INNOVATIONS
A Strategic Approach to Quality Improvement and Patient Safety Education and Resident Integration in a General Surgery Residency Colette T. O’Heron,* and Benjamin T. Jarman, MD† Department of Medical Education, Gundersen Medical Foundation, La Crosse, Wisconsin; and †Department of General & Vascular Surgery, Gundersen Health System, La Crosse, Wisconsin *
OBJECTIVE: To outline a structured approach for general
surgery resident integration into institutional quality improvement and patient safety education and development.
COMPETENCIES:
Professionalism, Interpersonal Communication Skills, Practice-Based Learning Improvement, Systems-Based Practice
and and
DESIGN: A strategic plan to address Accreditation Council for
Graduate Medical Education (ACGME) Clinical Learning Environment Review assessments for resident integration into Quality Improvement and Patient Safety initiatives is described. SETTING: Gundersen Lutheran Medical Foundation is an
independent academic medical center graduating three categorical residents per year within an integrated multispecialty health system serving 19 counties over 3 states. RESULTS: The quality improvement and patient safety
education program includes a formal lecture series, online didactic sessions, mandatory quality improvement or patient safety projects, institutional committee membership, an opportunity to serve as a designated American College of Surgeons National Surgical Quality Improvement Project and Quality in Training representative, mandatory morbidity and mortality conference attendance and clinical electives in rural surgery and international settings. CONCLUSIONS: Structured education regarding and partic-
ipation in quality improvement and patient safety programs are able to be accomplished during general surgery residency. The long-term outcomes and benefits of these strategies are unknown at this time and will be difficult to measure with objective data. C 2014 Association of Program Directors ( J Surg 71:18-20. J in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: general surgery residency, quality improvement, patient safety, quality curriculum, clinical learning environment review Correspondence: Inquiries to Benjamin T. Jarman, MD, Department of General and Vascular Surgery, Gundersen Health System, 1836 South Avenue, C05-001, La Crosse, WI 54601; fax: þ1-608-775-4460; e-mail: [email protected]
18
BACKGROUND Quality Improvement (QI) and Patient Safety (PS) education are integral to the maturation of general surgery residents. The inclusion of Clinical Learning Environment Review (CLER) visits as a significant factor in the Next Accreditation System (NAS) by the Accreditation Council for Graduate Medical Education (ACGME) has appropriately motivated a flurry of activity among graduate medical education programs to formally integrate residents into institutional plans of action with regard to QI and PS programs. In addition, exposure to disparities in health care and assurance that residents are involved in efforts to reduce this troubling issue is mandatory. Gundersen Health System (GHS) is an integrated, multispecialty health care system located in La Crosse, WI. The Quality and Patient Safety Department is robust with full-time staff, formal committees, and an educational focus that make their members visible throughout the system where they influence institutional change. We appreciate outstanding opportunities to integrate surgery residents into well-established programs to prepare them for future challenges, including a thorough understanding of patient safety initiatives, their integration into quality improvement (QI) projects, exposure to the transparency of surgical outcomes, and being cognizant of disparities in care. For this paper, we chose to address the QI and patient safety (PS) requirements of Clinical Learning Environment Review visits as we believe these are the most challenging to accomplish, given a myriad of other surgical education demands. Professionalism and monitoring of transitions in care, duty hours, and fatigue tend to be
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2013.09.018
more straightforward issues in our institution and are not the focus of this manuscript.
OBJECTIVE The objective of our QI and PS program is to educate general surgery residents about QI and PS issues, gain insight into performance improvement, serve on institutional committees with reporting responsibilities to the surgery residency, participate in national projects regarding QI, learn about disparities in health care, and to ultimately influence institutional change.
