responsibilities of the residents
• We worked to overcome this by reaching out to chief residents and clinical coordinators of the residency programs so that the task of collecting the data could be completed.
XII. Lessons Learned • Have a realistic time frame to collect the data • Frequent communication with clinical coordinators and chief
residents of the respective programs is important for success • Having a representative on the corporate level is helpful in
recruiting excitement about the project
XIII. Expectations Versus Results On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI III work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact • The residents have a better knowledge of the process and necessary steps to implement change with their respective quality improvement projects.
• However it may be necessary to provide maintenance teachings so that the core concepts are retained, therefore ensuring that the projects are carried out effectively
XVI. Next Steps • The next step is devising a way to help the residents with maintenance of the knowledge whether that be brief power points, noon conferences, small laminated
• cards that they can carry around, etc • Re-evaluate retention with the surveys after the these teaching
tools
96 of 131
Ove
rall
Go
al
•T
o e
val
uat
e re
sid
ents
’ re
ten
tio
n o
f Q
I kn
ow
led
ge
afte
r
form
al t
rain
ing
•T
o e
val
uat
e ef
fect
iven
ess
of
QI
core
curr
iculu
m a
nd
po
ssib
le n
eed
fo
r co
nti
nu
ed t
rain
ing
Qu
ali
ty I
mp
rovem
ent –
A H
um
bli
ng E
xp
erie
nce
Tri
gger
ing
Ch
an
ge
in R
esid
ent
Ed
uca
tion
Rev
isit
ed
Ma
lisa
Ag
ard
MD
, C
aro
lin
e N
gu
yen
-Min
MD
, an
d K
wab
ena
Ayes
u M
D
Orl
ando H
ealt
h, O
rlan
do F
L
Bac
kgro
un
d
Qual
ity I
mpro
vem
ent
(QI)
has
bec
om
e an
ess
enti
al p
art
of
all
aspec
ts o
f cl
inic
al m
edic
ine.
W
ith
the
Inst
itute
of
Med
icin
e’s
lan
dm
ark
rep
ort
“T
o E
rr I
s H
um
an”
in 1
999
,
man
y i
nst
ituti
on
s h
ave
inco
rpora
ted Q
I in
to t
hei
r G
ME
curr
icu
lum
, li
kew
ise
Orl
and
o H
ealt
h R
esid
ency
Pro
gra
ms.
Lac
kin
g f
orm
al Q
I tr
ain
ing
we
dec
ided
to i
mple
men
t th
e
IHI
Open
Sch
oo
l tr
ain
ing
modu
les
as a
core
tra
inin
g
curr
iculu
m f
or
resi
den
ts. W
ith
more
than
a y
ear
among
us,
a re
asse
ssm
ent
of
resi
den
ts Q
I k
no
wle
dg
e af
ter
IHI
trai
nin
g
was
dee
med
pru
den
t.
Vis
ion
Sta
tem
en
t T
o m
ain
tain
a Q
I cu
rric
ulu
m t
hat
is
sim
ple
, yet
eff
ecti
ve
and
adap
tab
le t
o a
ll r
esid
ency
pro
gra
ms
at O
RM
C t
o
faci
lita
te Q
I p
roje
cts
Mat
eri
als/
Met
ho
ds
•L
iter
ature
su
rvey
to
id
enti
fy a
vai
lab
le q
ues
tion
nai
res
•C
reat
ion
of
a b
asel
ine
qu
esti
onn
aire
•A
dm
inis
trat
ion
of
qu
esti
on
nai
re t
o r
esid
ents
of
IM
•IH
I Q
I tr
ain
ing
pro
vid
ed
•A
dm
inis
trat
ion
of
Mai
nte
nan
ce q
ues
tio
nn
aire
•P
ost
-tes
t as
sess
men
t co
mp
ared
wit
h m
ain
ten
ance
res
ult
s
Bib
liogr
aph
y •
Inst
itute
for
Hea
lth
care
Im
pro
vem
ent.
Under
sta
nd
ing
Med
ica
l E
rror
and
Pati
ent
Safe
ty.
Bar
rie
rs E
nco
un
tere
d/L
imit
atio
ns
•T
ime
man
agem
ent
•D
iffe
ren
t st
akeh
old
ers
•R
esid
ent
resi
stan
ce t
o c
om
ple
ting
Q
I cu
rric
ulu
m
des
pit
e ta
ilo
red m
odu
les
•D
iffi
cult
y c
onv
eyin
g i
mpo
rtan
ce o
f m
ain
tain
ing Q
I
kn
ow
led
ge
•L
ack o
f dat
a fr
om
res
iden
ts w
ho h
ave
com
ple
ted
curr
iculu
m d
ue
to m
atri
cula
tion
Re
sult
s
Co
ncl
usi
on
s •
NA
S a
nd C
LE
R h
ave
elev
ated
qual
ity
im
pro
vem
ent
to t
he
fore
fron
t of
all
resi
den
cy t
rain
ing
•R
esid
ents
hav
e a
pro
fou
nd
lac
k o
f re
ten
tio
n i
n t
he
QI
kn
ow
led
ge
des
pit
e fo
rmal
tra
inin
g
•M
ain
ten
ance
ques
tio
nn
aire
res
ult
s fo
rces
us
to r
e-
eval
uat
e th
e ef
fect
iven
ess
of
ou
r co
re c
urr
icu
lum
an
d
whet
her
the
lack
of
rete
nti
on r
equir
es o
ngo
ing
QI
trai
nin
g
•G
reat
er t
han
70
% r
espo
nd
ents
on
mai
nte
nan
ce
qu
esti
on
nai
re a
mon
g a
ll G
ME
pro
gra
ms
•C
oll
abo
rati
on
wit
h o
ther
GM
E p
rog
ram
s to
fac
ilit
ate
com
ple
tion
of
mai
nte
nan
ce q
ues
tio
nn
aire
Succ
ess
Fac
tors
0%
10
%
20
%
30
%
40
%
50
%
60
%
70
%
80
%
90
%
10
0%
64
.3%
52
.6%
78
.9%
10
0.0
%
64
.7%
10
0.0
%
88
.9%
Post
- te
st P
ass
ing
Rate
by D
epart
men
ts a
fter
QI
Cu
rric
ulu
m T
rain
ing
0%
10%
20
%
30
%
40
%
50
%
60
%
70
%
80
%
90
%
100
%
Su
rger
yP
ass
ing
wit
h6
5%
or
Ab
ov
e
Su
rger
y w
ith
less
th
an
65
%
Ort
ho
ped
ics
pa
ssin
g w
ith
65
% o
rA
bo
ve
Ort
ho
ped
ics
wit
h l
ess
tha
n 6
5%
Pa
tho
log
yp
ass
ing
wit
h6
5%
or
Ab
ov
e
Pa
tho
log
yw
ith
les
sth
an
65
%
EM
pa
ssin
gw
ith
65
% o
rA
bo
ve
EM
wit
h l
ess
tha
n 6
5%
Ped
iatr
ics
pa
ssin
g w
ith
65
% o
rA
bo
ve
Ped
iatr
ics
wit
h l
ess
tha
n 6
5%
OB
/GY
Np
ass
ing
wit
h6
5%
or
Ab
ov
e
OB
/GY
Nw
ith
les
sth
an
65
%
IM p
ass
ing
wit
h 6
5%
or
ab
ov
e
IM w
ith
les
sth
an
65
%
50
%
50
%
36
%
64
%
25
%
75
%
33
%
67
%
10%
90
%
17%
83
%
30
%
70
%
QI
Core
Cu
rric
ulu
m M
ain
ten
an
ce S
urv
eill
an
ce f
or
GM
E R
esid
ents
97 of 131
Team: OSF Focus Area: Transitions in care
I. Team Charter/Objectives (‘needs statement,’ project
requirements, project assumptions, stakeholders, etc.; Teams
should identify members and define responsibility/purpose)
Objectives-Embedding IPASS Resident hand off in programs Team members- Dr Beekman, Dr McBeeOrzulak, Crystal Coan, Kristin Crawford, Dr. Santoro, Dr. Miller, IPASS Program Champions, Hannah Wang, Mindy Reeter, Carmen Kirkness
II. Project Description Further embedding IPASS Resident Hand off in programs through IPASS program champions and simulation.
III. Necessary Resources (staff, finances, etc.)
Simulation Center and resources to develop curriculum. Resources to do re-assessments of PEDs and Internal Medicine and ED. Resources to support research.
IV. Measurement/Data Collection Plan (must partner/match with
Milestone Markers)
Reassessment of Resident satisfaction via survey. We will be assessing the verbal and written accuracy of the hand off tool. Reassessment of PEDs, Internal Medicine and ED hand off to compare to baseline. Report out on any resident hand off issues via Peminic. (online reporting tool) Chart audit to determine accuracy of written hand off.
V. Communication Plan (may be helpful to draft a flow chart of team
members & senior management, both internal & external)
Dr. Santoro and Dr Miller Programs Directors Program IPASS Champions Residents UICOMP resources
VI. Accountability
(list of team members and who is accountable for what)
Dr. Santoro, Dr. Miller Dr Beekman & Dr McBeeOrzulak IPASS Program champions Dr Wolford Crystal Coan& Kristin Crawford Hannah Wang Mindy Reeter Carmen Kirkness
VII. Potential Challenges (engagement, budget, time, skills
gaps, etc)
Lack of ability for interdisciplinary teams to view hand off Attending availability at resident hand off
VIII.
Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
Refine assessment tool 11/3013 Refine Resident Survey 12/15/13 Reassessment of programs by 2/14/14 Med/Peds- 1/14 Medicine-2/14 Peds-12/13 ED 2/14
Resurvey residents in PEDs, Internal Medicine and ED on satisfaction 3/14 Simulation Pilot ? 98 of 131
Simulation Med/Peds-? Medicine-? Peds-?
Team Steps tied into ED simulation with adding resident hand off 4/14- Dr Wolford has approved and meeting with TK next week to discuss
IX. Vision Statement/Closing Plan (markers of success by March 2015)
Reduction in Peminic reports for resident hand off issues Improved resident hand off post go live of Epic integrated tool Improved resident satisfaction on resident hand off via survey Reassessment Chart audit for hand off errors by resident resources
For your final work plan, please update sections I thru IX as needed and add your responses to sections X thru XVI. The collective data from all of the teams’ completed plans will be invaluable as we learn and publish from this collaborative experience.
Team: Focus Area:
I. Team Charter/Objectives
(‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
The objective of this project is to implement IPASS in adult ICU setting and to evaluate handoff pre and post educational intervention. Resident handoff was previously studied in Peds medical/surgical only. This is an opportunity to understand adult ICU. This project will increase our understanding of adverse events, near misses and good catches in an adult ICU. This will standardize the handoff in order to create a concise product with an increased safety for patients.
II. Project Description
This project will allow us to see an improved resident handoff in a controlled environment (verbally and electronically) and more reporting to our electronic event reporting system. This process will create a concise and standardized resident handoff tool using the IPASS to improve patient safety by enhancing communication and satisfaction among residents rotating through the adult ICU.
III. Necessary Resources (staff, finances, etc.)
Staff to do rounding with RNs and Residents every day. Providers to do education and do baseline and follow up on hand off.
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
V. Communication Plan (may be helpful to draft a flow chart of
team members & senior management, both internal & external)
We will be doing texting and e-mailing updates. Get up a sign up page for Providers to sign up for interventions and grading hand off first of month and last 2 weeks after intervention
99 of 131
VI. Accountability (list of team members and who
is accountable for what)
Attached is the implementation plan
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
The daily RN and Resident survey was more labor intensive than we thought. Observations were assigned to dedicated non-clinical team member to provide consistency but needed more round the clock vigilance to obtain true picture. In addition, more work is needed to get communication and transparency of good catches and near misses to staff and residents. A future opportunity in change management could include removal of the stigmatism associated with reporting and retribution
VIII. Markers (project phases, progress checks,
schedule, etc.; must partner/match measurement/data collection plan)
IX. Vision Statement/Closing Plan
(markers of success by March 2015)
This project will allow us to see an improved resident handoff in a controlled environment (verbally and electronically) and more reporting to our electronic event reporting system. This process will create a concise and standardized resident handoff tool using the IPASS to improve patient safety by enhancing communication and satisfaction among residents rotating through the adult ICU.
X. Success Factors The most successful component of our work was……….. We were inspired by……………….. Increased event reporting and reduced hand off errors
XI. Barriers The largest barrier we encountered was…….. We worked to overcome this by…….. The resident intervention was difficult due to clinical schedules. Timing of the verbal handoff was not always consistent and a future opportunity could include a standard provider observer with familiarity to the ICU patients. In addition, having one dedicated attending champion would be helpful to lead the research.
XII. Lessons Learned The single most important piece of advice to provide another team embarking on a similar initiative would be………… We underestimated the resources to do this project. Make sure you have backups to all of the tasked needed.
XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
100 of 131
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI III work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact What changes have you observed in your residency program(s), or at your institution, based upon your work? Hand off have improved and are more transparent.
XVI. Next Steps Describe next steps for your project, including plans for sustaining and spreading the changes made. Spread to other non-ICU Establish a Attending Provider Champion
101 of 131
Ove
rall
Go
al/A
bst
ract
Th
e o
bje
ctiv
e o
f th
is p
roje
ct is
to
imp
lem
ent
IPA
SS in
ad
ult
ICU
se
ttin
g an
d t
o e
valu
ate
han
do
ff p
re a
nd
po
st e
du
cati
on
al
inte
rven
tio
n.
Res
iden
t h
and
off
was
pre
vio
usl
y st
ud
ied
in P
eds
med
ical
/su
rgic
al o
nly
. Th
is is
an
op
po
rtu
nit
y to
un
der
stan
d
adu
lt IC
U.
This
pro
ject
will
incr
ease
ou
r u
nd
erst
and
ing
of
adve
rse
even
ts, n
ear
mis
ses
and
go
od
cat
ches
in a
n a
du
lt IC
U.
This
will
sta
nd
ard
ize
the
han
do
ff in
ord
er t
o c
reat
e a
con
cise
p
rod
uct
wit
h a
n in
crea
sed
saf
ety
for
pat
ien
ts.
Rat
es o
f M
edic
al E
rrors
and A
dver
se E
ven
ts i
n a
Med
ical
IC
U
foll
ow
ing i
mple
men
tati
on o
f a
stan
dar
diz
ed c
om
pute
rize
d h
andoff
syst
em,
Cry
stal
Dav
is-C
oan
, Kri
stin
Cra
wfo
rd, D
r. Te
resa
Lyn
ch,
Dr
Rac
hae
l Dav
is, D
r Ti
m M
iller
, Dr
San
toro
- a
ll fr
om
OSF
or
UIC
OM
P, P
eori
a, IL
This
pro
ject
will
eva
luat
e th
e ef
fect
iven
ess
and
sta
ff s
atis
fact
ion
o
f re
sid
ent
han
do
ffs
in t
he
OSF
SFM
C M
edic
al In
ten
sive
Car
e U
nit
(ad
ult
ICU
) u
tiliz
ing
the
I-PA
SS h
and
-off
sys
tem
(in
tegr
ated
w
ith
EP
IC)
at b
asel
ine
and
th
en p
ost
inte
rven
tio
n. W
e p
rovi
ded
a
con
tro
lled
an
d q
uie
t en
viro
nm
ent
for
han
d-o
ffs,
an
inte
grat
ed
han
d-o
ff t
oo
l (I-
PASS
plu
s EP
IC)
and
a r
ob
ust
ed
uca
tio
nal
bu
nd
le
wit
h s
imu
lati
on
/ro
le p
layi
ng,
did
acti
cs, a
nd
sm
all g
rou
p w
ork
. Th
e cu
rren
t p
roce
ss in
th
e ad
ult
ICU
do
es n
ot
incl
ud
e a
con
tro
lled
en
viro
nm
ent
or
a co
nsi
sten
t p
roce
ss f
or
del
iver
ing
han
d-o
ffs
or
stan
dar
diz
ed t
ime.
Th
is w
ill b
e an
alyz
ed o
n a
m
on
thly
bas
is o
ver
a 6
mo
nth
per
iod
.
Vis
ion
Sta
tem
en
t Th
is p
roje
ct w
ill a
llow
us
to s
ee a
n
imp
rove
d r
esid
ent
han
do
ff in
a
con
tro
lled
en
viro
nm
ent
(ver
bal
ly
and
ele
ctro
nic
ally
) an
d m
ore
re
po
rtin
g to
ou
r el
ectr
on
ic e
ven
t re
po
rtin
g sy
stem
. Th
is p
roce
ss
will
cre
ate
a co
nci
se a
nd
st
and
ard
ized
res
iden
t h
and
off
to
ol u
sin
g th
e IP
ASS
to
imp
rove
p
atie
nt
safe
ty b
y en
han
cin
g co
mm
un
icat
ion
an
d s
atis
fact
ion
am
on
g re
sid
ents
ro
tati
ng
thro
ugh
th
e ad
ult
ICU
.
Mat
eri
als/
Met
ho
ds
Th
ere
is a
mo
nth
ly r
ota
tio
n o
f R
esid
ents
in t
he
adu
lt IC
U.
We
ob
serv
e h
and
off
, co
mp
lete
inte
rven
tio
n e
du
cati
on
an
d f
inal
ly
ob
serv
e h
and
off
aga
in (
verb
ally
an
d e
lect
ron
ical
ly).
Sta
ff a
nd
p
rovi
der
s co
mp
lete
a d
aily
RN
or
Res
iden
t su
rvey
fo
r u
nre
po
rted
ev
ents
, go
od
cat
ches
an
d n
ear
mis
ses.
Th
ese
are
com
par
ed t
o
the
elec
tro
nic
eve
nt
rep
ort
ing
syst
em f
or
tran
spar
ency
.
