Jump-Starting Faculty Development in Quality Improvement and Patient Safety Education: A Team-Based Approach.

PROBLEM: Quality improvement (QI) and patient safety (PS) are cornerstones of health care delivery. Accreditation organizations increasingly require that learners engage in QIPS. For many faculty, these are new domains. Additional faculty development is needed for them to teach and mentor trainees. Existing programs, such as the Association of American Medical Colleges Teaching for Quality (Te4Q) program, target individual faculty and thus accommodate only limited participants at a time, which is problematic for institutions that need to train many faculty to support their learners. APPROACH: The authors invited diverse stakeholders from across the University of California, San Francisco (UCSF) School of Medicine and related health systems to participate in a team-based adaptation of the Te4Q program. The teams completed 5 projects based on previously identified priority areas to increase local capacity for QIPS teaching: (1) online modules for faculty new to QIPS, (2) a tool kit for graduate medical education programs, (3) a module for medical school clerkship directors, (4) guidelines for faculty to integrate early learners into QI projects, and (5) a "Teach-for-UCSF" certificate program in teaching QIPS. OUTCOMES: Thirty-five faculty members participated in the initial Te4Q workshop in January 2015, and by fall 2016, all projects were implemented. These projects led to additional faculty development initiatives and a rapidly expanding number of faculty across campus with expertise in teaching QIPS. NEXT STEPS: Further collaborations between faculty focused on QIPS in care delivery and those focused on QIPS education to promote QIPS teaching have resulted from these initial projects.

Aligning Delivery System and Training Missions in Academic Medical Centers to Promote High-Value Care.

Academic medical centers (AMCs) are transforming to improve their care delivery and learning environments so that they build a culture that fosters high-value care. However, AMCs struggle to create learning environments where trainees are part of the reason for institutional success and their initiatives have high impact and are sustainable. The authors believe that AMCs can reach these goals if they codevelop strategic priorities and provide infrastructure to support alignment between the missions of health delivery systems and graduate medical education (GME).They outline four steps for AMCs and policy makers to create an infrastructure that supports this alignment to deliver value-based care. First, AMCs can align strategic priorities between delivery systems and educators by creating a common understanding of why initiatives require priorities within the health care system. Second, AMCs can support alignment with data from multiple sources that are reliable, valid, and actionable for trainees. Third, resident initiatives can create sustained impact by linking trainees to the institutional staff and infrastructure supporting value improvement efforts. Fourth, incentive payment programs through medical education could augment current system incentives to propel further alignment between education and delivery systems. The authors support their recommendations with concrete examples from emerging models created by GME and health delivery system leaders at AMCs across the country.

Early Experiences After Adopting a Quality Improvement Portfolio Into the Academic Advancement Process.

PROBLEM: Academic medical centers (AMCs) and their academic departments are increasingly assuming leadership in the education, science, and implementation of quality improvement (QI) and patient safety efforts. Fostering, recognizing, and promoting faculty leading these efforts is challenging using traditional academic metrics for advancement. APPROACH: The authors adapted a nationally developed QI portfolio, adopted it into their own department's advancement process in 2012, and tracked its utilization and impact over the first two years of implementation. OUTCOMES: Sixty-seven QI portfolios were submitted with 100% of faculty receiving their requested academic advancement. Women represented 60% of the submitted portfolios, while the Divisions of General Internal Medicine and Hospital Medicine accounted for 60% of the submissions. The remaining 40% were from faculty in 10 different specialty divisions. Faculty attitudes about the QI portfolio were overwhelmingly positive, with 83% agreeing that it "was an effective tool for helping to better recognize faculty contributions in QI work" and 85% agreeing that it "was an effective tool for elevating the importance of QI work in our department." NEXT STEPS: The QI portfolio was one part of a broader effort to create opportunities to recognize and support faculty involved in improvement work. Further adapting the tool to ensure that it complements-rather than duplicates-other elements of the advancement process is critical for continued utilization by faculty. This will also drive desired dissemination to other departments locally and other AMCs nationally who are similarly committed to cultivating faculty career paths in systems improvement.

Improving the Ambulatory Patient Experience Within an Academic Department of Medicine.

