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Patient safety for residents

This document outlines the quality improvement and patient safety curriculum for the residency program at the University of California, San Francisco Department of Medicine. It includes an introduction that provides the rationale for teaching QI and PS to residents. It then describes the global goals and objectives of the curriculum, as well as the core concepts and tools taught. An overview of how the curriculum maps to ACGME milestones is presented. The document provides details on how the curriculum is organized and delivered, including descriptions by program, training site, and year. It concludes by discussing next steps for the curriculum. The goal of the curriculum is to prepare physicians to provide safe, high-quality, patient-centered care and cultivate future leaders in healthcare quality improvement

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Curricular Blueprint Residency Curriculum in Quality Improvement and Patient Safety Department of Medicine University of California, San FranciscoUniversity of California, San Francisco June 2012 Krishan Soni Chief Resident for Quality and Safety Sumant Ranji Associate Program Director
I. Rationale for Teaching QI and PS II. Global Goals and Objectives III. Core Concepts and Tools IV. Mapping to ACGME Milestones UCSF Quality Improvement and Patient Safety Curriculum IV. Mapping to ACGME Milestones V. Overview - Organization and Delivery VI. Detailed Description by Program VII. Next Steps 2
I. Rationale for Teaching Quality Improvement and Patient Safety to Residents UCSF Quality Improvement and Patient Safety Curriculum • Patients expect physicians to provide safe, effective, and high value care • Regulatory agencies (ACGME, Residency Review• Regulatory agencies (ACGME, Residency Review Committees) are demanding that residency programs integrate safety and quality training into the curriculum • Residents are interested in learning and acquiring tools to provide high quality, cost effective care that will be necessary to their future practice 3
II. Goals and Objectives of the UCSF Residency Program’s Quality and Safety Curriculum UCSF Quality Improvement and Patient Safety Curriculum • Prepare physicians to be stewards of safe, high quality, high value, patient centered care • Teach key principles of quality improvement, patient safety, and• Teach key principles of quality improvement, patient safety, and systems innovation to all residents in our training programs • Develop a culture of safety and quality that trainees will carry with them throughout their career • Cultivate future leaders in healthcare quality and systems innovation 4
III. Core Concepts and Tools Necessary to the Practice of Safe, High Quality, Patient Centered Medicine UCSF Quality Improvement and Patient Safety Curriculum Error & Systems Analysis Effective Handoffs Patient Satisfaction LeadershipSafe Discharge Planning Models for Quality Improvement Patient Panel Management High Value Healthcare Healthcare Policy 5
IV. Mapping ACGME Milestones to UCSF Curriculum UCSF Quality Improvement and Patient Safety Curriculum Practice-Based Learning Learn and Improve via Audit of Performance Systems-Based Practice Work effectively with other Improve the quality of care for a panel of patients Work effectively within Core Competency ACGME Milestone UCSF Patient Panel Management QI Work effectively with other care providers and settings Improve health care delivery Cost-effective care for patients and populations Interpersonal and Communication Skills Work effectively within • Multiple health delivery systems • An inter-professional team Recognize system error and advocate for system improvement Identify forces that impact the cost of healthcare, advocate for and practice cost-effective care Transitions of care Effective Handoffs Safe Discharge Planning Error & Systems Analysis Effective Handoffs Safe Discharge Planning High Value Healthcare 6
I. Rationale for Teaching QI and PS II. Global Goals and Objectives III. Core Concepts and Tools IV. Mapping to ACGME Milestones UCSF Quality Improvement and Patient Safety Curriculum IV. Mapping to ACGME Milestones V. Overview - Organization and Delivery VI. Detailed Description by Program VII. Next Steps 7
Background: Residency Program Sites UCSF medicine residents spend 3 years rotating through the inpatient medical service and outpatient clinics at four geographically separate sites. Inpatient+outpatient UCSF Medical Center Tertiary Care University Medical Center San Francisco Veteran’s Affairs Medical Center Federal government facility for US Veterans San Francisco General Hospital City & County Hospital UCSF Mount Zion Hospital Outpatient General Medicine Clinics Inpatient+outpatientPrimarilyOutpatient 8
Background: Quality & Safety Curriculum Overview • The Residency Quality Improvement and Patient Safety Curriculum is organized across all four sites and addresses both inpatient and outpatient training. • The curriculum is longitudinal and strives to develop resident competencies in QI and PS skills over three years of training. All residents are expected to develop a set of core competencies, while more advanced training is available for those with interest. • Education takes place through a series of: • Core Didactic Lessons • Case Based Discussions • QI and PS Rotations • Longitudinal QI projects • Electives and pathways for those with deeper interests Core Didactics (Years 1-3) Case Based Discussions (Years 1-3) Core QI Rotation (Year 1) Longitudinal Projects (Years 1-3) Electives, Pathways, Projects (Years 2-3) Foundation in QI & PS Advanced QI & PS 9
Background: Quality & Safety Curriculum Overview • The curriculum is broadly divided into 4 primary themes: • Inpatient QI + PS Training • Ambulatory QI + PS Training • Care Transitions • Electives in Advanced QI and Health Systems Inpatient QI + PS • Focused on improving care in Ambulatory QI + PS • Focused on improving care in• Focused on improving care in hospitalized patients • Conducted during residents inpatient training months • Focused on improving care in ambulatory patients • Conducted during residents ambulatory training months Care Transitions • Focused on maintaining patient safety during transitions between inpatient providers and on discharge from the hospital Electives in Advanced QI + PS • Opportunities for those with a special interest in QI and PS to gain advanced experience through training and projects 10
Curriculum Overview Across all Training Years Inpatient QI + PS Patient Safety M&M ConferencePatient Safety M&M Conference PQJ Rotation Housestaff IncentiveHousestaff Incentive Cost of Care ConferencesCost of Care Conferences QI Case ConferencesQI Case Conferences Inpatient DashboardsInpatient Dashboards Year 1 Year 2 Year 3 The key elements of the UCSF quality improvement and patient safety curriculum are shown below. Further detail is shown on the following slides. Care Transitions Effective Sign outEffective Sign out Safe Discharge +EPASafe Discharge +EPA QI ElectiveQI ElectiveElectives in Advanced QI / Health Systems HSL PathwayHSL Pathway Ambulatory QI + PS SFGH GEMSSFGH GEMS VAMC EDPACTVAMC EDPACT ZIONZION Amb ½ Day SFGH GEMSSFGH GEMS VAMC EDPACTVAMC EDPACT ZIONZION Amb ½ Day SFGH Ambulatory QI M&MSFGH Ambulatory QI M&M SFGH GEMSSFGH GEMS Quality and Safety Innovations Challenge Safe DischargeSafe Discharge
Inpatient QI Training Details Inpatient QI + PS Patient Safety M&M ConferencePatient Safety M&M Conference PQJ Rotation Housestaff IncentiveHousestaff Incentive Cost of Care ConferencesCost of Care Conferences QI Case ConferencesQI Case Conferences Inpatient DashboardsInpatient Dashboards Year 1 Year 2 Year 3 The inpatient curriculum focuses on teaching methods to deliver high value and safe patient care while understanding the potential harms and costs of inpatient medical care PQJ Rotation (Procedures, Quality, Jeopardy) • Foundational 2 week rotation all interns. • Interns learn core QI and PS concepts through: • 6 core didactic sessions • 2 projects – a patient safety case review; cost analysis of a medical case • Readings and online web modules Cost of Care Conferences • Monthly case based conference for all residents. • We review management of a medical case treated at UCSF and discuss evidence based guidelines and the hospital charges associated with care. Error & Systems Analysis High Value Healthcare High Value Healthcare
Inpatient QI Training Details (2) QI Case Conference and Inpatient M&M Conference • After completing a structured case review of a medical error, adverse event, or near miss, an intern presents the case to an audience of residents during a lunch conference. • All residents have an opportunity to discuss the case, learn key concepts in patient safety and reflect on their own practice. Housestaff Incentive Program • A financial incentive program developed by the medical center to incentivize all staff to participate in improvement of key quality metrics. Error & Systems Analysis all staff to participate in improvement of key quality metrics. • We have developed our own improvement goals, including improving communication with PCPs and timely completion of discharge summaries • Residents continuously monitor, evaluate, and make adjustments to improve performance. Inpatient Dashboards (in development) • Continuous feedback of relevant patient care metrics to housestaff in a specific, timely, and actionable way. • Aims to mirror increasing efforts to provide physicians with performance data at a national level • Possible metrics: patient satisfaction, length of stay, utilization of labs and radiology. Patient Panel Management Patient Satisfaction Quality Improvement
Ambulatory QI Training Details Year 1 Year 2 Year 3 Ambulatory QI + PS SFGH GEMSSFGH GEMS VAMC EDPACTVAMC EDPACT ZIONZION Amb ½ Day SFGH GEMSSFGH GEMS VAMC EDPACTVAMC EDPACT ZIONZION Amb ½ Day SFGH GEMSSFGH GEMS The ambulatory curriculum focuses on teaching methods to heighten awareness of patient safety issues in the outpatient setting, and provides residents with a hands-on experience to engage in a quality improvement project in their clinic. SFGH Ambulatory QI M&MSFGH Ambulatory QI M&M Clinic Specific Curricula • Educational sessions are clinic based, and are tailored to the needs of each clinic site (SFGH, VAMC and Mount Zion) • All sites include didactic sessions covering core topics in ambulatory patient safety, error analysis, and QI Improvement tools • Residents at each site have an opportunity to develop and conduct their own QI longitudinal projects. Approximately 2-5 projects/clinic site. Ambulatory QI M&M • Developed this year, the Ambulatory M&M is a bimonthly case based conference to discuss medical errors and adverse events in the SFGH GMC. Patient Panel Management Error & Systems Analysis Quality Improvement
Care Transitions Training Details Care Transitions Safe Discharge +EPASafe Discharge +EPA Year 1 Year 2 Year 3 Given the association of errors and adverse events associated with transitions in care, a renewed emphasis has been placed on educating trainees on safe and effective handoffs of care. This curriculum focuses on improving handoffs both between providers in the inpatient setting and improving communication and coordination of an entire discharge plan to the ambulatory setting. Effective Sign outEffective Sign out Safe DischargeSafe Discharge Effective Signout • Starting early in orientation, interns are given a model for effective signout communication. • During noon conference sessions and morning report, they are given an opportunity to practice these skills, to evaluate their piers, and to reflect on their own performance Safe Discharge • Through a series of noon conference sessions and morning reports, all residents are given a toolkit to address the principles of safe discharge. • Interns are extensively evaluated on their discharge communication (EPA). Effective Handoffs Safe Discharge Planning
Advanced QI & Health Systems Training Details QI ElectiveQI ElectiveElectives in Advanced QI / Health Systems HSL PathwayHSL Pathway Year 1 Year 2 Year 3 Quality and Safety Innovations Challenge Three structured options are available for residents wishing to pursue more advanced training in quality improvement, patient safety and systems redesign. QI Elective • Available for senior residents, this one month elective provides one on one• Available for senior residents, this one month elective provides one on one mentorship to deepen the experience with QI projects. Residents build their QI and PS skills through: • Additional readings and online web materials • Participation in several ongoing QI projects in the medical center • Participation in QI or PS committee activities in the department or med center • Development of their own QI project based on interest The Quality and Safety Innovations Challenge (QSIC) • Encourages active trainee participation in QI/PS projects by providing ongoing mentorship for project development and a forum for projects and posters to be presented at the end of the year.
