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Leveraging Front-Line Work
Graduate Medical Education: Focusing on Quality
and Safety in a Clinical Learning Environment
November 2013
Diane M. Hartmann, MD
Professor of Obstetrics & Gynecology
Senior Associate Dean for Graduate Medical Education
University of Rochester School of Medicine
Robert J. Panzer, MD
Georgia & Thomas Gosnell Professor of Quality & Safety
Chief Quality Officer
University of Rochester School of Medicine
NEW-NAS –Jan_2013
University of
Rochester
University of Rochester Medical
Center
HealthSciencesDivision
School ofMedicine
and Dentistry
URMFG
StrongMemorial Hospital
VisitingNurse
Service
EastmanInstitute of Oral Health
University of Rochester Medical Center Divisions
Highlands At
Brighton
StrongPartners
Highland Hospital
Highlandsat
Pittsford
HighlandLiving Center
ThompsonHealth System
Schoolof
Nursing
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CLER Focus Areas
• Patient Safety
• Health Care Quality
• Care Transitions
• Supervision
• Duty Hours/Fatigue Management and Mitigation
• Professionalism
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Intersection of QS and GME Leadership
• CQO active participant in GMEC
• DIO active participant in Quality Council
• Leadership Team meetings with individual training programs
• Resident Quality/Safety Council
• Trainee Education
• Safety Culture Survey
• Med Center-wide Quality Safety Initiatives
• Harm Reports
• Multidisciplinary CLER Team
• Collaboration with IT and I-CARE Groups
• Departmental Activities
• Quantros Reporting System
3
Chief Quality Officer and DIOactive participants on GMEC &
Quality Council
DIO, CQO, COO Meetings with Individual Training Programs
“What Hospital-Based issues are preventing you from delivering quality
care/getting a good education?”
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Resident Quality and Safety Council
Resident Quality and Safety CouncilConsult Guidelines
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Trainee Education Institutional
• Six On-line Quality/Safety Modules
• Institutional Orientation
• Annual Mandatory Sessions (ID,
QS, Communication)
On-line Quality/Safety Modules
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Institutional Orientation
Topics:
Quality & safety prioritiesAsking for help
Rapid response team
Annual Mandatory SessionsInfections
Each August:
Update on hospital acquired infections
Special topics:
Central line placement
Occupational blood exposure (needlesticks)
Sepsis detection & early managemetn
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Annual Mandatory SessionsQuality & Safety
Annual Mandatory Session-Quality & SafetyFocus on “measures that matter”
• Necessary to promoting high reliability and a
culture of safety
• Maintain professionalism and earn respect
As in clinical care
Beware of unintended consequences
Overtreatment of ED patients with bronchitis
Beware of unintended messages
Cleveland conference story
Scramble to document rather than improve
“Clicking is caring”
• Emphasize measuring doing the right “bundle” of best
practices
clicking is caring-bottom.jpg
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Annual Mandatory Session-Quality & SafetySMH – Current Year Top Safety Priorities
•Preventing harm from complications
CLABSI, SSI, C Diff, CAUTI
Falls, pressure ulcers
Hospital acquired severe sepsis (deployed with ED sepsis)
•Medications
Home medication lists
Reconciliation on admission, transfer(s), discharge
Ordering
•Handoffs
Shift to shift (and nights, weekends, holidays)
Unit to unit (and service to service, to or from OR, ICU, etc)
Wayne Gretzky
“I skate to where the puck is
going to be, not where it has
been.”
“A good hockey player plays
where the puck is. A great
hockey player plays where the
puck is going to be.”
RJP
9
Annual Mandatory Session-Quality & Safety Vision of the Future
• Quality measures derived from good clinical data, not bills
• Abstraction from paper records fully shifts to extraction from
EMR’s
• EMR data is codified and accurate
• Convergence of Meaningful Use and P4P measures
• EMR data created during the normal process of care, not
distorted by act of measurement
• Shift from measurement of hospital and outpatient episodes -
to population health, prevention, and chronic disease
processes and outcomes over time17
Annual Mandatory SessionsPatient & Family Centered Care
Introduced by Medical Center CEO
Special Topics
Patient & Family experiences at SMH
Managing acute and chronic pain
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Session Title 2013 DatesDiagnostic Error in Medical Decision Making: A Growing Risk January 29
Severe Sepsis and Septic Shock: Lessons from the Rory Staunton Story
February 19 & 26
Ensuring Comprehensive Hand-Offs at URMC: New Standards, New Tools March 5
Care Management Strategies for Integrated Health Systems March 21
Listening with a Stethoscope II April 23
Communication and Collaboration – Acute Pain in the Hospitalized Patient May 30
Raising the Bar on Performance: Accountability in a Just Culture June 3
Preventing Harm from Infections and Severe Sepsis August 23
Quality of Care – The Measurement Tsunami Continues September 13
Changing Safety Culture in a Hospital:Improving Use of Perioperative Antibiotics to Prevent Surgical Site Infection