Academic departments of medicine (ADOM) can provide an important vehicle to drive the sharing and dissemination of best practices in clinical care delivery. With the increased focus on improving the patient experience, particularly in the ambulatory setting, ADOM also should lead efforts to cultivate improvements in this arena. To address this need, the study ADOM established a Patient Experience Working Group (PEWG) that brought together physician and nonphysician leaders, set improvement goals, and created a structure for sharing and learning. Since initiation, the PEWG has implemented more than 20 performance improvement initiatives, which have resulted in measured positive changes at both the local practice settings and department-wide. Striking the right balance between top-down governance, bottom-up innovation and ownership, and shared goal setting was a key to success. This model is one that could easily be adopted by other ADOM in their own efforts to improve the patient experience.

"Choosing wisely" in an academic department of medicine.

The "Choosing Wisely" campaign seeks to reduce unnecessary care in the United States through self-published recommendations by professional societies. The research team sought to identify factors related to low-value care in the Department of Medicine at the University of California San Francisco, using a subset of clinical scenarios published by the American College of Physicians. The team further explored respondents' values on cost consciousness. A notable minority disagreed with the identified low-value tests. In 6 of 8 scenarios, faculty were more likely to rate the scenarios as representing low-value testing (P < .05). Level of training was the only predictor of attitudes toward unnecessary care after linear regression analysis (coefficient 3.14, P < .001). Increased postgraduate education about cost of care is recommended.

Role-modeling and medical error disclosure: a national survey of trainees.

PURPOSE: To measure trainees' exposure to negative and positive role-modeling for responding to medical errors and to examine the association between that exposure and trainees' attitudes and behaviors regarding error disclosure. METHOD: Between May 2011 and June 2012, 435 residents at two large academic medical centers and 1,187 medical students from seven U.S. medical schools received anonymous, electronic questionnaires. The questionnaire asked respondents about (1) experiences with errors, (2) training for responding to errors, (3) behaviors related to error disclosure, (4) exposure to role-modeling for responding to errors, and (5) attitudes regarding disclosure. Using multivariate regression, the authors analyzed whether frequency of exposure to negative and positive role-modeling independently predicted two primary outcomes: (1) attitudes regarding disclosure and (2) nontransparent behavior in response to a harmful error. RESULTS: The response rate was 55% (884/1,622). Training on how to respond to errors had the largest independent, positive effect on attitudes (standardized effect estimate, 0.32, P < .001); negative role-modeling had the largest independent, negative effect (standardized effect estimate, -0.26, P < .001). Positive role-modeling had a positive effect on attitudes (standardized effect estimate, 0.26, P < .001). Exposure to negative role-modeling was independently associated with an increased likelihood of trainees' nontransparent behavior in response to an error (OR 1.37, 95% CI 1.15-1.64; P < .001). CONCLUSIONS: Exposure to role-modeling predicts trainees' attitudes and behavior regarding the disclosure of harmful errors. Negative role models may be a significant impediment to disclosure among trainees.

Bringing continuing medical education to the bedside: the University of California, San Francisco Hospitalist Mini-College.

INTRODUCTION: As a relatively new generalist specialty, hospitalists must acquire new competencies that may not have been taught during their training years. Continuing medical education (CME) has traditionally been a mechanism to meet training needs but often fails to apply adult learning principles and fulfill current demands. METHODS: We developed an innovative 3-day course called the University of California, San Francisco Hospitalist Mini-College (UHMC) that brings adult learners to the bedside for small-group learning focused on content areas relevant to today's hospitalists. The program was built on a structure of 4 clinical domains and 2 clinical skills labs. Sessions about patient safety and immersion into traditional academic learning vehicles, such as morning report and a morbidity and mortality conference, were also included. Participants completed a precourse survey and a postcourse evaluation. RESULTS: Over 5 years, 152 participants enrolled and completed the program; 91% completed the pre-UHMC survey and 89% completed the postcourse evaluation. Overall, participants rated the quality of the UHMC course highly (4.65; 1-5 scale). Ninety-eight percent of UHMC participants (n = 57) in 2011 to 2012 reported a "high" or "definite" likelihood to change practice, higher than the 78% reported by the 11,447 participants in other UCSF CME courses during the same time period. DISCUSSION: The UHMC successfully brought participants to an academic health center for a participatory, hands-on, and small-group learning experience that was highly rated. A shift of CME from a hotel conference room to the bedside is feasible, valued by participants, and offers a new paradigm for how to maintain and improve hospitalist competencies.