Advanced QI & Health Systems Training Details HSL Pathway • A two year longitudinal curriculum designed to help residents build skills in leadership, health policy analysis, and health systems redesign. • As part of this pathway, during their ambulatory months, residents engage in: • Discussions with invited speakers from the realms of health policy, health administration, academia, and the private sectors • Weekly discussions of current literature in the policy and QI arenas Leadership Healthcare Policy • Intensive didactics in leadership, healthcare policy, and systems redesign • Yearly group project focusing on an important policy or systems redesign issue. Past projects include: • An analysis of prolonged Emergency Room admitting time with a presentation to the senior leadership of the UCSF Medical Center • Development of a model to increase efficiency and decrease costs of ambulatory care in high cost centers. Results were presented to the board of directors for a major group of healthcare purchasers
I. Rationale for Teaching QI and PS II. Global Goals and Objectives III. Core Concepts and Tools IV. Mapping to ACGME Milestones UCSF Quality Improvement and Patient Safety Curriculum IV. Mapping to ACGME Milestones V. Overview - Organization and Delivery VI. Detailed Description by Program VII. Next Steps 18
VI. Detailed Description by Program A. Curriculum by training site B. Curriculum by year C. Procedures, Quality, Jeopardy Rotation D. Inpatient QI M&M Conferences UCSF Quality Improvement and Patient Safety Curriculum D. Inpatient QI M&M Conferences E. Cost Awareness F. Housestaff Incentive Program G. Ambulatory QI/PS H. Transitions: Signout I. Transitions: Discharge 19
QI Curriculum by Training Site The UCSF Chief Resident for QI/PS implements the Quality Improvement and Patient Safety curriculum at 3 training sites. UCSF Medical Center Parnassus/MTZ San Francisco Veteran’s Affairs Medical Center San Francisco General HospitalParnassus/MTZ Affairs Medical Center Hospital Inpatient Activities Outpatient Activities CR Time 40% 40% 20% • PQJ Rotation (21/67) • PQJ Conference (12) • Cost Awareness (11) • Housestaff Incentive • QI Elective (5 months) • HSL • Inpatient QI M&M (10) • EDPACT Activities (22/48 conferences) • Inpatient QI M&M (9) • Ambulatory QI M&M (5) • GMC QI/PS Sessions (8) Tri Hospital Activities • Discharge Curriculum (7 at each site) • Signout Curriculum (7 at each site) • Discharge Curriculum (7 at each site) • Signout Curriculum (7 at each site) • QSIC • Ambulatory Half Day (2) • QSIC • Ambulatory Half Day (2)
QI/PS Educational Curriculum – INTERNS (First Year) Inpatient QI/PS Patient Safety M&MPatient Safety M&M PQJ RotationPQJ Rotation Housestaff IncentiveHousestaff Incentive Cost of Care ConferencesCost of Care Conferences QI Case ConferencesQI Case Conferences Inpatient DashboardsInpatient Dashboards Participants/Site All IM Interns While at Moffitt While at Moffitt While on Moffitt Wards While on Moffitt Wards All Interns, All Sites Time Frame One Month Monthly, year long Year Long Year Long Monthly, Year Long Monthly, year long Care Transitions Effective Sign outEffective Sign out Safe Discharge +EPASafe Discharge +EPA Electives in Advanced QI / Health Systems Ambulatory QI/PS All Sites SFGH Ambulatory QI M&MSFGH Ambulatory QI M&M MoffittAmbulatory Quality and Safety Innovations Challenge Quality and Safety Innovations Challenge Legend SFGH GEMSSFGH GEMS SF Clinic Interns SF Clinic Interns Year Long Bi-Monthly, year long All Interns, All Sites All Interns, All Sites Summer/Fall Summer/Fall All Interns, All Sites Year Long
QI/PS Educational Curriculum – R2 + R3’s (2nd and 3rd Year) Inpatient QI/PS Patient Safety M&M Housestaff IncentiveHousestaff Incentive Cost of Care ConferencesCost of Care Conferences QI Case ConferencesQI Case Conferences Inpatient DashboardsInpatient Dashboards Ambulatory QI/PS Participants/Site While at Moffitt While at Moffitt While on Moffitt Wards While on Moffitt Wards All Residents, All Sites Time Frame Monthly, year long Year Long Year Long Monthly, Year Long Monthly, year long Ambulatory ½ DayAmbulatory ½ Day All Residents One Session - Fall Care Transitions Safe Discharge Electives in Advanced QI / Health Systems All Sites SFGH Ambulatory QI M&MSFGH Ambulatory QI M&M MoffittAmbulatory QSIC Legend Clinic QI ProjectClinic QI Project All Residents SF Clinic Residents Year Long Bi-Monthly, year long All Residents, All Sites Summer/Fall All Interns, All Sites Year Long QI ElectiveQI Elective HSL PathwayHSL Pathway Ambulatory ½ Day All Residents One Session - Fall Self Selected One Month Self Selected 2 year course
In total, 185 hours of QI/PS didactic sessions were programmed and delivered during the 2011-2012 academic year. UCSF Quality Improvement and Patient Safety Curriculum PQJ Curriculum (year round) (month startson 22nd) Session Frequency Location Timing June July August Sept Oct Nov Dec Jan Feb Mar 1. Intro to Patient Safety Monthly Moffitt Tuesday AM Tue 7/5 Thu 7/28 Thu 8/25 Tue 9/27 Thu 10/27 Mon 11/28 Tue 1/10 Wed 1/25 Mon 2/27 Tue 3/27 2. Intro to Cost Awareness Monthly Moffitt Tuesday AM Tue 8/2 Tue 8/30 Tue 10/4 Tue 11/1 Tue 12/6 Mon 1/30 Thu 3/1 Wed 3/28 3. Review of Cost Awareness Case Monthly Moffitt Tuesday AM Tue 9/6 Tue 10/11 Tue 11/8 Tue 12/13 Mon 2/6 Thu 3/8 Thu 4/5 4. Intro to Quality Improvement Monthly Moffitt Tuesday AM Thu 7/7 Tue 8/9 Tue 9/13 Wed 10/12 Tue 11/15 Thu 12/15 Fri 1/13 Wed 2/8 Mon 3/5 Tue 4/10 5. Intro to Change Management Monthly Moffitt Tuesday AM Mon 7/11 Tue 8/16 Mon 9/19 Tue 10/18 Thu 11/17 Mon 12/19 Tue 1/17 Mon 2/13 Mon 3/12 Wed 4/11 6. Intro to Patient Satisfaction Monthly Moffitt Tuesday AM Mon 7/18 Thu 8/18 Wed 9/21 Mon 10/10 Mon 11/21 Thu 12/1 Fri 1/20 Mon 2/20 Mon 3/19 Tue 4/17 Regular QI Conference Schedule (year round) Conference Series Frequency Location Timing June July August Sept Oct Nov Dec Jan Feb Mar PQJ QI Conference Monthly Moffitt Last week of intern monthFri 6/17 Mon 7/18 Thu 8/18 Tue 9/13 Mon 10/10 Fri 11/18 Mon 12/19 Fri 1/20 Fri 2/17 Tue 3/13 PQJ Cost Awareness Conference Monthly Moffitt Last week of intern monthMon 6/20 Mon 7/11 Mon 8/15 Mon 9/12 Fri 10/21 Fri 11/11 Fri 12/16 Mon 2/20 Fri 3/16 Monthly Tri-Hosp QI M&M Monthly VAMC M,W, or F Wed 7/27 Fri 9/30 Mon 10/31 Mon 11/14 Wed 12/21 Wed 1/18 Wed 2/29 Wed 3/28 Monthly Tri-Hosp QI M&M Monthly SFGH WEDNESDAY Wed 7/6 Wed 8/10 Wed 9/14 Wed 10/19 Wed 11/9 Wed 12/14 Wed 1/11 Wed 3/14 Bi-Monthly SFGH Outpatient QI M&MBi-Monthly SFGH FRIDAY B A B Fri 9/9 Fri 10/14 A Fri 12/9 B A Fri 3/9 Short Series QI Conferences (occur in Fall only) 23 Short Series QI Conferences (occur in Fall only) Conference Series Frequency Location Timing June July August Sept Oct Nov Signout Curriculum Noon Conf Monthly x2 Moffitt Aug, Oct Mon 8/8 Fri 10/14 Signout Curriculum Noon Conf Monthly x2 VAMC Aug, Oct Fri 8/5 Fri 11/4 Signout Curriculum Noon Conf Monthly x2 SFGH Aug, Oct Fri 8/12 Fri 10/14 Signout Curriculum Intern Report Once 3 SITES July Thu 7/28 Discharge Curriculum Noon Conf Monthly x2 Moffitt Sept, Oct Thu 9/1 Mon 10/3 Discharge Curriculum Noon Conf Monthly x2 VAMC Sept, Oct Wed 9/21 Mon 11/7 Discharge Curriculum Noon Conf Monthly x2 SFGH Sept, Oct Mon 9/19 Mon 10/3 Discharge Curriculum Intern Report Once 3 SITES September Thu 9/29 Ambulatory QI Half Day Twice Zion Sept, Oct Fri 9/23 Fri 10/14 VAMC EDPACT Conferences (Occur during PI Blocks - Nov/Dec, Mar/Apr) Session Frequency Location Timing Tue/Wed Thur/Fri Tue/Wed Thur/Fri 1. Intro to PI Curriculum 1x per group EDPACT Nov, Dec Tue 11/1 Thu 11/3 Tue 12/6 Thu 12/1 2. Practice Data: QI Priorities 1x per group EDPACT Nov, Dec Tue 11/1 Thu 11/3 Tue 12/6 Thu 12/1 3. Systems Approach to Change 1x per group EDPACT Nov, Dec Wed 11/2 Fri 11/4 Fri 12/9 Fri 12/2 4. PDSA Cycle and Tools 1x per group EDPACT Nov, Dec Tue 11/8 Thu 11/10 Tue 12/13 Thu 12/8 5. Plan and Implement Project 1x per group EDPACT Nov, Dec Tue 11/8 Thu 11/10 Tue 12/13 Thu 12/8 6. PS 1: Root Cause Analysis 1x per group EDPACT Nov, Dec Tue 11/15 Thu 11/17 Wed 12/14 Fri 12/9 7. PS 2: Failure Modes Effects Analy 1x per group EDPACT Nov, Dec Wed 11/16 Fri 11/18 Wed 12/21 Fri 12/16 8. Patient Safety Journal Club #1 1x per group EDPACT Mar, Apr Tue 3/6 Thu 3/8 Tue 4/3 Thu 4/5 9. Trainee Led RCA #1 1x per group EDPACT Mar, Apr Wed 3/21 Thu 3/15 Tue 4/17 Thu 4/12 Trainee Led RCA #2 1x per group EDPACT Mar, Apr Fri 3/16 Fri 4/20 10. Panel Management Session 1x per group EDPACT Mar, Apr Tue 3/20 Thu 3/29 Tue 4/24 Thu 4/19 11. QI Work in Progress 1x per group EDPACT Mar, Apr Tue 3/6 Thu 3/15 Tue 4/24 Thu 4/26 QI Work in Progress #2 1x per group EDPACT Mar, Apr Wed 4/18 Fri 4/27 Block A (NOV/MAR) Block B (DEC/APR) SFGH GMC Clinic Conferences (Jan-April) Session Frequency Location Timing Mon Tues 1. AIM Statements and PDSA 1x per group GMC Jan Mon 1/30 Tue 1/31 2. Measuring for QI 1x per group GMC Feb Mon 2/27 Tue 2/28 3. Ambulatory Safety and Tools 1x per group GMC Mar Mon 3/26 Tue 3/27 4. Analysis of Project to date 1x per group GMC Apr Mon 4/23 Tue 4/24
