Who's in Our Neighborhood? Healthcare Disparities Experiential Education for Residents.

BACKGROUND: Residents and fellows frequently care for patients from diverse populations but often have limited familiarity with the cultural preferences and social determinants that contribute to the health of their patients and communities. Faculty physicians at academic health centers are increasingly interested in incorporating the topics of cultural diversity and healthcare disparities into experiential education activities; however, examples have not been readily available. In this report, we describe a variety of experiential education models that were developed to improve resident and fellow physician understanding of cultural diversity and healthcare disparities. METHODS: Experiential education, an educational philosophy that infuses direct experience with the learning environment and content, is an effective adult learning method. This report summarizes the experiences of multiple sponsors of Accreditation Council for Graduate Medical Education-accredited residency and fellowship programs that used experiential education to inform residents about cultural diversity and healthcare disparities. The 9 innovative experiential education activities described were selected to demonstrate a wide range of complexity, resource requirements, and community engagement and to stimulate further creativity and innovation in educational design. RESULTS: Each of the 9 models is characterized by residents' active participation and varies in length from minutes to months. In general, the communities in which these models were deployed were urban centers with diverse populations. Various formats were used to introduce targeted learners to the populations and communities they serve. Measures of educational and clinical outcomes for these early innovations and pilot programs are not available. CONCLUSION: The breadth of the types of activities described suggests that a wide latitude is available to organizations in creating experiential education programs that reflect their individual program and institutional needs and resources.

Health care and the environment: local champions, global impact.

Health care as a sector has recently become aware that it is a major user of energy and generator of waste. Now, many institutions are taking steps to curb their energy consumption, reduce waste, and design processes and facilities that are more environmentally friendly and, as a result, healthier. This article describes these trends as well as specific efforts underway in Minnesota that could serve as models for providers in other parts of the United States.

Incorporating patient- and family-centered care into resident education: approaches, benefits, and challenges.

PURPOSE: A design conference with participants from accredited programs and institutions was used to explore how the principles of patient- and family-centered care (PFCC) can be implemented in settings where residents learn and participate in care, as well as identify barriers to PFCC and simple strategies for overcoming them. APPROACH: In September 2009, the Accreditation Council for Graduate Medical Education (ACGME) held a conference with 74 participants representing a diverse range of educational settings and a group of expert presenters and facilitators. Small group sessions explored the status of PFCC in teaching settings, barriers that need to be overcome in some settings, simple approaches, and the value of a national program and ACGME support. FINDINGS: Participants shared information on the state of their PFCC initiatives, as well as barriers to implementing PFCC in the learning environment. These emerged in 6 areas: culture, the physical environment, people, time and other constraints, skills and capabilities, and teaching and assessment, as well as simple strategies to help overcome these barriers. Two Ishikawa (Fishbone) diagrams (one for barriers and one for simple strategies) make it possible to select strategies for overcoming particular barriers. CONCLUSIONS: A group of participants with a diversity of approaches to incorporating PFCC into the learning environment agreed that respectful communication with patients/families needs to be learned, supported, and continuously demanded of residents. In addition, for PFCC to be sustainable, it has to be a fundamental expectation for resident learning and attainment of competence. Participants concurred that improving the environment for patients concurrently improves the environment for learners.

Engaging physicians in CME: the power of theater.

HealthPartners Institute for Medical Education has developed an innovative continuing medical education model that uses elements of theater to explore complex issues in health care and increase participant engagement. The model was recently used during a hospital medicine retreat. The learning event included a four-part monologue in which an actor portrayed a patient, interactive didactic sessions, a game show titled "Who Wants to be Hospitalized a MillionTimes," computerized simulations, and a call for clinicians to help patients adopt healthier behaviors. Post-event evaluations demonstrated that participants gained valuable clinical knowledge and appreciated the combination of active learning and theater.

Integrating quality improvement and residency education: insights from the AIAMC National Initiative about the roles of the designated institutional official and program director.

Active engagement of both the designated institutional official (DIO) and the program director (PD) is essential to implement any change in graduate medical education (GME). Strategies that are established by the Accreditation Council for Graduate Medical Education or other entities are, in the end, effective only as implemented at the individual program level. The interpretation of national standards or guidelines, and the specific adaptation to the vagaries of individual institutions and programs, can lead to significant variability in implementation and potentially in outcomes. Variability occurs between programs within the same institution and between some specialty programs at different institutions. The National Initiative, sponsored by the Alliance of Independent Academic Medical Centers, was launched in 2007 to demonstrate the effectiveness of GME as a key driver to improve quality, patient safety, and cost-effectiveness of care. This report addresses (1) the key roles of both the DIO and the PD in achieving the goals of the National Initiative, (2) the challenges these goals presented to each role, and (3) some of the tactics drawn from the experiences of the National Initiative in overcoming those challenges. The experience of the National Initiative underscored the synergies of the DIO and PD roles to improve patient care while simultaneously fulfilling their critical responsibilities as institutional and program leaders in GME with even greater effectiveness.

