Anjala V. Tess

Creating a Quality Improvement Elective for Medical House Officers

The Accreditation Council on Graduate Medical Education (ACGME) requires that house officers demonstrate competencies in “practice-based learning and improvement” and in “the ability to effectively call on system resources to provide care that is of optimum value.” Anticipating this requirement, faculty at a Boston teaching hospital developed a 3-week elective for medical house officers in quality improvement (QI).The objectives of the elective were to enhance residents’ understanding of QI concepts, their familiarity with the hospital’s QI infrastructure, and to gain practical experience with root-cause analysis and QI initiatives. Learners participated in three didactic seminars, joined hospital-based QI activities, conducted a root-cause analysis, and completed a QI project under the guidance of a faculty mentor.The elective enrolled 26 residents in 3 years. Sixty-three percent of resident respondents said that the elective increased their understanding of QI in health care; 88% better understood QI in their own institution.

Medical Evaluation of Patients Undergoing Electroconvulsive Therapy

In evaluating patients before electroconvulsive therapy (ECT), especially those with conditions such as hypertension, coronary artery disease, and congestive heart failure, the medical consultant should undertake risk stratification, assess management of coexisting conditions, and use strategies to reduce the risk of such post-ECT complications as prolonged blood-pressure elevation, myocardial ischemia, and headache.

The Revolving Door of Resident Continuity Practice: Identifying Gaps in Transitions of Care

BackgroundIt is well documented that transitions of care pose a risk to patient safety. Every year, graduating residents transfer their patient panels to incoming interns, yet in our practice we consistently find that approximately 50% of patients do not return for follow-up care within a year of their resident leaving.ObjectiveTo examine the implications of this lapse of care with respect to chronic disease management, follow-up of abnormal test results, and adherence with routine health care maintenance.DesignRetrospective chart reviewSubjectsWe studied a subset of patients cared for by 46 senior internal medicine residents who graduated in the spring of 2008. 300 patients had been identified as high priority requiring follow-up within a year. We examined the records of the 130 of these patients who did not return for care.Main MeasuresWe tabulated unaddressed abnormal test results, missed health care screening opportunities and unmonitored chronic medical conditions. We also attempted to call these patients to identify barriers to follow-up.Key ResultsThese patients had a total of 185 chronic medical conditions. They missed a total of 106 screening opportunities including mammogram (24), Pap smear (60) and colon cancer screening (22). Thirty-two abnormal pathology, imaging and laboratory test results were not followed-up as the graduating senior intended. Among a small sample of patients who were reached by phone, barriers to follow-up included a lack of knowledge about the need to see a physician, distance between home and our office, difficulties with insurance, and transportation.ConclusionsThis study demonstrates the high-risk nature of patient handoffs in the ambulatory setting when residents graduate. We discuss changes that might improve the panel transfer process.

The Quality and Safety Educators Academy Fulfilling an Unmet Need for Faculty Development

Educating physician trainees in the principles of quality improvement (QI) and patient safety (PS) is a national imperative. Few faculty are trained in these disciplines, and few teaching institutions have the resources and infrastructure to develop faculty as instructors of these skills. The authors designed a 3-day, in-person academy to provide medical educators with the knowledge and tools to integrate QI and PS concepts into their training programs. The curriculum provided instruction in quality and safety, curriculum development and assessment, change management, and professional development while fostering peer networking, mentorship, and professional development. This article describes the characteristics, experiences, and needs of a cross-sectional group of faculty interested in acquiring skills to help them succeed as quality and safety educators. It also describes the guiding principles, curriculum blueprint, program evaluation, and lessons learned from this experience which could be applied to future faculty development programs in quality and safety education.

Bridging the Gap: A Framework and Strategies for Integrating the Quality and Safety Mission of Teaching Hospitals and Graduate Medical Education.

Integrating the quality and safety mission of teaching hospitals and graduate medical education (GME) is a necessary step to provide the next generation of physicians with the knowledge, skills, and attitudes they need to participate in health system improvement. Although many teaching hospital and health system leaders have made substantial efforts to improve the quality of patient care, few have fully included residents and fellows, who deliver a large portion of that care, in their efforts. Despite expectations related to the engagement of these trainees in health care quality improvement and patient safety outlined by the Accreditation Council for Graduate Medical Education in the Clinical Learning Environment Review program, a structure for approaching this integration has not been described. In this article, the authors present a framework that they hope will assist teaching hospitals in integrating residents and fellows into their quality and safety efforts and in fostering a positive clinical learning environment for education and patient care. The authors define the six essential elements of this framework—organizational culture, teaching hospital–GME alignment, infrastructure, curricular resources, faculty development, and interprofessional collaboration. They then describe the organizational characteristics required for each element and offer concrete strategies to achieve integration. This framework is meant to be a starting point for the development of robust national models of infrastructure, alignment, and collaboration between GME and health care quality and safety leaders at teaching hospitals.