Procedures, Quality, and Jeopardy Rotation UCSF Quality Improvement and Patient Safety Curriculum Procedures, Quality, and Jeopardy Rotation 24
The Intern Procedure, Quality, and Jeopardy (PQJ) rotation forms the foundation of QI/PS teaching in the residency program. FOUNDATION: Intern PQJ Rotation Six Core Didactic Sessions (Topics Covered): • Session 1: Fundamentals of Patient Safety and Systems Analysis • Introduction to error analysis • Latent/active errors/adverse events/near misses • Systems redesign • Session 2/3: Value and Quality in Healthcare• Session 2/3: Value and Quality in Healthcare • Session 4: Quality 101: Defining and Measuring Quality • Introduction to IHI Model for Improvement • Session 5: Improving Healthcare Quality - Change Management • Session 6: Patient Centered Care (Satisfaction) 25 Two One-Week Long Projects: I. Patient Safety Case Review II. Cost Awareness – Case Analysis
PQJ: Evaluation Interns complete a brief survey of QI/PS knowledge, attitudes and skills before and after the rotation. FOUNDATION: Intern PQJ Rotation Areas Tested: • Basic concepts in Patient Safety • Medical Errors • Adverse Events 26 • Adverse Events • QI Methodology • Writing SMART Statements • Using Measurement • Studying Processes • Making Changes • Using PDSA Analysis Ongoing
Inpatient QI M&M Conferences UCSF Quality Improvement and Patient Safety Curriculum Inpatient QI M&M Conferences 27
The QI M&M is a monthly noon conference at each site dedicated to addressing medical errors and adverse events Inpatient QI M&M Conferences Goal: To provide a safe environment to discuss cases from the inpatient medical service which highlight issues in patient care related to systems of care, care processes, care transitions, professionalism, and inter-professional communication. Specific Objectives: • Understanding and analyzing errors and adverse events • Identifying systems failures and opportunities to improve systems • Embracing a multidisciplinary approach as the standard • Integrating lessons into a culture of quality and safety 28
The QI M&M Conferences were successfully conducted across all three inpatient sites. Inpatient QI M&M Conferences • This year, 31 conferences were held across the sites • Moffitt: 12 conferences • SFGH: 9 conferences • VAMC: 10 conferences • Example topics covered to date: • Errors in communication with consults • Failure of communication among team members (handoffs) • Adverse events associated with hospital discharge • Errors regarding triage to proper level of care • Medication errors on discharge • Medication errors during procedures • Evaluation to date: None 29
Cost Awareness Curriculum UCSF Quality Improvement and Patient Safety Curriculum Cost Awareness Curriculum 30
At the end of this curriculum, interns should be able to: UCSF Cost Effective Care Curriculum: Objectives Specific objectives for PGY1 residents In the PGY1 year, receive an in depth cost awareness curriculum during the Procedures, Quality, Jeopardy (PQJ) rotation. 1. Understand evidence based guidelines 31 2. List the approximate costs of different tests at our university hospital 3. Recognize cost-inefficient medical practices 4. Reflect on their own ordering practices 5. Critique current cost-inefficient medical practices at our hospital
UCSF Cost Effective Care Curriculum: What’s the Process? Process: How the curriculum is delivered The cost awareness curriculum is delivered longitudinally through a monthly series of didactic and experiential learning sessions. 1. Upper GI Bleed 2. Acute Kidney Injury 3. Chest Pain • We selected 12 “core topics” of commonly encountered clinical scenarios with frequent practice and resource-utilization variability Delivery Core Topics 32 3. Chest Pain 4. Syncope 5. Pulmonary Embolism 6. Low Back Pain 7. Pre-Operative Testing 8. Cellulitis 9. Headaches 10. Altered Mental Status 11. Anemia 12. Urinary Tract Infection practice and resource-utilization variability • We created a longitudinal curriculum with two key components: •Experiential: Interns review a medical case, including guidelines and cost associated with the workup during a dedicated QI rotation •Didactic: A monthly case-based conference consolidating the findings from the case review is presented for medical students, residents, and attendings
UCSF Cost Effective Care Curriculum: What’s the Process? Description Time/Learners • 60 minutes • 5-6 PGY1s • 2-3 hours Small group session: Principles of cost awareness introduced in a case based learning conference. Group Project: A case Introduction “Core” topic and case assigned Interns divide into two groups Activity Process: How the curriculum is delivered The central experience for PGY1’s is a structured case review. 33 • 2-3 hours independently over 1 week • 5-6 PGY1s Group Project: A case demonstrating a common medical workup is assigned to the interns. Interns work in small groups review literature and apply evidence based guidelines to understand clinical and cost effective approaches to management. Dissemination: Learnings and best practices from the project are consolidated and shared at an interactive lunch conference with ALL residents each month. • 60 minutes • Medical Students • Residents (all levels) • Faculty Interns divide into two groups Guideline Review • Review literature Find evidence based best- practice guidelines • Suggest cost effective workups Case Analysis • Review recent case from our intuition • Analyze hospital bill, and clinical chart to evaluate care provided Case review debrief Case based noon conference for ALL residents
UCSF Cost Effective Care Curriculum: Evaluation Evaluation: How did learners perceive the curriculum? Pilot data indicates that residents find this curriculum highly relevant to their clinical practice, and likely to change behavior. • Overall, respondents reported that the conferences were: • To date, we have received 151 evaluations from eight conferences that the conferences were: • Highly relevant to their clinical practices (mean 4.51 +/- 0.63 on a 5- point Likert scale) • Likely to change their ordering behaviors (mean 4.24 +/- 0.72) 34
This project was successfully received by residents, and has been shown in abstract format at multiple conferences. UCSF Cost Effective Care Curriculum: Scholarly Dissemination 35
Housestaff Incentive Program UCSF Quality Improvement and Patient Safety Curriculum Housestaff Incentive Program 36
The Medical Center Housestaff Incentive Program (HIP) for all residents included 3 goals for the 2011-2012 academic year. Housestaff Incentive Program • Patient Satisfaction 37 • Hand Hygiene • Lab Utilization
Additionally, the Department of Medicine sponsored it’s own Incentive Program in 2011-2012 for Medicine Residents. GOAL: To improve documentation of Advance Care Planning wishes in the Discharge Summary to greater than 75% for all patients admitted to the medical service. Housestaff Incentive Program 38
This project has been very successful (goal met), and has been shown in abstract format at multiple conferences. Housestaff Incentive Program 39
Ambulatory QI UCSF Quality Improvement and Patient Safety Curriculum Ambulatory QI 40
VAMC EDPACT Curriculum Ambulatory QI: VAMC • Patient Communication Inter- Professional Communication Practice Improvement 1 Advanced Communication Practice Improvement 2 Transitions in patient care July/Aug Sept/Oct Nov/Dec Jan/Feb Mar/April May/June • EDPACT learners include second year medicine residents and NP Students • The curriculum is divided into 6 core themes, each taught over the course of one month while residents are on block. • Two blocks are dedicated to Performance Improvement (PI) • During the PI Modules, residents and NPs have didactic sessions and work on clinic QI projects. • QI/PS Didactics include: • Intro to Root Cause Analysis, FMEA, IHI Model for Improvement, QI Measurement Tools, Process Mapping 41