Residents' engagement in quality improvement: a systematic review of the literature.

PURPOSE: Residents are being asked to participate in quality improvement (QI) initiatives in hospitals and clinics with increasing frequency; however, the effectiveness of improving patient care through residents' participation in QI initiatives is unknown. METHOD: A thorough, systematic review of the English-language medical literature published between 1987 and October 2008 was performed to identify clinical QI initiatives in which there was active engagement of residents. Multiple search strategies were employed using PubMed, EMBASE, CINAHL, and ERIC. Articles were excluded in which residents played a passive or peripheral role in the QI initiative. RESULTS: Twenty-eight articles were identified that documented residents' active leadership, development, or participation in a clinical QI initiative, such as curriculum change, clinical guideline implementation, or involvement with a clinical QI team. The role and participation of residents varied widely. Measures of patient health are described as outcomes in the QI initiatives of 5 of the 28 articles. Twenty-three articles described process improvements in patient care or residents' education as the outcome measure. CONCLUSION: There are few articles that describe the clinical or educational effectiveness of residents' participation in QI efforts; the authors describe barriers that may be partly responsible. They conclude that there is a great need for additional research on the effectiveness of residents' participation in QI initiatives, particularly as they affect patient health outcomes.

"Renters" or "owners"? Residents' perceptions and behaviors regarding error reduction in teaching hospitals: a literature review.

PURPOSE: Residents' attitudes, practices, and behaviors vary in response to medical error within the context of the culture of their institutions. The purpose of this study was to conduct a systematic review of the literature focused on residents' attitudes and behaviors regarding medical errors in teaching hospitals, including a qualitative review of barriers and proposed countermeasures related to residents' engagement in patient safety. METHOD: The electronic literature databases of MEDLINE, CINAHL, and ERIC were searched for articles published between January 1988 and June 2008. The search strategy yielded 124 articles. A scoring system was developed to assess the quality of the overall literature. RESULTS: Nineteen studies met eligibility criteria, with 17 published since 2005. There were 12 cross-sectional, 5 qualitative, 1 cohort and 1 pre-post intervention study. Quality assessment scores ranged from 5.5 to 12.5 (possible range 1.0-16.0). Three studies obtained a score of < or = 8.0, 5 obtained scores of 8.5 to 10.5, and 11 studies had scores of 11.0 to 12.5. Personal, environmental, and system barriers, and environmental and system countermeasures, were identified. CONCLUSIONS: Although the published literature on this topic is limited, those articles that exist identify barriers that make residents reluctant to engage in institutional error identification and/or reduction. Key factors identified included a fear of retribution and the perception of residents as transient care providers. Whereas several countermeasures have been promulgated, the literature reveals scant evidence of their effectiveness. Institutions should recognize and capitalize on the unique experiences of residents and their potential to become owners in patient safety initiatives.

Residents' and attending physicians' handoffs: a systematic review of the literature.

PURPOSE: Effective communication is central to patient safety. There is abundant evidence of negative consequences of poor communication and inadequate handoffs. The purpose of the current study was to conduct a systematic review of articles focused on physicians' handoffs, conduct a qualitative review of barriers and strategies, and identify features of structured handoffs that have been effective. METHOD: The authors conducted a thorough, systematic review of English-language articles, indexed in PubMed, published between 1987 and June 2008, and focused on physicians' handoffs in the United States. The search strategy yielded 2,590 articles. After title review, 401 were obtained for further review by trained abstractors. RESULTS: Forty-six articles met inclusion criteria, 33 (71.7%) of which were published between 2005 and 2008. Content analysis yielded 91 handoffs barriers in eight major categories and 140 handoffs strategies in seven major categories. Eighteen articles involved research on handoffs. Quality assessment scores for research studies ranged from 1 to 13 (possible range 1-16). One third of the reviewed research studies obtained quality scores at or below 8, and only one achieved a score of 13. Only six studies included any measure of handoff effectiveness. CONCLUSIONS: Despite the negative consequences of inadequate physicians' handoffs, very little research has been done to identify best practices. Many of the existing peer-reviewed studies had design or reporting flaws. There is remarkable consistency in the anecdotally suggested strategies; however, there remains a paucity of evidence to support these strategies. Overall, there is a great need for high-quality handoff outcomes studies focused on systems factors, human performance, and the effectiveness of structured protocols and interventions.

Developing a community health promotion agenda for a managed care organization.

Coordination and collaboration between organizations interested in promoting the health of the populations they serve can potentially help to ensure that key services are provided as well as augment the efforts beyond that which could be accomplished by each organization alone. Understanding the perspectives of each organization can facilitate development of health promotion initiatives that will be of mutual benefit. In Maryland, when a Medicaid managed care program was initiated, Memoranda of Understanding were signed between each managed care organization (MCO) and each of the 24 local health departments; many stipulated that the parties will coordinate on community health issues. This report describes a telephone survey of the health departments that was performed by one MCO to better understand the interests and expectations of the health departments and discusses a process for developing a community health promotion agenda for an MCO.