Inte
rven
tio
n c
on
sist
s o
f a
3-4
ho
ur
trai
nin
g se
min
ar c
on
sist
ing
of
a st
and
ard
ized
did
acti
c co
mp
on
ent,
sam
ple
vid
eos
of
app
rop
riat
e an
d in
app
rop
riat
e h
and
-off
s, a
nd
inte
ract
ive
sim
ula
tio
n t
rain
ing
on
pro
per
han
d-o
ffs
and
eve
nt
rep
ort
ing
follo
wed
by
a d
ebri
efin
g p
erio
d.
Bar
rie
rs E
nco
un
tere
d/L
imit
atio
ns
Th
e re
sid
ent
inte
rven
tio
n w
as d
iffi
cult
du
e to
clin
ical
sc
hed
ule
s. T
imin
g o
f th
e ve
rbal
han
do
ff w
as n
ot
alw
ays
con
sist
ent
and
a f
utu
re o
pp
ort
un
ity
cou
ld in
clu
de
a st
and
ard
pro
vid
er o
bse
rver
wit
h f
amili
arit
y to
th
e IC
U
pat
ien
ts. I
n a
dd
itio
n, h
avin
g o
ne
ded
icat
ed a
tten
din
g ch
amp
ion
wo
uld
be
hel
pfu
l to
lead
th
e re
sear
ch.
The
dai
ly R
N a
nd
Res
iden
t su
rvey
was
mo
re la
bo
r in
ten
sive
th
an w
e th
ou
ght.
Ob
serv
atio
ns
wer
e as
sign
ed t
o d
edic
ated
n
on
-clin
ical
tea
m m
emb
er t
o p
rovi
de
con
sist
ency
bu
t n
eed
ed m
ore
ro
un
d t
he
clo
ck v
igila
nce
to
ob
tain
tru
e p
ictu
re.
In a
dd
itio
n, m
ore
wo
rk is
nee
ded
to
get
co
mm
un
icat
ion
an
d t
ran
spar
ency
of
goo
d c
atch
es a
nd
nea
r m
isse
s to
sta
ff a
nd
res
iden
ts.
A f
utu
re o
pp
ort
un
ity
in
chan
ge m
anag
emen
t co
uld
incl
ud
e re
mo
val o
f th
e st
igm
atis
m a
sso
ciat
ed w
ith
rep
ort
ing
and
ret
rib
uti
on
.
Re
sult
s (d
ata
gath
ere
d b
oth
qu
ant
& q
ual
.)
Co
ncl
usi
on
s Fi
nal
th
ou
ghts
- W
e h
ave
dat
a fo
r d
iscu
ssio
n b
ut
lack
th
e d
epth
nee
ded
to
sh
ow
sig
nif
ican
ce in
th
e in
terv
enti
on
m
on
th t
o m
on
th.
Ove
rall
exp
erie
nce
-Th
ere
is m
ore
tra
nsp
aren
cy o
f th
e h
and
o
ff p
roce
ss o
n a
du
lt IC
U. H
ow
ever
, we
lack
on
e tr
ue
ow
ner
o
f th
e IC
U r
esid
ents
wh
ich
has
mad
e p
hys
icia
n
cham
pio
nin
g d
iffi
cult
bec
ause
att
end
ing
pro
vid
ers
rota
te
wee
kly.
Was
it a
tra
nsf
orm
ativ
e/w
ort
hw
hile
exp
erie
nce
? Ye
s fo
r kn
ow
led
ge a
nd
ab
ility
to
gro
w.
We
are
lear
nin
g to
u
nd
erst
and
ho
w t
o c
om
mu
nic
ate
wit
h r
esid
ents
in a
mo
re
mea
nin
gfu
l way
.
Wh
at d
o y
ou
wan
t to
sh
are
wit
h t
he
aud
ien
ce?
Ther
e is
m
ore
wo
rk t
o d
o in
sta
nd
ard
izin
g th
e m
on
thly
cal
end
ar in
ad
van
ce in
ter
ms
of
tim
ing
of
edu
cati
on
an
d o
bse
rvat
ion
s.
The
pro
ject
was
bo
th s
ucc
essf
ul a
nd
op
po
rtu
nit
y fo
r fu
ture
im
pro
vem
ents
. Dr.
Lyn
ch w
as a
str
on
g le
ader
bu
t n
ot
ded
icat
ed
to t
he
MIC
U f
or
ob
serv
atio
ns
and
dai
ly r
esid
ent
inte
ract
ion
s.
Wh
at w
ork
ed?
We
bro
ugh
t aw
aren
ess
and
incr
ease
d
com
mu
nic
atio
n a
bo
ut
failu
re p
oin
ts in
th
e p
roce
ss. T
her
e
has
bee
n n
o s
ign
ific
ant
chan
ge in
dep
th o
f h
and
off
. Th
is p
roje
ct b
rou
ght
stro
ng
lead
ersh
ip c
om
mit
men
t to
th
e h
and
- o
ff. R
esid
ents
en
joye
d s
imu
lati
on
in in
terv
enti
on
. A
dd
ing
“go
od
cat
ch”
to R
esid
ent
Surv
ey w
as a
qu
ick
win
so
th
e
focu
s w
as n
ot
neg
ativ
e.
Succ
ess
Fac
tors
an
d L
ess
on
s Le
arn
ed
(Dis
cuss
ion
)
Bac
kgro
un
d
Bib
liogr
aph
y B
ost
on
Ch
ildre
n’s
: I-P
ass
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Team: Our Lady of the Lake Regional Medical Center Focus Area: Patient Safety
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
Our Lady of the Lake Regional Medical Center (OLOL) is the sponsoring institution for a pediatric program and has recently become the primary clinical site for 4 LSU residency programs and a major participating site for 13 additional LSU residency programs. Currently, there is variability in the QI curriculum offered in each of the residency programs and there is limited resident integration to hospital QI/Patient Safety initiatives. Our objective is to develop a standardized educational intervention, focused on patient safety, across the 4 residency programs. Representatives from each of the residency programs, patient safety officers, QI directors and C-Suite leaders are included in the AIAMC Patient Safety Team. Members include: Laurinda Calongne, Ed.D. – Chief Academic Officer/DIO Keith Rhynes, M.D., MBA – OLOL GME Medical Director, Associate Program Director, LSU General Surgery Residency Program Stephen Hosea, M.D. , FACS – Associate Medical Director of Quality and Patient Safety Christi Pierce, M.B.A.,M.S.H.A. – Senior Director of Quality Michael Bolton, M.D. – Assistant Director of Quality and Patient Safety, Children’s Hospital Trey Dunbar, M.D. – Program Director, OLOL Pediatric Residency Program Bear Caffery, M.D. – Program Director, LSU Emergency Medicine Residency Program Savarra Mantzor, M.D. – PGY3 Pediatric Resident (incoming chief) Deborah Ford, RN, MSN – Chief Nursing Officer Lauren Rabalais, MPA – Director of GME Mandi Musso, PhD – Academic Research Director, LSU Emergency Medicine Residency Rich Vath, M.Ed – Academic Research Director, LSU Psychiatry and OLOL Pediatrics Banhsen Miller, M.D. – PGY 3 Internal Medicine Resident (incoming chief) Angela Johnson, M.D. – Associate Program Director, LSU Internal Medicine Residency Program Lee Tynes, M.D., PH.D. – Faculty, LSU Psychiatry
II. Project Description
I. Phase 1: Baseline a. anonymously survey (using de-identified codes) residents
rotating on inpatient rotations using the modified AHRQ survey
b. key faculty members brainstormed a standardized educational intervention and determined that weekly text reminders to faculty, asking them to incorporate patient safety discussions on rounds, would be beneficial.
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c. Faculty asked for additional faculty development opportunities
i. We offered a video that demonstrated leading patient safety discussions on rounds
ii. The associate medical directors of quality and patient safety were available for additional tips and discussions
II. Phase 2: Implement Standardized Educational Intervention a. Each week, faculty members were texted a prompt,
reminding them to incorporate patient safety discussions on rounds
b. Faculty asked to notify investigators that patient safety discussions took place, and were invited to share patient safety discussions
c. When significant patient safety issues arose, they were passed up the chain and faculty members were notified of solutions, closing the feedback loop
III. Phase 3: Post-intervention Assessment a. anonymously survey (using de-identified codes) residents
and faculty to determine their perceptions of the hospital’s patient safety culture after completing the intervention.
III. Necessary Resources (staff, finances, etc.)
a. Team members have dedicated one hour per month to participate on the workgroup
b. Faculty members dedicated time weekly during rounds to incorporate patient safety discussions.
c. A subset of co-investigators dedicated time to send text reminders weekly and close feedback loops at every opportunity
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
a. Phase 1 i. Pre-intervention data was collected at baseline, using
the modified AHRQ survey. b. Phase 2
i. Faculty were required to respond that patient safety discussions had taken place. They were encouraged to share de-identified information about what type of discussion took place.
c. Phase 3 i. Post-intervention data was collected, using the
modified AHRQ survey
V. Communication Plan (may be helpful to draft a flow chart of
team members & senior management, both internal & external)
a. The workgroup met monthly to discuss the progress of the project
b. Team members were assigned to give presentations about the project to stakeholder groups
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c. The DIO reported to the CEO and CMO monthly
VI. Accountability (list of team members and who
is accountable for what)
• Team Leader - Laurinda Calongne, Ed.D. – Chief Academic Officer/DIO
• Project Manager - Lauren Rabalais, MPA – Director of GME
Keith Rhynes, M.D., MBA – OLOL GME Medical Director, Associate Program Director, LSU General Surgery Residency Program (responsible for implementation within Surgery Residency Program) Stephen Hosea, M.D. , FACS – Associate Medical Director of Quality and Patient Safety (responsible for keeping project on course with hospital quality and safety goals and core values) Christi Pierce, M.B.A.,M.S.H.A. – Senior Director of Quality (responsible for keeping project on course with hospital quality and safety goals and core values) Michael Bolton, M.D. – Assistant Director of Quality and Patient Safety, Children’s Hospital (responsible for keeping project on course with quality and safety goals and core values for Children’s Hospital; implementation for Pediatric Residency Program) Trey Dunbar, M.D. – Program Director, OLOL Pediatric Residency Program (responsible for implementation within Pediatric Residency Program) Bear Caffery, M.D. – Program Director, LSU Emergency Medicine Residency Program (responsible for implementation within Emergency Medicine Residency Program) Savarra Mantzor, M.D. – PGY3 Pediatric Resident (incoming chief) (responsible for implementation within Pediatric Residency Program and resident focus groups) Deborah Ford, RN, MSN – Chief Nursing Officer (responsible for keeping project on course with hospital quality and safety goals and core values; communication with nursing staff) Mandi Musso, PhD – Academic Research Director, LSU Emergency Medicine Residency (responsible for IRB proposal and research pertaining to project) Rich Vath, M.Ed – Academic Research Director, LSU Psychiatry and OLOL Pediatrics (responsible for IRB proposal and research pertaining to project) Banhsen Miller, M.D. – PGY 3 Internal Medicine Resident (incoming chief) (responsible for implementation within Internal Medicine Residency Program and resident focus groups)
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Angela Johnson, M.D. – Associate Program Director, LSU Internal Medicine Residency Program (responsible for implementation within Internal Medicine Residency Program) Lee Tynes, M.D., Ph.D. – Faculty, LSU Psychiatry (responsible for implementation within Psychiatry Residency Program)
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
a. Engagement of all faculty, particularly members were not participating in the workgroup
b. Variability in residents’ and faculty members’ QI and patient safety skills and knowledge
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
a. Baseline – February-March 2014 b. Intervention – April – May 2014 c. Post-intervention assessment – June – July 2014
IX. Vision Statement/Closing Plan (markers of success by March 2015)
a. The ultimate goal of this pilot project was to build a quality improvement initiative that would positively influence the culture of patient safety at the hospital and better integrate residents into the hospital’s patient safety initiatives
b. A second goal of this project is to publish a minimum of one peer-reviewed manuscript by March 2015.
X. Success Factors a. The most successful component of our work was engaging faculty and residents in patient safety discussions.
i. Our ability to close the feedback loop on several key patient safety issues allowed us to reinforce reporting and increase physician communication of patient safety issues.
b. We were inspired by a colleagues in NI-IV. Hearing them discuss problems they had been facing within their hospital enabled us to focus our project.
XI. Barriers a. The largest barrier we encountered was initially having faculty and residents buy in to completing patient safety discussions on rounds
b. We overcame this by offering faculty development to increase confidence in leading discussions and reinforce the importance of having these discussions. Also, we were able to close the feedback loop, so that residents and faculty could see the impact of identifying patient safety issues. This significantly reinforced the importance of patient safety
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discussions and empowered faculty and residents.
XII. Lessons Learned a. The single most important piece of advice we would provide another team embarking on a similar initiative would be to keep your project simple, focused, and structured.
b. It is also important to incorporate outcome measures that allow you to track whether your intervention has had an impact on the variable you wished to change.
XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI III work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact What changes have you observed in your residency program(s), or at your institution, based upon your work? Our faculty and residents have become more aware of patient safety, and preliminary evidence from one residency suggests residents have become more engaged in error reporting. In addition, faculty from other residency programs have asked to join our next initiative. We have entitled our working group, “scholars in quality” and meet regularly to discuss forward progress. We are developing a QI fellowship to begin in July 2015.
XVI. Next Steps Describe next steps for your project, including plans for sustaining and spreading the changes made. Our working group meets regularly to discuss plans for future research and quality improvement projects. Several residency programs have built upon the momentum of this project to incorporate additional patient safety tools into their rounds.
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Back
grou
nd a
nd G
oal
•R
esid
ency
pro
gram
s at o
ur in
stitu
tion
wer
e im
plem
entin
g pa
tient
safe
ty c
urric
ula
in a
var
iety
of
way
s but
rare
ly c
omm
unic
ated
with
one
ano
ther
.
•Th
e ob
ject
ive
of th
is p
roje
ct w
as to
dev
elop
and
im
plem
ent a
cam
pus-
wid
e, st
anda
rdiz
ed le
arni
ng
expe
rienc
e to
enh
ance
resi
dent
s’ kn
owle
dge
of p
atie
nt
safe
ty.
Impr
ovin
g Re
side
nt E
duca
tion
of P
atie
nt
Safe
ty:
A Ca
mpu
s-W
ide
Initi
ativ
e
Proj
ect C
onte
xt
Phas
e 1:
Co-
inve
stig
ator
s fro
m fi
ve re
side
ncy
prog
ram
s br
ains
torm
ed a
stan
dard
ized
lear
ning
exp
erie
nce:
•
The
wor
king
gro
up d
eter
min
ed th
at u
sing
text
mes
sage
re
min
ders
to fa
cilit
ate
patie
nt sa
fety
dis
cuss
ions
on
hosp
ital-b
ased
roun
ds w
ould
be
a no
vel *
and*
ac
cess
ible
mea
ns o
f eng
agin
g fa
culty
and
resi
dent
s. •
Parti
cipa
ting
facu
lty w
ere
prov
ided
with
a tr
aini
ng
vide
o m
odel
ing
how
to in
corp
orat
e pa
tient
safe
ty
disc
ussi
ons o
n ro
unds
. Ph
ase
2: P
ilot S
tudy
in S
prin
g 20
14
•O
ver a
2-m
onth
per
iod
parti
cipa
ting
facu
lty re
ceiv
ed
wee
kly
text
rem
inde
rs to
dis
cuss
PS
on ro
unds
. •
Res
iden
ts o
n ho
spita
l-bas
ed ro
tatio
ns p
artic
ipat
ed in
th
e sa
fety
roun
ds in
itiat
ive;
resi
dent
s on
alte
rnat
ive
rota
tions
serv
ed a
s a c
ontro
l gro
up.
Vi
sion
Sta
tem
ent
We
hope
d th
at b
y em
phas
izin
g th
e im
porta
nce
of p
atie
nt
safe
ty d
iscu
ssio
ns o
n ro
unds
, res
iden
ts a
nd fa
culty
acr
oss
the
hosp
ital m
ight
mor
e m
eani
ngfu
lly e
ngag
e w
ith th
e em
ergi
ng c
ultu
re o
f saf
ety
and
qual
ity.
Met
hods
Th
e fo
llow
ing
rem
inde
r was
sent
wee
kly
to p
artic
ipat
ing
facu
lty a
s a te
xt m
essa
ge. F
acul
ty re
plie
d to
text
s in
dica
ting
they
had
pat
ient
safe
ty d
iscu
ssio
ns. A
s spe
cific
is
sues
aro
se, p
atie
nt sa
fety
offi
cers
wer
e no
tifie
d an
d th
e fe
edba
ck lo
op w
as c
lose
d af
ter a
ctio
n w
as ta
ken.
•W
e ob
serv
ed in
crea
ses i
n re
side
nt p
erce
ptio
ns o
f the
cu
lture
of q
ualit
y an
d pa
tient
safe
ty a
t our
inst
itutio
n as
a re
sult
or o
ur in
itiat
ive,
par
ticul
arly
in th
e C
omm
unic
atio
n an
d E
vent
Rep
ortin
g se
ctio
ns o
f the
m
odifi
ed A
HR
Q (a
dmin
iste
red
pre
and
post
pilo
t).
•95
% o
f fac
ulty
who
com
plet
ed fo
llow
-up
surv
ey
repo
rted
that
they
wer
e co
ntin
uing
to in
corp
orat
e pa
tient
safe
ty d
iscu
ssio
ns o
n ro
unds
afte
r pilo
t pha
se.