VAMC EDPACT QI/PS Didactic Sessions Ambulatory QI: VAMC (1) Intro to the (2) Practice (3) Systems Eleven 90-minute didactic sessions were held during the 2 performance improvement blocks (8) Patient (9) Trainee Led 42 (1) Intro to the Performance Improvement Curriculum (2) Practice Data: QI Priorities (5) Plans to Implement QI Projects (6) Patient Safety: Root Cause Analysis (3) Systems Approach to Change (4) PDSA Cycle and Tools (8) Patient Safety Journal Club (9) Trainee Led Root Cause Analysis (7) Patient Safety: Failure Modes & Effects Analysis (10) Panel Management Session (11) QI Works in Progress Block1 Block2 QI Patient Safety
6 Clinic Based QI Projects were completed over a six month period (Nov-May): Ambulatory QI: VAMC Medical Practice Clinic: VAMC EDPACT QI Projects 43 Medical Practice Clinic: – Improve medication refill process in clinic – Improving surveillance rates of HA1c among diabetics – Improve coordination of a 48 hour post discharge phone call – Improve rate of LDL checked annually in diabetic patients Community Based Outpatient Clinics: – Improve HCV primary care measures – Improve healthcare maintenance compliance
Ambulatory QI: VAMC Projects VAMC EDPACT QI Projects (1 of 6) 44
Ambulatory QI: VAMC Projects VAMC EDPACT QI Projects (2 of 6) 45
Ambulatory QI: VAMC Projects VAMC EDPACT QI Projects (3 of 6) 46
Ambulatory QI: VAMC Projects VAMC EDPACT QI Projects (4 of 6) 47
Ambulatory QI: VAMC Projects VAMC EDPACT QI Projects (5 of 6) 48
Ambulatory QI: VAMC Projects VAMC EDPACT QI Projects (6 of 6) 49
SFGH General Medicine Clinic (GMC) Ambulatory QI: SFGH SFPC Curriculum Categorical Curriculum The Primary Care (SFPC) Residents and the categorical GMC residents each receive a unique QI curriculum during their continuity clinic experience. All residents in the HEAAT pathway attend ambulatory Patient Safety M&M conferences on Friday mornings. 50 SFPC Curriculum Categorical Curriculum Didactics: 9-10 half day sessions (Thursday Mornings) during block time Project: Required individual (or small group) QI project Didactics: Four 45 minute sessions dedicated to Patient Safety of QI during GEMS time (Monday and Tuesday) Project: Group clinic QI for all residents in a particular clinic day Ambulatory M&M Patient Safety Conferences
SFGH General Medicine Clinic Ambulatory QI: SFGH Categorical GEMS Curriculum: • Curriculum is taught during a 30 min didactic session each month. • Residents have an additional 30 minute clinic slot every 2 weeks for panel management and admin time. • GEMS Sessions Include: • Intro to GEMS & Huddle with primary preceptor• Intro to GEMS & Huddle with primary preceptor • Managing your Mailbox • Managing your e-referral Worklist • How to use QI data & Intro to the Firm QI Metrics Challenge • Huddle with MEAs • Chronic Pain Management • Buprenorphine • Panel Management • Effective Note writing • Working with RCNPs • Remote Communication/ Telephone Visits • Interpreters 51
SFGH General Medicine Clinic Ambulatory QI: SFGH Categorical QI Sessions: • Four 45 min didactic sessions covering core QI topics taught monthly, January through April. Sessions also allow time for advancement of clinic-based QI projects. QI Session Topics: 52 1. AIM statements and PDSA cycles 2. Measuring for QI • Review process, outcome, and balancing measures 3. Ambulatory safety and safety tools: • Introduction of RCA and fishbone 4. Analysis of project to date: • Revisit AIM statement, compare current metrics with baseline metrics, adjust project
SFGH Categorical Clinic Projects Ambulatory QI: SFGH Two QI projects were completed during the 2011-2012 academic year (1 of 2) 53
SFGH Categorical Clinic Projects Ambulatory QI: SFGH Two QI projects were completed during the 2011-2012 academic year (2 of 2) 54
The ambulatory patient safety M&M is a bi-monthly 60- minute conference dedicated to reviewing cases in the General Medicine Clinic at SFGH. Ambulatory QI: SFGH M&M Conferences Goal: To provide a safe environment to discuss cases which highlight issues in patient care related to ambulatory systems of care, care processes, care transitions, professionalism, and inter-professional communication.communication. Specific Objectives: • Understanding and analyzing errors and adverse events • Identifying systems failures and opportunities to improve systems • Embracing a multidisciplinary approach as the standard • Integrating lessons into a culture of quality and safety Five Conferences were held during the 2011-2012 academic year 55
Signout UCSF Quality Improvement and Patient Safety Curriculum Effective Handoffs Signout 56
Signout Curriculum Signout Curriculum Objectives: To create and deliver a brief curriculum with didactics, repetition, and real time feedback, targeted towards improving the consistency and quality of intern signout. The curriculum emphasizes: 1. The opportunity for medical errors when inter-professional communication is poor 2. The importance of MD to MD signout Effective Handoffs 2. The importance of MD to MD signout 3. Techniques for high quality and consistent written and verbal signout 4. Opportunities for practice/repetition of techniques and feedback on written/verbal signout 57 Intern Orientation (6/17) 1st Rotation (6/21-7/21) 2nd Rotation (7/22-8/21) Noon Conf VA: 8/5 Moffitt: 8/8 SFGH: 8/12 3nd Rotation (8/22-9/21) Noon Conf Early Oct VA, SFGH, Moffitt: TBS Intern Report 7/28 JULY AUGUST SEPTEMBER 4th Rotation (9/22-10/21) OCTOBER Sessions & Timeline:
Discharge UCSF Quality Improvement and Patient Safety Curriculum Safe Discharge Planning Discharge 58
Discharge Curriculum Discharge Curriculum Objectives: To create and deliver a brief curriculum with didactics, repetition, and real time feedback, targeted towards improving the consistency and quality of discharge plans. This mini-course will lay the groundwork for the rollout of the Discharge Entrustable Professional Activity (EPA) in the fall of 2011. The curriculum emphasizes: Safe Discharge Planning The curriculum emphasizes: 1. The importance of discharge plans in providing safe patient care and reducing preventable readmissions 2. A framework for thinking about the entire discharge plan (using a simple checklist) 3. Techniques for high quality, timely, and consistent discharge summaries 4. The essential elements clear communication at discharge 5. Opportunities for practice/discussion of the elements of discharge planning
Discharge Curriculum Sessions & Timeline Discharge Curriculum Safe Discharge Planning Four sessions were held during the first 4 months of the academic year: • Intern Half Day: 1 hour didactic session demonstrating good practices in writing discharge summaries. • Noon Conference : 2 lunchtime sessions which briefly cover objectives 1-4 above. • Review of Discharge Summaries at Intern Report: Interns were an opportunity to review and give feedback on the quality of their own discharge summaries. Intern Half Day (7/8 & 7/15) 1st Rotation (6/21-7/21) 2nd Rotation (7/22-8/21) Noon Conf UCSF: 9/1 SFGH: 9/19 VAMC: 9/21 3nd Rotation (8/22-9/21) Noon Conf UCSF: 10/3 SFGH: 10/3 VAMC: TBD Intern Report 9/29 JULY AUGUST SEPTEMBER 4th Rotation (9/22-10/21) OCTOBER EPA Rollout Faculty Development Resident / Intern Teaching Sessions Entrustable Professional Activity Intern Rotations Rollout Portfolio to review and give feedback on the quality of their own discharge summaries.
The discharge intern report session was well received by the interns. The curriculum was presented in abstract form at multiple conferences and won a Cooke Award for Teaching at the UCSF Medical Education Day. Discharge Curriculum Safe Discharge Planning
I. Rationale for Teaching QI and PS II. Global Goals and Objectives III. Core Concepts and Tools IV. Mapping to ACGME Milestones UCSF Quality Improvement and Patient Safety Curriculum IV. Mapping to ACGME Milestones V. Overview - Organization and Delivery VI. Detailed Description by Program VII. Next Steps 62
Four potential areas to target for improvement in 2012-2013… Next Steps • Outpatient QI: Expand ambulatory QI/PS curriculum to include Mount Zion Medical Clinic • Patient Care Data: Continue efforts to build systems for ongoing patient care data feedback to residents in the inpatient andpatient care data feedback to residents in the inpatient and outpatient settings • Integration: Continue to improve integration of QI/PS teaching across all sites • Evaluation: Develop a robust evaluation system to better understand strengths and weaknesses of curriculum 63
64

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Patient safety for residents

  • 1.
    Curricular Blueprint Residency Curriculumin Quality Improvement and Patient Safety Department of Medicine University of California, San FranciscoUniversity of California, San Francisco June 2012 Krishan Soni Chief Resident for Quality and Safety Sumant Ranji Associate Program Director
  • 2.
