Eliot J. Lazar

Internal medicine housestaff and attending physician perceptions of the impact of the New York State Section 405 regulations on working conditions and supervision of residents in two training programs.

Objectives: To assess the attitudes of internal medicine housestaff and their attending physicians regarding the impact of the reduction in on-call working hours and increased supervision mandated in New York by a revision of the State Health Code (Section 405).Design: Survey of senior medical housestaff and attendings two years after the adoption of the mandated changes.Setting: Two independent medicine housestaff training programs of the Albert Einstein College of Medicine in the Bronx, New York.Participants: Fifty-three percent of third- and fourth-year residents (n=79) and 60% of voluntary and full-time attendings (n=266) responded.Measurements: A factor analysis of 13 variables that appeared on both versions of the survey identified two interpretable factors. A multivariate analysis of variance compared responses to each factor by group and by campus, and Bonferroni post-hoc comparisons analyzed the items within factors. Chi-square analyses compared responses of residents and attendings to the open-ended questions.Results: Significant differences between the housestaff and attendings groups were found for all fixed-response items (minimum p<0.05 for all analyses), but both groups agreed that the regulations had a positive impact on resident attitudes regarding the demands on their time. Both groups were also uncertain whether the new regulations had a beneficial effect on the choice of internal medicine as a career, the quality of resident supervision, and residents’ intellectual interest in challenging medical problems. Whereas residents agreed that the regulations diminished their fatigue, had no impact on their ability to observe the full impact of interventions on patients, and resulted in better patient care, attendings were uncertain or disagreed. While attendings agreed that the regulations had caused a shift-work mentality among residents, housestaff were uncertain.Conclusions: Housestaff had more positive attitudes about the impact of the mandated changes in working conditions for residents than did attending physicians in the same institutions. The major benefits seen by residents were less fatigue and more spare time. There was no consensus about whether these changes had a positive impact on internal medicine practice and clinical supervision. There was some concern that a shift-work mentality is developing among residents and that continuity of patient care has suffered. Thus, despite some substantial benefits, Section 405 may not be achieving its goals of improving resident supervision and the quality of patient care by houseofficers.

Analysis of Hospitalizations for COPD Exacerbation: Opportunities for Improving Care

ABSTRACT Background: Little is known about the actual treatment of patients with chronic obstructive pulmonary disease (COPD), either in the inpatient or outpatient settings. We hypothesized that there are substantial opportunities for improvement in adherence with current guidelines and recommendations. Methods: We reviewed the medical records of all patients hospitalized with acute exacerbation of COPD between January 2005 and December 2006 at 5 New York City hospitals. Results: There were 1285 unique patients with 1653 hospitalizations. Of these 1653, 83% were for patients with a prior history of COPD and 368 (22%) represented repeat admissions during our study period. The majority were treated during their hospitalization with a combination of systemic steroids (85%), bronchodilators (94%) and antibiotics (80%). There were 59 deaths (3.6%). Smoking cessation counseling was offered to 48% of active smokers. Influenza and pneumococcal vaccines were administered to half of eligible patients. On discharge, only 46.0% were prescribed maintenance bronchodilators and 24% were not prescribed any inhaled therapy. Even in the 226 unique patients (17.6%) readmitted at least once during course of the study, on discharge only 44.7% were prescribed maintenance bronchodilators and 23% were not prescribed any regular inhaled therapy. Conclusions: Patients hospitalized with acute exacerbation of COPD generally receive adequate hospital care, but there may be opportunities to improve care pharmacologically and with smoking cessation counseling and vaccination during and after hospitalization.

Quality Measurement in Healthcare

Measurement is the basis for assessing potential improvements in healthcare quality. Measures may be classified into four categories: volume, structure, outcome, and process (VSOP). Measures of each type should be used with a full understanding of their cost and benefit. Although volume and structure measures are easily collected, impact on healthcare results is not always clear. Process measures are generally more difficult and expensive to collect, and the relationship between process and outcomes is only recently being explored. Knowledge of measure types and relationships among them, as well as emerging evidence on the role of patient satisfaction, must be used to guide improvements and ultimately for demonstrating value in healthcare.