Barr
iers
Enc
ount
ered
/Lim
itatio
ns
Mea
sura
ble
Impa
cts
Conc
lusi
ons
•W
e be
lieve
that
this
stan
dard
ized
lear
ning
ex
perie
nce
led
to a
n in
crea
sed
sens
e of
ow
ners
hip
of q
ualit
y an
d pa
tient
safe
ty o
n th
e pa
rt of
our
ph
ysic
ian
lear
ners
and
teac
hers
, as e
vide
nced
by
sign
ifica
nt m
ovem
ent i
n re
side
nts p
erce
ptio
ns a
nd
repo
rting
act
ivity
. •
Add
ition
ally
, our
exp
erie
nce
in N
I IV
bro
ught
fa
culty
and
resi
dent
s out
of d
epar
tmen
tal s
ilos a
nd
enga
ged
them
to w
ork
with
qua
lity
lead
ers a
t the
ho
spita
l to
impr
ove
patie
nt sa
fety
out
com
es.
•Th
is c
olla
bora
tive
mom
entu
m y
ield
ed a
n ad
ditio
nal o
utco
me:
the
crea
tion
of a
Qua
lity
and
Patie
nt S
afet
y Fe
llow
ship
beg
inni
ng in
AY
201
5.
Succ
ess F
acto
rs a
nd L
esso
ns L
earn
ed
•C
o-in
vest
igat
ors w
ere
resp
onsi
ble
for t
ext
mes
sagi
ng a
nd e
rror
mon
itorin
g, a
met
hodo
logy
th
at p
rove
d di
fficu
lt to
mai
ntai
n af
ter t
he st
udy
perio
d. T
houg
h fa
culty
repo
rted
cont
inua
tion
of
patie
nt sa
fety
roun
ds, t
he su
stai
nabi
lity
abse
nt
prom
ptin
g an
d m
onito
ring
was
unc
lear
.
•To
add
ress
thes
e co
ncer
ns, w
e ha
ve b
egun
to
inco
rpor
ate
PS/Q
I rem
inde
rs a
nd te
achi
ng p
oint
s in
to o
ur e
xtan
t GM
E co
mm
unic
atio
n ch
anne
ls.
•Fa
culty
als
o re
porte
d lim
itatio
ns in
the
curr
ent
repo
rting
arc
hite
ctur
e at
our
hos
pita
l. Th
is re
mai
ns
an a
rea
of fo
cuse
d in
tere
st fo
r bot
h G
ME
lead
ers
and
qual
ity o
ffice
rs a
t the
hos
pita
l.
L. C
alon
gne,
M. M
usso
, R. V
ath,
K. R
hyne
s, S
. Hos
ea, M
. Bol
ton,
A. D
unba
r, T.
Caf
fery
, S. M
antz
or, L
. Rab
alai
s, B
. Mill
er, A
. Joh
nson
, L. T
ynes
•W
eekl
y te
xt m
essa
ge re
min
ders
ens
ured
that
our
fa
culty
rem
aine
d en
gage
d an
d th
at p
atie
nt sa
fety
di
scus
sion
s wer
e re
lativ
ely
stan
dard
ized
. •
The
maj
ority
of f
acul
ty re
porte
d th
at sa
fety
roun
ds
wer
e ef
fect
ive
and
man
agea
ble
and
that
resi
dent
s wer
e ve
ry re
spon
sive
to th
eir i
ncor
pora
tion.
•
Som
e fa
culty
who
wer
e in
itial
ly sk
eptic
al a
bout
the
proj
ect r
aved
abo
ut it
s effe
ctiv
enes
s in
clos
ing
the
feed
back
loop
.
Bibl
iogr
aphy
1.
Jast
i H.,
Shet
h H
., Ve
rric
o M
., Pe
rera
S.,
Bum
p G
., et
al.
Ass
essi
ng P
atie
nt
Safe
ty C
ultu
re o
f Int
erna
l Med
icin
e H
ouse
Sta
ff in
an
Aca
dem
ic T
each
ing
Hos
pita
l. Jo
urna
l of G
radu
ate
Med
ical
Edu
catio
n 20
09; 1
(1):
139-
145.
108 of 131
Team: OhioHealth Riverside Methodist Hospital Focus Area: Quality Improvement
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
This QI initiative was designed to engage residents to work closely with hospital administration on QI projects and to actively participate in improving their clinical learning environment. -QI should be a part of daily life not just during initiatives/projects -QI is not just the job of nurses/administration -Residents should be empowered to report/identify areas for improvement -Residents should drive change with the support of an engaged C-suite and the GME staff -Key stakeholders include: residents, faculty, program directors, DIO, C-suite (especially VPMA and VP of Quality), nursing, GME staff
II. Project Description
-“Find It, Fix It” -Kaizen approach—process boards and idea cards -Central place/process to post improvement opportunities (large and small) -Visually show progress and track completed issues -Use of PDSA cycles to address issues raised on idea cards -Engagement of residents and C-suite to identify issues, actively work to provide solutions and close feedback loop
III. Necessary Resources (staff, finances, etc.)
-Resident-driven for better buy in--Resident “champions” from each program -Kaizen boards -GME staff -C-suite support (presence, participation, financial support) -Finances will vary (GME vs hospital support) -Time—residents, GME staff, administration, project manager, faculty, DIO
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
Outcome measures -Self-efficacy/empowerment/engagement survey data of residents—Pre/Post -Project success rates—number of ideas per resident/residency, number of completed projects, type of projects -Engagement of C-suite -Success of 5/2014 CLER visit—positive feedback from site visitors -National presentations (AIAMC 3/2015, ACGME 2/2015)
V. Communication Plan (may be helpful to draft a flow chart of
team members & senior management, both internal & external)
RESIDENTS---------------------C-suite Champions President All programs DIO VP Q/S, VPMA Underlying GME support (staff, money, time) Reporting at interdisciplinary meetings, executive meetings, GMEC, etc.
VI. Accountability (list of team members and who
is accountable for what)
-Residents: identifying issues, participating in action plans, scholarly activities -C-suite: support, action planning -Med Ed leadership/staff: support, planning, organizing resources,
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data management -Research support: protocol development, data analysis, scholarly activities -Faculty project manager: management of ideas, collection of outcomes
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
-Engagement is top concern (apathy, time, interest, buy-in, stigma, etc.) -Resources depending on issues raised -Project management—resources limited -Skills, knowledge of QI process -Scope of project -Too many ideas to work all—need for prioritization to best utilize scare resources (time) -Resident “champions” not all engaged
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
-Resident & team meeting: November--DONE -Protocol/IRB: Nov/Dec--DONE -Information dissemination/kickoff: Jan/Feb—DONE (2/18) -Pre-surveys: Jan/Feb—DONE (2/18/14); Interns (6/2014) -Kaizen identification/action: ONGOING as of 2/2014 -Revision/continuation of project: Summer 2014—ongoing -Post-surveys: DONE 6/2014 (4 month), 2/2015 (1 year, 8 month for interns) -Analysis: Winter 2015 -Presentation: AIAMC 3/2015, ACGME 2/2015
IX. Vision Statement/Closing Plan (markers of success by March 2015)
-Our Find It, Fix It project engaged residents and the C-suite in QI projects -Resident knowledge and participation in QI processes improved as seen on surveys -The project allowed GME to have weekly meetings with C-suite members -Beginnings of cultural change seen: IM and FM developed Quality rotations, outpatient faculty more engaged in QI outside of Find It, Fix It -Project was highlighted at May 2014 CLER visit -Project created opportunities for scholarly activity (AIAMC, ACGME, STFM presentations as of February 2015) -Sustainability of project in current form is being examined as it is resource intensive
X. Success Factors -The project engaged residents from all programs and increased QI knowledge -C-suite and GME collaboration led to successful completion of projects: improved access to resources, better alignment with ongoing hospital QI work -Providing residents protected time increased their involvement in QI -Unexpected win: The project was showcased at our successful CLER visit
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XI. Barriers -Scope of project required significant project management (time, effort, expertise) -Engagement of residents was variable and challenging -Knowledge improved over the year while attitudes toward QI did not -Need to involve all stakeholders from the start (faculty, program directors) -Expectations should be realistic -Goals/metrics should be carefully considered at the start -Continuous evaluation and improvement of the project important -Recognize and manage project fatigue early
XII. Lessons Learned Success of this type of project requires early engagement of all stakeholders and ensuring that there is sufficient time available for active participation.
XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI IV work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact -124 ideas were submitted by 72 residents -71 projects were initiated (57% of ideas) -36 projects were QI/PS and patient focused (51% of initiated projects) -32 projects were completed (45% of initiated projects) including 10 QI projects -Engagement in QI outside of the project increased: development of QI rotations in FM and IM programs, outpatient faculty-led initiatives outside of Find It, Fix It -QI work creates opportunity for scholarly activity: Posters/presentations at three national conferences as of 2/2015
XVI. Next Steps The planning committee is evaluating the project and considering options for a next phase that would ensure sustainability. We are also determining how this project fits into our overall QI education for our trainees.
111 of 131
Ove
rall
Goa
l/Abs
trac
t Ri
vers
ide
Met
hodi
st H
ospi
tal i
s a la
rge
com
mun
ity h
ospi
tal w
ith a
ppro
xim
atel
y 12
2 re
siden
ts in
5
resid
enci
es (I
nter
nal M
edic
ine,
Fam
ily M
edic
ine,
Gen
eral
Sur
gery
, OB/
GYN
and
Tra
nsiti
onal
Ye
ar).
Our
inst
itutio
nal q
ualit
y im
prov
emen
t/pa
tient
safe
ty (Q
I/PS
) ini
tiativ
es ra
rely
invo
lved
tr
aine
es a
nd th
ere
was
litt
le e
duca
tion
or p
artic
ipat
ion
in Q
I/PS
at t
he G
ME
leve
l. Th
is ga
p hi
ghlig
hts a
n op
port
unity
for e
ngag
ing
resid
ents
and
the
C-su
ite in
a sh
ared
QI i
nitia
tive.
The
aim
s of t
he A
IAM
C N
I IV
QI i
nitia
tive
wer
e to
: •
Prov
ide
GM
E-w
ide
expo
sure
to Q
I •
Deve
lop
a G
ME-
led
QI i
nitia
tive
•En
gage
the
C-Su
ite in
the
initi
ativ
e •
Bett
er a
lign
GM
E Q
I effo
rts w
ith in
stitu
tiona
l prio
ritie
s •
Lay
the
grou
ndw
ork
for c
ultu
re c
hang
e
Find
It, F
ix It
: Eng
agin
g Re
side
nts a
nd
the
C-Su
ite in
Qua
lity
Impr
ovem
ent
Sara
Suk
alic
h M
D an
d M
iriam
Cha
n Ph
arm
D,
on b
ehal
f of t
he F
ind
It, F
ix It
Pla
nnin
g Co
mm
ittee
O
hioH
ealth
Riv
ersid
e M
etho
dist
Hos
pita
l, Co
lum
bus O
H
Back
grou
nd
The
ACG
ME
Clin
ical
Lear
ning
Env
ironm
ent R
evie
w (C
LER)
pro
gram
cal
ls fo
r res
iden
ts to
pa
rtic
ipat
e in
qua
lity
impr
ovem
ent a
nd p
atie
nt sa
fety
(QI/
PS) i
nitia
tives
. Al
igni
ng G
ME-
led
QI/
PS
initi
ativ
es w
ith th
e sp
onso
ring
inst
itutio
n’s p
riorit
ies a
nd e
nlist
ing
the
supp
ort o
f the
C-s
uite
are
th
e ke
ys to
ach
ievi
ng o
ptim
al c
linic
al le
arni
ng e
nviro
nmen
t in
the
area
s of Q
I and
PS.
Visi
on S
tate
men
t O
ur v
ision
is th
at th
e Fi
nd It
, Fix
It p
roje
ct w
ill e
ngag
e re
siden
ts a
nd th
e C-
Suite
in Q
I and
will
ul
timat
ely
lead
to a
cul
tura
l shi
ft w
here
resid
ents
act
ivel
y pa
rtic
ipat
e in
QI o
n a
daily
bas
is.
Bibl
iogr
aphy
•A
CGM
E CL
ER P
athw
ays t
o Ex
celle
nce
(201
4).
•Gra
ban
M, S
war
tz JE
. Hea
lthca
re K
aize
n (C
RC P
ress
: Boc
a Ra
ton,
201
2).
•Hill
A, G
wad
ry-S
ridha
r F, A
rmst
rong
T, S
ibba
ld W
J. De
velo
pmen
t of t
he C
ontin
uous
Q
ualit
y Im
prov
emen
t Que
stio
nnai
re (C
QIQ
). Jo
urna
l of C
ritic
al C
are
2001
;16(
4): 1
50-1
60.
•Ogr
inc
G, H
eadr
ick
LA, M
orris
on L
J, Fo
ster
T. Te
achi
ng a
nd A
sses
sing
Resid
ent
Com
pete
nce
in P
ract
ice-
base
d Le
arni
ng a
nd Im
prov
emen
t. Jo
urna
l of G
ener
al In
tern
al
Med
icin
e 20
04;1
9:49
6-50
0. [Q
IKAT
]
Barr
iers
Enc
ount
ered
/Lim
itatio
ns
•Sco
pe o
f pro
ject
requ
ired
signi
fican
t pro
ject
man
agem
ent (
time,
effo
rt, e
xper
tise)
•Eng
agem
ent o
f res
iden
ts w
as v
aria
ble
and
chal
leng
ing
•Kno
wle
dge
impr
oved
ove
r the
yea
r whi
le a
ttitu
des t
owar
d Q
I did
not
•Nee
d to
invo
lve
all s
take
hold
ers f
rom
the
star
t (fa
culty
, pro
gram
dire
ctor
s)
•Exp
ecta
tions
shou
ld b
e re
alist
ic
•Goa
ls/m
etric
s sho
uld
be c
aref
ully
con
sider
ed a
t the
star
t
•Con
tinuo
us e
valu
atio
n an
d im
prov
emen
t of t
he p
roje
ct im
port
ant
•Rec
ogni
ze a
nd m
anag
e pr
ojec
t fat
igue
ear
ly
Resu
lts
Conc
lusi
ons
•Fi
nd It
, Fix
It w
as a
succ
essf
ul in
itiat
ive
to e
ngag
e re
siden
ts a
nd th
e C-
suite
in q
ualit
y im
prov
emen
t
•Th
e Ka
izen
appr
oach
allo
wed
wid
espr
ead
expo
sure
and
invo
lvem
ent i
n Q
I
•Su
stai
nabi
lity
of th
is la
rge
proj
ect w
ill re
quire
sign
ifica
nt ti
me
and
effo
rt fo
r fac
ulty
•A
GM
E-le
d qu
ality
initi
ativ
e ca
n sp
ur c
ultu
re c
hang
e ar
ound
QI w
ithin
resid
ency
pr
ogra
ms a
nd c
reat
e op
port
uniti
es to
show
case
med
ical
edu
catio
n at
the
inst
itutio
nal
and
orga
niza
tiona
l lev
el
AIAM
C N
I IV
Find
It, F
ix It
Pla
nnin
g Co
mm
ittee
incl
udes
: Ben
Brin
g DO
, Miri
am C
han
Phar
mD,
Tom
Har
mon
MD,
Mic
hael
Kas
ten
MD,
Mat
t Kun
ar D
O, K
imbe
rly M
orto
n M
D, Ji
m
O’B
rien
MD,
Jenn
ifer S
tubb
s MBA
, She
ri So
uthw
orth
RN
, Sar
a Su
kalic
h M
D
Mat
eria
ls/M
etho
ds
•Pla
nnin
g Co
mm
ittee
was
form
ed (r
esid
ents
, fac
ulty
mem
bers
, GM
E st
aff,
nurs
ing,
hos
pita
l VP
MA,
hos
pita
l VP
of q
ualit
y) in
Oct
ober
201
3
• Q
ualit
y im
prov
emen
t pro
ject
“Fi
nd It
, Fix
It”
was
deve
lope
d us
ing
a Ka
izen
proc
ess b
oard
app
roac
h
•Fin
d It,
Fix
It k
icke
d of
f in
Febr
uary
201
4
•Res
iden
ts a
re e
ncou
rage
d to
subm
it “i
dea
card
s”
w
hen
they
iden
tify
oppo
rtun
ities
for i
mpr
ovem
ent
in
thei
r env
ironm
ent
•The
C-s
uite
, GM
E st
aff a
nd fa
culty
mee
t wee
kly
to
revi
ew th
e ce
ntra
l boa
rd a
nd h
elp
resid
ents
fine
tune
thei
r ide
as a
nd fa
cilit
ate
the
proj
ects
•The
resid
ents
lear
n Q
I han
ds-o
n by
wor
king
thro
ugh
PDSA
cyc
les
•A su
rvey
of k
now
ledg
e an
d at
titud
es b
ased
on
the
Cont
inuo
us Q
ualit
y Im
prov
emen
t Q
uest
ionn
aire
and
Qua
lity
Impr
ovem
ent K
now
ledg
e Ap
plic
atio
n To
ol p
re-t
est w
as a
dmin
ister
ed
to A
cade
mic
Year
13-
14 tr
aine
es p
re-p
roje
ct (2
/201
4), a
t 4 m
onth
s (6/
2014
) and
at 1
2 m
onth
s (2
/201
5) a
nd a
lso to
inco
min
g Ac
adem
ic Ye
ar 1
4-15
inte
rns 6
/201
4 an
d at
7 m
onth
s (2/
2015
).