    I. Rationale forTeaching QI and PS II. Global Goals and Objectives III. Core Concepts and Tools IV. Mapping to ACGME Milestones UCSF Quality Improvement and Patient Safety Curriculum IV. Mapping to ACGME Milestones V. Overview - Organization and Delivery VI. Detailed Description by Program VII. Next Steps 2
  • 3.
    I. Rationale forTeaching Quality Improvement and Patient Safety to Residents UCSF Quality Improvement and Patient Safety Curriculum • Patients expect physicians to provide safe, effective, and high value care • Regulatory agencies (ACGME, Residency Review• Regulatory agencies (ACGME, Residency Review Committees) are demanding that residency programs integrate safety and quality training into the curriculum • Residents are interested in learning and acquiring tools to provide high quality, cost effective care that will be necessary to their future practice 3
  • 4.
    II. Goals andObjectives of the UCSF Residency Program’s Quality and Safety Curriculum UCSF Quality Improvement and Patient Safety Curriculum • Prepare physicians to be stewards of safe, high quality, high value, patient centered care • Teach key principles of quality improvement, patient safety, and• Teach key principles of quality improvement, patient safety, and systems innovation to all residents in our training programs • Develop a culture of safety and quality that trainees will carry with them throughout their career • Cultivate future leaders in healthcare quality and systems innovation 4
  • 5.
    III. Core Conceptsand Tools Necessary to the Practice of Safe, High Quality, Patient Centered Medicine UCSF Quality Improvement and Patient Safety Curriculum Error & Systems Analysis Effective Handoffs Patient Satisfaction LeadershipSafe Discharge Planning Models for Quality Improvement Patient Panel Management High Value Healthcare Healthcare Policy 5
  • 6.
    IV. Mapping ACGMEMilestones to UCSF Curriculum UCSF Quality Improvement and Patient Safety Curriculum Practice-Based Learning Learn and Improve via Audit of Performance Systems-Based Practice Work effectively with other Improve the quality of care for a panel of patients Work effectively within Core Competency ACGME Milestone UCSF Patient Panel Management QI Work effectively with other care providers and settings Improve health care delivery Cost-effective care for patients and populations Interpersonal and Communication Skills Work effectively within • Multiple health delivery systems • An inter-professional team Recognize system error and advocate for system improvement Identify forces that impact the cost of healthcare, advocate for and practice cost-effective care Transitions of care Effective Handoffs Safe Discharge Planning Error & Systems Analysis Effective Handoffs Safe Discharge Planning High Value Healthcare 6
  • 7.
    I. Rationale forTeaching QI and PS II. Global Goals and Objectives III. Core Concepts and Tools IV. Mapping to ACGME Milestones UCSF Quality Improvement and Patient Safety Curriculum IV. Mapping to ACGME Milestones V. Overview - Organization and Delivery VI. Detailed Description by Program VII. Next Steps 7
  • 8.
    Background: Residency ProgramSites UCSF medicine residents spend 3 years rotating through the inpatient medical service and outpatient clinics at four geographically separate sites. Inpatient+outpatient UCSF Medical Center Tertiary Care University Medical Center San Francisco Veteran’s Affairs Medical Center Federal government facility for US Veterans San Francisco General Hospital City & County Hospital UCSF Mount Zion Hospital Outpatient General Medicine Clinics Inpatient+outpatientPrimarilyOutpatient 8
  • 9.
    Background: Quality &Safety Curriculum Overview • The Residency Quality Improvement and Patient Safety Curriculum is organized across all four sites and addresses both inpatient and outpatient training. • The curriculum is longitudinal and strives to develop resident competencies in QI and PS skills over three years of training. All residents are expected to develop a set of core competencies, while more advanced training is available for those with interest. • Education takes place through a series of: • Core Didactic Lessons • Case Based Discussions • QI and PS Rotations • Longitudinal QI projects • Electives and pathways for those with deeper interests Core Didactics (Years 1-3) Case Based Discussions (Years 1-3) Core QI Rotation (Year 1) Longitudinal Projects (Years 1-3) Electives, Pathways, Projects (Years 2-3) Foundation in QI & PS Advanced QI & PS 9
  • 10.
    Background: Quality &Safety Curriculum Overview • The curriculum is broadly divided into 4 primary themes: • Inpatient QI + PS Training • Ambulatory QI + PS Training • Care Transitions • Electives in Advanced QI and Health Systems Inpatient QI + PS • Focused on improving care in Ambulatory QI + PS • Focused on improving care in• Focused on improving care in hospitalized patients • Conducted during residents inpatient training months • Focused on improving care in ambulatory patients • Conducted during residents ambulatory training months Care Transitions • Focused on maintaining patient safety during transitions between inpatient providers and on discharge from the hospital Electives in Advanced QI + PS • Opportunities for those with a special interest in QI and PS to gain advanced experience through training and projects 10
  • 11.
    Curriculum Overview Acrossall Training Years Inpatient QI + PS Patient Safety M&M ConferencePatient Safety M&M Conference PQJ Rotation Housestaff IncentiveHousestaff Incentive Cost of Care ConferencesCost of Care Conferences QI Case ConferencesQI Case Conferences Inpatient DashboardsInpatient Dashboards Year 1 Year 2 Year 3 The key elements of the UCSF quality improvement and patient safety curriculum are shown below. Further detail is shown on the following slides. Care Transitions Effective Sign outEffective Sign out Safe Discharge +EPASafe Discharge +EPA QI ElectiveQI ElectiveElectives in Advanced QI / Health Systems HSL PathwayHSL Pathway Ambulatory QI + PS SFGH GEMSSFGH GEMS VAMC EDPACTVAMC EDPACT ZIONZION Amb ½ Day SFGH GEMSSFGH GEMS VAMC EDPACTVAMC EDPACT ZIONZION Amb ½ Day SFGH Ambulatory QI M&MSFGH Ambulatory QI M&M SFGH GEMSSFGH GEMS Quality and Safety Innovations Challenge Safe DischargeSafe Discharge
  • 12.
    Inpatient QI TrainingDetails Inpatient QI + PS Patient Safety M&M ConferencePatient Safety M&M Conference PQJ Rotation Housestaff IncentiveHousestaff Incentive Cost of Care ConferencesCost of Care Conferences QI Case ConferencesQI Case Conferences Inpatient DashboardsInpatient Dashboards Year 1 Year 2 Year 3 The inpatient curriculum focuses on teaching methods to deliver high value and safe patient care while understanding the potential harms and costs of inpatient medical care PQJ Rotation (Procedures, Quality, Jeopardy) • Foundational 2 week rotation all interns. • Interns learn core QI and PS concepts through: • 6 core didactic sessions • 2 projects – a patient safety case review; cost analysis of a medical case • Readings and online web modules Cost of Care Conferences • Monthly case based conference for all residents. • We review management of a medical case treated at UCSF and discuss evidence based guidelines and the hospital charges associated with care. Error & Systems Analysis High Value Healthcare High Value Healthcare
  • 13.
    Inpatient QI TrainingDetails (2) QI Case Conference and Inpatient M&M Conference • After completing a structured case review of a medical error, adverse event, or near miss, an intern presents the case to an audience of residents during a lunch conference. • All residents have an opportunity to discuss the case, learn key concepts in patient safety and reflect on their own practice. Housestaff Incentive Program • A financial incentive program developed by the medical center to incentivize all staff to participate in improvement of key quality metrics. Error & Systems Analysis all staff to participate in improvement of key quality metrics. • We have developed our own improvement goals, including improving communication with PCPs and timely completion of discharge summaries • Residents continuously monitor, evaluate, and make adjustments to improve performance. Inpatient Dashboards (in development) • Continuous feedback of relevant patient care metrics to housestaff in a specific, timely, and actionable way. • Aims to mirror increasing efforts to provide physicians with performance data at a national level • Possible metrics: patient satisfaction, length of stay, utilization of labs and radiology. Patient Panel Management Patient Satisfaction Quality Improvement
  • 14.
    Ambulatory QI TrainingDetails Year 1 Year 2 Year 3 Ambulatory QI + PS SFGH GEMSSFGH GEMS VAMC EDPACTVAMC EDPACT ZIONZION Amb ½ Day SFGH GEMSSFGH GEMS VAMC EDPACTVAMC EDPACT ZIONZION Amb ½ Day SFGH GEMSSFGH GEMS The ambulatory curriculum focuses on teaching methods to heighten awareness of patient safety issues in the outpatient setting, and provides residents with a hands-on experience to engage in a quality improvement project in their clinic. SFGH Ambulatory QI M&MSFGH Ambulatory QI M&M Clinic Specific Curricula • Educational sessions are clinic based, and are tailored to the needs of each clinic site (SFGH, VAMC and Mount Zion) • All sites include didactic sessions covering core topics in ambulatory patient safety, error analysis, and QI Improvement tools • Residents at each site have an opportunity to develop and conduct their own QI longitudinal projects. Approximately 2-5 projects/clinic site. Ambulatory QI M&M • Developed this year, the Ambulatory M&M is a bimonthly case based conference to discuss medical errors and adverse events in the SFGH GMC. Patient Panel Management Error & Systems Analysis Quality Improvement
  • 15.
    Care Transitions TrainingDetails Care Transitions Safe Discharge +EPASafe Discharge +EPA Year 1 Year 2 Year 3 Given the association of errors and adverse events associated with transitions in care, a renewed emphasis has been placed on educating trainees on safe and effective handoffs of care. This curriculum focuses on improving handoffs both between providers in the inpatient setting and improving communication and coordination of an entire discharge plan to the ambulatory setting. Effective Sign outEffective Sign out Safe DischargeSafe Discharge Effective Signout • Starting early in orientation, interns are given a model for effective signout communication. • During noon conference sessions and morning report, they are given an opportunity to practice these skills, to evaluate their piers, and to reflect on their own performance Safe Discharge • Through a series of noon conference sessions and morning reports, all residents are given a toolkit to address the principles of safe discharge. • Interns are extensively evaluated on their discharge communication (EPA). Effective Handoffs Safe Discharge Planning
  • 16.