METHODS Our approach to this process is multifaceted and has required the support of numerous individuals throughout our system. The program includes a formal lecture and online didactic series, mandatory QI or PS projects, institutional committee membership, an opportunity to serve as a designated American College of Surgeons National Surgical Quality Improvement Project (NSQIP)1 and Quality in Training (QIT) representative, mandatory Morbidity and Mortality conference (M&M) attendance, and clinical electives in rural surgery and international settings. GHS participates in the Institute for Healthcare Improvement, which provides our residents with the opportunity to participate in the Institute for Healthcare Improvement Open School—an online program that facilitates education in QI and PS.2 We designed lectures moderated by a teaching faculty (TF) and a member of the Quality and Safety Department that use the modules and time schedule outlined in Table 1. The residents are required to complete
the appropriate module before the discussion. The residents participating in this lecture series work together as a team to generate a clinical project to address a QI or PS concern, and their work is mentored by a TF and presented to the Department of Surgery. Resident representation on a variety of high-impact committees would facilitate their education, provide an opportunity for them to report clinical environment concerns of the surgery residents, and formally report system challenges and issues to the residents. The committees with required resident involvement include Quality Committee, Safety Culture Committee, and the NSQIP working group. In addition, we have a variety of informal “committees” that serve to address internal challenges with issues regarding care delivery. Some target examples over the past 5 years have included multidisciplinary rounding, mandatory data needed by nurses before paging a resident, and issues with our electronic medical record to address safety concerns. These less formal but very important aspects of resident development and participation are recorded in a spreadsheet and the resident's portfolios. NSQIP is a nationally validated, risk-adjusted, outcomesbased program to measure and improve the quality of surgical care.1 GHS participates in NSQIP and we have had integrated quarterly reviews of our hospital data for the past 4 years at our M&M. This has provided a baseline education regarding QI terminology and initiatives in addition to generating a variety of projects leading to QI and PS projects among residents and TF. The QIT project was designed as part of NSQIP to develop a national collaborative of training programs interested in linking quality and education personnel and to investigate the possibilities of creating patient outcome reports for individual surgery residents.3 We recently began data accumulation
TABLE 1. Gundersen Medical Foundation General Surgery Residency Patient Safety and Quality Improvement Curriculum Quality and Safety Curricular Meetings 2013-2014 Courses offered through the Institute for Healthcare Improvement Open School1 Quality Improvement (July-November 2013) QI 101 Fundamentals of Improvement QI 102 The Model for Improvement; your engine for change QI 103 Measuring for Improvement QI 104 Putting it All Together: How Quality Improvement Works in Real Health Care Settings QI 105 The Human Side of Quality Improvement QI 106 Level 100 Tools Patient Safety (February-June 2014) PS 100 Introduction to Patient Safety PS 101 Fundamentals of Patient Safety PS 102 Human Factors and Safety PS 103 Team Work and Communication PS 104 Root Cause and Systems Analysis PS 105 Communicating with Patient after Adverse Events PS 106 Introduction to the Culture of Safety Additional Topics to be addressed L101 Leadership: You Want to Be a Leader in Health Care? PFC101 Patient and Family Centered Care Dignity and Respect MHO 101 Managing Health Care Operations—Achieving Breakthrough Quality, Access, and Affordability Journal of Surgical Education Volume 71/Number 1 January/February 2014
19
for the QIT project in an effort to provide our residents with insight regarding their clinical performance and associated morbidity and mortality. Each year, a resident will serve as a representative for our NSQIP department that will entail attendance at the national NSQIP meeting, attendance of appropriate NSQIP committee meetings, and completion of a QI project with anticipated presentation at the national NSQIP meeting in the following year. This type of assignment has been described as a dedicated year with notable influence by Morales and associates,4 but we have decided to try to incorporate the activity with ongoing clinical responsibilities. M&M at GHS is a multidisciplinary exercise that has been integral to positive changes throughout our system. We devote a session each quarter to NSQIP reporting and QI education. We have a quarterly combined surgery and medicine M&M that has helped to identify system and clinical issues that have been addressed with resident participation. Participation in rural surgery and international electives has been integral in resident recognition of disparities in health care at national and international levels. Residents have gained experience at the Pine Ridge Indian Reservation (Pine Ridge, SD) and in rural cities in the tristate area of Wisconsin, Minnesota, and Iowa where exposure to Amish, Latino, Native American, and Hmong cultures affects their professional development and recognition of variations in health care delivery, resources, and efficiency. International experiences in the Dominican Republic and Ecuador have yielded similar, if not more profound, experiences. Residents who participate in these rotations are required to present their experience to the Department of Surgery.
