Intr
oduc
tion
& B
ackg
roun
d
Aim
Met
hods
Less
ons L
earn
ed
Refe
renc
es:
1.Hu
ang
GC e
t al.
Beyo
nd th
e Co
mfo
rt Z
one:
Res
iden
ts A
sses
s The
ir Co
mfo
rt P
erfo
rmin
g In
patie
nt M
edic
al P
roce
dure
s. Am
eric
an Jo
urna
l of M
edic
ine
(200
6) 1
19, 7
1.e1
7-71
.e24
.2.
The
Join
t Com
issio
n. S
peak
Up:
The
Uni
vers
al P
roto
col f
or P
reve
ntin
g W
rong
Site
, Wro
ng
Proc
edur
e, a
nd W
rong
Per
son
Surg
ery.
http
s://
ww
w.jo
intc
omiss
ion.
org/
asse
ts/1
/18/
UP_P
oste
r1.p
df
GOAL
:Im
prov
eth
esa
fety
ofpa
tient
sun
derg
oing
beds
ide
proc
edur
esw
hile
mai
ntai
ning
the
full
spec
trum
ofgr
adua
ted
auto
nom
yin
proc
edur
etr
aini
ngfo
rres
iden
ts.
SMAR
TAi
m:
Incr
ease
the
rate
oftim
eout
sdo
cum
ente
dfo
rbed
side
proc
edur
esfr
om29
%to
50%
byJu
ne20
18.
Asu
rvey
was
dist
ribut
edto
hous
est
afft
oas
sess
attit
udes
rega
rdin
gtim
eout
sfo
rbe
dsid
epr
oced
ures
toas
cert
ain
base
line
attit
udes
surr
ound
ing
timeo
uts(
Figu
re1)
.Th
eVi
zient
Data
base
was
quer
ied
for
thor
acen
tesis
,pa
race
ntes
is,an
dlu
mba
rpu
nctu
res,
repr
esen
tativ
ebe
dsid
epr
oced
ures
,pe
rfor
med
betw
een
July
and
Sept
embe
r20
17in
orde
rto
esta
blish
aba
selin
era
teof
perf
orm
ance
ofpr
epro
cedu
ral
timeo
ut.
234
char
tsw
ere
iden
tifie
dan
dre
view
ed.
The
aver
age
timeo
utdo
cum
enta
tion
rate
was
29%
(Fig
ure
2).
Two
inte
rven
tions
wer
etr
iale
d:a
visu
alTi
meo
utch
eckl
istpl
aced
onul
tras
ound
san
dpr
oced
ure
kits
inth
em
edic
alin
tens
ive
care
unit,
and
asim
ulat
edca
seto
educ
ate
resid
ents
onpr
oced
ure
docu
men
tatio
nm
etho
ds.
Our
inte
rven
tions
had
mod
erat
e su
cces
s in:
a)Ra
ising
aw
aren
ess o
f the
nee
d to
per
form
a
high
-qua
lity
inte
rpro
fess
iona
ltim
eout
b)In
crea
sing
self-
repo
rted
rate
of t
imeo
ut
perf
orm
ance
in th
e M
ICU
c)Cr
eatin
ga
high
lyva
lued
,se
lf-pa
ced
lear
ning
oppo
rtun
ityfo
rapp
ropr
iate
docu
men
tatio
n.
Lim
itatio
nsin
clud
eth
esm
all
sam
ple
size,
singl
eun
itim
plem
enta
tion
ofth
ech
eckl
ist,
and
shor
tdu
ratio
nof
follo
w-th
roug
h.Th
efa
ctth
atth
epr
e-an
dpo
st-in
terv
entio
nsa
mpl
esiz
esw
ere
not
iden
tical
sugg
ests
that
the
sam
epa
rtic
ipan
tsdi
dno
tco
mpl
ete
the
surv
ey,w
hich
intr
oduc
esso
me
repo
rtin
gbi
as.