    Advanced QI &Health Systems Training Details QI ElectiveQI ElectiveElectives in Advanced QI / Health Systems HSL PathwayHSL Pathway Year 1 Year 2 Year 3 Quality and Safety Innovations Challenge Three structured options are available for residents wishing to pursue more advanced training in quality improvement, patient safety and systems redesign. QI Elective • Available for senior residents, this one month elective provides one on one• Available for senior residents, this one month elective provides one on one mentorship to deepen the experience with QI projects. Residents build their QI and PS skills through: • Additional readings and online web materials • Participation in several ongoing QI projects in the medical center • Participation in QI or PS committee activities in the department or med center • Development of their own QI project based on interest The Quality and Safety Innovations Challenge (QSIC) • Encourages active trainee participation in QI/PS projects by providing ongoing mentorship for project development and a forum for projects and posters to be presented at the end of the year.
  • 17.
    Advanced QI &Health Systems Training Details HSL Pathway • A two year longitudinal curriculum designed to help residents build skills in leadership, health policy analysis, and health systems redesign. • As part of this pathway, during their ambulatory months, residents engage in: • Discussions with invited speakers from the realms of health policy, health administration, academia, and the private sectors • Weekly discussions of current literature in the policy and QI arenas Leadership Healthcare Policy • Intensive didactics in leadership, healthcare policy, and systems redesign • Yearly group project focusing on an important policy or systems redesign issue. Past projects include: • An analysis of prolonged Emergency Room admitting time with a presentation to the senior leadership of the UCSF Medical Center • Development of a model to increase efficiency and decrease costs of ambulatory care in high cost centers. Results were presented to the board of directors for a major group of healthcare purchasers
  • 18.
    I. Rationale forTeaching QI and PS II. Global Goals and Objectives III. Core Concepts and Tools IV. Mapping to ACGME Milestones UCSF Quality Improvement and Patient Safety Curriculum IV. Mapping to ACGME Milestones V. Overview - Organization and Delivery VI. Detailed Description by Program VII. Next Steps 18
  • 19.
    VI. Detailed Descriptionby Program A. Curriculum by training site B. Curriculum by year C. Procedures, Quality, Jeopardy Rotation D. Inpatient QI M&M Conferences UCSF Quality Improvement and Patient Safety Curriculum D. Inpatient QI M&M Conferences E. Cost Awareness F. Housestaff Incentive Program G. Ambulatory QI/PS H. Transitions: Signout I. Transitions: Discharge 19
  • 20.
    QI Curriculum byTraining Site The UCSF Chief Resident for QI/PS implements the Quality Improvement and Patient Safety curriculum at 3 training sites. UCSF Medical Center Parnassus/MTZ San Francisco Veteran’s Affairs Medical Center San Francisco General HospitalParnassus/MTZ Affairs Medical Center Hospital Inpatient Activities Outpatient Activities CR Time 40% 40% 20% • PQJ Rotation (21/67) • PQJ Conference (12) • Cost Awareness (11) • Housestaff Incentive • QI Elective (5 months) • HSL • Inpatient QI M&M (10) • EDPACT Activities (22/48 conferences) • Inpatient QI M&M (9) • Ambulatory QI M&M (5) • GMC QI/PS Sessions (8) Tri Hospital Activities • Discharge Curriculum (7 at each site) • Signout Curriculum (7 at each site) • Discharge Curriculum (7 at each site) • Signout Curriculum (7 at each site) • QSIC • Ambulatory Half Day (2) • QSIC • Ambulatory Half Day (2)
  • 21.
    QI/PS Educational Curriculum– INTERNS (First Year) Inpatient QI/PS Patient Safety M&MPatient Safety M&M PQJ RotationPQJ Rotation Housestaff IncentiveHousestaff Incentive Cost of Care ConferencesCost of Care Conferences QI Case ConferencesQI Case Conferences Inpatient DashboardsInpatient Dashboards Participants/Site All IM Interns While at Moffitt While at Moffitt While on Moffitt Wards While on Moffitt Wards All Interns, All Sites Time Frame One Month Monthly, year long Year Long Year Long Monthly, Year Long Monthly, year long Care Transitions Effective Sign outEffective Sign out Safe Discharge +EPASafe Discharge +EPA Electives in Advanced QI / Health Systems Ambulatory QI/PS All Sites SFGH Ambulatory QI M&MSFGH Ambulatory QI M&M MoffittAmbulatory Quality and Safety Innovations Challenge Quality and Safety Innovations Challenge Legend SFGH GEMSSFGH GEMS SF Clinic Interns SF Clinic Interns Year Long Bi-Monthly, year long All Interns, All Sites All Interns, All Sites Summer/Fall Summer/Fall All Interns, All Sites Year Long
  • 22.
    QI/PS Educational Curriculum– R2 + R3’s (2nd and 3rd Year) Inpatient QI/PS Patient Safety M&M Housestaff IncentiveHousestaff Incentive Cost of Care ConferencesCost of Care Conferences QI Case ConferencesQI Case Conferences Inpatient DashboardsInpatient Dashboards Ambulatory QI/PS Participants/Site While at Moffitt While at Moffitt While on Moffitt Wards While on Moffitt Wards All Residents, All Sites Time Frame Monthly, year long Year Long Year Long Monthly, Year Long Monthly, year long Ambulatory ½ DayAmbulatory ½ Day All Residents One Session - Fall Care Transitions Safe Discharge Electives in Advanced QI / Health Systems All Sites SFGH Ambulatory QI M&MSFGH Ambulatory QI M&M MoffittAmbulatory QSIC Legend Clinic QI ProjectClinic QI Project All Residents SF Clinic Residents Year Long Bi-Monthly, year long All Residents, All Sites Summer/Fall All Interns, All Sites Year Long QI ElectiveQI Elective HSL PathwayHSL Pathway Ambulatory ½ Day All Residents One Session - Fall Self Selected One Month Self Selected 2 year course
  • 23.
    In total, 185hours of QI/PS didactic sessions were programmed and delivered during the 2011-2012 academic year. UCSF Quality Improvement and Patient Safety Curriculum PQJ Curriculum (year round) (month startson 22nd) Session Frequency Location Timing June July August Sept Oct Nov Dec Jan Feb Mar 1. Intro to Patient Safety Monthly Moffitt Tuesday AM Tue 7/5 Thu 7/28 Thu 8/25 Tue 9/27 Thu 10/27 Mon 11/28 Tue 1/10 Wed 1/25 Mon 2/27 Tue 3/27 2. Intro to Cost Awareness Monthly Moffitt Tuesday AM Tue 8/2 Tue 8/30 Tue 10/4 Tue 11/1 Tue 12/6 Mon 1/30 Thu 3/1 Wed 3/28 3. Review of Cost Awareness Case Monthly Moffitt Tuesday AM Tue 9/6 Tue 10/11 Tue 11/8 Tue 12/13 Mon 2/6 Thu 3/8 Thu 4/5 4. Intro to Quality Improvement Monthly Moffitt Tuesday AM Thu 7/7 Tue 8/9 Tue 9/13 Wed 10/12 Tue 11/15 Thu 12/15 Fri 1/13 Wed 2/8 Mon 3/5 Tue 4/10 5. Intro to Change Management Monthly Moffitt Tuesday AM Mon 7/11 Tue 8/16 Mon 9/19 Tue 10/18 Thu 11/17 Mon 12/19 Tue 1/17 Mon 2/13 Mon 3/12 Wed 4/11 6. Intro to Patient Satisfaction Monthly Moffitt Tuesday AM Mon 7/18 Thu 8/18 Wed 9/21 Mon 10/10 Mon 11/21 Thu 12/1 Fri 1/20 Mon 2/20 Mon 3/19 Tue 4/17 Regular QI Conference Schedule (year round) Conference Series Frequency Location Timing June July August Sept Oct Nov Dec Jan Feb Mar PQJ QI Conference Monthly Moffitt Last week of intern monthFri 6/17 Mon 7/18 Thu 8/18 Tue 9/13 Mon 10/10 Fri 11/18 Mon 12/19 Fri 1/20 Fri 2/17 Tue 3/13 PQJ Cost Awareness Conference Monthly Moffitt Last week of intern monthMon 6/20 Mon 7/11 Mon 8/15 Mon 9/12 Fri 10/21 Fri 11/11 Fri 12/16 Mon 2/20 Fri 3/16 Monthly Tri-Hosp QI M&M Monthly VAMC M,W, or F Wed 7/27 Fri 9/30 Mon 10/31 Mon 11/14 Wed 12/21 Wed 1/18 Wed 2/29 Wed 3/28 Monthly Tri-Hosp QI M&M Monthly SFGH WEDNESDAY Wed 7/6 Wed 8/10 Wed 9/14 Wed 10/19 Wed 11/9 Wed 12/14 Wed 1/11 Wed 3/14 Bi-Monthly SFGH Outpatient QI M&MBi-Monthly SFGH FRIDAY B A B Fri 9/9 Fri 10/14 A Fri 12/9 B A Fri 3/9 Short Series QI Conferences (occur in Fall only) 23 Short Series QI Conferences (occur in Fall only) Conference Series Frequency Location Timing June July August Sept Oct Nov Signout Curriculum Noon Conf Monthly x2 Moffitt Aug, Oct Mon 8/8 Fri 10/14 Signout Curriculum Noon Conf Monthly x2 VAMC Aug, Oct Fri 8/5 Fri 11/4 Signout Curriculum Noon Conf Monthly x2 SFGH Aug, Oct Fri 8/12 Fri 10/14 Signout Curriculum Intern Report Once 3 SITES July Thu 7/28 Discharge Curriculum Noon Conf Monthly x2 Moffitt Sept, Oct Thu 9/1 Mon 10/3 Discharge Curriculum Noon Conf Monthly x2 VAMC Sept, Oct Wed 9/21 Mon 11/7 Discharge Curriculum Noon Conf Monthly x2 SFGH Sept, Oct Mon 9/19 Mon 10/3 Discharge Curriculum Intern Report Once 3 SITES September Thu 9/29 Ambulatory QI Half Day Twice Zion Sept, Oct Fri 9/23 Fri 10/14 VAMC EDPACT Conferences (Occur during PI Blocks - Nov/Dec, Mar/Apr) Session Frequency Location Timing Tue/Wed Thur/Fri Tue/Wed Thur/Fri 1. Intro to PI Curriculum 1x per group EDPACT Nov, Dec Tue 