•Met
rics o
vera
ll an
d fo
r the
indi
vidu
al re
siden
cy p
rogr
ams w
ere
trac
ked
incl
udin
g: n
umbe
r of
idea
car
ds su
bmitt
ed, n
umbe
r of p
roje
cts s
tart
ed, n
umbe
r of p
roje
cts c
ompl
eted
, typ
e of
pr
ojec
t, an
d nu
mbe
r of r
esid
ents
invo
lved
Out
com
e M
easu
res
•124
idea
s wer
e su
bmitt
ed b
y 72
resid
ents
•7
1 pr
ojec
ts w
ere
initi
ated
(57%
of i
deas
) •3
6 pr
ojec
ts w
ere
QI/
PS a
nd p
atie
nt fo
cuse
d (5
1% o
f ini
tiate
d pr
ojec
ts)
•32
proj
ects
wer
e co
mpl
eted
(45%
of i
nitia
ted
proj
ects
) inc
ludi
ng 1
0 Q
I pro
ject
s
Succ
ess F
acto
rs a
nd L
esso
ns L
earn
ed
•The
pro
ject
eng
aged
resid
ents
from
all
prog
ram
s and
incr
ease
d Q
I kno
wle
dge
•C-s
uite
and
GM
E co
llabo
ratio
n le
d to
succ
essf
ul c
ompl
etio
n of
pro
ject
s: im
prov
ed
acce
ss to
reso
urce
s, b
ette
r alig
nmen
t with
ong
oing
hos
pita
l QI w
ork
•Pro
vidi
ng re
siden
ts p
rote
cted
tim
e in
crea
sed
thei
r inv
olve
men
t in
QI
•Eng
agem
ent i
n Q
I out
side
of th
e pr
ojec
t inc
reas
ed: d
evel
opm
ent o
f QI r
otat
ions
in F
M
and
IM p
rogr
ams,
out
patie
nt fa
culty
-led
initi
ativ
es o
utsid
e of
Fin
d It,
Fix
It
•Une
xpec
ted
win
: The
pro
ject
was
show
case
d at
our
succ
essf
ul C
LER
visit
•QI w
ork
crea
tes o
ppor
tuni
ty fo
r sch
olar
ly a
ctiv
ity:
Post
ers/
pres
enta
tions
at t
hree
na
tiona
l con
fere
nces
as o
f 2/2
015
Exam
ples
of O
ngoi
ng P
roje
cts
Proj
ect T
itle
(Tea
m)
Prob
lem
In
terv
entio
n
New
born
Han
doff
(FM
, OBG
YN)
Poor
com
mun
icat
ion
betw
een
FM a
nd O
BGYN
resid
ents
on
mat
erna
l-inf
ant i
ssue
s Im
plem
ent a
dai
ly fa
ce-to
-face
sign
out
and
stan
dard
ize in
form
atio
n to
be
signe
d ou
t
OB
Sign
-out
Loc
atio
n (O
BGYN
) Si
gn-o
ut c
urre
ntly
take
s pla
ce in
a c
omm
on a
rea
on L&
D th
at is
noi
sy a
nd n
ot p
rivat
e
Reno
vate
unu
sed
room
on
L&D
and
equi
p th
e ro
om w
ith c
ompu
ter
acce
ss
Resid
ent-I
nitia
ted
Cons
ulta
nt
Proj
ect
(IM)
Lack
of a
clo
sed
loop
com
mun
icat
ion
betw
een
prim
ary
team
s and
cons
ulta
nts
Deve
lop
a st
anda
rdize
d pr
oces
s to
faci
litat
e ph
ysic
ian
to p
hysic
ian
com
mun
icat
ion
The
Gree
n Pr
ojec
t (IM
, OBG
YN, S
urge
ry)
Lack
of r
ecyc
ling
bins
in M
ed E
d or
cal
l roo
ms
Plac
e re
cycl
ing
bins
in M
ed E
d/ca
ll ro
oms w
ith h
ope
to e
xpan
d in
to p
ublic
ar
eas
Impa
ct o
f Com
plet
ed P
roje
cts
N
umbe
r of P
roje
cts
Proj
ects
that
led
to im
prov
emen
t in
patie
nt c
are
qual
ity
10
Proj
ects
that
led
to e
quip
men
t/st
orag
e im
prov
emen
t 18
Proj
ects
that
led
to im
prov
emen
t in
educ
atio
n/tr
aini
ng
1
Proj
ects
acc
epte
d fo
r nat
iona
l pre
sent
atio
ns (a
s of 2
/201
5)
3
n=45
pa
ired
t-te
sts
Surv
ey R
esul
ts:
•97
, 106
, and
125
resid
ents
com
plet
ed th
e pr
e-, 4
-mon
th p
ost,
and
12-m
onth
pos
t sur
vey
resp
ectiv
ely
•
In th
e 12
mon
ths p
rior t
o pr
ojec
t, 40
% o
f res
iden
ts w
ere
invo
lved
in a
t lea
st o
ne Q
I pro
ject
w
hile
87%
wer
e in
volv
ed d
urin
g th
e fir
st 1
2 m
onth
s of t
he in
itiat
ive
•45
resid
ents
com
plet
ed a
ll th
ree
surv
eys (
Pre-
, 4-m
onth
pos
t, 12
-mon
th p
ost)
–
Know
ledg
e of
QI i
mpr
oved
and
lack
of k
now
ledg
e w
as fe
lt to
be
less
of a
bar
rier
–In
tere
st in
QI d
ecre
ased
and
mea
sure
s of a
ttitu
de to
war
d Q
I did
not
impr
oved
112 of 131
Abst
ract
A Re
sear
ch S
imul
atio
n w
ith O
B/GY
N R
esid
ents
to
Asse
ss C
urre
nt L
angu
age
Serv
ice
Prac
tices
Br
ian
Rile
y, D
O, L
awre
nce
Youn
g, M
PH, M
arcu
s M
cKin
ney,
D.M
in.,
LPC,
Jeri
Hepw
orth
, PhD
, Eliz
abet
h Si
pusi
c, M
.D.,
Aman
da W
ilson
, DO
, Ash
ley
Neg
rini,
MS
Sain
t Fra
ncis
Hos
pita
l, Ha
rtfo
rd, C
T
Sain
t Fr
anci
s Ca
re h
as a
com
mitm
ent
to h
ighe
st le
vels
of q
ualit
y an
d sa
fety
, with
em
phas
is on
the
criti
cal d
omai
ns o
f com
mun
icat
ion,
team
wor
k, tr
ansit
ion
in c
are,
m
edic
atio
n us
e, a
nd m
inim
ally
eva
sive
proc
edur
es.
Heal
th e
quity
is a
boa
rd le
vel
prio
rity,
and
effe
ctiv
e co
mm
unic
atio
n, in
clud
ing
appr
opria
te la
ngua
ge s
ervi
ces,
is
an e
quity
and
saf
ety
conc
ern.
Enh
anci
ng a
cces
s to
app
ropr
iate
lang
uage
ser
vice
s is
a sy
stem
wid
e in
itiat
ive,
led
by th
e Cu
rtis
D. R
obin
son
Cent
er fo
r Hea
lth E
quity
, a
Sain
t Fr
anci
s in
stitu
te.
As
part
of
that
effo
rt,
an e
duca
tion,
sim
ulat
ion
and
eval
uatio
n ac
tivity
with
OB/
GYN
res
iden
ts s
erve
d as
an
initi
al d
emon
stra
tion
for
syst
em w
ide
impl
emen
tatio
n. T
he sp
ecifi
c ta
rget
is to
enh
ance
use
of t
he M
ARTT
I- vi
deo
rem
ote
inte
rpre
ter
devi
ce to
impr
ove
the
serv
ices
for
patie
nts
with
Lim
ited
Engl
ish P
rofic
ienc
y (L
EP).
A g
roup
of
15 O
B/GY
N r
esid
ents
par
ticip
ated
in
a pr
etes
t, ed
ucat
iona
l ses
sion,
and
a s
imul
atio
n ac
tivity
whe
re 5
res
iden
ts w
orke
d w
ith a
pat
ient
with
LEP
and
acc
esse
d la
ngua
ge s
ervi
ces.
The
rem
aini
ng 1
0 se
rved
as
obs
erve
rs a
nd p
artic
ipat
ed i
n a
disc
ussio
n as
sess
ing
the
activ
ity,
curr
ent
hosp
ital
med
ical
sta
ndar
ds,
and
prov
ided
rec
omm
enda
tions
for
oth
er t
rain
ings
fo
cuse
d on
lan
guag
e se
rvic
e.
Follo
win
g th
e di
scus
sion,
a p
ostt
est
abou
t th
e M
ARTT
I w
as g
iven
. O
ur p
roje
ct in
crea
sed
awar
enes
s ab
out
the
impo
rtan
ce o
f la
n gua
ge s
ervi
ces
in o
ur h
ospi
tal.
Issu
es w
ith l
angu
age
and
com
mun
icat
ion
betw
een
phys
icia
ns a
nd p
atie
nts
have
bee
n id
entif
ied
as p
oten
tial
barr
iers
to
prov
idin
g eq
uita
ble
care
.
Back
grou
nd
Di
scus
sions
with
com
mun
ity m
embe
rs, r
esid
ents
and
clin
icia
ns in
dica
ted
that
he
alth
equ
ity is
sues
can
be
refle
cted
in si
mpl
e bu
t im
port
ant w
ays s
uch
as
acce
ss to
lang
uage
serv
ices
.
Lang
uage
bar
riers
impa
ct th
e us
e of
hea
lth se
rvic
es fo
r pat
ient
s with
LEP
. The
y ca
n c a
use
patie
nts t
o av
oid
seek
ing
care
, lea
ve th
e ho
spita
l aga
inst
med
ical
ad
vice
, not
hav
e a
regu
lar p
rimar
y ca
re p
rovi
der,
and
not c
ompl
y w
ith m
edic
al
reco
mm
enda
tions
1,2
3
LEP
patie
nts a
re m
ore
likel
y th
an E
nglis
h-sp
eaki
ng p
atie
nts t
o ex
perie
nce
med
ical
err
ors c
ause
d by
com
mun
icat
ion
erro
rs. 4
, 6
LEP
patie
nts w
ho e
xper
ienc
e m
edic
al co
mm
unic
atio
n er
rors
are
mor
e lik
ely
to
be h
arm
ed m
ore
seve
rely
whe
n co
mpa
red
to E
nglis
h sp
eaki
ng p
atie
nts 5
,6
Spec
ific
Aim
s
To id
entif
y sp
ecifi
c fa
ctor
s tha
t im
pact
the
effe
ctiv
e ut
iliza
tion
of th
e M
ARTT
I de
vice
am
ong
phys
icia
ns.
To o
btai
n in
sight
on
how
phy
sicia
ns w
ould
like
to u
se th
e M
ARTT
I dev
ice
to
effe
c tiv
ely
trea
t and
dia
gnos
e th
eir p
atie
nts.
To
pro
duce
reco
mm
enda
tions
and
impr
ovem
ents
to o
ur c
urre
nt la
ngua
ge
serv
ice
use
guid
elin
es th
at p
rom
ote
equi
tabl
e ca
re fo
r all
patie
nts.
Met
hods
Pre
Asse
ssm
ent-
A b
rief a
sses
smen
t abo
ut la
ngua
ge se
rvic
e gu
idel
ines
, pro
toco
l, an
d ho
w th
e us
e M
ARTI
dev
ice
(10
Que
stio
n As
sess
men
t)
Pr
esen
tatio
n ab
out M
ARTT
I Vid
eo R
emot
e In
terp
rete
r
2
patie
nt ca
se sc
enar
ios f
or O
B/GY
N re
siden
ts to
do
in si
mul
atio
n la
b
8
Item
Obs
erve
r che
ck li
st- m
easu
rea b
le it
ems b
ased
on
lang
uage
serv
ice/
M
ARTI
I and
bes
t pra
ctic
e gu
idel
ines
to c
heck
the
resid
ent’s
use
of p
roto
col
durin
g th
e sim
ulat
ion
and
serv
e as
poi
nts o
f disc
ussio
n af
ter t
he e
xerc
ise.
Disc
ussio
n ab
out t
he im
port
ance
of l
angu
age
serv
ice,
the
simul
atio
n ac
tivity
(w
hat w
ent w
ell/w
hat w
as d
iffic
ult)
, qua
lity
outc
omes
, how
med
ical
err
ors c
an
be a
void
ed, a
nd h
ow la
ngua
ge b
arrie
rs ca
n im
pact
hea
lth o
utco
mes
.
Po
st A
sses
smen
t - A
sim
ilar a
sses
smen
t was
giv
en fo
llow
ing
simul
atio
n ac
tivity
an
d di
scus
sion
Resu
lts
5/
5 Re
siden
ts u
sed
the
MAR
TTI w
ithin
1 m
inut
e of
pat
ient
enc
ount
er.
2/5R
esid
ents
acc
urat
ely
reac
hed
the
diag
nosis
.
3/5
Resid
ents
cont
inue
d in
tera
ctio
n w
ith p
atie
nt th
roug
hout
enc
ount
er.
2/5
Res
iden
ts ch
ecke
d to
see
if th
ere
wer
e qu
estio
ns re
gard
ing
the
diag
nosis
.
No
resid
ents
acc
urat
ely
desc
ribed
the
MAR
TTI p
roce
ss u
sing
the
tran
slatio
n se
rvic
e.
3
/5 R
esid
ents
des
crib
ed M
ARTT
I prio
r to
havi
ng th
e tr
ansla
tor p
rese
nt.
7/1
5 Re
siden
ts im
prov
ed th
eir s
core
s fro
m p
re-a
sses
smen
t to
post
-as
sess
men
t.
6/1
5 Sc
ores
rem
aine
d th
e sa
me.
Succ
ess F
acto
rs a
nd L
esso
ns L
earn
ed
Th
is pr
ojec
t inc
reas
ed a
war
enes
s of d
iffer
ent t
rans
latio
n se
rvic
es a
nd b
roug
ht t
o lig
ht a
reas
of d
efic
ienc
y fo
r whi
ch w
e ca
n im
prov
e.
Onc
e M
ARTT
I was
impl
emen
ted,
resid
ents
effe
ctiv
ely
com
mun
icat
ed w
ith th
e pa
tient
. MAR
TTI w
as im
plem
ente
d in
a ti
mel
y fa
shio
n, w
ithou
t del
ay in
pat
ient
care
.
In
crea
sed
awar
enes
s reg
ardi
ng o
ther
tran
slatio
n se
rvic
es, i
nclu
ding
“La
ngua
ge B
oxes
” an
d re
cord
tran
slatio
n, w
as a
chie
ved
thro
ugh
this
proj
ect.
Lim
itatio
ns
Th
e sim
ulat
ion
coul
d ha
ve b
een
impr
oved
by
mor
e at
tent
ion
to re
alist
ic c
onte
xt,
(i.e.
, with
out t
he M
ARTT
I dev
ice
posit
ione
d at
the
beds
ide.
)
Th
e sim
ulat
ion
was
lim
ited
by a
smal
l sam
ple
size
and
shou
ld b
e op
ened
up
to
othe
r res
iden
ts, f
acul
ty, a
nd a
ncill
ary
staf
f
O
ne o
f the
requ
este
d la
ngua
ges w
as n
ot a
vaila
ble
with
MAR
TTI;
this
chal
leng
e co
uld
have
bee
n ci
rcum
vent
ed b
y ha
ving
mul
tiple
lang
uage
serv
ices
ava
ilabl
e fo
r tr
ansla
tion,
as w
ell a
s diff
eren
t mod
aliti
es
Conc
lusi
on
Th
e sim
ulat
ion
prov
ided
a v
alua
ble
expe
rienc
e fo
r res
iden
ts a
nd in
sight
in
to h
ow th
e M
ARTT
I dev
ice
is cu
rren
tly u
tilize
d am
ong
phys
icia
ns.
The
lect
ure
and
disc
ussio
n as
soci
ated
with
the
simul
atio
n im
prov
ed
resid
ent k
now
ledg
e ab
out l
angu
age
serv
ices
and
reso
urce
s.
The
simul
atio
n ca
n be
eas
ily e
xpan
ded
to in
clud
e ot
her r
esid
ent g
roup
s,
as w
ell a
s fac
ulty
and
staf
f.
Bibl
iogr
aphy
1
) Flo
res,
G.,
Law
s, M
.B.,
May
o, S
.J., Z
uker
man
, B.,
Mila
gros
, A.,
Med
ina,
L., H
ardt
y, E
.J. E
rror
s in
Med
ical
Inte
rpre
tatio
n an
d Th
eir P
oten
tial C
linic
al C
onse
quen
ces i
n Pe
diat
ric E
ncou
nter
s.
Jour
nal o
f the
Am
eric
an A
cade
my
Pedi
atric
s Vol
. 111
No.
1 Ja
nuar
y 20
03
2) F
lore
s G. C
ultu
re a
nd th
e pa
tient
-phy
sicia
n re
latio
nshi
p: a
chie
ving
cultu
ral c
ompe
tenc
y in
hea
lth ca
re. J
ourn
al o
f Ped
iatr
ics.
Apr
il 20
00;1
36:1
4–23
3) F
lore
s G, A
breu
M, O
livar
MA,
Kas
tner
B. A
cces
s ba
rrie
rs to
hea
lth ca
re fo
r Lat
ino
child
ren.
Jour
nal o
f Ped
iatr
ic A
dole
scen
t Med
icin
e Ju
ly 1
998;
152:
1119
–112
5
4) D
ivi,
C., K
oss,
R. G
., Sc
hmal
tz, S
. P.,
& L
oeb,
J. M
. Lan
guag
e pr
ofic
ienc
y an
d ad
vers
e ev
ents
in U
S ho
spita
ls: A
pilo
t stu
dy. I
nter
natio
nal J
ourn
al fo
r Qua
lity
Heal
th C
are:
Jour
nal o
f the
In
tern
atio
nal S
ocie
ty fo
r Qua
lity
in H
ealth
Care
, Mar
ch 2
0071
9, 6
0–67
.
5) T
he Jo
int C
omm
issio
n. (2
010)
. Adv
anci
ng e
ffect
ive
com
mun
icat
ion,
cul
tura
l com
pete
nce,
and
pat
ient
and
fam
ily-c
ente
red
care
: A ro
adm
ap fo
r hos
pita
ls.