representatives and raised awareness of an apparent disconnect between objective data and operating room team member perception. Informal projects tend to have the most clinical influence with regard to system improvements, but aside from recording these resident-based initiatives, it is difficult to demonstrate a precise variable to report. NSQIP representation would generate numerous projects in the future that serve as a direct reflection of resident integration. We have current projects with urinary tract infection risk factors and colorectal surgery accelerated recovery order sets. This is the first academic year with an assigned resident to this group and we are excited about the prospects. QIT would provide a wealth of data regarding areas of resident performance improvement which would hopefully lead to system changes and ultimately prepare them for clinical practice. We are optimistic about our program and approach to the new requirements but recognize that affording the same opportunity and experience to each resident would not be possible. Surgery residents have unique perspectives and focal interests which they explore during their training. We have established mandatory requirements within our program for curriculum completion and performance of a QI or PS project. We designate residents to certain committees and expect that they are engaged with our QI and PS initiatives; however, all of these initiatives take time away from their clinical development as general surgeons, and finding an appropriate balance with the demands of resident training is challenging. We recognize the importance of QI and PS training and anticipate that our plan will positively effect individual resident development and patient care.
RESULTS AND DISCUSSION Objective measurements of success with a multidisciplinary program as outlined previously would be challenging. The baseline expectation of curriculum completion can be determined by resident participation in discussions and completion of the modules. Last year, our senior residents were presented with completion certificates. We have not implemented a formal testing modality to ensure that their retention of the information is appropriate but have implemented questions regarding QI and PS in M&M, Journal Clubs, and day-to-day patient care to assess their knowledge. QI and PS projects are assessed with required presentations. One of our residents presented her PS project, “Safety Culture: Perception vs. Reality” at the Wisconsin Surgical Society (a chapter of the American College of Surgeons). The findings were surprising to our QI and PS
20
REFERENCES 1. American College of Surgeons National Surgical Quality
Improvement Program. Available at: http://site.acsnsqip. org. Accessed September 17, 2013. 2. Institute for Healthcare Improvement Open School.
Available at: http://www.ihi.org/offerings/IHIOpenSchool/ courses/pages/default.aspx. Accessed August 29, 2013. 3. Sellers MM, Reinke CE, Kreider S, et al. American
College of Surgeons NSQIP: quality in-training initiative pilot study. J Am Coll Surg. in press. doi:pii: S10727515(13)00503-6. 10.1016/j.jamcollsurg.2013.07.005. 4. Morales CS, Kontonicolas F, Volpe AA, Saldinger PF,
Fukumoto R. Performance improvement: getting an early start. J Surg Educ. 2012;69(6):774-779.
Journal of Surgical Education Volume 71/Number 1 January/February 2014
A Strategic Approach to Quality Improvement and Patient Safety Education and Resident Integration in a General Surgery Residency Colette T. O’Heron,* and Benjamin T. Jarman, MD† Department of Medical Education, Gundersen Medical Foundation, La Crosse, Wisconsin; and †Department of General & Vascular Surgery, Gundersen Health System, La Crosse, Wisconsin *
OBJECTIVE: To outline a structured approach for general
surgery resident integration into institutional quality improvement and patient safety education and development.
COMPETENCIES:
Professionalism, Interpersonal Communication Skills, Practice-Based Learning Improvement, Systems-Based Practice
and and
DESIGN: A strategic plan to address Accreditation Council for
Graduate Medical Education (ACGME) Clinical Learning Environment Review assessments for resident integration into Quality Improvement and Patient Safety initiatives is described. SETTING: Gundersen Lutheran Medical Foundation is an
independent academic medical center graduating three categorical residents per year within an integrated multispecialty health system serving 19 counties over 3 states. RESULTS: The quality improvement and patient safety
education program includes a formal lecture series, online didactic sessions, mandatory quality improvement or patient safety projects, institutional committee membership, an opportunity to serve as a designated American College of Surgeons National Surgical Quality Improvement Project and Quality in Training representative, mandatory morbidity and mortality conference attendance and clinical electives in rural surgery and international settings. CONCLUSIONS: Structured education regarding and partic-
ipation in quality improvement and patient safety programs are able to be accomplished during general surgery residency. The long-term outcomes and benefits of these strategies are unknown at this time and will be difficult to measure with objective data. C 2014 Association of Program Directors ( J Surg 71:18-20. J in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: general surgery residency, quality improvement, patient safety, quality curriculum, clinical learning environment review Correspondence: Inquiries to Benjamin T. Jarman, MD, Department of General and Vascular Surgery, Gundersen Health System, 1836 South Avenue, C05-001, La Crosse, WI 54601; fax: þ1-608-775-4460; e-mail: [email protected]
18
BACKGROUND Quality Improvement (QI) and Patient Safety (PS) education are integral to the maturation of general surgery residents. The inclusion of Clinical Learning Environment Review (CLER) visits as a significant factor in the Next Accreditation System (NAS) by the Accreditation Council for Graduate Medical Education (ACGME) has appropriately motivated a flurry of activity among graduate medical education programs to formally integrate residents into institutional plans of action with regard to QI and PS programs. In addition, exposure to disparities in health care and assurance that residents are involved in efforts to reduce this troubling issue is mandatory. Gundersen Health System (GHS) is an integrated, multispecialty health care system located in La Crosse, WI. The Quality and Patient Safety Department is robust with full-time staff, formal committees, and an educational focus that make their members visible throughout the system where they influence institutional change. We appreciate outstanding opportunities to integrate surgery residents into well-established programs to prepare them for future challenges, including a thorough understanding of patient safety initiatives, their integration into quality improvement (QI) projects, exposure to the transparency of surgical outcomes, and being cognizant of disparities in care. For this paper, we chose to address the QI and patient safety (PS) requirements of Clinical Learning Environment Review visits as we believe these are the most challenging to accomplish, given a myriad of other surgical education demands. Professionalism and monitoring of transitions in care, duty hours, and fatigue tend to be
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2013.09.018
more straightforward issues in our institution and are not the focus of this manuscript.