11/1 Thu 11/3 Tue 12/6 Thu 12/1 2. Practice Data: QI Priorities 1x per group EDPACT Nov, Dec Tue 11/1 Thu 11/3 Tue 12/6 Thu 12/1 3. Systems Approach to Change 1x per group EDPACT Nov, Dec Wed 11/2 Fri 11/4 Fri 12/9 Fri 12/2 4. PDSA Cycle and Tools 1x per group EDPACT Nov, Dec Tue 11/8 Thu 11/10 Tue 12/13 Thu 12/8 5. Plan and Implement Project 1x per group EDPACT Nov, Dec Tue 11/8 Thu 11/10 Tue 12/13 Thu 12/8 6. PS 1: Root Cause Analysis 1x per group EDPACT Nov, Dec Tue 11/15 Thu 11/17 Wed 12/14 Fri 12/9 7. PS 2: Failure Modes Effects Analy 1x per group EDPACT Nov, Dec Wed 11/16 Fri 11/18 Wed 12/21 Fri 12/16 8. Patient Safety Journal Club #1 1x per group EDPACT Mar, Apr Tue 3/6 Thu 3/8 Tue 4/3 Thu 4/5 9. Trainee Led RCA #1 1x per group EDPACT Mar, Apr Wed 3/21 Thu 3/15 Tue 4/17 Thu 4/12 Trainee Led RCA #2 1x per group EDPACT Mar, Apr Fri 3/16 Fri 4/20 10. Panel Management Session 1x per group EDPACT Mar, Apr Tue 3/20 Thu 3/29 Tue 4/24 Thu 4/19 11. QI Work in Progress 1x per group EDPACT Mar, Apr Tue 3/6 Thu 3/15 Tue 4/24 Thu 4/26 QI Work in Progress #2 1x per group EDPACT Mar, Apr Wed 4/18 Fri 4/27 Block A (NOV/MAR) Block B (DEC/APR) SFGH GMC Clinic Conferences (Jan-April) Session Frequency Location Timing Mon Tues 1. AIM Statements and PDSA 1x per group GMC Jan Mon 1/30 Tue 1/31 2. Measuring for QI 1x per group GMC Feb Mon 2/27 Tue 2/28 3. Ambulatory Safety and Tools 1x per group GMC Mar Mon 3/26 Tue 3/27 4. Analysis of Project to date 1x per group GMC Apr Mon 4/23 Tue 4/24
  • 24.
    Procedures, Quality, andJeopardy Rotation UCSF Quality Improvement and Patient Safety Curriculum Procedures, Quality, and Jeopardy Rotation 24
  • 25.
    The Intern Procedure,Quality, and Jeopardy (PQJ) rotation forms the foundation of QI/PS teaching in the residency program. FOUNDATION: Intern PQJ Rotation Six Core Didactic Sessions (Topics Covered): • Session 1: Fundamentals of Patient Safety and Systems Analysis • Introduction to error analysis • Latent/active errors/adverse events/near misses • Systems redesign • Session 2/3: Value and Quality in Healthcare• Session 2/3: Value and Quality in Healthcare • Session 4: Quality 101: Defining and Measuring Quality • Introduction to IHI Model for Improvement • Session 5: Improving Healthcare Quality - Change Management • Session 6: Patient Centered Care (Satisfaction) 25 Two One-Week Long Projects: I. Patient Safety Case Review II. Cost Awareness – Case Analysis
  • 26.
    PQJ: Evaluation Interns completea brief survey of QI/PS knowledge, attitudes and skills before and after the rotation. FOUNDATION: Intern PQJ Rotation Areas Tested: • Basic concepts in Patient Safety • Medical Errors • Adverse Events 26 • Adverse Events • QI Methodology • Writing SMART Statements • Using Measurement • Studying Processes • Making Changes • Using PDSA Analysis Ongoing
  • 27.
    Inpatient QI M&MConferences UCSF Quality Improvement and Patient Safety Curriculum Inpatient QI M&M Conferences 27
  • 28.
    The QI M&Mis a monthly noon conference at each site dedicated to addressing medical errors and adverse events Inpatient QI M&M Conferences Goal: To provide a safe environment to discuss cases from the inpatient medical service which highlight issues in patient care related to systems of care, care processes, care transitions, professionalism, and inter-professional communication. Specific Objectives: • Understanding and analyzing errors and adverse events • Identifying systems failures and opportunities to improve systems • Embracing a multidisciplinary approach as the standard • Integrating lessons into a culture of quality and safety 28
  • 29.
    The QI M&MConferences were successfully conducted across all three inpatient sites. Inpatient QI M&M Conferences • This year, 31 conferences were held across the sites • Moffitt: 12 conferences • SFGH: 9 conferences • VAMC: 10 conferences • Example topics covered to date: • Errors in communication with consults • Failure of communication among team members (handoffs) • Adverse events associated with hospital discharge • Errors regarding triage to proper level of care • Medication errors on discharge • Medication errors during procedures • Evaluation to date: None 29
  • 30.
    Cost Awareness Curriculum UCSFQuality Improvement and Patient Safety Curriculum Cost Awareness Curriculum 30
  • 31.
    At the endof this curriculum, interns should be able to: UCSF Cost Effective Care Curriculum: Objectives Specific objectives for PGY1 residents In the PGY1 year, receive an in depth cost awareness curriculum during the Procedures, Quality, Jeopardy (PQJ) rotation. 1. Understand evidence based guidelines 31 2. List the approximate costs of different tests at our university hospital 3. Recognize cost-inefficient medical practices 4. Reflect on their own ordering practices 5. Critique current cost-inefficient medical practices at our hospital
  • 32.
    UCSF Cost EffectiveCare Curriculum: What’s the Process? Process: How the curriculum is delivered The cost awareness curriculum is delivered longitudinally through a monthly series of didactic and experiential learning sessions. 1. Upper GI Bleed 2. Acute Kidney Injury 3. Chest Pain • We selected 12 “core topics” of commonly encountered clinical scenarios with frequent practice and resource-utilization variability Delivery Core Topics 32 3. Chest Pain 4. Syncope 5. Pulmonary Embolism 6. Low Back Pain 7. Pre-Operative Testing 8. Cellulitis 9. Headaches 10. Altered Mental Status 11. Anemia 12. Urinary Tract Infection practice and resource-utilization variability • We created a longitudinal curriculum with two key components: •Experiential: Interns review a medical case, including guidelines and cost associated with the workup during a dedicated QI rotation •Didactic: A monthly case-based conference consolidating the findings from the case review is presented for medical students, residents, and attendings
  • 33.
    UCSF Cost EffectiveCare Curriculum: What’s the Process? Description Time/Learners • 60 minutes • 5-6 PGY1s • 2-3 hours Small group session: Principles of cost awareness introduced in a case based learning conference. Group Project: A case Introduction “Core” topic and case assigned Interns divide into two groups Activity Process: How the curriculum is delivered The central experience for PGY1’s is a structured case review. 33 • 2-3 hours independently over 1 week • 5-6 PGY1s Group Project: A case demonstrating a common medical workup is assigned to the interns. Interns work in small groups review literature and apply evidence based guidelines to understand clinical and cost effective approaches to management. Dissemination: Learnings and best practices from the project are consolidated and shared at an interactive lunch conference with ALL residents each month. • 60 minutes • Medical Students • Residents (all levels) • Faculty Interns divide into two groups Guideline Review • Review literature Find evidence based best- practice guidelines • Suggest cost effective workups Case Analysis • Review recent case from our intuition • Analyze hospital bill, and clinical chart to evaluate care provided Case review debrief Case based noon conference for ALL residents
  • 34.
    UCSF Cost EffectiveCare Curriculum: Evaluation Evaluation: How did learners perceive the curriculum? Pilot data indicates that residents find this curriculum highly relevant to their clinical practice, and likely to change behavior. • Overall, respondents reported that the conferences were: • To date, we have received 151 evaluations from eight conferences that the conferences were: • Highly relevant to their clinical practices (mean 4.51 +/- 0.63 on a 5- point Likert scale) • Likely to change their ordering behaviors (mean 4.24 +/- 0.72) 34
  • 35.
    This project wassuccessfully received by residents, and has been shown in abstract format at multiple conferences. UCSF Cost Effective Care Curriculum: Scholarly Dissemination 35
  • 36.
    Housestaff Incentive Program UCSFQuality Improvement and Patient Safety Curriculum Housestaff Incentive Program 36
  • 37.
    The Medical CenterHousestaff Incentive Program (HIP) for all residents included 3 goals for the 2011-2012 academic year. Housestaff Incentive Program • Patient Satisfaction 37 • Hand Hygiene • Lab Utilization
  • 38.
    Additionally, the Departmentof Medicine sponsored it’s own Incentive Program in 2011-2012 for Medicine Residents. GOAL: To improve documentation of Advance Care Planning wishes in the Discharge Summary to greater than 75% for all patients admitted to the medical service. Housestaff Incentive Program 38
  • 39.
    This project hasbeen very successful (goal met), and has been shown in abstract format at multiple conferences. Housestaff Incentive Program 39
  • 40.
