Prathibha Varkey

Basics of Quality Improvement in Health Care

With the rapid expansion of knowledge and technology and a health care system that performs far below acceptable levels for ensuring patient safety and needs, front-line health care professionals must understand the basics of quality improvement methodologies and terminology. The goals of this review are to provide clinicians with sufficient information to understand the fundamentals of quality improvement, provide a starting point for improvement projects, and stimulate further inquiry into the quality improvement methodologies currently being used in health care. Key quality improvement concepts and methodologies, including plan-do-study-act, six-sigma, and lean strategies, are discussed, and the differences between quality improvement and quality-of-care research are explored.

Stress Management and Resilience Training Among Department of Medicine Faculty: A Pilot Randomized Clinical Trial

BackgroundPhysician distress is common and related to numerous factors involving physicians’ personal and professional lives. The present study was designed to assess the effect of a Stress Management and Resiliency Training (SMART) program for increasing resiliency and quality of life, and decreasing stress and anxiety among Department of Medicine (DOM) physicians at a tertiary care medical center.ParticipantsForty DOM physicians were randomized in a wait-list controlled clinical trial to either the SMART intervention or a wait-list control group for 8 weeks. The intervention involved a single 90 min one-on-one training in the SMART program. Primary outcome measures assessed at baseline and week 8 included the Connor Davidson Resilience Scale (CDRS), Perceived Stress Scale (PSS), Smith Anxiety Scale (SAS) and Linear Analog Self Assessment Scale (LASA).ResultsThirty-two physicians completed the study. A statistically significant improvement in resiliency, perceived stress, anxiety, and overall quality of life at 8 weeks was observed in the study arm compared to the wait-list control arm: CDRS: mean ± SD change from baseline +9.8 ± 9.6 vs. -0.8 ± 8.2, t(30) = 3.18, p = 0.003; PSS: -5.4 ± 8.1 vs. +2.2 ± 6.1, t(30) = -2.76, p = 0.010; SAS: -11.8 ± 12.3 vs.+ 2.9 ± 8.9, t(30) = -3.62, p = 0.001; and LASA: +0.4 ± 1.4 vs. -0.6 ± 1.0, t(30) = 2.29, p = 0.029.ConclusionsA brief training to enhance resilience and decrease stress among physicians using the SMART program was feasible. Further, the intervention provided statistically significant improvement in resilience, stress, anxiety, and overall quality of life. In the future, larger clinical trials with longer follow-up and possibly wider dissemination of this intervention are warranted.

The effectiveness of self‐directed learning in health professions education: a systematic review

Medical Education 2010: 44: 1057–1068

Physician Satisfaction and Burnout at Different Career Stages

OBJECTIVE To explore the work lives, professional satisfaction, and burnout of US physicians by career stage and differences across sexes, specialties, and practice setting. PARTICIPANTS AND METHODS We conducted a cross-sectional study that involved a large sample of US physicians from all specialty disciplines in June 2011. The survey included the Maslach Burnout Inventory and items that explored professional life and career satisfaction. Physicians who had been in practice 10 years or less, 11 to 20 years, and 21 years or more were considered to be in early, middle, and late career, respectively. RESULTS Early career physicians had the lowest satisfaction with overall career choice (being a physician), the highest frequency of work-home conflicts, and the highest rates of depersonalization (all P<.001). Physicians in middle career worked more hours, took more overnight calls, had the lowest satisfaction with their specialty choice and their work-life balance, and had the highest rates of emotional exhaustion and burnout (all P<.001). Middle career physicians were most likely to plan to leave the practice of medicine for reasons other than retirement in the next 24 months (4.8%, 12.5%, and 5.2% for early, middle, and late career, respectively). The challenges of middle career were observed in both men and women and across specialties and practice types. CONCLUSION Burnout, satisfaction, and other professional challenges for physicians vary by career stage. Middle career appears to be a particularly challenging time for physicians. Efforts to promote career satisfaction, reduce burnout, and facilitate retention need to be expanded beyond early career interventions and may need to be tailored by career stage.

Mentoring Programs for Physicians in Academic Medicine: A Systematic Review

Purpose Mentoring is vital to professional development in the field of medicine, influencing career choice and faculty retention; thus, the authors reviewed mentoring programs for physicians and aimed to identify key components that contribute to these programs’ success. Method The authors searched the MEDLINE, EMBASE, and Scopus databases for articles from January 2000 through May 2011 that described mentoring programs for practicing physicians. The authors reviewed 16 articles, describing 18 programs, extracting program objectives, components, and outcomes. They synthesized findings to determine key elements of successful programs. Results All of the programs described in the articles focused on academic physicians. The authors identified seven mentoring models: dyad, peer, facilitated peer, speed, functional, group, and distance. The dyad model was most common. The authors identified seven potential components of a formal mentoring program: mentor preparation, planning committees, mentor–mentee contracts, mentor–mentee pairing, mentoring activities, formal curricula, and program funding. Of these, the formation of mentor–mentee pairs received the most attention in published reports. Mentees favored choosing their own mentors; mentors and mentees alike valued protected time. One barrier to program development was limited resources. Written agreements were important to set limits and encourage accountability to the mentoring relationship. Program evaluation was primarily subjective, using locally developed surveys. No programs reported long-term results. Conclusions The authors identified key program elements that could contribute to successful physician mentoring. Future research might further clarify the use of these elements and employ standardized evaluation methods to determine the long-term effects of mentoring.

