Julie Oyler

Teaching Internal Medicine Residents Quality Improvement Techniques using the ABIM’s Practice Improvement Modules

SummaryIntroduction/aimStandard curricula to teach Internal Medicine residents about quality assessment and improvement, important components of the Accreditation Council for Graduate Medical Education core competencies practiced-based learning and improvement (PBLI) and systems-based practice (SBP), have not been easily accessible.Program descriptionUsing the American Board of Internal Medicine’s (ABIM) Clinical Preventative Services Practice Improvement Module (CPS PIM), we have incorporated a longitudinal quality assessment and improvement curriculum (QAIC) into the 2 required 1-month ambulatory rotations during the postgraduate year 2. During the first block, residents complete the PIM chart reviews, patient, and system surveys. The second block includes resident reflection using PIM data and the group performing a small test of change using the Plan–Do–Study–Act (PDSA) cycle in the resident continuity clinic.Program EvaluationTo date, 3 resident quality improvement (QI) projects have been undertaken as a result of QAIC, each making significant improvements in the residents’ continuity clinic. Resident confidence levels in QI skills (e.g., writing an aim statement [71% to 96%, P < .01] and using a PDSA cycle [9% to 89%, P < .001]) improved significantly.DiscussionThe ABIM CPS PIM can be used by Internal Medicine residency programs to introduce QI concepts into their residents’ outpatient practice through encouraging practice-based learning and improvement and systems-based practice.

Musculoskeletal exam and joint injection training for internal medicine residents

We developed a musculoskeletal education intervention for internal medicine residents consisting of lectures, anatomic models, and a joint injection clinic. Written tests, observed musculoskeletal exams, and self-confidence scales were administered to 27 internal medicine residents before and after the intervention. Improvement was found in observed physical exam and self-reported confidence levels in performing knee injections. Confidence in shoulder injection skills improved, but remained low. Improved scores on written examination, though statistically significant, were not educationally significant. This single-institution pilot study demonstrates that a simple educational program results in improved knee and shoulder examination skills and confidence in performing knee injections.

A Resident-Led Quality Improvement Initiative to Improve Obesity Screening

Instruction on quality improvement (QI) methods is required as part of residency education; however, there is limited evidence regarding whether internal medicine residents can improve patient care using these methods. Because obesity screening is not done routinely in clinical practice, residents aimed to improve screening using QI techniques. Residents streamlined body mass index (BMI) documentation, created educational materials about obesity, and launched an obesity screening QI initiative in a residency clinic. Residents designed plan-do-study-act cycles focused on increasing awareness and maintaining improvements in screening over a 1-year period. Documentation rates were collected at baseline, 2 weeks, 6 months, and 1 year post-intervention. At 1 year, obesity treatment rates also were collected. BMI documentation rates after 1 year were higher than baseline (43% vs 4%, P < .0001). In obese patients, BMI documentation was associated with lifestyle counseling (34% vs 14%, P < .01). An internal medicine resident-led QI project targeting obesity can improve screening.

Results of an enhanced clinic handoff and resident education on resident patient ownership and patient safety

Purpose Although internal medicine resident clinic handoffs present risks for patients, few interventions exist. The authors evaluated an enhanced handoff. Method In 2011, the authors formalized a handoff protocol including a standardized sign-out process, resident education, improved scheduling, and time to establish care through telephone visits. The authors surveyed 25 residents in 2011 and 19 in 2010 regarding their perceptions and performed chart audits to examine patient outcomes. Results Compared with 2010, residents in 2011 reported longer handoffs (>20 minutes, 52% versus 6%, P < .01), more verbal handoffs (80% versus 38%, P < .01), more patients aware of the handoff (100% versus 74%, P = .01), less discomfort with paperwork for patients not yet seen (40% versus 74%, P =.03), and more ownership of patients before the first visit (56% versus 26%, P =.05). In 2011, more patients saw their correct primary care provider (82% versus 44%, P < .01), and more tests were followed up appropriately (67% versus 46%, P = .02). The authors detected in 2011 a trend for patients to be seen the month their physician intended (40% versus 33%, P= .06) and a trend toward fewer acute (hospital and emergency department) visits three months post handoff (20% versus 26%, P = .06). Conclusions Enhancing clinic handoffs can improve the handoff process, increase the likelihood of patients seeing the correct primary care provider within the target time frame, reduce missed tests, and possibly reduce acute visits.