    Ambulatory QI UCSF QualityImprovement and Patient Safety Curriculum Ambulatory QI 40
  • 41.
    VAMC EDPACT Curriculum Ambulatory QI:VAMC • Patient Communication Inter- Professional Communication Practice Improvement 1 Advanced Communication Practice Improvement 2 Transitions in patient care July/Aug Sept/Oct Nov/Dec Jan/Feb Mar/April May/June • EDPACT learners include second year medicine residents and NP Students • The curriculum is divided into 6 core themes, each taught over the course of one month while residents are on block. • Two blocks are dedicated to Performance Improvement (PI) • During the PI Modules, residents and NPs have didactic sessions and work on clinic QI projects. • QI/PS Didactics include: • Intro to Root Cause Analysis, FMEA, IHI Model for Improvement, QI Measurement Tools, Process Mapping 41
  • 42.
    VAMC EDPACT QI/PS DidacticSessions Ambulatory QI: VAMC (1) Intro to the (2) Practice (3) Systems Eleven 90-minute didactic sessions were held during the 2 performance improvement blocks (8) Patient (9) Trainee Led 42 (1) Intro to the Performance Improvement Curriculum (2) Practice Data: QI Priorities (5) Plans to Implement QI Projects (6) Patient Safety: Root Cause Analysis (3) Systems Approach to Change (4) PDSA Cycle and Tools (8) Patient Safety Journal Club (9) Trainee Led Root Cause Analysis (7) Patient Safety: Failure Modes & Effects Analysis (10) Panel Management Session (11) QI Works in Progress Block1 Block2 QI Patient Safety
  • 43.
    6 Clinic BasedQI Projects were completed over a six month period (Nov-May): Ambulatory QI: VAMC Medical Practice Clinic: VAMC EDPACT QI Projects 43 Medical Practice Clinic: – Improve medication refill process in clinic – Improving surveillance rates of HA1c among diabetics – Improve coordination of a 48 hour post discharge phone call – Improve rate of LDL checked annually in diabetic patients Community Based Outpatient Clinics: – Improve HCV primary care measures – Improve healthcare maintenance compliance
  • 44.
    Ambulatory QI: VAMCProjects VAMC EDPACT QI Projects (1 of 6) 44
  • 45.
    Ambulatory QI: VAMCProjects VAMC EDPACT QI Projects (2 of 6) 45
  • 46.
    Ambulatory QI: VAMCProjects VAMC EDPACT QI Projects (3 of 6) 46
  • 47.
    Ambulatory QI: VAMCProjects VAMC EDPACT QI Projects (4 of 6) 47
  • 48.
    Ambulatory QI: VAMCProjects VAMC EDPACT QI Projects (5 of 6) 48
  • 49.
    Ambulatory QI: VAMCProjects VAMC EDPACT QI Projects (6 of 6) 49
  • 50.
    SFGH General MedicineClinic (GMC) Ambulatory QI: SFGH SFPC Curriculum Categorical Curriculum The Primary Care (SFPC) Residents and the categorical GMC residents each receive a unique QI curriculum during their continuity clinic experience. All residents in the HEAAT pathway attend ambulatory Patient Safety M&M conferences on Friday mornings. 50 SFPC Curriculum Categorical Curriculum Didactics: 9-10 half day sessions (Thursday Mornings) during block time Project: Required individual (or small group) QI project Didactics: Four 45 minute sessions dedicated to Patient Safety of QI during GEMS time (Monday and Tuesday) Project: Group clinic QI for all residents in a particular clinic day Ambulatory M&M Patient Safety Conferences
  • 51.
    SFGH General MedicineClinic Ambulatory QI: SFGH Categorical GEMS Curriculum: • Curriculum is taught during a 30 min didactic session each month. • Residents have an additional 30 minute clinic slot every 2 weeks for panel management and admin time. • GEMS Sessions Include: • Intro to GEMS & Huddle with primary preceptor• Intro to GEMS & Huddle with primary preceptor • Managing your Mailbox • Managing your e-referral Worklist • How to use QI data & Intro to the Firm QI Metrics Challenge • Huddle with MEAs • Chronic Pain Management • Buprenorphine • Panel Management • Effective Note writing • Working with RCNPs • Remote Communication/ Telephone Visits • Interpreters 51
  • 52.
    SFGH General MedicineClinic Ambulatory QI: SFGH Categorical QI Sessions: • Four 45 min didactic sessions covering core QI topics taught monthly, January through April. Sessions also allow time for advancement of clinic-based QI projects. QI Session Topics: 52 1. AIM statements and PDSA cycles 2. Measuring for QI • Review process, outcome, and balancing measures 3. Ambulatory safety and safety tools: • Introduction of RCA and fishbone 4. Analysis of project to date: • Revisit AIM statement, compare current metrics with baseline metrics, adjust project
  • 53.
    SFGH Categorical ClinicProjects Ambulatory QI: SFGH Two QI projects were completed during the 2011-2012 academic year (1 of 2) 53
  • 54.
    SFGH Categorical ClinicProjects Ambulatory QI: SFGH Two QI projects were completed during the 2011-2012 academic year (2 of 2) 54
  • 55.
    The ambulatory patientsafety M&M is a bi-monthly 60- minute conference dedicated to reviewing cases in the General Medicine Clinic at SFGH. Ambulatory QI: SFGH M&M Conferences Goal: To provide a safe environment to discuss cases which highlight issues in patient care related to ambulatory systems of care, care processes, care transitions, professionalism, and inter-professional communication.communication. Specific Objectives: • Understanding and analyzing errors and adverse events • Identifying systems failures and opportunities to improve systems • Embracing a multidisciplinary approach as the standard • Integrating lessons into a culture of quality and safety Five Conferences were held during the 2011-2012 academic year 55
  • 56.
    Signout UCSF Quality Improvementand Patient Safety Curriculum Effective Handoffs Signout 56
  • 57.
    Signout Curriculum Signout Curriculum Objectives:To create and deliver a brief curriculum with didactics, repetition, and real time feedback, targeted towards improving the consistency and quality of intern signout. The curriculum emphasizes: 1. The opportunity for medical errors when inter-professional communication is poor 2. The importance of MD to MD signout Effective Handoffs 2. The importance of MD to MD signout 3. Techniques for high quality and consistent written and verbal signout 4. Opportunities for practice/repetition of techniques and feedback on written/verbal signout 57 Intern Orientation (6/17) 1st Rotation (6/21-7/21) 2nd Rotation (7/22-8/21) Noon Conf VA: 8/5 Moffitt: 8/8 SFGH: 8/12 3nd Rotation (8/22-9/21) Noon Conf Early Oct VA, SFGH, Moffitt: TBS Intern Report 7/28 JULY AUGUST SEPTEMBER 4th Rotation (9/22-10/21) OCTOBER Sessions & Timeline:
  • 58.
    Discharge UCSF Quality Improvementand Patient Safety Curriculum Safe Discharge Planning Discharge 58
  • 59.
    Discharge Curriculum Discharge Curriculum Objectives:To create and deliver a brief curriculum with didactics, repetition, and real time feedback, targeted towards improving the consistency and quality of discharge plans. This mini-course will lay the groundwork for the rollout of the Discharge Entrustable Professional Activity (EPA) in the fall of 2011. The curriculum emphasizes: Safe Discharge Planning The curriculum emphasizes: 1. The importance of discharge plans in providing safe patient care and reducing preventable readmissions 2. A framework for thinking about the entire discharge plan (using a simple checklist) 3. Techniques for high quality, timely, and consistent discharge summaries 4. The essential elements clear communication at discharge 5. Opportunities for practice/discussion of the elements of discharge planning
  • 60.
    Discharge Curriculum Sessions& Timeline Discharge Curriculum Safe Discharge Planning Four sessions were held during the first 4 months of the academic year: • Intern Half Day: 1 hour didactic session demonstrating good practices in writing discharge summaries. • Noon Conference : 2 lunchtime sessions which briefly cover objectives 1-4 above. • Review of Discharge Summaries at Intern Report: Interns were an opportunity to review and give feedback on the quality of their own discharge summaries. Intern Half Day (7/8 & 7/15) 1st Rotation (6/21-7/21) 2nd Rotation (7/22-8/21) Noon Conf UCSF: 9/1 SFGH: 9/19 VAMC: 9/21 3nd Rotation (8/22-9/21) Noon Conf UCSF: 10/3 SFGH: 10/3 VAMC: TBD Intern Report 9/29 JULY AUGUST SEPTEMBER 4th Rotation (9/22-10/21) OCTOBER EPA Rollout Faculty Development Resident / Intern Teaching Sessions Entrustable Professional Activity Intern Rotations Rollout Portfolio to review and give feedback on the quality of their own discharge summaries.
  • 61.
    The discharge internreport session was well received by the interns. The curriculum was presented in abstract form at multiple conferences and won a Cooke Award for Teaching at the UCSF Medical Education Day. Discharge Curriculum Safe Discharge Planning
  • 62.
    I. Rationale forTeaching QI and PS II. Global Goals and Objectives III. Core Concepts and Tools IV. Mapping to ACGME Milestones UCSF Quality Improvement and Patient Safety Curriculum IV. Mapping to ACGME Milestones V. Overview - Organization and Delivery VI. Detailed Description by Program VII. Next Steps 62
  • 63.
    Four potential areasto target for improvement in 2012-2013… Next Steps • Outpatient QI: Expand ambulatory QI/PS curriculum to include Mount Zion Medical Clinic • Patient Care Data: Continue efforts to build systems for ongoing patient care data feedback to residents in the inpatient andpatient care data feedback to residents in the inpatient and outpatient settings • Integration: Continue to improve integration of QI/PS teaching across all sites • Evaluation: Develop a robust evaluation system to better understand strengths and weaknesses of curriculum 63
  • 64.