Therapeutic challenges of pancreatic ascites and the role of endoscopic pancreatic stenting.

Management of pancreatic ascites poses significant therapeutic challenges. Treatment usually consists of either conservative management or interventional therapy with little consensus between the two options. Conservative therapy is the most common initial treatment option but has high failure rates hence arguing for interventional therapy as a preferred primary treatment option. Endoscopic treatment is particularly appealing due to lower failure rates and mortality than conservative therapy or surgery. We describe a patient with recurrent pancreatic ascites who was successfully managed with endoscopic transpapillary stenting. This report contributes to the limited but growing literature on the management of pancreatic ascites.

A patient safety curriculum for graduate medical education: results from a needs assessment of educators and patient safety experts.

Graduate medical education (GME) has traditionally focused on the diagnosis and management of disease with little attention devoted to patient safety and systems thinking. In this article, we describe the results of a needs assessment conducted to develop a patient safety curriculum for GME. Eight program directors, 10 patient safety experts, and 9 experts in education technology were interviewed for this project. A total of 21 patient safety topics were identified in the categories of cultural, cognitive, and technical content and included communications and handoffs, sentinel event reporting and management, calling for help when in doubt, hand hygiene, universal protocol, fatigue, and the culture of safety and transparency. Objective structured clinical examinations and experiential learning (including simulation) were viewed as the most effective methods for teaching and assessing competence in patient safety. The results of this study provide a framework for the development of patient safety curricula in GME.

A systems approach for implementing practice-based learning and improvement and systems-based practice in graduate medical education.

The Accreditation Council for Graduate Medical Education (ACGME) initiated its Outcome Project to better prepare physicians-in-training to practice in the rapidly changing medical environment and mandated assessment of competency in six outcomes, including Practice-Based Learning and Improvement (PBLI) and Systems-Based Practice (SBP). Before the initiation of the Outcome Project, these competencies were not an explicit element of most graduate medical education training programs. Since 1999, directors of ACGME-accredited programs nationwide have been challenged to teach and assess these competencies. The authors describe an institution-wide curriculum intended to facilitate the teaching and assessment of PBLI and SBP competencies in the 115 ACGME-accredited residency and fellowship programs (serving 1,327 trainees) sponsored by Mayo School of Graduate Medical Education. Strategies to establish the curriculum in 2005 included development of a Quality Improvement (QI) curriculum Web site, one-on-one consultations with program directors, a three-hour program director workshop, and didactic sessions for residents and fellows on core topics. An interim program director self-assessment survey revealed a 13% increase in perceived ability to measure competency in SBP, no change in their perceived ability to measure competence in PBLI, a 15% increase in their ability to provide written documentation of competence in PBLI, and a 35% increase in their ability to provide written documentation of competence in SBP between 2005 and 2007. Nearly 70% of the programs had trainees participating in QI projects. Further research is needed to evaluate the cost-effectiveness of such a program and to measure its impact on learner knowledge, skills, and attitudes and, ultimately, on patient outcomes.

Lessons learned from a 5-year experience with a 4-week experiential quality improvement curriculum in a preventive medicine fellowship.

BACKGROUND: Competency in practice-based learning and improvement (PBLI) and systems-based practice (SBP) empowers learners with the skills to plan, lead, and execute health care systems improvement efforts. Experiences from several graduate medical education programs describe the implementation of PBLI and SBP curricula as challenging because of lack of adequate curricular time and faculty resources, as well as a perception that PBLI and SBP are not relevant to future careers. A dedicated experiential rotation that requires fellow participation in a specialty-specific quality improvement project (QIP) may address some of these challenges. METHOD: We describe a retrospective analysis of our 5-year experience with a dedicated 3-week PBLI-SBP experiential curriculum in a preventive medicine fellowship program at Mayo Clinic, Rochester, Minnesota. RESULTS: Between 2004 and 2008, 19 learners including 7 preventive medicine fellows participated in the rotation. Using just-in-time learning, fellows work together on a relatively complex QIP of community or institutional significance. Since 2004, all 19 learners (100%) participating in this rotation have consistently demonstrated statistically significant increase in their quality improvement knowledge application tool (QIKAT) scores at the end of the rotation. At the end of the rotation, all 19 learners stated that they were either confident or very confident of making a change to improve health care in a local setting. Most of the QIPs resulted in sustainable practice improvements, and resultant solutions have been disseminated beyond the location of the original QIP. CONCLUSION: A dedicated experiential rotation that requires learner participation in a QIP is one of the effective methods to address the needs of the SBP and PBLI competencies.

Teaching quality improvement: a collaboration project between medicine and engineering.

Systems failures and their impact on quality and cost have fueled the need for a paradigm shift in medical education. Despite a growing interest in health care quality improvement (QI), few physician educators possess the necessary expertise in either systems engineering or QI. In this article, we describe a novel teaching partnership between engineers and physicians in implementing a 3-week elective QI training curriculum on health care QI. Nine learners, 2 preventive medicine and 7 endocrinology fellows, participated in this rotation. Key concepts taught by the 4 engineering faculty include stake-holder analysis, root cause analysis, process mapping, failure mode and effects analysis, resource management, negotiation, and leadership. Learner scores on the QI knowledge application tool improved significantly (P < .004) from 7.33 prerotation to 11.89 postrotation. Further research is necessary to study the effectiveness, efficacy, and scope of using engineering expertise in QI education initiatives.

The impact of a quality improvement program on employee satisfaction in an academic microsystem.

Quality improvement is a potential method to enhance employee satisfaction. This study describes the impact of a program instituted to enhance employee satisfaction using the principles of high-performing microsystems. A shared leadership committee, participatory meetings, suggestion boxes, and quality improvement projects were implemented as part of the program. A follow-up survey 1 year after implementation of the program demonstrated an increase in employee perception of the division's desire to improve service (16%), opportunities to expand skills (17%), involvement in work decisions (25%), and the institution's interest in employee well-being (17%). Key drivers of discretionary effort (4 of 5), job satisfaction (2 of 6), and overall satisfaction (1 of 8) with the institution showed statistically significant improvement in the study division as compared with the other divisions in which no such program was implemented. Further research is needed to study systems changes that enhance employee satisfaction and their impact on patient and financial outcomes.

A systems approach to teach core topics across graduate medical education programmes.

INTRODUCTION: Core curricula including Ethics, Medico-legal issues, Socioeconomics, and Quality Improvement (QI) are relevant and significant for graduate medical education programmes, regardless of specialty. A lack of faculty expertise in these content areas is a frequently cited concern among specialty programmes in graduate medical education. We report the results of an institutional systems-approach to assist this challenge. Our institution has 86 post-graduate residency and fellowship training programmes serving 1068 learners. Directors of these programmes expressed the need for a centralised approach to teach learners about insurance systems and the basics of QI. MATERIALS AND METHODS: Two subject matter experts in the fields of insurance systems and 1 expert in QI conducted 2 institution-wide didactics on each of the content areas, attended by 192 and 225 learners respectively. RESULTS: Significant improvement in learner knowledge was noted for all 3 knowledge-based questions for both content areas (P <0.0001). Learner self-assessment of knowledge of insurance systems increased from a pre-session mean of 2.86 to a post-session mean of 3.80 (P <0.0001) and from 3.29 to a post-session mean of 4.17 (P <0.0001) for the QI didactics. CONCLUSION: Systems-wide didactic sessions for learners of different residencies has several advantages including the efficient use of content experts, prevention of resource burnout, and cost effectiveness. This strategy may also assist programmes directors in meeting external accreditation requirements.