An advanced quality improvement and patient safety elective.

BACKGROUND: Practising doctors must be competent in quality improvement (QI) and patient safety (PS). Despite this need, QI and PS have yet to be fully integrated into the undergraduate medical curriculum. Furthermore, there are few resources available for motivated senior medical students to receive advanced training prior to starting residency. To address these needs, we piloted an elective in QI/PS for senior medical students. METHODS: We measured changes in knowledge, attitude and QI/PS skills with before and after surveys and skill assessments. Post-elective measures included an assessment of reaction to the curriculum and an assessment of a QI project proposal. RESULTS: Six students participated in two 2-week electives. Mean knowledge test scores improved after the elective [mean score (SD)]: before, 7.3 (1.4), versus after, 8.2 (0.4); p = 0.19. There were improvements in confidence in all aspects queried, and this was significant in six of the seven confidence questions. Students had high motivation for future QI/PS involvement both before and after the elective. Validated measures assessing QI/PS skills showed high levels of performance both before and after the elective. Experiential components of the elective were most highly valued. DISCUSSION: Motivated students may not have the confidence needed to effectively actuate their desire to incorporate QI/PS in their continuing training and careers. This 2-week elective significantly improved students' confidence and maintained their motivation for QI/PS work. Experiential activities may be particularly beneficial for students to learn QI/PS throughout medical school.

Enculturation of unsafe attitudes and behaviors: student perceptions of safety culture.

PURPOSE: Safety culture may exert an important influence on the adoption and learning of patient safety practices by learners at clinical training sites. This study assessed students' perceptions of safety culture and identified curricular gaps in patient safety training. METHOD: A total of 170 fourth-year medical students at the University of California, San Francisco, were asked to complete a modified version of the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture in 2011. Students responded on the basis of either their third-year internal medicine or surgery clerkship experience. Responses were recorded on a five-point Likert scale. Percent positive responses were compared between the groups using a chi-square test. RESULTS: One hundred twenty-one students (71% response rate) rated "teamwork within units" and "organizational learning" highest among the survey domains; "communication openness" and "nonpunitive response to error" were rated lowest. A majority of students reported that they would not speak up when witnessing a possible adverse event (56%) and were afraid to ask questions if things did not seem right (55%). In addition, 48% of students reported feeling that mistakes were held against them. Overall, students reported a desire for additional patient safety training to enhance their educational experience. CONCLUSIONS: Assessing student perceptions of safety culture highlighted important observations from their clinical experiences and helped identify areas for curricular development to enhance patient safety. This assessment may also be a useful tool for both clerkship directors and clinical service chiefs in their respective efforts to promote safe care.

Communicating discharge instructions to patients: a survey of nurse, intern, and hospitalist practices.

BACKGROUND: Comprehensive discharge education can improve patient understanding and may reduce unnecessary rehospitalization. OBJECTIVES: To understand nurse and physician communication practices around patient discharge education. SETTING: University of California, San Francisco Medical Center (UCSFMC). PARTICIPANTS: Nurses, interns, and hospitalists caring for hospitalized medicine patients. MEASUREMENTS: Participants were surveyed regarding discharge education practices. The survey asked respondents about 13 elements of discharge education found in the literature. For each element, participants were queried regarding: 1) the provider responsible for this element of patient education; 2) the frequency with which they communicate this teaching to patients; 3) how often they directly communicate with the nurse or physician caring for the patient about each element; and 4) tools to improve nurse-physician communication. RESULTS: A total of 129/184 (70%) nurses, interns, and hospitalists responded to the survey. The majority of respondents in all 3 groups felt that 9 of 13 elements were a combined responsibility. Nurses reported educating patients on these 9 items significantly more often than physicians (P < 0.05). All groups also agreed that instruction on 2 of the elements, summary of hospital findings and pending results, should be primarily the physicians' responsibility; these were the elements least often discussed by any provider. Despite the majority of items being agreed upon as a shared responsibility, communication between nurses and physicians regarding discharge education was low. Standardized verbal communication on the day of discharge was supported most strongly by all providers. CONCLUSIONS: Ambiguous responsibility for providing discharge education and poor communication between nurses and physicians offers an opportunity for improvement. Journal of Hospital Medicine 2013. © 2012 Society of Hospital Medicine.