The Accreditation Council on Graduate Medical Education (ACGME) requires that house officers demonstrate competencies in "practice-based learning and improvement" and in "the ability to effectively call on system resources to provide care that is of optimum value." Anticipating this requirement, faculty at a Boston teaching hospital developed a 3-week elective for medical house officers in quality improvement (QI).The objectives of the elective were to enhance residents' understanding of QI concepts, their familiarity with the hospital's QI infrastructure, and to gain practical experience with root-cause analysis and QI initiatives. Learners participated in three didactic seminars, joined hospital-based QI activities, conducted a root-cause analysis, and completed a QI project under the guidance of a faculty mentor.The elective enrolled 26 residents in 3 years. Sixty-three percent of resident respondents said that the elective increased their understanding of QI in health care; 88% better understood QI in their own institution. The Institute of Medicine issued a report in 1999 on medical error and in 2001 on the "chasm" that stands between the promise of health care in America and its current state. 2,3Citing the need for fundamental change in the health care system, thought leaders in medical education called for the introduction of training in quality improvement (QI) and patient safety in the education of health care professionals.1-5 The Accreditation Council on Graduate MedicalEducation (ACGME) required in 2002 that house officers demonstrate competencies in "practice-based learning and improvement" and in "the ability to effectively call on system resources to provide care that is of optimum value."6 Anticipating the implementation of the ACGME requirements, faculty at our academic medical center developed a QI elective in 2000 for medical house officers. We report here on the format and content of the elective and our experience to date. PROGRAM DESCRIPTION BackgroundBeth Israel Deaconess Medical Center (BIDMC) is a 534-bed Boston teaching hospital. It offers residency training programs in medicine, surgery, neurology, pathology, anesthesiology, emergency medicine, pathology, radiology, and obstetrics-gynecology, and participates in Harvardwide residency programs in orthopedic surgery, psychiatry, and radiation therapy. The medicine training program is the largest in the United States, with 62 postgraduate year 1 (PGY-1) interns and 98 PGY-2 and PGY-3 residents in 2002 to 2003.In 2000, the hospital vice president of Healthcare Quality and faculty in the Division of General Medicine and Primary Care submitted a successful proposal to BIDMC's Stoneman Center for Quality Improvement in General Medicine and Primary Care to establish a QI elective for medical house officers. Internal grant proposals were solicited for research, demonstration, and educational projects. Applicants were required to emphasize medication safety in order to align the initiative with an institutional strategic objective. 7 Objectives...
Teamwork principles can be adapted from other disciplines and applied to internal medicine. After a single session, residents displayed greater knowledge of teamwork principles and reported changed attitudes toward key teamwork behaviors.
BACKGROUND: It is well documented that transitions of care pose a risk to patient safety. Every year, graduating residents transfer their patient panels to incoming interns, yet in our practice we consistently find that approximately 50% of patients do not return for follow-up care within a year of their resident leaving. OBJECTIVE: To examine the implications of this lapse of care with respect to chronic disease management, follow-up of abnormal test results, and adherence with routine health care maintenance. DESIGN: Retrospective chart review SUBJECTS: We studied a subset of patients cared for by 46 senior internal medicine residents who graduated in the spring of 2008. 300 patients had been identified as high priority requiring follow-up within a year. We examined the records of the 130 of these patients who did not return for care. MAIN MEASURES: We tabulated unaddressed abnormal test results, missed health care screening opportunities and unmonitored chronic medical conditions. We also attempted to call these patients to identify barriers to follow-up. KEY RESULTS: These patients had a total of 185 chronic medical conditions. They missed a total of 106 screening opportunities including mammogram (24), Pap smear (60) and colon cancer screening (22). Thirty-two abnormal pathology, imaging and laboratory test results were not followed-up as the graduating senior intended. Among a small sample of patients who were reached by phone, barriers to follow-up included a lack of knowledge about the need to see a physician, distance between home and our office, difficulties with insurance, and transportation. CONCLUSIONS: This study demonstrates the highrisk nature of patient handoffs in the ambulatory setting when residents graduate. We discuss changes that might improve the panel transfer process.KEY WORDS: patient safety; resident continuity practice; transitions of care. J Gen Intern Med 26(9):995-8
Beth Israel Deaconess Medical Center's internal medicine residency program was admitted to the new Education Innovation Project accreditation pathway of the Accreditation Council of Graduate Medical Education to begin in July 2006. The authors restructured the inpatient medical service to create clinical microsystems in which residents practice throughout residency. Program leadership then mandated an active curriculum in quality improvement based in those microsystems. To provide the experience to every graduating resident, a core faculty in patient safety was trained in the basics of quality improvement. The authors hypothesized that such changes would increase the number of residents participating in quality improvement projects, improve house officer engagement in quality improvement work, enhance the culture of safety the residents perceive in their training environment, improve work flow on the general medicine ward rotations, and improve the overall educational experience for the residents on ward rotations.The authors describe the first 18 months of the intervention (July 2006 to January 2008). The authors assessed attitudes and the educational experience with surveys and evaluation forms. After the intervention, the authors documented residents' participation in projects that overlapped with hospital priorities. More residents reported roles in designing and implementing quality improvement changes. Residents also noted greater satisfaction with the quality of care they deliver. Fewer residents agreed or strongly agreed that the new admitting system interfered with communication. Ongoing residency program assessment showed an improved perception of workload, and educational ratings of rotations improved. The changes required few resources and can be transported to other settings.
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