6) W
asse
rman
, M
., Re
nfre
w, M
., G
reen
, A.,
Lope
z, L
., Ta
n-M
cGro
y, A
., Br
ach,
C.,
Beta
ncou
rt, J
.R. I
dent
ifyin
g an
d Pr
even
ting
Med
ical
Err
ors i
n Pa
tient
s With
Lim
ited
Engl
ish P
rofic
ienc
y: K
ey
Find
ings
and
Tool
s for
the
Fiel
d. J
ourn
al fo
r Hea
lthca
re q
ualit
y Vo
l. 36
No.
3 M
ay/J
une
2014
113 of 131
Team: Scott and White Healthcare Focus Area: Transitions in Care
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
Develop system-wide transitions in care and build on the current work of House Staff Quality Council. Disseminate & systematize standardized Transitions in Care/Hand-Off Process building off the work of the HSQC and bring to a system level leveraging system quality. Assess the current state of hand-offs and transitions in care protocol. All stakeholders from each of the departments need to participate and provide input. The assumption is that this is an institutional priority as such there will be a buy-in from all to develop a standard process and allow each department to add items as needed so that they will own the process rather than feeling like coming from the “top”. Team: Drs. Wesson, Kallur, Mirkes, McAllister, Wehbe-Janek, Manning, Papaconstantinou, Dixon, Williams, Thomas, Ms. Peters, Ms. Hochhalter, Ms. Sanford.
II. Project Description To develop system-wide “transitions in care” protocol and allow individual departments to add information as needed to meet the departmental requirements.
III. Necessary Resources (staff, finances, etc.)
Funding for meetings Incentives for residents to actively participate EPIC team to setup a standard template Education and training of all involved on the team as well as the users Support from House Staff Quality Council and House Staff Utilization of New Innovations software
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
AHRQ Survey Data (Baseline HRQ Culture and Safety) Develop and Collect information using baseline survey in January 14-15 Conduct a perspective survey of House Staff
V. Communication Plan (may be helpful to draft a flow chart of team
members & senior management, both internal & external)
Developed template be placed in New Innovations (NI) / Let programs/departments build upon HSQC template. • Dr. McAllister and Dr. Thomas to contact Surgery/Sub-Surgical
specialties and request templates being used in their programs. • Dr. Mirkes to contact Medicine subspecialties and request templates
being used in their programs o Collected Plastic Surgery, General Surgery, Family Medicine
and Internal Medicine templates • Obtain Checklists – SBAR and IPASS
o DATA Checklist; System-wide Checklist – See attached • Develop Standardized care transition processes for in hospital, and
transition out of hospital care transitions. Dr. Manning is PD “Champion” for this. We will have a common standardized template that will be used by all programs hospital wide with the option for some programs to add a few items if that is required.
Present the information to Nursing Council APPS House Staff and Quality Council Chair Caucus CMO Monthly Newsletter BOD and AO Council Presentation
• Create an Institutional Policy
114 of 131
VI. Accountability (list of team members and who
is accountable for what)
Discuss roles at next team meeting • Help HSQC get support they need to move their project forward. • Are HSQC members getting time off?
Involve residents, faculty, nursing staff, chairs and GME administration.
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
Time for meetings • Not all participants attended teleconferences and meetings due
to clinical responsibilities. • Budget
EPIC Implementation Schedule • EPIC is fully integrated at S&W.
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
Establish monthly milestones in parallel with the webinars Webinar’s; Monthly Teleconferences Small groups to discuss and plan Next six months – Strategize for dissemination of information to all concerned including House Staff
IX. Vision Statement/Closing Plan (markers of success by March 2015)
Develop sustaining system-wide process for transitions of care and patient safety that can be modified annually.
X. Success Factors The most successful component of our work was creating a system-wide TIC Checklist. We were inspired by the work and energy the HSQC had previously achieved. After CLER visit our program directors took the lead in developing workable solutions in the areas of “Transitions in Care and Supervision” along with our House Staff Quality Council.
XI. Barriers The largest barrier we encountered was time. Our Team members are nearly all clinicians and very challenging to organize meetings with their limited availability. We worked to overcome this by communicating via email and adding as a GMEC Agenda item when necessary.
XII. Lessons Learned The single most important piece of advice to provide another team embarking on a similar initiative would be consider the availability of your members and getting the House Staff involved as early on as possible.
XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI III work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact What changes have you observed in your residency program(s), or at your institution, based upon your work? We are still working on fully integrating the checklist as system-wide practice.
XVI. Next Steps Describe next steps for your project, including plans for sustaining and spreading the changes made. Upload DATA Checklist in New Innovations; list a resource on GME Website. EPIC – Coordinate with EPIC Team and upload DATA Checklist into EPIC. Follow-up in 2015-2015 on effectiveness.
115 of 131
CLER
: One
Ins,tu,on
’s Experience an
d the Im
portan
ce of Integra,ng
the C-‐Suite in Gradu
ate Med
ical Edu
ca,on
Ravi Kallur, Ph
D, M
PA; M
arguerite Peters, M
Ed; H
ania W
ehbe
-‐Jan
ek, P
hD
ScoM
& W
hite Healthcare, Tem
ple, TX
Overall Goa
l/Abstract
Objec,ve of you
r project?
Share lesson
s learne
d pre an
d po
st CLER visit.
Wha
t mad
e you choo
se th
is project?
To gain more kn
owledge in und
erstan
ding th
e CLER
visit.
Gap
?
Lack of informa,
on to
involve all con
s,tuen
ts of G
ME at
the ins,tu,on
al level, includ
ing the C-‐suite.
Backgrou
nd
Describe your project in a detailed, yet con
cise, m
anne
r.
With CLER
, the
en,
re ins,tu,on
is held accoun
table
includ
ing the C-‐suite, Qua
lity an
d Safety personn
el, and
the Nursing staff. Plans were mad
e to ta
ckle th
e “an,
cipa
ted CLER
” visit as an op
portun
ity rather th
an an
accred
ita,
on visit. Th
is app
roach requ
ired
a te
am effort
consis,ng of h
ouse staff, program
coo
rdinators, program
directors, fa
culty mem
bers, safety an
d qu
ality staff
, and
C-‐suite to work as a te
am with the DIO.
Vision Statem
ent
Wha
t wou
ld you
like to
see hap
pen?
Establish a team
app
roach to add
ress six areas of C
LER
(Pa,
ent Safety, P
rofessiona
lism, Fa,
gue Man
agem
ent/
Duty Hou
rs, Q
uality Im
provem
ent, Transi,on
s in Care,
and Supe
rvision.)
Wha
t are you
aim
ing to cha
nge/im
prove?
Stan
dardize pa
,en
t han
dover process througho
ut th
e ho
spital; improve sharing of inform
a,on
and
involvem
ent of hou
se staff at the ins,tu,on
al level of
Pa,en
t Safety & Qua
lity Co
uncil, an
d im
prove
commun
ica,
on between ho
use staff
and
sen
ior
administra,
on of the
ins,tu,on
.
Materials/M
etho
ds
1. Han
douts for Hou
se Staff, Program
Directors, Faculty, C-‐Suite, an
d Nursing Staff.
2. Bad
ge holde
r insert with de
scrip,
on of “six focus areas”
3. M
ee,ngs that includ
ed CLER ad
visory group
con
sis,ng of h
ouse staff,
coordina
tors, P
Ds, fa
culty an
d GME Staff
4. Presenta,
on to
nursing execu,ves, Cha
ir cau
cus, GMEC Boa
rd of D
irectors and
Acade
mic Ope
ra,on
s Co
uncil
5. Sha
red up
dates at GMEC m
ee,ngs
Bibliograp
hy
1. Weiss KB, W
agne
r R., N
asca TJ D
evelop
men
t, Tes,ng
, and
Implem
enta,on
of the
ACG
ME Clinical Learning Environm
ent
Review
(CLER) Program
. J G
rad Med
Ed 20
12; 4:396
-‐398
.
2. CLER
Pathw
ays to Excellence; Pub
lishe
d by th
e ACG
ME.
www.acgme.org.
Barriers Encou
ntered
/Lim
ita,
ons-‐
Wha
t cou
ld you
have do
ne differen
tly?
BeMer und
erstan
ding of p
a,en
t safety an
d qu
ality ho
spital
team
work, risk mgm
t. policies an
d proced
ures fo
r “m
isses”.
Improvem
ent of fo
llow throu
gh on incide
nt re
ports.
Opp
ortuni,es fo
r im
provem
ent?
Includ
e Hou
se Staff on ho
spital safety an
d qu
ality commiMees.
Have C-‐suite reps m
eet w
ith ho
use staff
regarding ho
spital
issues, p
riori,es, fi
nance, etc. Hospital w
ide pa
,en
t ha
ndover
policy de
velopm
ent.
Une
xpected challenges (a
nd solu,
ons)?
Time lim
ita,
on to
gathe
r C-‐suite an
d safety and
qua
lity staff
to m
eet w
ith site visitors. A
CGME’s strict re
quirem
ent a
s to
who
sho
uld be
at the table for op
ening an
d closing sessions.
Results
Conclusion
s Fina
l tho
ughts…
Overall expe
rien
ce…
It paved
the
way fo
r de
veloping beM
er re
la,on
ships with
house staff
and
und
erstan
ding of ins,tu,on
al goa
ls, p
olicies,
and qu
ality an
d safety projects.
Will be very useful and
cri,cal for th
e success of th
e GME
programs.
A fe
w areas from
the repo
rt and
have the PD
s take owne
rship
and im
plem
ent im
provem
ents. CLER is an on
going process,
and will help ins,tu,on
s to be all the
y can po
ssibly be.
Wha
t mad
e your project successful?
Early plan
ning; w
illing an
d supp
or,ve te
am m
embe
rs. C-‐suite that und
erstoo
d the im
portan
ce of G
ME an
d wan
ted to m
ake it th
e be
st. PD
s taking on the
ini,a,
ve to
work with the DIO.
Wha
t worked?
Alignm
ent o
f respo
nsibili,es to
the right ind
ividua
ls. All concerne
d with GME
making it a priority.
Wha
t are you
most sa,
sfied
with?
Fina
l rep
ort refl
ec,ng m
any po
si,ves.
Une
xpected ‘wins?’
Reaffi
rming that our han
doff ,me an
d programspecific po
licy is working. Hou
se
staff
reaffi
rming that th
ey have a safe environ
men
t to learn an
d to express
them
selves.
Success Factors an
d Lesson
s Learne
d
(D
iscussion)
1. Excellent te
am re
presen
ta,on
that con
tributed
to dissemina,
on of informa,
on
to all concerne
d.
2. Tim
ely supp
ort an
d inpu
t from
the
Boa
rd of D
irectors and
C-‐suite.
3. Program
Directors, faculty, and
hou
se staff led each of g
roup
s in dissemina,
ng
inform
a,on
and
coo
rdina,
ng te
am fo
r actual site visit.
4. Coh
eren
t, enthu
sias,c, and
com
mon
plarorm re
spon
se during site visit, a
proa
c,ve app
roach rather tha
n a reac,ve one
.
116 of 131
Team: Scottsdale Healthcare Focus Area: Quality Improvement/Patient Safety
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
Create a project to engage residents in SHC Quality Improvement efforts using the “ZERO CAUTI” collaborative as a model. Team members include (listed alphabetically): Greg Alaestante DO- FM resident member Cheralyn Beaudry- Assoc. VP Quality/Safety M. Moe Bell MD- chair; Assoc Dir FM residency James Burke MD- Sr VP- CMO Chip Finch DO- Chief Academic Officer/DIO Wendy Hardina- FM Residency Coordinator Lafe Harris DO- FM resident member Cindy Kegowicz MD- FM Residency Director Todd LaPorte- Sr VP CFO Carol Mayer- Academic Project Coordinator, GME
II. Project Description
“ZERO CAUTI” Collaborative- The AIAMC IV team will collaborate with hospital quality leaders in a multidisciplinary, multifaceted fashion, with resident leadership, with a long-term goal of reducing the SHC CAUTI rate to ZERO. Elements include: 1. Collaborate with the SHC CAUTI taskforce (creating a CAUTI bundle, working on nursing-led efforts to reduce catheter use, and picking a high-risk unit for implementation- the SHC Osborn ICU) 2. Help prepare and present a CME multidisciplinary conference addressing CAUTI prevention 3. A resident teaching service initiative to record Foley use and indication on patient census and in progress notes. 4. Work with administration and the medical staff on physician efforts to reduce catheter use (require daily order for catheter as with restraints?) 5. Collaborate with the Emergency department to reduce unnecessary urinary catheter insertions (education regarding indications and supporting alternatives) 6. Collaborate with surgical units to reduce intra-operative urinary catheter use and encourage removal in the recovery room when catheter no longer indicated) 7. Collaborate with urology to create a protocol to address urine retention in the hospital (stopping anticholinergic medications, bladder scans, and timing of straight caths)
III. Necessary Resources (staff, finances, etc.)
1. Administrative support 2. Quality consultant support 3. Financial budget for research and statistical data retrieval, IRB,
design, and development Physician support/time
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
1. Collect monthly CAUTI rate and location data to compare with baseline (Milestone SBP-2 Emphasizes patient safety) 2. Meet every other month to monitor team progress
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(BP-4 Coordinates team based care) 3. Monitor progress on physician initiatives (PBLI-3 Improves systems in which the physician provides care)
V. Communication Plan (may be helpful to draft a flow chart of team
members & senior management, both internal & external)
The AIAMC IV team will have a tele-conference meeting in February as a trial to improve attendance and efficiency. Updates of the AIAMC team’s work will be provided to the SHC QRM committee and to the CAUTI initiative team. Communication with residents with will occur through updates at resident faculty meetings.
VI. Accountability (list of team members and who
is accountable for what)
Greg Alaestante DO- working on CME forum and resident liaison with QRM committee Cheralyn Beaudry- liaison with the QRM committee and the CAUTI TASKFORCE M. Moe Bell MD- coordinate the project, liaison with QRM and CAUTI taskforce James Burke MD- support physician initiatives and liaison with C-suite regarding CLER visit Chip Finch DO- working on CME forum and liaison for ED initiative Wendy Hardina- prepare for CLER visit Lafe Harris DO- working on resident service initiative and resident liaison with QRM committee Cindy Kegowicz MD- support resident teaching service Foley initiative Todd LaPorte- ensure financial resources for the initiatives Carol Mayer- coordinate meetings, prepare for CLER visit
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
Complex project with several initiatives involves many departments and requires collaboration among nursing, medical staff, and administration. Solutions involve new ways of thinking and new technologies (such as wicking pads to measure urine output in the ICU).
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
Timeline was created to prepare the multidisciplinary clinical forum on CAUTI (Alaestante and Finch). The CAUTI initiative has a timeline and agenda for the next year. The team will explore the feasibility of the other elements and create timelines for each.
IX. Vision Statement/Closing Plan (markers of success by March 2015)
Vision: Residents will be actively involved in Quality Improvement efforts at SHC and the institution will be well along the path to the quality goal of zero CAUTI’s.
X. Success Factors The most successful component of our work was culture change in the emergency department and on the medical floors to significantly reduce urinary catheter use in our hospital. A conversation was started that helped reduce Foley days in our ICU by 30%. We were inspired by the teamwork witnessed- a true multidisciplinary and inter-professional effort of nursing, physician leadership, the quality improvement team, and the IT team to help with EMR changes.
118 of 131
XI. Barriers The largest barrier we encountered was entrenched practices by both physicians and nurses in the ICU setting, it proved hard to change the culture in that arena. We worked to overcome this by ongoing education and instituting a daily management system with daily huddles and tracking of patients who had foley catheters.
XII. Lessons Learned The single most important piece of advice to provide another team embarking on a similar initiative would be teamwork and ongoing communication and education are critical.
XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI III work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact What changes have you observed in your residency program(s), or at your institution, based upon your work? 1. A resident quality champion position was created and will be continued after the end of the initiative. 2. The emergency room drastically reduced urinary catheter use due to education efforts and an electronic medical record system prompt to enter the reason for a urinary catheter when one was ordered. 3. Daily management plans now take place and include tracking of all patients who have urinary catheters on both the medical floors and the ICU. 4. A urine retention protocol has been implemented to help manage patients with urine retention after catheter removal. 5. A CAUTI bundle was instituted in the ICU and wicking pads were adopted as an alternative to urinary catheters. 6. An automated prompt was incorporated in the hospital EMR to ask physicians each day if a urinary catheter could be removed, and if not to list the indication for continued use. 7. Due to all these efforts, our hospital ICU had 35% fewer CAUTI’s and reduced total Foley days by 31% in 2014 compared with 2012. (National data from 2009 through 2013 showed an increase in CAUTI of 6%
XVI. Next Steps Describe next steps for your project, including plans for sustaining and spreading the changes made. 1. The CAUTI committee will continue its work because CAUTI rates remain high in our hospital ICU setting. The group will join a statewide initiative organized by HSAG to attempt to reduce CAUTI rates. They are also participating in a national group. 2. The quality department will attempt to create standard work processes across all hospitals in our institution to reduce CAUTI rates in the hospitals where rates remain high.
119 of 131
Ove
rall
Goa
l/Ab
stra
ct
Obj
ectiv
e of
you
r pro
ject
?
Decr
ease
cat
hete
r ass
ocia
ted
urin
ary
trac
t inf
ectio
ns
(CAU
TI) a
t Sco
ttsd
ale
Heal
thca
re (S
HC).
Wha
t mad
e yo
u ch
oose
this
pro
ject
? CA
UTI
rate
s wer
e ve
ry h
igh,
esp
ecia
lly in
the
Osb
orn
cam
pus
ICU.