The Quality and Safety Track: Training Future Physician Leaders

Future physician leaders will need the knowledge and skills necessary to improve systems of care. To address this need, Pritzker School of Medicine implemented a 4-year scholarly track in quality and patient safety for medical students. The Quality and Safety Track (QST) includes an intensive elective that teaches basic quality-improvement skills, an individual mentored scholarly project, and engagement in the Institute for Healthcare Improvement Open School. The first-year elective incorporates a group project that allows students to apply basic process improvement skills. Institutional quality and safety leaders also present their work, giving students context for how these skills are used. To date, 23 students have completed the elective, and 11 chose to pursue QST throughout their medical school experience. Students who completed the elective reported improved confidence in using core quality improvement skills. QST is a feasible and innovative program to develop future health care leaders in quality and safety.

Preparing for the primary care clinic: an ambulatory boot camp for internal medicine interns

Introduction Internal medicine (IM) interns start continuity clinic with variable ambulatory training. Multiple other specialties have utilized a boot camp style curriculum to improve surgical and procedural skills, but boot camps have not been used to improve interns’ ambulatory knowledge and confidence. The authors implemented and assessed the impact of an intern ambulatory boot camp pilot on primary care knowledge, confidence, and curricular satisfaction. Methods During July 2014, IM interns attended ambulatory boot camp. It included clinically focused case-based didactic sessions on common ambulatory topics as well as orientation to the clinic and electronic medical records. Interns anonymously completed a 15-question pre-test on topics covered in the boot camp as well as an identical post-test after the boot camp. The interns were surveyed regarding their confidence and satisfaction. Results Thirty-eight interns participated in the boot camp. Prior to the boot camp, few interns reported confidence managing common outpatient conditions. The average pre-test knowledge score was 46.3%. The average post-test knowledge score significantly improved to 76.1% (p<0.001). All interns reported that the boot camp was good preparation for clinics and 97% felt that the boot camp boosted their confidence. Conclusions The ambulatory boot camp pilot improved primary care knowledge, and interns thought it was good preparation for clinic. The ambulatory boot camp was well received and may be an effective way to improve the preparation of interns for primary care clinic. Further assessment of clinical performance and expansion to other programs and specialties should be considered.

Evaluation and Treatment of Hirsutism in Premenopausal Women

GUIDELINE TITLE Evaluation and Treatment of Hirsutism in Premenopausal Women DEVELOPER Endocrine Society, Androgen Excess and Polycystic Ovary Syndrome Society, European Society of Endocrinology RELEASE DATE March 2018 PRIOR VERSION February 5, 2008 FUNDING SOURCE Endocrine Society TARGET POPULATION Premenopausal women with excess hair growth MAJOR RECOMMENDATIONS Diagnosis Pharmacologic treatment

Bridging the Gap: Interdepartmental Quality Improvement and Patient Safety Curriculum Created by Hospital Leaders, Faculty, and Trainees

Background The Accreditation Council for Graduate Medical Education Clinical Learning Environment Review recommends that quality improvement/patient safety (QI/PS) experts, program faculty, and trainees collectively develop QI/PS education. Objective Faculty, hospital leaders, and resident and fellow champions at the University of Chicago designed an interdepartmental curriculum to train postgraduate year 1 (PGY-1) residents on core QI/PS principles, measuring outcomes of knowledge, attitudes, and event reporting. Methods The curriculum consisted of 3 sessions: PS, quality assessment, and QI. Faculty and resident and fellow leaders taught foundational knowledge, and hospital leaders discussed institutional priorities. PGY-1 residents attended during protected conference times, and they completed in-class activities. Knowledge and attitudes were assessed using pretests and posttests; graduating residents (PGY-3-PGY-8) were controls. Event reporting was compared to a concurrent control group of nonparticipating PGY-1 residents. Results From 2015 to 2017, 140 interns in internal medicine (49%), pediatrics (33%), and surgery (13%) enrolled, with 112 (80%) participating and completing pretests and posttests. Overall, knowledge scores improved (44% versus 57%, P < .001), and 72% of residents demonstrated increased knowledge. Confidence comprehending quality dashboards increased (13% versus 49%, P < .001). PGY-1 posttest responses were similar to those of 252 graduate controls for accessibility of hospital leaders, filing event reports, and quality dashboards. PGY-1 residents in the QI/PS curriculum reported more patient safety events than PGY-1 residents not exposed to the curriculum (0.39 events per trainee versus 0.10, P < .001). Conclusions An interdepartmental curriculum was acceptable to residents and feasible across 3 specialties, and it was associated with increased event reporting by participating PGY-1 residents.