Itis
also
poss
ible
that
resid
ents
who
did
notc
ompl
ete
atim
eout
did
notc
ompl
ete
the
surv
ey.
Resu
lts
Educ
atio
nal
inte
rven
tions
are
ofte
nco
nsid
ered
low
yiel
d.Fo
rpro
cess
esre
liant
ontr
aine
es,w
here
staf
ftur
nove
rha
ppen
sye
arly
,it
isim
port
ant
that
educ
atio
nis
hard
wire
d,an
dth
atEH
Rin
fras
truc
ture
and
inst
itutio
nal
cultu
resu
ppor
tsa
fepa
tient
care
prac
tices
.M
ultip
rong
edap
proa
ches
are
mor
elik
ely
tobe
effe
ctiv
eth
ansin
gle
inte
rven
tions
.
Conc
lusio
ns
Inac
adem
icm
edic
alce
nter
s,in
vasiv
ebe
dsid
epr
oced
ures
are
freq
uent
lype
rfor
med
bytr
aine
es.1
Univ
ersa
lpro
toco
land
timeo
utar
eto
bepe
rfor
med
prio
rto
any
inva
sive
proc
edur
eto
avoi
d'n
ever
even
ts’.2
Afte
rJoi
ntCo
mm
issio
nan
dCl
inic
alLe
arni
ngEn
viro
nmen
tRe
view
(CLE
R),
beds
ide
proc
edur
alsa
fety
was
iden
tifie
das
aar
eafo
rim
prov
emen
tat
our
inst
itutio
n.Th
eHo
uses
taff
Qua
lity
and
Safe
tyLe
ader
ship
Coun
cil
elec
ted
impr
ovin
gtim
eout
rate
sas
our
2017
impr
ovem
entp
roje
ct.
Impr
ovin
g Be
dsid
e Pr
oced
ural
Saf
ety
thro
ugh
Opt
imiz
ing
Tim
eout
Doc
umen
tati
on a
nd a
Pre
-pro
cedu
re C
heck
list
Jenn
ifer
Har
ris
MD
, R.
Ben
son
Jone
s M
D,
Kris
tin
Lohr
MD
, G
rant
Tur
ner
MD
, D
rew
Kot
ler
MD
, Ju
stin
e Bl
um M
D,
Meg
an M
argi
otta
MD
, M
atth
ew B
okha
riM
D,
Eric
a Li
MD
, Ri
tiKa
nesa
-Tha
san
MD
, Br
acke
n Ba
bula
MD
, Re
becc
a Ja
ffe
MD
Thom
as J
eff
ers
on U
niv
ers
ity
Hos
pit
al,
Philad
elp
hia
PA
N =
45, r
epre
sent
ing
dive
rse
spec
ialti
esN
= 45
, rep
rese
ntin
g di
vers
e sp
ecia
lties
Figu
re1:
66%
ofho
use
staf
fre
spon
dent
sth
ough
tth
attim
eout
sar
eim
port
ant
toen
surin
gpr
oced
ural
safe
ty,
how
ever
only
50%
ofre
spon
dent
sth
ough
tth
attim
eout
spr
iort
oth
ein
terv
entio
nw
ere
high
orhi
ghes
tqua
lity.
29%
Figu
re2:
Beds
ide
proc
edur
esw
ere
iden
tifie
dfo
rre
view
with
inth
eVi
zient
data
base
.Wid
eva
riatio
nw
asap
pare
ntin
the
rate
ofdo
cum
entin
ga
timeo
utde
pend
ing
onth
epr
oced
ure,
with
anav
erag
edo
cum
enta
tion
rate
of29
%.
Figu
re 3
: Cop
y of
tim
eout
che
cklis
t.
Figu
re4:
Resu
ltsof
pre
and
post
-inte
rven
tion
surv
ey.
Rate
ofre
port
edtim
eout
sco
nsist
ently
perf
orm
edim
prov
edfr
om31
%to
86%
;rat
eof
repo
rted
nurs
ing
invo
lvem
enti
nbe
dsid
epr
oced
ures
impr
oved
from
27%
to64
%.
