Darlene Tad-y

Leveraging a Redesigned Morbidity and Mortality Conference That Incorporates the Clinical and Educational Missions of Improving Quality and Patient Safety.

PROBLEM The morbidity and mortality (M&M) conference is a vital event that can affect medical education, quality improvement, and peer review in academic departments. Historically, M&M conferences have emphasized cases that highlight diagnostic uncertainty or complex management conundrums. In this report, the authors describe the development, pilot, and refinement of a systems-based M&M conference model that combines the educational and clinical missions of improving quality and patient safety in the University of Colorado Department of Medicine. APPROACH In 2011, a focused taskforce completed a literature review that informed the development of a framework for the redesigned systems-based M&M conference. The new model included a restructured monthly conference, longitudinal curriculum for residents, and formal channels for interaction with clinical effectiveness departments. Each conference features an in-depth discussion of an adverse event using specific quality improvement tools. Areas for improvement and suggested action items are identified during the conference and delegated to the relevant clinical departments. OUTCOMES The new process has enabled the review of 27 adverse events over two years. Sixty-three action items were identified, and 33 were pursued. An average of 50 to 60 individuals participate in each conference, including interprofessional and interdisciplinary colleagues. Resident and faculty feedback regarding the new format has been positive, and other departments are starting to adopt this model. NEXT STEPS A more robust process for identifying and selecting cases to discuss is needed, as is a stable, sufficient mechanism to manage the improvement initiatives that come out of each conference.

How Residents Develop Trust in Interns: A Multi-Institutional Mixed-Methods Study.

Purpose Although residents trust interns to provide patient care, little is known about how trust forms. Method Using a multi-institutional mixed-methods study design, the authors interviewed (March–September 2014) internal medicine (IM) residents in their second or third postgraduate year at a single institution to address how they develop trust in interns. Transcript analysis using grounded theory yielded a model for resident trust. Authors tested (January–March 2015) the model with residents from five IM programs using a two-section quantitative survey (38 items; 31 rated 0 = not at all to 100 = very much; 7 rated 0 = strongly disagree to 100 = strongly agree) to identify influences on how residents form trust. Results Qualitative analysis of 29 interviews yielded 14 themes within five previously identified factors of trust (resident, intern, relationship, task, and context). Of 478 residents, 376 (78.7%) completed the survey. Factor analysis yielded 11 factors that influence trust. Respondents rated interns’ characteristics (reliability, competence, and propensity to make errors) highest when indicating importance to trust (respective means 86.3 [standard deviation = 9.7], 76.4 [12.9], and 75.8 [20.0]). They also rated contextual factors highly as influencing trust (access to an electronic medical record, duty hours, and patient characteristics; respective means 79.8 [15.3], 73.1 [14.4], and 71.9 [20.0]). Conclusions Residents form trust based on primarily intern- and context-specific factors. Residents appear to consider trust in a way that prioritizes interns’ execution of essential patient care tasks safely within the complexities and constraints of the hospital environment.

The evolution of morbidity and mortality conferences

Morbidity and mortality conferences (MMCs) have become a vital element of patient care, sitting at the intersection of medical education, quality improvement and risk management. MMCs may have increased in importance as a staple of safety education since the Accreditation Council for Graduate Medical Education has identified that the discussion and analysis of adverse events in a structured fashion promotes the learning of key quality and safety concepts.1–3 Groups across specialties and disciplines have implemented innovative models of MMCs as a vehicle to engage clinicians in discussions to learn from adverse events and to identify opportunities to improve care. In studying these new models, it has become clear that deliberate attention to the structure, processes and content of the conference yields the greatest opportunity for improving the quality of patient care beyond just learning the concepts of quality and safety.4 ,5 We now face the next iteration of the MMC and are tasked with describing the facets that will best allow MMCs to drive learning and improved outcomes. In this issue, Kwok and colleagues highlight the impact of implementing a structured MMC, the Ottawa M&M Model (‘OM3 model’), at their acute care tertiary centre across multiple specialties.6 The model consists of five key elements, including appropriate case selection, structured case analysis, the creation of and dissemination of bottom-line summaries, the development of effective pathways for action items and interprofessional and multidisciplinary participation. The authors conducted a yearlong study of 16 clinical groups implementing the OM3 model. The investigators provided an OM3 toolkit that included relevant educational materials, dedicated coaching to the teams, encouraged the groups to establish a quality committee for subsequent action …

The Health Innovations Scholars Program A Model for Accelerating Preclinical Medical Students’ Mastery of Skills for Leading Improvement of Clinical Systems