The
AIA
MC
team
invo
lved
resid
ents
and
qua
lity
lead
ers
in a
n ef
fort
to im
prov
e ca
re a
nd sa
ve li
ves.
Back
grou
nd /
acc
ompl
ishm
ents
CAU
TI re
duct
ion
effo
rts /
initi
ativ
es a
ccom
plish
ed in
clud
ed:
•Pre
sent
ed a
mul
ti-di
scip
linar
y CM
E fo
rum
on
CAU
TI
•Col
labo
rate
d w
ith a
syst
em-w
ide
CAU
TI ta
skfo
rce
•Cre
ated
a re
siden
t qua
lity
cham
pion
pos
ition
for G
ME
•Im
plem
ente
d da
ily m
anag
emen
t pla
ns to
trac
k ca
thet
er u
se
•Impl
emen
ted
a ur
ine
rete
ntio
n pr
otoc
ol
•Inst
itute
d Em
erge
ncy
dept
. edu
catio
n an
d EM
R pr
ompt
to
ente
r the
reas
on fo
r a u
rinar
y ca
thet
er w
hen
orde
red
•Inst
itute
d ho
spita
l EM
R pr
ompt
to a
sk p
hysic
ians
if a
urin
ary
cath
eter
cou
ld b
e re
mov
ed, a
nd to
list
the
indi
catio
n fo
r co
ntin
ued
use
Vi
sion
Sta
tem
ent
Wha
t wou
ld y
ou li
ke to
see
hap
pen?
Re
siden
ts w
ill b
e ac
tivel
y in
volv
ed in
Qua
lity
Impr
ovem
ent
effo
rts a
t SHC
and
the
inst
itutio
n w
ill b
e w
ell a
long
the
path
to
the
qual
ity g
oal o
f zer
o CA
UTI
’s.
Wha
t are
you
aim
ing
to c
hang
e/im
prov
e?
Our
prim
ary
aim
is to
adv
ance
Sco
ttsd
ale
Heal
thca
re C
AUTI
pr
even
tion.
How
ever
, a b
road
er g
oal i
s to
dire
ct G
ME
and
CME
tow
ards
qua
lity
impr
ovem
ent p
roje
cts.
Our
hop
e is
to d
evel
op
and
enco
urag
e le
ader
ship
from
our
resid
ents
to g
uide
syst
em-
wid
e ch
ange
thro
ugh
patie
nt sa
fety
and
qua
lity
impr
ovem
ent.
Mat
eria
ls/M
etho
ds
Bibl
iogr
aphy
/Sou
rces
Con
sulte
d 1.
Cent
ers f
or D
iseas
e Co
ntro
l and
Pre
vent
ion.
Hea
lthca
re In
fect
ion
Cont
rol P
ract
ices
Adv
isory
Co
mm
ittee
(HIC
PAC)
Web
pag
e. h
ttp:
// w
ww
.cdc
.gov
/hic
pac/
inde
x.ht
ml.
Acce
ssed
20
April
20
14.
2.Go
uld
CV, U
msc
heid
CA,
Aga
rwal
RK,
Kun
tz G
, Peg
ues D
A, a
nd H
ICPA
C. G
uide
line
for
Prev
entio
n of
Cat
hete
r -as
soci
ated
Urin
ary
Trac
t Inf
ectio
ns
2009
.htt
p://
ww
w.c
dc.g
ov/h
icpa
c/ca
uti/0
01_c
auti.
htm
l. Ac
cess
ed 2
0 Ap
ril 2
014.
3.Lo
E, N
icol
le L
, Cla
ssen
D, e
t al.
Stra
tegi
es to
pre
vent
cath
eter
-ass
ocia
ted
urin
ary
trac
t in
fect
ions
in a
cute
care
hos
pita
ls. In
fect
Con
trol
Hos
p Ep
idem
iol.
2008
;29:
S41-
S50.
4.Ho
oton
TM
, Bra
dley
SF,
Card
enas
DD,
Col
gan
R, G
eerli
ngs S
E, R
ice
JC, S
aint
S, S
chae
ffer A
J, Ta
mba
yh P
A, Te
nke
P, N
icol
le L
E, In
fect
ious
Dise
ases
Soc
iety
of A
mer
ica.
Dia
gnos
is,
prev
entio
n, a
nd tr
eatm
ent o
f cat
hete
r-as
soci
ated
urin
ary
tract
infe
ctio
n in
adu
lts: 2
009
Inte
rnat
iona
l Clin
ical
Pra
ctic
e G
uide
lines
from
the
Infe
ctio
us D
isea
ses S
ocie
ty o
f Am
eric
a.
Clin
Infe
ct D
is. 2
010
Mar
1; 5
0(5)
:625
-63.
Barr
iers
Enc
ount
ered
/Lim
itatio
ns
Wha
t cou
ld y
ou h
ave
done
diff
eren
tly?
The
larg
est b
arrie
r we
enco
unte
red
was
ent
renc
hed
prac
tices
from
bot
h ph
ysic
ians
and
nu
rses
in th
e IC
U.
Opp
ortu
nitie
s for
impr
ovem
ent?
In
volv
ing
thos
e sa
me
phys
icia
ns a
nd n
urse
s to
lead
qua
lity
impr
ovem
ent.
Une
xpec
ted
chal
leng
es (a
nd so
lutio
ns)?
Di
ffere
nt p
ract
ices
with
in a
sing
le g
roup
of p
hysic
ians
and
som
e nu
rses
in th
e IC
U
mad
e it
diffi
cult
to p
inpo
int s
peci
fic w
ays t
o ch
ange
‘bad
hab
its’. (
The
emer
genc
y De
pt. p
hysic
ians
and
nur
ses,
on
the
othe
r han
d, fu
lly e
mbr
aced
cha
nges
to
redu
ce ca
thet
er u
se.)
Resu
lts
Conc
lusi
ons
As a
pro
ject
that
focu
sed
on p
atie
nt sa
fety
and
dec
reas
ing
mor
talit
y an
d m
orbi
dity
, we
wer
e su
cces
sful
. Our
hop
e to
co
mpl
etel
y el
imin
ate
CAU
TIs i
n ou
r sys
tem
was
not
met
. Ho
wev
er, m
any
key
initi
ativ
es w
ill c
ontin
ue a
nd sh
ould
lead
to
furt
her r
educ
tion
in C
AUTI
in fu
ture
yea
rs.
A m
ultid
iscip
linar
y, m
ultif
acet
ed a
ppro
ach
with
resid
ent
invo
lvem
ent i
s fea
sible
and
resu
lted
in p
ositi
ve im
pact
in o
ur
syst
em.
The
resid
ent q
ualit
y ch
ampi
on p
ositi
on w
ill
cont
inue
and
as w
ill e
ffort
s to
redu
ce C
AUTI
.
Succ
ess F
acto
rs a
nd L
esso
ns
Lear
ned(
Disc
ussi
on)
CA
UT
I Pre
vent
ion
thro
ugh
educ
atio
n, c
ontin
uum
of c
are,
and
syst
em-w
ide
buy-
in
Greg
Ala
esta
nte,
DO
, PGY
3; M
. Moe
Bel
l, M
D, M
PH; C
harle
s ‘Ch
ip’ F
inch
, DO
Sc
otts
dale
Lin
coln
Hea
lth N
etw
ork,
Sco
ttsd
ale,
AZ
8525
1 Wha
t mad
e yo
ur p
roje
ct su
cces
sful
? By
far t
he m
ost s
ucce
ssfu
l com
pone
nt o
f our
wor
k w
as a
cu
lture
cha
nge
in th
e em
erge
ncy
depa
rtm
ent a
nd o
n th
e m
edic
al fl
oors
to si
gnifi
cant
ly re
duce
urin
ary
cath
eter
use
.
Wha
t wor
ked?
Al
low
ing
all p
artie
s to
impl
emen
t the
ir ow
n m
etho
ds o
f ad
dres
sing
cath
eter
use
and
CAU
TI p
reve
ntio
n w
ith su
ppor
t pr
ovid
ed b
y th
e CA
UTI
Initi
ativ
e te
am.
Wha
t are
you
mos
t sat
isfie
d w
ith?
The
over
all d
ecre
ase
of c
athe
ter u
se b
y ap
prox
imat
ely
30%
an
d a
simila
r red
uctio
n of
CAU
TIs f
rom
our
bas
elin
e.
120 of 131
Team: TriHealth Focus Area: Patient Safety /Event Reporting
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
AIM: By March 2015 all of our residents and teaching faculty will know and recognize the list of serious reportable events (SRE’s) and will demonstrate a four fold increase in the use the event reporting system (within 48 hours from occurrence the event). Project Assumptions:
1. Faculty and Staff are a captured audience where we can get significant participation.
2. Technology will be available. 3. Educational resources that can be disseminated to 100% of
residents and faculty 4. Current culture does not encourage and at times discourages
consistent safety event reporting. Team Members: David Dhanraj MD, MBA: Generalist Division Director, Dept of OB/GYN Michelle Louis MD: Associate Program Director, Department of Internal Medicine Michael Marcotte, MD: Director of Quality and Safety, Women’s Services Alex Saba MD: Associate Program Director, Department of Surgery Lorraine Stephens: Chairman and Program Director, Family Medicine Becky Williams MA: Administrative Director of Graduate Medical Education Ginger Klarquist DO/Lindsey Crawford DO: OB/GYN Residents Fiza Warsi MD: Family Practice Resident Bilal Khan: Internal Medicine Resident Dee Murphy RN, MBA: Director, Patient Safety and Accreditation
II. Project Description
The project will be composed of the following elements 1. Residents and faculty will become knowledgeable of SRE’s for
their specialty 2. We will establish the desired culture and behavior and model
it (actual and simulation, DATIX in-services) 3. Assisting with the successful implementation of the new
event reporting system (DATIX) 4. We will develop a process map of what happens with a
reported event and ensure all residents understand this. Outcome: Belief by our residents and faculty that this process is effective (Survey Data)
III. Necessary Resources (staff, finances, etc.)
Working event reporting system (Dee Murphy) Trainers, superusers (resident time) Faculty time to develop mastery Research/Data collection staff (residents from each program, QA Nurses, Research Division)
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
Completion rate of educational modules Resident feedback of result of reporting (consequences, attitudes etc.) --use some questions of Culture of Safety questions (by January 1) --goal of 5 minute to complete all surveys (MedHub?)—Dawn Kelly Pre and Post Surveys of Knowledge of SRE, PS Concepts (RCA’s)
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Knowledge of Management of SRE’s in each department Pre and post Datix for event reporting. Time from event to report (decrease) Number of events that are self-reported
V. Communication Plan (may be helpful to draft a flow chart of
team members & senior management, both internal & external)
Dr. Welling, Program Director (PD Advisor meeting), GMEC, Departmental level with resident and faculty leader. Layered communication plan: Lectures, email of lectures, presentations at department meeting. Datix Communication plan
VI. Accountability (list of team members and who
is accountable for what)
Dave Dhanraj and Michelle Louis will co-lead these efforts. Program faculty and residents from each specialty Dave Dhanraj: Project Management, Monthly calls, AIAMC communications Mike Marcotte: Communication Plan, Key Driver Diagram Alex Saba: Work with Dawn on how to use Med Hub in pre and post assessments Michelle Louis: Will work with Patient Safety and accreditation in coordinating our efforts with current hospital programs and with the implementation of the new safety event reporting system (Datix). Residents: working with faculty on communication in their program and organizing participation and data collection.
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
Delay in implementing new technology Engagement of residents, faculty staff Leadership support (PD’s Chairs, Adminstration)
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
Baseline data: Current reporting number (last year), determination of SRE list for each program. Pre: First week in January 2014 Assessment of current working knowledge of patient safety concepts and management skills for SRE’s. Mid: August 2014: All residents will have been through didactics and training. Post: First week in January 2015 (data through December 2014) Follow-up assessments of working knowledge of patient safety concepts and management skills for SRE’s, post intervention. Abstract and publications beginning in August 2015
IX. Vision Statement/Closing Plan (markers of success by March 2015)
A sustainable program of culture of safety will be fully integrated into all GME programs: 1. We will see an increase in self-reporting faculty and staff who will lead these efforts for their respective specialties. 2. Technology will be effectively leveraged in these efforts.
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X. Success Factors The most successful component of our work was………. - Having representatives from each residency program involved which included both residents and faculty. We received excellent financial support from our administration. We were inspired by………………..Our CLER Report. The feedback and guidance from our ACGME site-visitors was constructive and specific.
XI. Barriers The largest barrier we encountered was…….. The delay in implementation of our new event reporting system We worked to overcome this by…….. focusing on resident and faculty education on Serious Reportable Events. We believe this improved the effectiveness of our intervention once the event reporting system was ready for go-live.
XII. Lessons Learned The single most important piece of advice to provide another team embarking on a similar initiative would be………… GME leadership needs to involve Program Directors into the process early. It was difficult to get buy in and interest from all the programs early in the process
XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI III work? 1 2 3 4 5 6 7 8 9 10
XV. Project Impact What changes have you observed in your residency program(s), or at your institution, based upon your work? We demonstrated an increased use of event reporting by our residents and faculty
XVI. Next Steps Describe next steps for your project, including plans for sustaining and spreading the changes made. -Instituting event report training into new resident orientation -Reinforcing event reporting into quarterly GME quality/safety curriculum -“Closing the Loop”: Reporting back to resident and faculty the outcomes of submitted event reports.
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Bac
kgro
und
A Ju
ne 2
012
site
vis
it re
port
from
the
Acc
redi
tatio
n C
ounc
il fo
r Gra
duat
e M
edic
al
Edu
catio
n (A
CG
ME
) Clin
ical
Lea
rnin
g E
nviro
nmen
t Rev
iew
(CLE
R) r
evea
led
resi
dent
s an
d ph
ysic
ians
lack
of a
war
enes
s an
d un
ders
tand
ing
of th
e ho
spita
l’s
syst
em fo
r rep
ortin
g pa
tient
saf
ety
conc
erns
in th
e fo
llow
ing
thre
e ar
eas:
1) l
ack
of k
now
ledg
e of
wha
t con
stitu
tes
a re
porta
ble
patie
nt s
afet
y ev
ent;
2) la
ck o
f aw
aren
ess
of th
e pe
rson
resp
onsi
ble
for r
epor
ting;
and
3) l
ack
of u
nder
stan
ding
of
the
curre
nt re
porti
ng s
yste
m.
Ove
rall
Goa
l and
Vis
ion
Sta
tem
ent
A qu
ality
impr
ovem
ent s
tudy
was
con
duct
ed c
onsi
stin
g of
an
educ
atio
nal
prog
ram
(int
erve
ntio
n) fo
cusi
ng o
n th
e im
porta
nce
of e
vent
repo
rting
and
a p
re
/ pos
t edu
catio
nal s
urve
y to
mea
sure
atti
tude
s, k
now
ledg
e an
d se
lf-re
porte
d be
havi
ors.
Fol
low
ing
the
impl
emen
tatio
n of
a n
ew p
atie
nt s
afet
y ev
ent (
PS
E)
repo
rting
sys
tem
, we
com
pare
d th
e re
porte
d ev
ents
with
bas
elin
e da
ta to
de
term
ine
impr
ovem
ent i
n P
SE
repo
rting
. The
com
bina
tion
of a
n ed
ucat
iona
l in
terv
entio
n an
d a
new
PS
E re
porti
ng s
yste
m w
ould
impr
ove
PS
E re
porti
ng
amon
g re
side
nts
and
teac
hing
facu
lty in
our
resi
denc
y pr
ogra
ms
and
optim
ize
thei
r eng
agem
ent i
n 6
Focu
s A
reas
of A
CG
ME
CLE
R.
Met
hods
Th
e su
bjec
ts in
clud
ed re
side
nts
and
teac
hing
facu
lty fr
om th
e fo
llow
ing
Gra
duat
e M
edic
al E
duca
tion
(GM
E) p
rogr
ams:
Inte
rnal
Med
icin
e, F
amily
M
edic
ine,
Gen
eral
Sur
gery
, Obs
tetri
cs a
nd G
ynec
olog
y (O
B/G
YN),
Uro
gyne
colo
gy, a
nd V
ascu
lar S
urge
ry.
Dat
a C
olle
ctio
n Q
uest
ionn
aire
: A q
uest
ionn
aire
was
ada
pted
from
pre
viou
s re
sear
ch a
nd
incl
uded
item
s to
ass
ess
attit
udes
and
exp
erie
nce
rega
rdin
g pa
tient
saf
ety
even
t rep
ortin
g [1
]. Th
e qu
estio
nnai
re in
clud
ed th
e fo
llow
ing
elem
ents
: (1)
ex
perie
nce
repo
rting
, (2)
resp
onsi
bilit
y to
sel
f, (3
) res
pons
ibili
ty to
com
mun
ity,
(4) r
espo
nsib
ility
to p
rofe
ssio
n, (5
) atti
tudi
nal b
arrie
rs o
f rep
ortin
g, (6
) fee
lings
of
unce
rtain
ty, (
7) a
nd fe
ars
of re
porti
ng. A
com
men
ts s
ectio
n w
as p
rovi
ded
for
feed
back
. The
que
stio
nnai
re w
as c
ompl
eted
ano
nym
ousl
y by
the
subj
ects
be
fore
and
afte
r the
edu
catio
nal p
rogr
am.
Pat
ient
Saf
ety
Eve
nts:
We
retro
spec
tivel
y co
llect
ed 3
yea
rs o
f rep
orte
d P
SE
for
base
line
data
and
trac
ked
the
even
ts re
porte
d fo
llow
ing
the
educ
atio
nal
inte
rven
tion
from
Jul
y 20
14 to
Dec
embe
r 201
4 (o
ngoi
ng d
ata
colle
ctio
n un
til
June
201
5).
