Resident-initiated interventions to improve inpatient heart-failure management
ABSTRACT Third-year internal medicine residents participating in a quality improvement rotation identified gaps between the Joint Commission's ORYX quality guidelines and clinical practices for the inpatient management of heart failure (HF) at the William S. Middleton Memorial Veterans Hospital. Residents focused on the performance metrics associated with tobacco-cessation counselling documentation, ejection fraction assessment and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker prescriptions.
After analysing data collected by the External Peer Review Program, residents reviewed the institution's admissions and discharge processes with the aim of improving quality and compliance. In redesigning these processes, residents created an admissions template and a discharge face sheet, and compared specific ORYX measure compliance rates before and after institution-wide implementation.
Following implementation of the tobacco-cessation admissions template, 100% of HF patients who used tobacco received documented cessation counselling, compared with 59% prior to intervention (p<0.01, n=32). Following implementation of the mandatory discharge face sheet, 97% of HF patients (compared with 92% preintervention, p>0.05) received comprehensive discharge instruction; LV function assessment went from 98% to 100% (p>0.05); and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker prescription for left ventricular systolic dysfunction at discharge (or documentation of a contra-indication) went from 82% to 100% (p<0.01, n=48).
By implementing a standardised admissions template and a mandatory discharge face sheet, the hospital improved its processes of documentation and increased adherence to quality-performance measures. By strengthening residents' learning and commitment to quality improvement, the hospital created a foundation for future changes in the systems that affect patient care.
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ABSTRACT: When quality improvement processes are integrated into resident education, many opportunities are created for improved outcomes in patient care. For Bethesda Family Medicine (BFM), integrating quality improvement into resident education is paramount in fulfilling the Accreditation Council for Graduate Medical Education Practice-Based Learning and Improvement core competency requirements. A resident-developed diabetes management treatment protocol that targeted 11 evidence-based measures recommended for successful diabetes management was implemented within the BFM residency and all physician practices under its parent healthcare system. This study compares diabetes management at BFM and at 2 other family medicine practices at timepoints before and after protocol implementation. We measured hemoglobin A1c (HbA1c), low-density lipoprotein (LDL) cholesterol, and systolic blood pressure (SBP) in adult diabetics and compared patient outcomes for these measures for the first and third quarters of 2009 and 2010. In BFM patients, HbA1c, LDL, and SBP levels decreased, but only HbA1c improvement persisted long term. For the comparison groups, in general levels were lower than those of BFM patients but not significantly so after the first measurement period. A resident-led treatment protocol can improve HbA1c outcomes among residents' diabetic patients. Periodic educational interventions can enhance residents' focus on diabetes management. Residents in graduate medical education can initiate treatment protocols to improve patient care in a large healthcare system.Ochsner Journal 01/2012; 12(4):323-30.
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ABSTRACT: Purpose Quality improvement (QI) is a common competency that must be taught in all physician training programmes, yet, there is no clear best approach to teach this content in clinical settings. We conducted a realist systematic review of the existing literature in QI curricula within the clinical setting, highlighting examples of trainees learning QI by doing QI. Method Candidate theories describing successful QI curricula were articulated a priori. We searched MEDLINE (1 January 2000 to 12 March 2013), the Cochrane Library (2013) and Web of Science (15 March 2013) and reviewed references of prior systematic reviews. Inclusion criteria included study design, setting, population, interventions, clinical and educational outcomes. The data abstraction tool included categories for setting, population, intervention, outcomes and qualitative comments. Themes were iteratively developed and synthesised using realist review methodology. A methodological quality tool assessed the biases, confounders, secular trends, reporting and study quality. Results Among 39 studies, most were before-after design with resident physicians as the primary population. Twenty-one described clinical interventions and 18 described educational interventions with a mean intervention length of 6.58 (SD=9.16) months. Twenty-eight reported successful clinical improvements; no studies reported clinical outcomes that worsened. Characteristics of successful clinical QI curricula include attention to the interface of educational and clinical systems, careful choice of QI work for the trainees and appropriately trained local faculty. Conclusions This realist review identified success characteristics to guide training programmes, medical schools, faculty, trainees, accrediting organisations and funders to further develop educational and improvement resources in QI educational programmes.BMJ quality & safety 09/2014; 91(1072). DOI:10.1136/bmjqs-2014-002846 · 3.28 Impact Factor