Intercepting Wrong-Patient Orders in a Computerized Provider Order Entry System

STUDY OBJECTIVE We evaluate the short- and long-term effect of a computerized provider order entry-based patient verification intervention to reduce wrong-patient orders in 5 emergency departments. METHODS A patient verification dialog appeared at the beginning of each ordering session, requiring providers to confirm the patients identity after a mandatory 2.5-second delay. Using the retract-and-reorder technique, we estimated the rate of wrong-patient orders before and after the implementation of the intervention to intercept these errors. We conducted a short- and long-term quasi-experimental study with both historical and parallel controls. We also measured the amount of time providers spent addressing the verification system, and reasons for discontinuing ordering sessions as a result of the intervention. RESULTS Wrong-patient orders were reduced by 30% immediately after implementation of the intervention. This reduction persisted when inpatients were used as a parallel control. After 2 years, the rate of wrong-patient orders remained 24.8% less than before intervention. The mean viewing time of the patient verification dialog was 4.2 seconds (SD=4.0 seconds) and was longer when providers indicated they placed the order for the wrong patient (4.9 versus 4.1 seconds). Although the display of each dialog took only seconds, the large number of display episodes triggered meant that the physician time to prevent each retract-and-reorder event was 1.5 hours. CONCLUSION A computerized provider order entry-based patient verification system led to a moderate reduction in wrong-patient orders that was sustained over time. Interception of wrong-patient orders at data entry is an important step in reducing these errors.

Ten Years After the IOM Report: Engaging Residents in Quality and Patient Safety by Creating a House Staff Quality Council

Ten years after the 1999 Institute of Medicine report, it is clear that despite significant progress, much remains to be done to improve quality and patient safety (QPS). Recognizing the critical role of postgraduate trainees, an innovative approach was developed at New York-Presbyterian Hospital, Weill Cornell Medical Center to engage residents in QPS by creating a Housestaff Quality Council (HQC). HQC leaders and representatives from each clinical department communicate and partner regularly with hospital administration and other key departments to address interdisciplinary quality improvement (QI). In support of the mission to improve patient care and safety, QI initiatives included attaining greater than 90% compliance with medication reconciliation and reduction in the use of paper laboratory orders by more than 70%. A patient safety awareness campaign is expected to evolve into a transparent environment where house staff can openly discuss patient safety issues to improve the quality of care.

Perspective: call to action: it is time for academic institutions to appoint a resident quality and patient safety officer.

In meeting the Accreditation Council for Graduate Medical Education (ACGME) core competency requirements, teaching hospitals often find it challenging to ensure effective involvement of housestaff in the area of quality and patient safety (QPS). Because housestaff are the frontline providers of care to patients, and medical errors occasionally occur based on their actions, it is essential for health care organizations to engage them in QPS processes.In early 2008 a Housestaff Quality Council (HQC) was established at New York-Presbyterian Hospital, Weill Cornell Medical Center, to improve QPS by engaging housestaff in policy and decision-making processes and to promote greater housestaff participation in QPS initiatives. It was quickly realized that the success of the HQC was highly contingent on alignment with the institutions overall QPS agenda. To this end, the position of resident QPS officer was created to strengthen the relationship between the hospitals strategic goals and the HQC. The authors describe the success of the resident QPS officers at their institution and observe that by appointing and supporting resident QPS officers, hospitals will be better able to meet their quality and safety goals, residency programs will be able to fulfill their required ACGME core competencies, and the overall quality and safety of patient care can be improved. Simultaneously, the creation of this position will help to create a new cadre of physician leaders needed to further the goals of QPS in health care.

