Brian M. Wong

Quality improvement in medical education: current state and future directions

Medical Education 2012: 46: 107–119

Effect of a Postdischarge Virtual Ward on Readmission or Death for High-Risk Patients: A Randomized Clinical Trial

IMPORTANCE Hospital readmissions are common and costly, and no single intervention or bundle of interventions has reliably reduced readmissions. Virtual wards, which use elements of hospital care in the community, have the potential to reduce readmissions, but have not yet been rigorously evaluated. OBJECTIVE To determine whether a virtual ward-a model of care that uses some of the systems of a hospital ward to provide interprofessional care for community-dwelling patients-can reduce the risk of readmission in patients at high risk of readmission or death when being discharged from hospital. DESIGN, SETTING, AND PATIENTS High-risk adult hospital discharge patients in Toronto were randomly assigned to either the virtual ward or usual care. A total of 1923 patients were randomized during the course of the study: 960 to the usual care group and 963 to the virtual ward group. The first patient was enrolled on June 29, 2010, and follow-up was completed on June 2, 2014. INTERVENTIONS Patients assigned to the virtual ward received care coordination plus direct care provision (via a combination of telephone, home visits, or clinic visits) from an interprofessional team for several weeks after hospital discharge. The interprofessional team met daily at a central site to design and implement individualized management plans. Patients assigned to usual care typically received a typed, structured discharge summary, prescription for new medications if indicated, counseling from the resident physician, arrangements for home care as needed, and recommendations, appointments, or both for follow-up care with physicians as indicated. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of hospital readmission or death within 30 days of discharge. Secondary outcomes included nursing home admission and emergency department visits, each of the components of the primary outcome at 30 days, as well as each of the outcomes (including the composite primary outcome) at 90 days, 6 months, and 1 year. RESULTS There were no statistically significant between-group differences in the primary or secondary outcomes at 30 or 90 days, 6 months, or 1 year. The primary outcome occurred in 203 of 959 (21.2%) of the virtual ward patients and 235 of 956 (24.6%) of the usual care patients (absolute difference, 3.4%; 95% CI, -0.3% to 7.2%; P = .09). There were no statistically significant interactions to indicate that the virtual ward model of care was more or less effective in any of the prespecified subgroups. CONCLUSIONS AND RELEVANCE In a diverse group of high-risk patients being discharged from the hospital, we found no statistically significant effect of a virtual ward model of care on readmissions or death at either 30 days or 90 days, 6 months, or 1 year after hospital discharge. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01108172.

The intended and unintended consequences of communication systems on general internal medicine inpatient care delivery: a prospective observational case study of five teaching hospitals.

BACKGROUND Effective clinical communication is critical to providing high-quality patient care. Hospitals have used different types of interventions to improve communication between care teams, but there have been few studies of their effectiveness. OBJECTIVES To describe the effects of different communication interventions and their problems. DESIGN Prospective observational case study using a mixed methods approach of quantitative and qualitative methods. SETTING General internal medicine (GIM) inpatient wards at five tertiary care academic teaching hospitals. PARTICIPANTS Clinicians consisting of residents, attending physicians, nurses, and allied health (AH) staff working on the GIM wards. METHODS Ethnographic methods and interviews with clinical staff (doctors, nurses, medical students, and AH professionals) were conducted over a 16-month period from 2009 to 2010. RESULTS We identified four categories that described the intended and unintended consequences of communication interventions: impacts on senders, receivers, interprofessional collaboration, and the use of informal communication processes. The use of alphanumeric pagers, smartphones, and web-based communication systems had positive effects for senders and receivers, but unintended consequences were seen with all interventions in all four categories. CONCLUSIONS Interventions that aimed to improve clinical communications solved some but not all problems, and unintended effects were seen with all systems.

It's not about pager replacement: an in-depth look at the interprofessional nature of communication in healthcare.

BACKGROUND Institutions have tried to replace the use of numeric pagers for clinical communication by implementing health information technology (HIT) solutions. However, failing to account for the sociotechnical aspects of HIT or the interplay of technology with existing clinical workflow, culture, and social interactions may create other unintended consequences. OBJECTIVE To evaluate a Web-based messaging system that allows asynchronous communication between health providers and identify the unintended consequences associated with implementing such technology. DESIGN Intervention-a Web-based messaging system at the University Health Network to replace numeric paging practices in May 2010. The system facilitated clinical communication on the medical wards for coordinating patient care. Study design-pre-post mixed methods utilizing both quantitative and qualitative measures. PARTICIPANTS Five residents, 8 nurses, 2 pharmacists, and 2 social workers were interviewed. Pre-post interruption-15 residents from 5 clinical teams in both periods. MEASUREMENTS The study compared the type of messages sent to physicians before and after implementation of the Web-based messaging system; a constant comparative analysis of semistructured interviews was used to generate key themes related to unintended consequences. RESULTS Interruptions increased 233%, from 3 pages received per resident per day pre-implementation to 10 messages received per resident per day post-implementation. Key themes relating to unintended consequences that emerged from the interviews included increase in interruptions, accountability, and tactics to improve personal productivity. CONCLUSIONS Meaningful improvements in clinical communication can occur but require more than just replacing pagers. Introducing HIT without addressing the sociotechnical aspects of HIT that underlie clinical communication can lead to unintended consequences.

