Resident-Initiated Interventions to Improve Inpatient Heart Failure Management

Article · February 2011with14 Reads
DOI: 10.1136/bmjqs.2009.039339 · Source: PubMed
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.
    • interns and residents) to have ever completed an incident report (58.4% v. 85.4%), while doctors with . 5 years experience – post-entry level – were less likely to have ever completed an incident report than those with less experience (58.1% v. 79.2%) (Evans et al., 2006) " Effective " : providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively) 3 Contemporary Knowledge to be able to question front line implementation of clinical decisions and practice Knowledge of safety science, including benchmarking and standardizing of practice 1 Beginner's mind Opportunity to challenge the status quo 5 Peripatetic Insights into variations in work practice on different units and different wards Opportunity to assist in bridging information silos 6 Front line Opportunity to promote adherence 5 Non-threatening Engage peers and other health professionals Example Third year internal medicine residents in the US were able to identify and fix a disconnect between guidelines and actual clinical practice in the inpatient management of heart failure (Oujiri et al., 2011) " Patient centered " : providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions 2 Heterogeneity Greater heterogeneity among the population of junior doctors allows for greater opportunities for symmetry between physician and patient values, thereby increasing patient cooperation (Cvengros et al., 2009) How to increase the integration of junior doctors into organizational activities is well described (Agents for Change, 2011). One potential approach is to include a junior doctor representative at departmental level and senior management meetings with the purpose of feeding back patient safety specific issues.
    [Show abstract] [Hide abstract] ABSTRACT: The purpose of this paper is to re-frame perceptions surrounding junior doctors' capacity to contribute to patient safety and quality improvement. A targeted literature review was conducted followed by individual telephone interviews and a half-day forum involving junior doctor representatives and selected leaders in the sector. Junior doctors' entry into health care is an ideal time to cultivate practitioners' interest and expertise in improving the health system for better patient care. Junior doctors are more likely to bring or embrace new ideas, and recognize the importance of transparency and integration of technology into healthcare systems. Engaging with junior doctors in collaborative processes, rather than focusing on their more senior colleagues, may create a more effective culture. The attributes of junior doctors (as they are in the absence of specific quality improvement or leadership training) that are currently underutilized in patient safety and quality improvement are explored, along with the factors limiting and facilitating the utilization of these attributes.
    Article · May 2013
  • [Show abstract] [Hide abstract] 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.
    Article · Dec 2012
  • [Show abstract] [Hide abstract] 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.
    Article · Sep 2014
  • [Show abstract] [Hide abstract] ABSTRACT: Background and objectives: Over 70% of smokers visit a physician annually, and physicians are well-positioned to assist patients in smoking cessation. Residency offers the ideal setting to train physicians in best practices for treatment of nicotine dependence. We hypothesized that experiential learning during a smoking cessation medical clinic (SCMC) rotation would be associated with an improvement in smoking cessation practice of internal medicine (IM) interns in outpatient primary care and inpatient settings. Methods: This was a prospective study performed at a large university-affiliated hospital. Forty IM interns rotated through SCMC. After a lecture on nicotine addiction and treatment, interns treated SCMC patients under direct supervision of an attending pulmonologist. Interns' smoking cessation practices before and after SCMC rotation were evaluated through chart review over 1 year. Upon study completion, a survey to assess confidence was administered. Paired t tests measured changes in rates of identifying smokers, offering pharmacological treatment and counseling. Results: A total of 5,622 outpatient and 683 inpatient charts of interns' encounters with patients were reviewed. Following SCMC rotation, there was an increase in identifying active smokers (7.1% versus 18.7%), prescribing therapy for smoking cessation (6.5% versus 18.0%), and providing counseling (30.9% versus 42.3%) to outpatients. For inpatients, there was an increase in nicotine replacement during admission (12.9% versus 37.4%) and prescription of therapy upon discharge (5.7% versus 16.1%). Interns reported confidence in providing appropriate counseling and treatment. Conclusions: SCMC experience positively impacted smoking cessation treatment by IM interns, causing a measurable change in their practice.
    Article · Jun 2016
October 2011 · Postgraduate medical journal · Impact Factor: 1.45
    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,... [Show full abstract]
    December 2009 · American Journal of Medical Quality · Impact Factor: 1.25
      Patient safety and quality of care are public concerns that demand personal responsibility at all levels of the health care organization. Senior residents in our graduate medical education program took responsibility for a capstone quality improvement project designed to transform them into champions for health care quality. Residents (n = 26) participated alone or in pairs in a 1-month... [Show full abstract]
      February 2009 · Journal of General Internal Medicine · Impact Factor: 3.42
        Chart review represents a critical cornerstone for practice-based learning and improvement in our internal medicine residency program. To document residents' performance monitoring and improvement skills in their continuity clinics, their satisfaction with practice-based learning and improvement, and their ability to self-reflect on their performance. Retrospective longitudinal design with... [Show full abstract]
        March 2010 · Journal of Clinical Densitometry · Impact Factor: 2.03
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