October 9
Physician Stress, Burnout, and Compassion Fatigue November 18
Patient Safety Grand Rounds
AHRQ Safety Culture Survey Response Rate - Spring 2013
Residents
Attending Physicians
Staff
34%
100%
28%
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Minimal Handoff Standards
1. A hand-off communication will occur between the sender and receiver for all transfers of patient care responsibility.
2. The hand-off process will include use of an on-screen clinical summary, a printable report and/or verbal communication between the sender and receiver of the hand-off information.
3. Hand-offs will occur with minimal interruptions.
4. Hand-offs will occur in an appropriate environment conducive to good communication.
5. The sender of the hand-off communication will have sufficient knowledge of the patient to effectively communicate the key and pertinent information to the receiver.
Patient Story
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Weekly Report of Harm:Focusing Attention on the Front Lines
• Johns Hopkins Model – 2008
• Selling the idea – Fall 2008
• Mock report
• Gathering the data
• Start January 2009
• Expansion to affiliated community hospital25
Culture ChangeWeekly “Report of Harm”
Since Jan 3, 2009
• Updated each Wednesday through the previous Saturday
•Raw numbers for each of past 8 weeks
•Central line associated blood stream infections
•Hospital acquired C. difficile infections
•MRSA bacteremia
•Surgical site infections (NHSN cardiac, colon)
•Serious hospital acquired pressure ulcers
•Fall with fracture or head bleed
•Serious safety event stories or improvement story of the
month
14
Culture ChangeWeekly “Report of Harm”
Since Jan 3, 2009
•Leadership responses:
•Board quality committee chair
• “Bob - Greetings from nyc.......why so many c diff? We
were doing well and this seems very high. Thoughts?
Thanks, DC”
•Board chair
• “Ray. Any understanding of CLABSI increases the last
few weeks?”
•Cardiology chief (8 minutes after report emailed)
•“I hold my breath as a I page down through the
results, scanning for the CCU and Cardiac rows...”
Harm Report – Handoff Data
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Multidisciplinary CLER Team
• Operational • Aspirational/Idea Generating
“integrating safety practices, ICARE behaviors, and lean strategies into daily work”
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“ever better, every day across the six aims of healthcare improvement – safe, effective,
patient-centered, timely, efficient, and equitable”
16
Collaboration with ITand I-Care Teams
• Professionalism in the use of Electronic Records
• Building a culture of Respect
Professionalism
• EMR Guidelines• Cultural Respect
17
Electronic Use Guidelines
Provider eRecord Etiquette Overview
Purpose and Rationale
eRecord is a powerful patient‐centric tool, shared across ambulatory and inpatient settings. Effective and
safe use of eRecord requires careful adherence to URMC guidelines. While many clinical workflows are changing, the fundamental responsibilities of independent patient evaluation, original documentation and individualized patient care remain the centerpiece of our professional obligations to the patient and the health care system. In addition, there are many robust and interactive portions of this electronic patient record that now demand all providers consider the impact of their documentation on others in the health care system. Many patient-specific databases will be populated by individual providers and shared with other professionals throughout eRecord. Some documents and data will be shared with patients and their families. There are shared functionalities (e.g. Problem Lists, Handoff templates, Medical History) that will be edited by many different providers at different times. More than ever, this collective, evolving record will be co-managed and co-owned by many providers and the patient. This reality necessitates the development of a set of rules and guidelines to ensure that appropriate evaluation, documentation, communication and record-sharing occur, to allow for the best outcomes for our patients and for the professional satisfaction of all members of the health care team.
This document is not intended to be a final product nor an explicit piece of policy. It is not a step by step account of how to use the record. This document contains the current expectations and workflows that should encourage the best use of eRecord and support our professional missions of patient care, teaching and research. As we become more experienced and facile as an organization with eRecord, and as the software evolves, we expect this etiquette document to evolve as well.
Building a Culture of Respect
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Building a Culture of Respect (cont.)
Departmental/Program Activities
• PCMH Ambulatory Quality Council
• Resident QS Projects• Data driven and “Systems”
approach to M&M• “Team drills” via simulation
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To Do
• Improve alignment with departmental quality leader, program director and trainees
• Consistent attendance by trainees at RCA’s, quality rounds, system redesign activities
• Better reporting system
38
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