Dramatic changes in health care require physician leadership. Efforts to instill necessary skills often occur late in training. The Heath Innovations Scholars Program (HISP) provided preclinical medical students with experiential learning focused on process improvement. Students led initiatives to improve the discharge process for stroke patients. All students completed an aptitude survey and Quality Improvement Knowledge Assessment Test (QIKAT) before and after the program. Significant improvements occurred across subject areas of leadership (18.4%, P < .001), quality and safety (14.7%, P < .001), and health care systems operations (21.2%, P < .008), and in the domains of knowledge (25.9%, P < .001) and skills (25.2%, P < .001). Average cumulative QIKAT results improved significantly (8.33 to 9.83, P = .04). Three of 4 recommended interventions were implemented. Furthermore, students engaged in other process improvement work on return to their home institutions. The HISP successfully advanced preclinical medical students’ ability to lead clinical systems improvement.

Leadership Observation and Feedback Tool: A Novel Instrument for Assessment of Clinical Leadership Skills

Background While leadership training is increasingly incorporated into residency education, existing assessment tools to provide feedback on leadership skills are only applicable in limited contexts. Objective We developed an instrument, the Leadership Observation and Feedback Tool (LOFT), for assessing clinical leadership. Methods We used an iterative process to develop the tool, beginning with adapting the Leadership Practices Inventory to create an open-ended survey for identification of clinical leadership behaviors. We presented these to leadership experts who defined essential behaviors through a modified Delphi approach. In May 2014 we tested the resulting 29-item tool among residents in the internal medicine and pediatrics departments at 2 academic medical centers. We analyzed instrument performance using Cronbachs alpha, interrater reliability using intraclass correlation coefficients (ICCs), and item performance using linear-by-linear test comparisons of responses by postgraduate year, site, and specialty. Results A total of 377 (of 526, 72%) team members completed the LOFT for 95 (of 519, 18%) residents. Overall ratings were high-only 14% scored at the novice level. Cronbachs alpha was 0.79, and the ICC ranged from 0.20 to 0.79. Linear-by-linear test comparisons revealed significant differences between postgraduate year groups for some items, but no significant differences by site or specialty. Acceptability and usefulness ratings by respondents were high. Conclusions Despite a rigorous approach to instrument design, we were unable to collect convincing validity evidence for our instrument. The tool may still have some usefulness for providing formative feedback to residents on their clinical leadership skills.

Engaging Others in Patient Safety and Quality Improvement

Quality Improvement and Patient Safety curricula that are designed for trainees can improve the learners’ knowledge, provide an invaluable skillset and hence lead to safer clinical care. It requires a robust approach with curricula, faculty, and mindfulness of the requirements of the training program. The Accreditation Council of Graduate Medical Education (ACGME) has developed new requirements to incorporate such learnings in graduate medical education.

Teaching and Feedback

Hospitalists have an ever increasing role teaching students and residents in the inpatient setting. Clinical evaluation and management, physical exam, decision-making, high value care, communication, efficiency, and a systems approach to improvement are essential skills for which hospitalists have unique expertise to convey. For academic hospitalists, success as a teacher and educator is vital for promotion. Training the next generation of physicians is rewarding, but can pose new challenges to a hospitalist’s daily workflow. This chapter provides strategies for incorporating teaching seamlessly into the inpatient setting and a practical framework for feedback to help learners to improve.

Hospital Medicine Resident Training Tracks: Developing the Hospital Medicine Pipeline

BACKGROUND: Hospital medicine (HM) is rapidly evolving into new clinical and nonclinical roles. Traditional internal medicine (IM) residency training likely does not optimally prepare residents for success in HM. Hospital medicine residency training tracks may offer a preferred method for specialized HM education. METHODS: Internet searches and professional networks were used to identify HM training tracks. Information was gathered from program websites and discussions with track directors. RESULTS: The 11 HM tracks at academic medical centers across the United States focus mostly on senior residents. Track structure and curricular content are determined largely by the structure and curricula of the IM residency programs in which they exist. Almost all tracks feature experiential quality improvement projects. Content on healthcare economics and value is common, and numerous track leaders report this content is expanding from HM tracks into entire residency programs. Tracks also provide opportunities for scholarship and professional development, such as workshops on abstract creation and job procurement skills. Almost all tracks include HM preceptorships as well as rotations within various disciplines of HM. CONCLUSIONS: HM residency training tracks focus largely on quality improvement, health care economics, and professional development. The structures and curricula of these tracks are tightly linked to opportunities within IM residency programs. As HM continues to evolve, these tracks likely will expand to bridge clinical and extra‐clinical gaps between traditional IM training and contemporary HM practice.