Teaching Patient Safety: Conference Proceedings and Consensus Statements of the Millennium Conference 2009

Purpose: The 2003 Institute of Medicines report “Health Professions Education: A Bridge to Quality” argued for the education of health professionals in patient safety. In response to this call, a number of organizations and institutions have developed frameworks and curricula that provide the educational foundation essential for learning about patient safety. However, there is limited guidance on strategies for implementation of training programs in patient safety. Summary: We convened the “Millennium Conference 2009: Patient Safety—Implications for Teaching in the 21st Century” to develop concrete approaches to teach patient safety in undergraduate and graduate medical education. We selected 9 medical schools through a competitive application process to participate as school teams. We led attendees through structured discussions on three topics: (a) promoting a culture of patient safety, (b) implementing patient safety content into preexisting curricula, and (c) providing faculty development. School teams also met to refine their current local initiatives in patient safety teaching. Conclusions: A group of committed stakeholders gathered to collectively consider strategies for the integration of patient safety education into undergraduate and graduate medical education. The recommendations from this conference proceed from consensus reached by the participants.

Developing a Quality and Safety Curriculum for Fellows: Lessons Learned From a Neonatology Fellowship Program

Formal training in health care quality and safety has become an important component of medical education at all levels, and quality and safety are core concepts within the practice-based learning and system-based practice medical education competencies. Residency and fellowship programs are rapidly attempting to incorporate quality and safety curriculum into their training programs but have encountered numerous challenges and barriers. Many program directors have questioned the feasibility and utility of quality and safety education during this stage of training. In 2010, we adopted a quality and safety educational module in our neonatal fellowship program that sought to provide a robust and practical introduction to quality improvement and patient safety through a combination of didactic and experiential activities. Our module has been successfully integrated into the fellowship programs curriculum and has been beneficial to trainees, faculty, and our clinical services, and our experience suggests that fellowship may be particularly well suited to incorporation of quality and safety training. We describe our module and share tools and lessons learned during our experience; we believe these resources will be useful to other fellowship programs seeking to improve the quality and safety education of their trainees.

Using a patient internet portal to prevent adverse drug events: a randomized, controlled trial.

Objectives Adverse drug events (ADEs) are common in ambulatory care and may result from poor patient-physician communication about medication-related symptoms. A module was developed within an electronic patient portal that was designed to enhance communication about medication symptoms and, in turn, reduce ADEs and health-care utilization. Methods The researchers conducted a randomized, controlled clinical trial of MedCheck, an automated electronic message generated in a patient Internet portal. MedCheck asked intervention patients if they had filled a recent prescription and if they had experienced any problems with the medication. Patients’ responses were forwarded automatically to primary care physicians. The study enrolled 375 intervention patients and 363 controls. After 3 months, the investigators reviewed patients’ medical records and conducted telephone interviews to identify ADEs and to assess health-care utilization. Results Among the 375 intervention patients, 184 (49%) responded to at least 1 MedCheck message. Patients reported 52 unfilled prescriptions and 56 medication problems. Patients responded to 72% of messages within 1 day. There was no statistically significant difference between intervention and control groups in the rate of ADEs, preventable or ameliorable ADEs, serious ADEs, or in subjects’ health-care utilization. Conclusions Internet portals have the potential to enhance patient-physician communication. However, additional development is required to demonstrate that such interventions can improve medication safety or health-care utilization. ClinicalTrials.gov NCT00140504

Long-term culture change related to rapid response system implementation

Increasing attention to patient safety in training hospitals may come at the expense of trainee autonomy and professional growth. This study sought to examine changes in medical trainees’ self‐reported behaviour after the institution‐wide implementation of a rapid response system.

Transfer of Graduating Residents’ Continuity Practices.

Authors Reply: We agree with Drs. Pincavage, Ratner, and Arora that resident patients are indeed often at higher risk for missing appointments. We did not in our study look at the issue of prior behavior with respect to missed appointments, but in a sample of ten patients in our study population, six of the ten had missed several appointments in the years preceding their resident PCP’s graduation. In our practice in general, resident patients are more likely to miss scheduled appointments than faculty patients; indeed, resident patients missed 17% of appointments as compared to 7% missed appointments for faculty patients in the past year. We suspect that residents were particularly concerned about patients who missed appointments and may have explicitly listed these patients as high risk for that reason. We agree that handoffs in these patients are likely to be more risky than in patients who generally keep appointments and that special outreach efforts should be made to these patients. This is particularly problematic since the graduated residents most familiar with these at-risk patients and their medical problems are no longer available to detect missed opportunities for care such as overdue radiology studies or blood tests. We analyzed visits to our own emergency room for this sample of ten patients and found that only a single patient had an ER visit within the year after their resident’s graduation. We are unable to capture ER visits and admissions to other hospitals and agree that ER utilization would indeed be a useful variable to examine in future studies of this phenomenon. We agree that a year is a longer than desired interval for follow-up of many patients and that many of these patients should have had multiple visits during this study year. We set the year as an intentionally long period. We agree that a future study of diabetics in which there are clear guidelines for intervals of visits might indeed look at shorter intervals between visits. Finally, we were similarly intrigued with the study by Young and colleagues in which case loads were rebalanced, though note that the number of trainees in that program was much smaller. Young described 16 graduating residents having a mean of only 18–22 patients in each psychiatry resident’s case load compared to our population of 46 residents. These investigators did not report on patient retention, so it is not clear that rebalancing loads will indeed improve patient follow-up. We have attempted rebalancing of case loads to a small degree for certain target diagnoses for educational reasons, but many of our patients who do follow up return to see a different resident PCP than our assignment due to a variety of factors. We are skeptical as to whether rebalancing will improve retention unless it is coupled with early intensive outreach from a new provider.