Edu
catio
nal P
rogr
am (I
nter
vent
ion)
E
duca
tiona
l Lec
ture
: An
educ
atio
nal l
ectu
re w
as d
evel
oped
and
pro
vide
d w
ithin
eac
h G
ME
prog
ram
to im
prov
e kn
owle
dge
and
skills
rela
ted
to
patie
nt s
afet
y an
d ev
ent r
epor
ting.
Dep
artm
ent o
f Pat
ient
Saf
ety:
The
inve
stig
ator
s co
llabo
rate
d w
ith P
atie
nt
Saf
ety
Adm
inis
tratio
n fo
r effe
ctiv
e im
plem
enta
tion
of th
e ne
w o
nlin
e ev
ent
repo
rting
sys
tem
.
Sta
tistic
al a
naly
sis
was
com
pute
d us
ing
R S
tatis
tical
Ana
lysi
s S
oftw
are
(ver
sion
3.
0.3)
, and
χ2
or F
ishe
r’s e
xact
test
wer
e us
ed to
test
the
diffe
renc
es b
etw
een
pre-
and
pos
t-edu
catio
nal q
uest
ionn
aire
dat
a. C
ontro
l cha
rt m
etho
dolo
gy w
as
adap
ted
to d
evel
op th
e go
al c
hart
to m
onito
r pro
gres
s [2
]. R
esul
ts
Am
ong
105
resi
dent
s, re
spon
se ra
te w
as 5
6% -
92%
for p
re-in
terv
entio
n su
rvey
an
d 68
% -
100%
for p
ost-i
nter
vent
ion
surv
ey. A
mon
g 78
teac
hing
facu
lty,
resp
onse
rate
was
43%
- 67
% fo
r pre
-inte
rven
tion
surv
ey a
nd 3
3% -
92%
for
post
-inte
rven
tion
surv
ey.
Maj
ority
of a
ll re
spon
dent
s ag
reed
that
as
a he
alth
car
e pr
ovid
er, t
hey
will
be
resp
onsi
ble
for m
edic
al e
rror a
t som
e po
int i
n tim
e; a
nd to
impr
ove
patie
nt
safe
ty, s
erio
us e
vent
s sh
ould
be
repo
rted
to h
ospi
tal a
dmin
istra
tion.
•62
% o
f all
resp
onde
nts
did
not h
ave
med
ical
erro
r rep
ort t
rain
ing
in th
eir
med
ical
sch
ools
•71
% o
f all
resp
onde
nts
had
neve
r use
d on
line
erro
r eve
nt re
porti
ng
syst
em in
our
hea
lth c
are
orga
niza
tion
•33
% o
f all
resp
onde
nts
indi
cate
d th
ey d
id n
ot re
ceiv
e ed
ucat
ion
/ tra
inin
g on
how
to d
iscl
ose
med
ical
erro
rs to
hos
pita
l adm
inis
tratio
n, y
et 7
6% w
ill
likel
y re
port
med
ical
erro
rs
Mos
t im
porta
ntly,
the
num
ber o
f rep
orte
d pa
tient
saf
ety
even
ts in
crea
sed
(Fig
ure
1).
Con
clus
ions
Th
is w
as a
uni
que
qual
ity im
prov
emen
t pro
ject
that
spa
nned
4 d
iffer
ent r
esid
ency
pr
ogra
ms
addr
essi
ng p
atie
nt s
afet
y ev
ent r
epor
ting.
The
aim
of i
ncre
asin
g ev
ent
repo
rting
was
ach
ieve
d du
e to
bot
h a
new
eve
nt re
porti
ng s
yste
m fo
r TriH
ealth
and
new
cu
rricu
lum
that
was
dev
elop
ed a
nd d
eliv
ered
with
in e
ach
resi
denc
y pr
ogra
m.
The
keys
to o
ngoi
ng s
usta
inab
ility
will
be
thre
efol
d:
•C
ontin
ue to
dev
elop
pat
ient
saf
ety
facu
lty a
nd re
side
nt e
xper
ts w
ithin
eac
h re
side
ncy
prog
ram
to b
oth
teac
h an
d be
pat
ient
saf
ety
role
mod
els
•C
ontin
ue to
wor
k to
dec
reas
e ba
rrier
s to
repo
rting
•S
usta
in e
rror r
epor
ting
rate
s th
roug
h tim
ely
feed
back
and
sys
tem
cha
nges
Ref
eren
ces
1.Je
richo
BG
, Tas
sone
RF,
Cen
tom
ani N
M, C
lary
J, T
urne
r C, S
ikor
a M
, May
er D
, McD
onal
d T.
(2
010)
. An
asse
ssm
ent o
f an
educ
atio
nal i
nter
vent
ion
on re
side
nt p
hysi
cian
atti
tude
s,
know
ledg
e, a
nd s
kills
rela
ted
to a
dver
se e
vent
repo
rting
. Jou
rnal
of g
radu
ate
med
ical
ed
ucat
ion
2 (2
):188
-194
.
2.W
hite
EM
, Kai
ghob
adi M
. (19
94).
Proc
ess
Goa
l Cha
rts fo
r Qua
lity
Impr
ovem
ent P
rogr
amm
es.
Inte
rnat
iona
l Jou
rnal
of Q
ualit
y &
Rel
iabi
lity
Man
agem
ent 1
1(2)
:26-
40.
Impr
ovin
g pa
tient
saf
ety
even
t rep
ortin
g am
ong
resi
dent
s an
d te
achi
ng fa
culty
Mic
helle
Lou
is M
D, L
ala
Hus
sain
MSc
, Dav
id D
hanr
aj M
D M
BA, B
ilal K
han
MD
, Ste
ven
Jung
MD
, Wen
dy Q
uile
s M
D, M
ark
Broe
ring
MD
,
Ke
vin
Schr
and
MD
, Lin
dsey
Cra
wfo
rd D
O, L
ori K
larq
uist
DO
, Lor
rain
e St
ephe
ns M
D, A
lexa
nder
Sab
a M
D, M
icha
el M
arco
tte M
D, B
ecky
Willi
ams
MEd
Tr
iHea
lth, C
inci
nnat
i, O
hio
Suc
cess
Fac
tors
Im
med
iate
ly a
fter t
he in
terv
entio
n, w
e ac
hiev
ed a
ppro
xim
atel
y 5-
fold
incr
ease
in
the
num
ber o
f rep
orte
d ev
ents
by
resi
dent
s an
d te
achi
ng fa
culty
.
The
educ
atio
nal i
nter
vent
ion
that
was
pro
vide
d di
d im
prov
e kn
owle
dge
of
whi
ch in
cide
nts
or e
rrors
to re
port
(Lik
ert r
espo
nse
grap
h).
Als
o, a
fter t
he in
terv
entio
n, in
3 o
f the
4 re
side
ncy
prog
ram
s m
ore
resi
dent
s w
ould
repo
rt an
erro
r eve
n if
thei
r col
leag
ues
or a
ttend
ings
dis
agre
ed.
Barr
iers
Enc
ount
ered
Le
sson
s Lea
rned
& O
ppor
tuni
ties f
or
Impr
ovem
ent
Our
cur
rent
syst
em is
una
ble
to tr
ack
or
acce
ss a
nony
mou
s rep
orts
.
The
excl
uded
resid
ents
and
teac
hing
facu
lty th
at re
port
ed
anon
ymou
sly w
ould
hav
e co
ntrib
uted
to o
vera
ll im
prov
emen
t in
even
ts re
port
ed.
Due
to ti
me
cons
trai
nts
and
adm
inist
rativ
e bu
rden
, phy
sicia
ns a
re re
luct
ant t
o re
port
ev
ents
.
Cont
inue
to si
mpl
ify th
e re
port
ing
proc
ess o
r ass
ign
a de
signa
ted
patie
nt sa
fety
adm
inist
rato
r to
call
for r
epor
ting
even
ts.
Our
cur
rent
syst
em la
cks a
dire
ct fe
edba
ck
proc
ess
to th
e re
port
er a
fter
an
even
t is
anal
yzed
.
Impr
ove
dire
ct a
nd ti
mel
y fe
edba
ck to
the
repo
rter
in
dica
ting
the
chan
ge o
r im
prov
emen
t tha
t res
ulte
d fr
om
the
repo
rt.
Acro
ss G
ME,
we
obse
rved
diff
erin
g re
spon
ses
to sa
me
ques
tions
that
may
hav
e re
flect
ed
prog
ram
diff
eren
ces
for r
epor
ting.
Prov
ide
ongo
ing
educ
atio
n to
resid
ents
and
teac
hing
fa
culty
.
Mos
t res
iden
ts a
nd te
achi
ng fa
culty
did
not
ha
ve e
rror
repo
rtin
g in
med
ical
scho
ol.
Prov
ide
ongo
ing
educ
atio
n to
hig
hlig
ht im
port
ance
of e
vent
re
port
ing
to m
aint
ain
sust
aina
bilit
y.
Figu
re 1
. Num
ber o
f eve
nts
repo
rted
from
Jun
e 20
11 to
Dec
embe
r 20
14.
Pre
-inte
rven
tion
aver
age:
1.5
; pos
t-int
erve
ntio
n av
erag
e: 4
.6.
P <
0.05
P <
0.05
012345678
Jun11
Jul11
Aug11
Sep11
Oct11
Nov11
Dec11
Jan12
Feb12
Mar12
Apr12
May12
Jun12
Jul12
Aug12
Sep12
Oct12
Nov12
Dec12
Jan13
Feb13
Mar13
Apr13
May13
Jun13
Jul13
Aug13
Sep13
Oct13
Nov13
Dec13
Jan14
Feb14
Mar14
Apr14
May14
Jun14
Jul14
Aug14
Sept14
Oct14
Nov14
Dec14
Reported Events
Resi
dent
and
Tea
chin
g Fa
culty
Saf
ety
Even
t Rep
ortin
g
In J
uly
2014
, edu
catio
nal l
ectu
re w
as
prov
ided
to re
side
nts
and
teac
hing
fa
culty
on
the
impo
rtanc
e of
adv
erse
ev
ent r
epor
ting
and
train
ing
on th
e ne
w o
nlin
e ev
ent r
epor
ting
syst
em.
124 of 131
Team: University of Utah Focus Area: Quality Improvement
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
ACGME requirements and CLER focus on quality improvement, as well as the hospital’s QI goals and priorities, are driving the need to improve resident QI education and align their improvement projects with the hospital system’s strategic plan for quality. As a result of our CLER visit, it was determined that an unacceptable percentage of our residents understand the hospital’s priorities for QI, are engaged with hospital leadership in advancing the hospital’s quality strategy, have linked their quality projects with hospital goals, are engaged in inter-professional QI teams, understand QI terminology and methods, and have access to organized systems for collecting and analyzing data for quality improvement. Consequently, the purpose of our project is to develop action plans for addressing these opportunities for improvement.
II. Project Description
A GME Value Council (GMEVC) will be established to oversee and coordinate alignment and integration of resident QI projects with the hospital’s goals and priorities; provide expertise and resources for residents in developing and implementing their projects; develop Qi curriculum and educational experiences for residents; and promote resident participation in interprofessional QI teams within the hospital system. GMEVC will be comprised of program directors/associate directors, chief residents, residents/fellows, Quality Department staff, GME office staff, and hospital administration. GMEVC members will work with the health system’s quality and patient safety professionals/experts to: (1) align departmental QI efforts with the system’s priorities, goals and strategic initiatives; (2) develop QI educational experiences for residents; and (3) ensure residents’ active participation in interdisciplinary clinical quality improvement and patient safety programs. The GMEVC will be organized as a subcommittee of the GMEC.
III. Necessary Resources (staff, finances, etc.)
• Scheduling support • Data generation and distribution support • Quality Department support and access to data, tracking
measures, QI initiatives • Program coordinator support • Program Director and resident time.
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
TBD
V. Communication Plan (may be helpful to draft a flow chart of
team members & senior management, both
• Monthly Value Counsel meeting • Monthly GME Value Committee meeting • Monthly GMEC meeting
125 of 131
internal & external)
• Annual Program Director Retreat • Reports to senior management
VI. Accountability
(list of team members and who is accountable for what)
• Graduate Medical Education Committee (GME) (initiative development, implementation and assessment)
• University Hospital Quality Department • Program Directors • GME Office
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
• Program director, resident, and administration commitment • Program director, resident, and administration
time/availability for meetings and task completion • Development and delivery of resident training
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
• Form GME Value Council and fix meeting schedule (January 2015)
• Identify current program and resident Quality and Patient Safety projects and educational resources.
• Review current program/resident QPS projects and educational resources.
• Review current health system operational QPS goals (Feb – Mar 2015)
• Create quality curriculum (May 2015) • Align/integrate program & resident QPS projects with system
operational goals and CLER requirements (FY 2016) • Finalize measurable goals for FY2016
IX. Vision Statement/Closing Plan (markers of success by March 2015)
Identification of GMEVC members and initial meeting.
126 of 131
Ove
rall
Goa
l/Ab
stra
ct
Ove
rall
proj
ect g
oals
are:
1.To
incr
ease
resid
ent a
war
enes
s of t
he h
ospi
tal s
yste
m’s
goal
s and
prio
ritie
s for
qua
lity
impr
ovem
ent (
QI).
2.To
incr
ease
resid
ent e
ngag
emen
t with
hos
pita
l lea
ders
hip
in d
evel
opin
g th
e ho
spita
l’s st
rate
gic
goal
s for
qua
lity
impr
ovem
ent.
3.To
incr
ease
alig
nmen
t bet
wee
n re
siden
t QI p
roje
cts a
nd
hosp
it al g
oals
and
stra
tegi
es.
4.To
incr
ease
resid
ent e
ngag
emen
t in
inte
rpro
fess
iona
l QI
team
s.
Alig
ning
Res
iden
t QI A
ctiv
ities
with
In
stitu
tiona
l Str
ateg
ic G
oals
Al
an J.
Sm
ith, P
hD, M
Ed
Uni
vers
ity o
f Uta
h He
alth
Sci
ence
s Cen
ter
Salt
Lake
City
, Uta
h
Back
grou
nd
ACGM
E re
quire
men
ts a
nd th
e CL
ER fo
cus o
n qu
ality
im
prov
emen
t, as
wel
l as t
he h
ospi
tal’s
QI g
oals
and
prio
ritie
s, a
re d
rivin
g th
e ne
ed to
impr
ove
resid
ent Q
I ed
ucat
ion
and
alig
n th
eir i
mpr
ovem
ent p
roje
cts w
ith th
e ho
spita
l sys
tem
’s st
rate
gic
plan
for q
ualit
y. A
s a re
sult
of o
ur
CLER
visi
t, it
was
det
erm
ined
that
an
unac
cept
able
pe
rcen
tage
of o
ur re
siden
ts u
nder
stan
d th
e ho
spita
l’s
prio
ritie
s for
QI,
are
enga
ged
with
hos
pita
l lea
ders
hip
in
adva
ncin
g th
e ho
spita
l’s q
ualit
y st
rate
gy, h
ave
linke
d th
eir
qual
ity p
roje
cts w
ith h
ospi
tal g
oals,
are
eng
aged
in
inte
rpro
fess
iona
l QI t
eam
s, u
nder
stan
d Q
I ter
min
olog
y an
d m
etho
ds, a
nd h
ave
acce
ss to
org
anize
d sy
stem
s for
co
llect
ing
and
anal
yzin
g da
ta fo
r qua
lity
impr
ovem
ent.
Co
nseq
uent
ly, th
e pu
rpos
e of
our
pro
ject
is to
dev
elop
ac
tion
plan
s for
add
ress
ing
thes
e op
port
uniti
es fo
r im
prov
emen
t.
Visi
on S
tate
men
t
Resid
ent p
roje
cts w
ill b
e lin
ked
to h
ospi
tal s
trat
egic
qu
ality
impr
ovem
ent g
oals;
resid
ents
will
be
invo
lved
in in
terp
rofe
ssio
nal i
mpr
ovem
ent t
eam
s,
and
will
pro
vide
inpu
t to
esta
blish
ing
the
hosp
ital’s
Q
I prio
ritie
s and
focu
sed
actio
n pl
ans.
Mat
eria
ls/M
etho
ds
A GM
E Va
lue
Coun
cil (
GMEV
C) w
as e
stab
lishe
d un
der t
he G
radu
ate
Med
ical
Edu
catio
n Co
mm
ittee
(G
MEC
) to
over
see
and
coor
dina
te a
lignm
ent a
nd
inte
grat
ion
of re
siden
t QI p
roje
cts w
ith th
e ho
spita
l’s
goal
s and
prio
ritie
s; p
rovi
de e
xper
tise
and
reso
urce
s fo
r res
iden
ts in
dev
elop
ing
and
impl
emen
ting
thei
r pr
ojec
ts; d
evel
op Q
i cur
ricul
um a
nd e
duca
tiona
l ex
perie
nces
for r
esid
ents
; and
pro
mot
e re
siden
t pa
rtic
ipat
ion
in in
terp
rofe
ssio
nal Q
I tea
ms w
ithin
th
e ho
spita
l sys
tem
. M
embe
rs o
f the
GM
EVC
incl
ude
the
DIO
, GM
EC C
hair,
CM
O, C
QO
, pro
gram
di
rect
ors,
resid
ents
and
a v
alue
eng
inee
r.
Bibl
iogr
aphy
1.
ACGM
E Co
mm
on P
rogr
am R
equi
rem
ents
, Jul
y 1,
20
13.
2.AC
GME
Inst
itutio
nal R
equi
rem
ents
, Jul
y 1,
201
4.
3.AC
GME
CLER
Pat
hway
s to
Exce
llenc
e, M
arch
18,
20
14.