Teaching Medical Error Disclosure to Physicians-in-training: A Scoping Review

Purpose This scoping review identified published studies of error disclosure curricula targeting physicians-in-training (residents or medical students). Method In 2011, the authors searched electronic databases (e.g., MEDLINE, EMBASE, ERIC) for eligible studies published between 1960 and July 2011. From the studies that met their inclusion criteria, they extracted and summarized key aspects of each curriculum (e.g., level of learner, program discipline) and educational features (e.g., curriculum design, teaching and assessment methods, and learner outcomes). Results The authors identified 21 studies that met their inclusion criteria. These studies described 19 error disclosure curricula, which were either a stand-alone educational activity, part of a larger curriculum in patient safety or communication skills, or part of simulation training. Most curricula consisted of a brief, single encounter, combining didactic lectures or small-group discussions with role-play. Fourteen studies described learners’ self-reported improvements in knowledge, skills, and attitudes. Five studies used a structured assessment and reported that learners’ error disclosure skills improved after completing the curriculum; however, these studies were limited by their small to medium sample size and lack of assessment of skills retention. Attempts to assess the change in learners’ error disclosure behavior in the clinical context were limited. Conclusions Studies of existing error disclosure curricula demonstrate improvements in learners’ knowledge, skills, and attitudes. A greater emphasis is needed on the more rigorous assessment of skills acquisition and behavior change to determine whether formal training leads to long-term effects on learner outcomes that translate into real-world clinical practice.

Implementation and Evaluation of an Alphanumeric Paging System on a Resident Inpatient Teaching Service

BACKGROUND Numeric pagers are commonly used communication devices in healthcare, but cannot convey important information such as the reason for or urgency of the page. Alphanumeric pagers can display both numbers and text, and may address some of these communication problems. OBJECTIVE Our primary aim was to implement an alphanumeric paging system. DESIGN Continuous quality improvement study using rapid-cycle change methods. SETTING General Internal Medicine (GIM) inpatient wards at 1 tertiary care academic teaching hospital. PARTICIPANTS All residents, attending physicians, nurses, and allied health staff working on the general medicine (GM) wards. MEASUREMENTS We measured: (1) the proportion of pages sent as text pages, (2) the source of the pages, (3) the content of the text pages, (4) the pages that disrupted scheduled education activities, and (5) satisfaction with the alphanumeric paging system. RESULTS After implementation, 52% of pages sent from physicians or the GM wards were sent as text pages (P < 0.001). 93% of pages between physicians were text pages, compared to 27% of pages from the GM wards to physicians (P < 0.001). The most common reason for text paging among physicians was to arrange work or teaching rounds (33%). The most common reason for text paging from the GM wards was to request a patient assessment or for notification of a patients clinical status (25%). There was a 29% reduction in disruptive pages sent during scheduled educational rounds (P < 0.001). CONCLUSIONS We successfully implemented an alphanumeric paging system that reduced disruptive pages on a GM inpatient service.

Frequency and clinical importance of pages sent to the wrong physician.

E ffective communication between health care providers is essential to patient safety and quality of care. A retrospective study of 14 000 admissions found that communication failures were the most common cause of preventable disability or death and were nearly twice as common as those due to inadequate medical skill. A major type of communication failure is sending a page to the wrong physician. Prior studies have described paging problems such as paging the wrong physician, unanswered pages, and delayed responses but do not quantify the extent of the problem. Our primary aim was to quantify the frequency of pages sent to the wrong physician in 2 academic teaching hospitals and to examine the potential clinical importance of these errors.

Improving hospital care and collaborative communications for the 21st century: key recommendations for general internal medicine.