Chec
klist
Inte
rven
tion
Durin
ga
one-
mon
thpi
lot,
64%
ofre
siden
ts(N
=14
)in
the
med
ical
ICU
repo
rted
notic
ing
the
timeo
utch
eckl
istsig
ns(F
igur
e3)
,and
50%
ofre
siden
tsre
port
edth
atth
esig
nsin
crea
sed
the
likel
ihoo
dth
atth
eyw
ould
perf
orm
atim
eout
(Fig
ure
4).
surv
eyed
Befo
rean
daf
ter
plac
emen
tof
the
chec
klist
s,re
siden
tsw
ere
surv
eyed
rega
rdin
gth
elik
elih
ood
ofbo
thin
volv
ing
nurs
ing
staf
fan
dpe
rfor
min
ga
timeo
utpr
iort
oan
inva
sive
beds
ide
proc
edur
e.
Proc
edur
eDo
cum
enta
tion
Inte
rven
tion
Nota
ble
hete
roge
neity
was
obse
rved
inpr
oced
ure
docu
men
tatio
nm
etho
dsw
ithin
Epic
,inc
ludi
ngfr
eete
xtno
tes,
dot
phra
ses,
and
use
ofth
ePr
oced
ure
Docu
men
ter.
The
Proc
edur
eDo
cum
ente
ris
the
pref
erre
dm
etho
dof
docu
men
ting,
and,
whe
nsu
rvey
ed,r
esid
ents
who
used
the
docu
men
terr
epor
ted
ahi
ghde
gree
ofsa
tisfa
ctio
n.W
ede
signe
da
case
for
use
ina
simul
ated
EHR
envi
ronm
ent
allo
win
gre
siden
tsto
prac
tice
this
docu
men
tatio
nm
etho
dan
dte
achi
ng"t
ipsa
ndtr
icks
"for
effic
ient
note
writ
ing.
We
cond
ucte
dus
abili
tyte
stin
gw
ith16
resid
ents
acro
ssva
ried
GME
spec
ialti
esto
dete
rmin
eth
eva
lue
ofth
isex
erci
ses.
•Av
erag
eof
5m
inut
esto
com
plet
eon
eca
se
•O
nly
62%
alre
ady
used
proc
essd
emon
stra
ted
todo
cum
entp
roce
dure
s
•75
%re
port
edle
arni
ngne
wto
olst
odo
cum
entp
roce
dure
sand
50%
repo
rted
they
will
chan
geth
ew
ayth
eydo
cum
entp
roce
dure
sin
the
futu
re
•88
%of
resp
onde
ntsf
eltt
heca
sesh
adm
oder
ate
tohi
ghed
ucat
iona
lval
ue
Next
step
s inc
lude
:
•Im
prov
em
odel
ing
oftim
eout
sby
supe
rvisi
ngph
ysic
ians
,in
clud
ing
seni
orre
siden
ts,
fello
ws,
and
facu
lty•
Part
nerin
gw
ithnu
rsin
gle
ader
ship
tode
velo
pro
bust
and
bett
erde
fined
inte
rpro
fess
iona
lpr
oces
ses
•In
corp
orat
ing
perip
roce
dura
led
ucat
ion
inal
lre
quire
dpr
oced
ure
trai
ning
sess
ions
,in
clud
ing
ours
imul
ated
docu
men
tatio
nca
se•
Iden
tifyi
ngac
cura
teso
urce
sof
data
fora
udit
and
feed
back
inte
rven
tions
and
totr
ack
chan
geov
ertim
e
The
prob
abili
tyof
succ
ess
inch
angi
ngin
vasiv
ebe
dsid
epr
oced
ure
safe
tycu
lture
impr
oves
whe
nbo
thnu
rses
and
hous
esta
ffpl
aya
role
inth
epr
e-pr
oced
ure
timeo
ut.
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