Barr
iers
Enc
ount
ered
/Lim
itatio
ns
The
GMEV
C w
as in
itally
form
ed u
nder
the
hosp
ital’s
Va
lue
Coun
cil,
then
mov
ed to
the
GMEC
. W
e lo
st
valu
able
tim
e in
dev
elop
ing
the
GMEV
C’s m
issio
n,
visio
n an
d go
als a
nd in
ope
ratio
naliz
ing
the
com
mitt
ee d
urin
g th
is tr
ansit
ion.
Gai
ning
pro
gram
di
rect
or le
ader
ship
of t
he g
roup
was
also
a c
halle
nge.
Resu
lts
Conc
lusi
ons
We
belie
ve th
at in
tegr
atio
n of
resid
ent Q
I act
iviti
es
and
the
hosp
ital’s
stra
tegi
c Q
I goa
ls, w
ith G
MEV
C ov
ersig
ht a
nd su
ppor
t, w
ill e
nhan
ce th
e re
siden
ts’
clin
ical
lear
ning
env
ironm
ent w
hile
eng
agin
g th
em a
s ac
tive
cont
ribut
ors i
n cr
eatin
g an
d im
plem
entin
g th
e in
stitu
tion'
s str
ateg
ic p
lan
for q
ualit
y.
The
proj
ect i
s stil
l in
prog
ress
. Su
cces
s Fac
tors
and
Les
sons
Lea
rned
(D
iscu
ssio
n)
The
proj
ect i
s stil
l in
prog
ress
. .
127 of 131
Team: Virginia Mason Focus Area: Quality Improvement
I. Team Charter/Objectives (‘needs statement,’
project requirements, project assumptions, stakeholders, etc.; Teams should identify
members and define responsibility/purpose)
Virginia Mason wants to ensure that resident/fellows have access to data to reduce health care disparities, to improve patient outcomes and to provide opportunities to participate in quality improvement initiatives. All staff currently receive limited training on diversity (i.e. an on-line learning module, “Understanding Cultural Diversity”). We have systems and processes available which may reduce disparities; however we believe that faculty and residents may have limited understanding of how to engage these resources. In defining disparities, we wish to consider not only racial or ethnic differences but also other causes of disparities (both health system factors and patient factors). “The causes of disparities in health status are not limited to poverty, race and ethnicity but are further linked to social determinants.” Health Care Disparities: A Bimodal Approach to Curriculum, Academic Internal Medicine Insight 2010 8:4. Our team consisted of two internal medicine residents, an anesthesiology resident and three members of the GME Leadership team.
II. Project Description
Our project was designed to increase provider awareness of deficiencies in health literacy and to provide tools that providers can implement in their daily practice to help all patients, including those who have deficiencies in health literacy. Our intent is that application of these skills will improve individual patient care and the system of care. Using the ADDIE model of curriculum development, we identified educational needs and preferred means of addressing the need for a group of primary care givers in our medical center. We created 3 to 5 minute teaching modules using patient testimonials to introduce proven communication tools and methods and presented the modules to our pilot group of primary care physicians. We will work with the Center for Health Services Research to publish our
results.
III. Necessary Resources (staff, finances, etc.)
Staff time: NI IV Team, including GME Leadership (DIO, SVP for GME, GME Operations Director) and three residents were the primary team members. We enlisted other VM teams as needed: Director of Patient Education and Health Literacy; VM’s Med Photo team, Funds for travel to AIAMC National Initiative meetings; Director, Center of Health Services Research. Administrative Support for preparing documents, meeting set-up,
tracking
IV. Measurement/Data Collection Plan (must partner/match
with Milestone Markers)
Preliminary data collection with the REALM-R tool was completed in a general internal medicine outpatient clinic. Participating providers included physicians and nurses in an integrated care management team. Initial survey demonstrated that providers felt 20% of patients were at risk for health literacy challenges. We will resurvey in the same pilot group after our educational intervention to determine what percentage of patients providers feel are at risk for difficulty with a care plan as a result of health literacy issues.
128 of 131
V. Communication Plan (may be helpful to draft a flow chart of team
members & senior management, both internal & external)
Our team includes two members of the Executive Leadership Group, one of whom also serves on the Senior Council. One executive reports to the CEO; the other to the Medical Director of the Hospital. Both brief their supervisors regularly about this initiative. In addition, both the DIO and the Sr VM for GME meet periodically with quality leadership of the organization and NI 4 has been on the agenda for several of the meetings.
VI. Accountability (list of team members and who
is accountable for what)
Co-Team Leaders: Ananth Shenoy and Justin Liberman Ananth and Justin are accountable for continued development of curriculum, implementation and data gathering. Team Members: Gillian Abshire, Lynne Chafetz, Lauren Sullenberger and Brian Owens. The extended team is responsible for guidance and support of team co-leaders.
VII. Potential Challenges (engagement, budget, time,
skills gaps, etc)
We’ve noted numerous challenges to our project including limitations on time and prioritization of tasks. We’ve struggled with timely implementation of project pieces due to conflicting schedules and availability.
VIII. Markers (project phases, progress checks, schedule,
etc.; must partner/match measurement/data collection plan)
After implementation of our educational curriculum we will resurvey our providers for anticipation of health literacy deficiencies in their patient panel. This will be our primary marker for impact of the curriculum and we are looking for an improvement in provider rate of listing or noting a concern for health literacy deficiencies. This will be taking place in March 2015.
IX. Vision Statement/Closing Plan (markers of success by March 2015)
Vision: To improve patient outcomes by increasing awareness and by implementing a curriculum to enhance patient-provider communication. These interventions must be sustainable in our current health care delivery model and assessed for impact on patient health outcomes. Plan: Our plan to continue this project is to further develop the curriculum in response to provider/user feedback and reassess if changes persist. We will know if our project has been a success if our providers anticipate that every patient has a health literacy deficiency and adjust their communication accordingly.
X. Success Factors The most successful component of our work was our collaboration amongst our group and with team members across our medical center. This was helpful for many reasons including exposure to new ideas and approaches and perspectives as well as facilitating our work. We were inspired by the work of our providers and by the work of Victor Montori which highlighted our patient’s and community’s vulnerabilities in communication and understanding.
129 of 131
XI. Barriers The largest barriers we encountered were scope and time. Our team consisted of members of the GME leadership and residents and we had difficulty narrowing down the scope of our project. We started off with a very ambitious goal but this was difficult to meet for many reasons, including its breadth. We have worked to hone the scope to be more manageable and have run into the difficulty of trying to tackle more than we have time for amongst our team.
XII. Lessons Learned The single most important piece of advice to provide another team embarking on a similar initiative would be managing scope and finding how to align this with the organization’s goals is essential to developing and implanting a project.
XIII. Expectations Versus Results
On a scale of 1 to 10 (with “1” meaning nothing and “10” meaning everything), how much of what you set out to do was your team able to accomplish? We are still working on this and at present, have not been able to implement the main element of our plan but we are completing the main element and will soon be able to trial it. 1 2 3 4 5 6 7 8 9 10
XIV. Satisfaction On a scale of 1 to 10 (with “1” meaning not at all satisfied and “10” meaning completely satisfied), how satisfied are you with what you were able to accomplish in your NI III work? Given what is coming and where we plan to take it, we are very excited with where this will go. 1 2 3 4 5 6 7 8 9 10
XV. Project Impact It is too early to note the changes in the organization. There is now more of a dialogue on the role of health literacy but we will need to expand this and with our educational initiative, we will be able to measure the impact.
XVI. Next Steps Our next step will be to implement the main piece of the curriculum – which will be instructional videos and measure the immediate impact on practice. For sustainability, we will be able to integrate the videos and tools for providers into resident didactics but still need to do work to see how we role this out to the other providers in our organization.
130 of 131
Char
ter
Visio
n: T
o im
prov
e pa
tient
out
com
es b
y in
crea
sing
aw
aren
ess a
nd b
y im
plem
entin
g a
curr
icul
um to
enh
ance
pa
tient
-pro
vide
r com
mun
icat
ion.
The
se in
terv
entio
ns
mus
t be
sust
aina
ble
in o
ur c
urre
nt h
ealth
car
e de
liver
y m
odel
and
ass
esse
d fo
r im
pact
on
patie
nt h
ealth
ou
tcom
es.
The
“Sile
nt”
Disp
arity
- He
alth
Lite
racy
: En
hanc
ing
Prov
ider
Aw
aren
ess
Li
berm
an JS
, She
noy
AK, S
ulle
nber
ger L
., Ab
shire
G.,
Ow
ens B
.
Virg
inia
Mas
on M
edic
al C
ente
r – S
eatt
le, W
ashi
ngto
n
Back
grou
nd
Hea
lth li
tera
cy is
an
esse
ntia
l con
cept
in p
atie
nt-c
ente
red
med
ical
car
e. It
repr
esen
ts a
com
bina
tion
of li
tera
cy
skill
s with
the
abili
ty to
und
erst
and,
pro
cess
and
eng
age
in h
ealth
car
e to
furth
er o
ne’s
ow
n he
alth
and
pro
vide
a
sens
e of
pat
ient
aut
onom
y.
D
efic
ienc
y in
this
skill
is a
com
mon
pro
blem
, and
the
Inst
itute
of M
edic
ine
estim
ates
that
hal
f the
adu
lt po
pula
tion
in th
e U
nite
d St
ates
, app
roxi
mat
ely
nine
ty
mill
ion
peop
le, h
ave
diffi
culty
und
erst
andi
ng a
nd a
ctin
g up
on h
ealth
info
rmat
ion.
1,2
The
impa
ct o
f poo
r hea
lth li
tera
cy is
strik
ing.
Low
er
heal
th li
tera
cy le
vels
are
ass
ocia
ted
with
a n
early
two-
fold
incr
ease
in m
orta
lity.
3 Pat
ient
s with
lim
ited
heal
th
liter
acy
ofte
n ha
ve d
iffic
ulty
with
trea
tmen
t adh
eren
ce
and
are
likel
y to
mis
inte
rpre
t ins
truct
ions
such
as
med
icat
ion
labe
ls4 .
This
, in
turn
, lea
ds to
pro
gres
sion
of
dise
ase,
subs
eque
nt h
ospi
taliz
atio
ns, p
oor h
ealth
ou
tcom
es a
nd in
crea
sed
cost
s.
We
choo
se to
inve
stig
ate
the
inci
denc
e of
lim
ited
heal
th
liter
acy
in a
subs
et o
f the
Virg
inia
Mas
on M
edic
al C
ente
r pa
tient
pop
ulat
ion
in o
ne o
f our
prim
ary
care
clin
ics.
Lite
racy
Ass
essm
ent -
Mem
bers
of t
he h
ealth
care
team
(atte
ndin
g ph
ysic
ians
, res
iden
ts a
nd n
urse
pra
ctiti
oner
s) w
ere
asse
ssed
as t
o th
eir a
bilit
y to
acc
urat
ely
iden
tify
patie
nts
with
def
icie
ncie
s in
he
alth
care
lite
racy
. We
sele
cted
the
Rap
id A
sses
smen
t of A
dult
Lite
racy
in M
edic
ine
(REA
LM-R
) as o
ur L
itera
cy a
sses
smen
t too
l (B
ass e
t al,
2003
). D
esig
nate
d m
edic
al te
am m
embe
rs a
dmin
iste
red
REA
LM-R
surv
eys t
o pa
tient
s, w
hich
wer
e sc
ored
and
kep
t an
onym
ous a
nd c
onfid
entia
l. Pr
ovid
ers w
ere
then
ask
ed tw
o qu
estio
ns, 1
) Hav
e yo
u m
et th
is p
atie
nt b
efor
e an
d 2)
doe
s thi
s pa
tient
hav
e a
prob
lem
with
hea
lth li
tera
cy. A
nsw
ers p
rovi
ded
by
heal
th c
are
prov
ider
s wer
e th
en c
ompa
red
to th
e ob
ject
ive
data
pr
ovid
ed b
y th
e R
EALM
-R su
rvey
to a
sses
s pro
vide
r ide
ntifi
catio
n of
hea
lth li
tera
cy d
efic
ienc
y.
Dev
elop
men
t of L
itera
cy C
urric
ulum
– A
mul
ti-di
scip
linar
y te
am
was
ass
embl
ed in
ord
er to
dev
elop
an
educ
atio
nal
inte
rven
tion/
curr
icul
um u
sing
the A
DD
IE m
odel
and
bas
ed fr
om
prev
ious
ly p
ublis
hed
liter
acy
inte
rven
tions
. O
ur g
oal i
s to
incr
ease
aw
aren
ess o
f def
icie
ncie
s in
hea
lth li
tera
cy a
nd to
pro
vide
tool
s tha
t pr
ovid
ers c
an im
plem
ent i
n th
eir d
aily
pra
ctic
e to
hel
p pa
tient
s w
ho
may
hav
e de
ficie
ncie
s in
hea
lth li
tera
cy. A
serie
s of v
ideo
s hi
ghlig
htin
g in
divi
dual
stor
ies f
rom
pat
ient
s w
ho e
xper
ienc
ed a
n in
abili
ty to
und
erst
and
thei
r ow
n he
alth
car
e w
as c
reat
ed. T
hese
vi
deos
will
be
avai
labl
e th
roug
h a
web
site
dev
oted
to a
ddre
ssin
g th
e to
pic
of h
ealth
lite
racy
and
als
o pr
ovid
e fu
rther
tool
s pro
vide
rs c
an
use
for f
urth
er se
lf-di
rect
ed e
duca
tion
in o
rder
to im
prov
e th
e pa
tient
-pro
vide
r com
mun
icat
ion
in th
eir o
wn
prac
tice.
Mat
eria
ls/M
etho
ds
Bibl
iogr
aphy
1.
Nie
lsen
-Boh
lman
L, P
anze
r AM
, Kin
dig
DA
, eds
. Hea
lth li
tera
cy: A
pre
scri
ptio
n to
end
co
nfus
ion.
Was
hing
ton,
DC
: Ins
titut
e of
Med
icin
e, 2
004.
2.
Sudo
re R
L, Y
affe
K, S
atte
rfie
ld S
, et a
l. Li
mite
d lit
erac
y an
d m
orta
lity
in th
e el
derly
: the
he
alth
, 3.
a gin
g, a
nd b
ody
com
posi
tion
stud
y. J
Gen
Inte
rn M
ed 2
006;
21:8
06–8
12. [
PubM
ed:
1688
1938
] 4.
Dav
is T
C, W
olf M
S, B
ass P
F 3r
d, e
t al.
Lite
racy
and
mis
unde
rsta
ndin
g pr
escr
iptio
n dr
ug
labe
ls.
Conc
lusi
ons
Our
pro
vide
r tea
ms
have
diff
icul
ty in
con
sist
ently
iden
tifyi
ng
thos
e pa
tient
s with
hea
lth li
tera
cy d
efic
ienc
ies
and
this
is
cons
iste
nt w
ith n
atio
nal t
rend
s. R
athe
r tha
n fo
cus o
n id
entif
ying
thos
e at
risk
, we
are
exam
inin
g th
e be
nefit
of
assu
min
g ev
ery
patie
nt m
ay b
e at
risk
in th
eir h
ealth
lite
racy
an
d ta
rget
com
mun
icat
ion
to a
llevi
ate
and
addr
ess t
his.
We
are
diss
emin
atin
g to
ols t
hat i
mpr
ove
prov
ider
com
mun
icat
ion
and
our m
easu
re w
ill b
e de
term
inin
g if
prov
ider
per
cept
ion
of th
e sc
ope
of th
e pr
oble
m h
as c
hang
ed. O
ur g
oal i
s tha
t by
shar
ing
the
impo
rtanc
e an
d im
pact
of p
oor h
ealth
lite
racy
and
pro
vidi
ng
tool
s to
help
with
com
mun
icat
ion,
we
will
impr
ove
heal
th c
are
outc
omes
. Re
sults
Pr
elim
inar
y da
ta c
olle
ctio
n w
ith th
e R
EALM
-R to
ol w
as c
ompl
eted
in a
ge
nera
l int
erna
l med
icin
e ou
tpat
ient
clin
ic.
Parti
cipa
ting
prov
ider
s in
clud
ed p
hysi
cian
s and
nur
ses i
n an
inte
grat
ed c
are
man
agem
ent t
eam
. Fo
llow
ing
surv
ey a
dmin
istra
tion
it w
as d
eter
min
ed th
at 2
0% o
f pat
ient
s w
ith h
ealth
lite
racy
def
icits
wer
e id
entif
ied
corr
ectly
by
thei
r pro
vide
rs.
This
will
be
com
pare
d to
the
rate
of i
dent
ifica
tion
post
iden
tific
atio
n.
Less
ons L
earn
ed &
Bar
riers
In
terd
isci
plin
ary
team
wor
k fa
cilit
ates
idea
gen
erat
ion
and
new
pe
rspe
ctiv
es.
Larg
e sc
ale
chan
ge is
diff
icul
t and
alig
ning
with
org
aniz
atio
nal
goal
s fac
ilita
tes
chan
ge im
plem
enta
tion.
Le
arni
ng th
e ch
alle
nges
of t
akin
g id
eas t
o im
plem
enta
tion
in a
la
rge
orga
niza
tion.
Id
entif
ying
a m
anag
eabl
e sc
ope
is k
ey to
bei
ng a
ble
to
impl
emen
t im
prov
emen
ts.
Bar
rier
s Enc
ount
ered
/ L
imita
tions
Ti
me
limita
tions
in g
ivin
g su
rvey
des
pite
lim
ited
time
need
ed
to a
dmin
iste
r. O
ur in
itial
sco
pe w
as n
ot in
line
with
our
cap
abili
ties.
We
have
ha
d to
re-s
cope
our
pro
ject
mul
tiple
tim
es in
ord
er to
find
a
feas
ible
targ
et to
add
ress
. D
ata
colle
ctio
n w
as v
ery
time
cons
umin
g an
d di
fficu
lt to
m
aint
ain
cons
iste
ncy.
131 of 131