Improving Medication Reconciliation in the Outpatient Setting

BACKGROUND A systematic study into outpatient medication reconciliation was conducted to determine if a multifaceted intervention influencing providers and patients reduced discrepancies related to inadequate prescription medication reconciliation in an outpatient setting. METHODS A prospective trial was conducted on 104 primary care patients at the Mayo Clinic. Patients in Phase I received standard care. Patients in Phase II received the intervention reconciliation process, which consisted of (1) mailed letters before appointments to remind patients to bring medication bottles or updated medication lists to their visits, (2) verification, and (3) correction of the medication list in the electronic medical record by the patient, and academic detailing and weekly audit and feedback of performance. RESULTS Interventions resulted in a decrease in prescription medication errors from 88.9% of the visits in Phase 1 to 66% of the visits in Phase II (p = .005) and from 98.2% of the visits in Phase I to 84% of the visits in Phase II (p = .0134) when all medications were considered. The average number of discrepancies per patient decreased by more than 50% from 5.24 in Phase I to 2.46 in Phase II. The majority of discrepancies were minor. DISCUSSION A multifaceted intervention including various members of the health care provider team (and the patient) is crucial to enhancing medication reconciliation.

A systems approach for implementing practice-based learning and improvement and systems-based practice in graduate medical education

The Accreditation Council for Graduate Medical Education (ACGME) initiated its Outcome Project to better prepare physicians-in-training to practice in the rapidly changing medical environment and mandated assessment of competency in six outcomes, including Practice-Based Learning and Improvement (PBLI) and Systems-Based Practice (SBP). Before the initiation of the Outcome Project, these competencies were not an explicit element of most graduate medical education training programs. Since 1999, directors of ACGME-accredited programs nationwide have been challenged to teach and assess these competencies. The authors describe an institution-wide curriculum intended to facilitate the teaching and assessment of PBLI and SBP competencies in the 115 ACGME-accredited residency and fellowship programs (serving 1,327 trainees) sponsored by Mayo School of Graduate Medical Education. Strategies to establish the curriculum in 2005 included development of a Quality Improvement (QI) curriculum Web site, one-on-one consultations with program directors, a three-hour program director workshop, and didactic sessions for residents and fellows on core topics. An interim program director self-assessment survey revealed a 13% increase in perceived ability to measure competency in SBP, no change in their perceived ability to measure competence in PBLI, a 15% increase in their ability to provide written documentation of competence in PBLI, and a 35% increase in their ability to provide written documentation of competence in SBP between 2005 and 2007. Nearly 70% of the programs had trainees participating in QI projects. Further research is needed to evaluate the cost-effectiveness of such a program and to measure its impact on learner knowledge, skills, and attitudes and, ultimately, on patient outcomes.

Innovation in health care: a primer.

As organizations strive for ways to control health care spending, address the growing needs of an aging population, and respond satisfactorily to a more informed and demanding consumer base, the opportunities for innovation have increased exponentially. By means of this article, the authors describe the basic concepts of purposeful innovation, and compare and contrast it to quality improvement. The authors also provide an overview of the terminology and types of innovation, describe the innovation life cycle, and discuss diffusion and commercialization of innovations. This article provides a primer on innovation for quality improvement practitioners and physician leaders who play a key role in creating innovation and environments for innovations to flourish. (Am J Med Qual 2008;23:382-388)

Validity evidence for an OSCE to assess competency in systems-based practice and practice-based learning and improvement: a preliminary investigation.

Purpose To determine the psychometric properties and validity of an OSCE to assess the competencies of Practice-Based Learning and Improvement (PBLI) and Systems-Based Practice (SBP) in graduate medical education. Method An eight-station OSCE was piloted at the end of a three-week Quality Improvement elective for nine preventive medicine and endocrinology fellows at Mayo Clinic. The stations assessed performance in quality measurement, root cause analysis, evidence-based medicine, insurance systems, team collaboration, prescription errors, Nolan’s model, and negotiation. Fellows’ performance in each of the stations was assessed by three faculty experts using checklists and a five-point global competency scale. A modified Angoff procedure was used to set standards. Evidence for the OSCE’s validity, feasibility, and acceptability was gathered. Results Evidence for content and response process validity was judged as excellent by institutional content experts. Interrater reliability of scores ranged from 0.85 to 1 for most stations. Interstation correlation coefficients ranged from −0.62 to 0.99, reflecting case specificity. Implementation cost was approximately

An Experiential Interdisciplinary Quality Improvement Education Initiative

255 per fellow. All faculty members agreed that the OSCE was realistic and capable of providing accurate assessments. Conclusions The OSCE provides an opportunity to systematically sample the different subdomains of Quality Improvement. Furthermore, the OSCE provides an opportunity for the demonstration of skills rather than the testing of knowledge alone, thus making it a potentially powerful assessment tool for SBP and PBLI. The study OSCE was well suited to assess SBP and PBLI. The evidence gathered through this study lays the foundation for future validation work.