OBJECTIVE The objective of our QI and PS program is to educate general surgery residents about QI and PS issues, gain insight into performance improvement, serve on institutional committees with reporting responsibilities to the surgery residency, participate in national projects regarding QI, learn about disparities in health care, and to ultimately influence institutional change.
METHODS Our approach to this process is multifaceted and has required the support of numerous individuals throughout our system. The program includes a formal lecture and online didactic series, mandatory QI or PS projects, institutional committee membership, an opportunity to serve as a designated American College of Surgeons National Surgical Quality Improvement Project (NSQIP)1 and Quality in Training (QIT) representative, mandatory Morbidity and Mortality conference (M&M) attendance, and clinical electives in rural surgery and international settings. GHS participates in the Institute for Healthcare Improvement, which provides our residents with the opportunity to participate in the Institute for Healthcare Improvement Open School—an online program that facilitates education in QI and PS.2 We designed lectures moderated by a teaching faculty (TF) and a member of the Quality and Safety Department that use the modules and time schedule outlined in Table 1. The residents are required to complete
the appropriate module before the discussion. The residents participating in this lecture series work together as a team to generate a clinical project to address a QI or PS concern, and their work is mentored by a TF and presented to the Department of Surgery. Resident representation on a variety of high-impact committees would facilitate their education, provide an opportunity for them to report clinical environment concerns of the surgery residents, and formally report system challenges and issues to the residents. The committees with required resident involvement include Quality Committee, Safety Culture Committee, and the NSQIP working group. In addition, we have a variety of informal “committees” that serve to address internal challenges with issues regarding care delivery. Some target examples over the past 5 years have included multidisciplinary rounding, mandatory data needed by nurses before paging a resident, and issues with our electronic medical record to address safety concerns. These less formal but very important aspects of resident development and participation are recorded in a spreadsheet and the resident's portfolios. NSQIP is a nationally validated, risk-adjusted, outcomesbased program to measure and improve the quality of surgical care.1 GHS participates in NSQIP and we have had integrated quarterly reviews of our hospital data for the past 4 years at our M&M. This has provided a baseline education regarding QI terminology and initiatives in addition to generating a variety of projects leading to QI and PS projects among residents and TF. The QIT project was designed as part of NSQIP to develop a national collaborative of training programs interested in linking quality and education personnel and to investigate the possibilities of creating patient outcome reports for individual surgery residents.3 We recently began data accumulation
TABLE 1. Gundersen Medical Foundation General Surgery Residency Patient Safety and Quality Improvement Curriculum Quality and Safety Curricular Meetings 2013-2014 Courses offered through the Institute for Healthcare Improvement Open School1 Quality Improvement (July-November 2013) QI 101 Fundamentals of Improvement QI 102 The Model for Improvement; your engine for change QI 103 Measuring for Improvement QI 104 Putting it All Together: How Quality Improvement Works in Real Health Care Settings QI 105 The Human Side of Quality Improvement QI 106 Level 100 Tools Patient Safety (February-June 2014) PS 100 Introduction to Patient Safety PS 101 Fundamentals of Patient Safety PS 102 Human Factors and Safety PS 103 Team Work and Communication PS 104 Root Cause and Systems Analysis PS 105 Communicating with Patient after Adverse Events PS 106 Introduction to the Culture of Safety Additional Topics to be addressed L101 Leadership: You Want to Be a Leader in Health Care? PFC101 Patient and Family Centered Care Dignity and Respect MHO 101 Managing Health Care Operations—Achieving Breakthrough Quality, Access, and Affordability Journal of Surgical Education Volume 71/Number 1 January/February 2014
19