The Effect of a Novel Housestaff Quality Council on Quality and Patient Safety

Article-at-a-Glance Background In 2008 New York-Presbyterian Hospital (NYP)/Weill Cornell Medical Center, New York City, the largest not-for-profit, nonsectarian hospital in the United States, created and implemented a novel approach—the Housestaff Quality Council (HQC)—to engaging housestaff in quality and patient safety activities. Methods The HQC represented an innovative collaboration between the housestaff, the Department of Anesthesiology, the Division of Quality and Patient Safety, the Office of Graduate Medical Education, and senior leadership. As key managers of patient care, the housestaff sought to become involved in the quality and patient safety decision- and policy-making processes at the hospital. Its members were determined to decrease or minimize adverse events by facilitating multimodal communication, ensuring smart work flow, and measuring outcomes to determine best practices. The HQC, which also included frontline hospital staff or managers from areas such as nursing, pharmacy, and information technology, aligned its initiatives with those of the division of quality and patient safety and embarked on two projects—medication reconciliation and use of the electronic medical record. More than three years later, the resulting improvements have been sustained and three new projects—hand hygiene, central line–associated bloodstream infections, and patient handoffs—have been initiated. Conclusions The HQC model is highly replicable at other teaching institutions as a complementary approach to their other quality and patient safety initiatives. However, the ability to sustain positive momentum is dependent on the ability of residents to invest time and effort in the face of a demanding residency training schedule and focus on specialty-specific clinical and research activities.

Lack of Adherence with Preoperative B-blocker Recommendations in a Multicenter Study

AbstractBACKGROUND: Clinical guidelines support the use of preoperative B-blocker in select patients. Patient safety groups have sought to measure the level of adherence to these recommendations. OBJECTIVE: This study was performed to compare the utilization of preoperative B-blocker with current guidelines across multiple diverse institutions. DESIGN: Retrospective chart review was performed of inpatients undergoing noncardiac surgery across 5 hospital centers during 2003 to 2004. The primary outcome of interest was the administration of preoperative B-blocker. PARTICIPANTS: The study sample included 1,304 randomly selected patients meeting the guideline criteria for preoperative B-blockade. MEASUREMENTS AND MAIN RESULTS: Among patients meeting recommendations for preoperative B-blocker, only 44% (430/983) received B-blocker before surgery. Patients who had not previously received B-blocker were given B-blocker before surgery in only 14% (85/600) of cases. Target heart rates goals for perioperative B-blockade were achieved in 26% (113/430) of cases. Predictors for initiating preoperative B-blocker included nonelective surgery or a history of hypertension or diabetes. Individual hospitals were independently predictive of preoperative B-blocker administration in multivariable models. CONCLUSIONS: Preoperative B-blocker was significantly underutilized when compared with the current guideline recommendations. Target heart rate goals were not achieved in clinical practice, and few hospitalized patients had preoperative B-blockade initiated. The lack of adherence to preoperative B-blocker recommendations in practice may be impacted by ongoing clinical questions regarding the appropriate selection of candidates for this therapy. Further efforts toward achieving guideline recommendations for preoperative B-blocker use should be focused on the subset of patients that are uniformly agreed upon to be at high risk for cardiac events.

The Role of Housestaff in Implementing Medication Reconciliation on Admission at an Academic Medical Center

Since 2006, the Joint Commission has required all hospitals to have a process in place for medication reconciliation (MR). Although it has been shown that MR decreases medical errors, achieving compliance has proven difficult for many health care institutions. This article describes a housestaff-championed intervention of a “hard stop” for on-admission MR orders that led to a statistically significant increase in compliance that was sustained at 6 months after intervention. Academic medical centers, which comprise large numbers of housestaff, can improve compliance with on-admission MR by engaging housestaff in the development of solutions and in communication to their peers, leading to sustained results.

Virtual Patient Safety Rounds: One Hospital System's Approach to Sharing Knowledge

Abstract: Understanding how and why errors in healthcare happen is essential to improving patient safety. Yet exposure to this learning process is usually limited to those events occurring in ones own institution. Virtual Safety Rounds expands this learning opportunity to multiple hospitals. Twice each month physicians; nurses; and quality, risk, and patient safety staff participate in a discussion about a recent safety event within the healthcare system. Within this safe collegial environment experiences, plans of correction and lessons learned are shared. Hospitals are learning from each other without having to experience the patient safety issue directly.