Background Communication and collaboration failures can have negative impacts on the efficiency of both individual clinicians and health care system delivery as well as on the quality of patient care. Recognizing the problems associated with clinical and collaboration communication, health care professionals and organizations alike have begun to look at alternative communication technologies to address some of these inefficiencies and to improve interprofessional collaboration. Objective To develop recommendations that assist health care organizations in improving communication and collaboration in order to develop effective methods for evaluation. Methods An interprofessional meeting was held in a large urban city in Canada with 19 nationally and internationally renowned experts to discuss suitable recommendations for an ideal communication and collaboration system as well as a research framework for general internal medicine (GIM) environments. Results In designing an ideal GIM communication and collaboration system, attendees believed that the new system should possess attributes that aim to: a) improve workflow through prioritization of information and detection of individuals’ contextual situations; b) promote stronger interprofessional relationships with adequate exchange of information; c) enhance patient-centered care by allowing greater patient autonomy over their health care information; d) enable interoperability and scalability between and within institutions; and e) function across different platforms. In terms of evaluating the effects of technology in GIM settings, participants championed the use of rigorous scientific methods that span multiple perspectives and disciplines. Specifically, participants recommended that consistent measures and definitions need to be established so that these impacts can be examined across individual, group, and organizational levels. Conclusions Discussions from our meeting demonstrated the complexities of technological implementations in GIM settings. Recommendations on the design principles and research paradigms for an improved communication system are described.

Application of a trigger tool in near real time to inform quality improvement activities: a prospective study in a general medicine ward

Background Retrospective record review using trigger tools remains the most widely used method for measuring adverse events (AEs) to identify targets for improvement and measure temporal trends. However, medical records often contain limited information about factors contributing to AEs. We implemented an augmented trigger tool that supplemented record review with debriefing front-line staff to obtain details not included in the medical record. We hypothesised that this would foster the identification of factors contributing to AEs that could inform improvement initiatives. Method A trained observer prospectively identified events in consecutive patients admitted to a general medical ward in a tertiary care academic medical centre (November 2010 to February 2011 inclusive), gathering information from record review and debriefing front-line staff in near real time. An interprofessional team reviewed events to identify preventable and potential AEs and characterised contributing factors using a previously published taxonomy. Results Among 141 patients, 14 (10%; 95% CI 5% to 15%) experienced at least one preventable AE; 32 patients (23%; 95% CI 16% to 30%) experienced at least one potential AE. The most common contributing factors included policy and procedural problems (eg, routine protocol violations, conflicting policies; 37%), communication and teamwork problems (34%), and medication process problems (23%). However, these broad categories each included distinct subcategories that seemed to require different interventions. For instance, the 32 identified communication and teamwork problems comprised 7 distinct subcategories (eg, ineffective intraprofessional handovers, poor interprofessional communication, lacking a shared patient care, paging problems). Thus, even the major categories of contributing factors consisted of subcategories that individually related to a much smaller subset of AEs. Conclusions Prospective application of an augmented trigger tool identified a wide range of factors contributing to AEs. However, the majority of contributing factors accounted for a small number of AEs, and more general categories were too heterogeneous to inform specific interventions. Successfully using trigger tools to stimulate quality improvement activities may require development of a framework that better classifies events that share contributing factors amenable to the same intervention.

Morning Handover of On-Call Issues: Opportunities for Improvement

IMPORTANCE Handover is the process of transferring pertinent patient information and clinical responsibility between health care practitioners. Few studies have examined morning handover from the overnight trainee to the daytime team. OBJECTIVE To characterize current morning handover practices in 2 academic medical centers by assessing the frequency of omissions of clinically important overnight issues during morning handover and identifying factors that influence the occurrence of such omissions. DESIGN, SETTING, AND PARTICIPANTS A prospective, point-prevalence study was conducted in the general internal medicine wards of 2 tertiary care academic medical centers in Toronto, Ontario, Canada, in 2012 and 2013. Participants included on-call third-year medical students and first- and second-year residents. MAIN OUTCOMES AND MEASURES Completeness of morning handover of clinically important overnight issues identified using a targeted medical records review and processes of morning handover characterized by direct observation. RESULTS We identified 141 clinically important overnight issues during 26 days of observation. The on-call trainee omitted 40.4% (95% CI, 32.3%-48.5%) of clinically important issues during morning handover and did not document any information in the patients medical record for 85.8% (95% CI 80.1%-91.6%) of these issues. By univariate analysis, running the list patient-by-patient (ie, the entire team discusses each patient) (OR, 4.32; 95% CI, 1.94-9.60; P < .001) and using a dedicated handover location (OR, 2.61; 95% CI, 1.30-5.22; P = .007) positively correlated with handover of an issue taking place, whereas distractions in the meeting area inversely correlated with the likelihood of handover of an issue taking place (OR, 0.96 for every increase in 1 distraction; 95% CI, 0.93-0.98; P = .002). Using a multivariate mixed-effects model, only running the list remained as an independent predictor of the handover of an issue (OR, 3.80; 95% CI, 1.25-11.49; P = .02). CONCLUSIONS AND RELEVANCE On-call trainees omit numerous clinically important issues when handing over to the daytime team. Training programs should introduce educational activities and workflow changes, and provide dedicated time and a distraction-free environment, to improve handover of on-call issues.