for the QIT project in an effort to provide our residents with insight regarding their clinical performance and associated morbidity and mortality. Each year, a resident will serve as a representative for our NSQIP department that will entail attendance at the national NSQIP meeting, attendance of appropriate NSQIP committee meetings, and completion of a QI project with anticipated presentation at the national NSQIP meeting in the following year. This type of assignment has been described as a dedicated year with notable influence by Morales and associates,4 but we have decided to try to incorporate the activity with ongoing clinical responsibilities. M&M at GHS is a multidisciplinary exercise that has been integral to positive changes throughout our system. We devote a session each quarter to NSQIP reporting and QI education. We have a quarterly combined surgery and medicine M&M that has helped to identify system and clinical issues that have been addressed with resident participation. Participation in rural surgery and international electives has been integral in resident recognition of disparities in health care at national and international levels. Residents have gained experience at the Pine Ridge Indian Reservation (Pine Ridge, SD) and in rural cities in the tristate area of Wisconsin, Minnesota, and Iowa where exposure to Amish, Latino, Native American, and Hmong cultures affects their professional development and recognition of variations in health care delivery, resources, and efficiency. International experiences in the Dominican Republic and Ecuador have yielded similar, if not more profound, experiences. Residents who participate in these rotations are required to present their experience to the Department of Surgery.
representatives and raised awareness of an apparent disconnect between objective data and operating room team member perception. Informal projects tend to have the most clinical influence with regard to system improvements, but aside from recording these resident-based initiatives, it is difficult to demonstrate a precise variable to report. NSQIP representation would generate numerous projects in the future that serve as a direct reflection of resident integration. We have current projects with urinary tract infection risk factors and colorectal surgery accelerated recovery order sets. This is the first academic year with an assigned resident to this group and we are excited about the prospects. QIT would provide a wealth of data regarding areas of resident performance improvement which would hopefully lead to system changes and ultimately prepare them for clinical practice. We are optimistic about our program and approach to the new requirements but recognize that affording the same opportunity and experience to each resident would not be possible. Surgery residents have unique perspectives and focal interests which they explore during their training. We have established mandatory requirements within our program for curriculum completion and performance of a QI or PS project. We designate residents to certain committees and expect that they are engaged with our QI and PS initiatives; however, all of these initiatives take time away from their clinical development as general surgeons, and finding an appropriate balance with the demands of resident training is challenging. We recognize the importance of QI and PS training and anticipate that our plan will positively effect individual resident development and patient care.
RESULTS AND DISCUSSION Objective measurements of success with a multidisciplinary program as outlined previously would be challenging. The baseline expectation of curriculum completion can be determined by resident participation in discussions and completion of the modules. Last year, our senior residents were presented with completion certificates. We have not implemented a formal testing modality to ensure that their retention of the information is appropriate but have implemented questions regarding QI and PS in M&M, Journal Clubs, and day-to-day patient care to assess their knowledge. QI and PS projects are assessed with required presentations. One of our residents presented her PS project, “Safety Culture: Perception vs. Reality” at the Wisconsin Surgical Society (a chapter of the American College of Surgeons). The findings were surprising to our QI and PS
20
REFERENCES 1. American College of Surgeons National Surgical Quality
Improvement Program. Available at: http://site.acsnsqip. org. Accessed September 17, 2013. 2. Institute for Healthcare Improvement Open School.
Available at: http://www.ihi.org/offerings/IHIOpenSchool/ courses/pages/default.aspx. Accessed August 29, 2013. 3. Sellers MM, Reinke CE, Kreider S, et al. American
College of Surgeons NSQIP: quality in-training initiative pilot study. J Am Coll Surg. in press. doi:pii: S10727515(13)00503-6. 10.1016/j.jamcollsurg.2013.07.005. 4. Morales CS, Kontonicolas F, Volpe AA, Saldinger PF,
Fukumoto R. Performance improvement: getting an early start. J Surg Educ. 2012;69(6):774-779.
Journal of Surgical Education Volume 71/Number 1 January/February 2014
