Excellent Clinical Educational Laboratory: EXCEL

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Excellent Clinical Educational Laboratory EXCEL

• Abington Memorial Hospital
• David Gary Smith
• Doron Schneider
• Richard Eisenstaedt

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Internal Medicine Program

• 44 residents
• 36 Categorical
• 8 Preliminary
• 2 PGY4 Chief Residents
• 560 bed Hospital
• Second busiest hospital in Metropolitan Area-
  Philadelphia

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Basic Goals

• Develop clinical rotations that would be
  primarily educational without the competing
  demands for resident and attending attention
• Limit patient responsibilities to an optimal
  number
• Attend to each of the 6 competencies for each
  patient on service
• Define a quality of care criteria map specific
  for each patient
• Create a laboratory environment that analyzes the
  entire process of care for each part and the
  whole of the clinical encounter

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Challenges

• Provide a learner centered focus in accomplishing
  all six competencies
• Produce a critical mass of quality champions to
  support quality initiatives throughout the health
  system during their residencies and their careers
• Develop scorecards of performance for residents
  and faculty in important quality programs
• Evaluate different tools for resident and faculty
  assessment

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Current Rotations EIP Rotation

• High patient volume
• Little time to reflect on care
• Multiple attendings
• Little direct observation
• Rare meaningful evaluation
• from all staff
• Rare direct patient evaluation
• Faculty learning sporadic
• Residents sometimes follow
• hospital quality agenda
• Retrospective audits of performance

• Patient volume lessened
• Frequent care based discussions
• Few attendings
• Frequent direct observation
• High quality evaluations through staff education
• Frequent patient evaluation
• Faculty development integral
• Residents help lead hospital quality agenda
• Concurrent audit of performance helps drive
  quality and safety

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Excellent Clinical Educational Laboratory EXCEL

• Ad Hoc Faculty/Programs
• Behavioralist
• Subspecialists
• Proceduralists
• Simulations
• Patient centered

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Excellent Clinical Educational Laboratory EXCEL

• Tracer methodology- an evaluation method in which
  surveyors select a patient, resident or client
  and use that individual's record as a roadmap to
  move through an organization to assess and
  evaluate the organization's compliance with
  selected standards and the organization's systems
  of providing care and services. 
• Total Patient as unit of analysis on EXCEL
• For each of the 6 competencies
• Quality, Safety, Satisfaction framework

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Outpatient EXCEL

• Work in progress
• Implementation with new ASU-2007
• Similar in philosophy and structure
• Block Rotations

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Innovation Products

• EXCEL Learning Laboratory
• Integrated into every PGY level schedule
• Quality scorecards
• Targeted to safe practices/core measures
• Scorecard for each patient across the six
  competencies
• Team based assessments
• PGY-3 Quality Champion Rotation
• Joint projects
• Eclipsys
• ISMP
• Communication

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Barriers to Implementation

• Increased time commitment from core faculty
• Core faculty acceptance of their care evaluation
• Protection of core faculty time by administration
• Support of nursing, case management, social work
• Administrative Costs
• Research Costs

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Impact on Patients

• Increased patient satisfaction
• Quality of care
• Communication
• Empathy
• Improved performance on quality measures
• Decreased errors
• Medication
• Cognitive
• Management

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Impact on.

• Residents
• Increased resident satisfaction
• Better feedback and performance across the six
  competencies
• Improved empathy skills
• Greater scrutiny

• Faculty
• Professional growth and clinical development
• Enhanced professional satisfaction
• Integration with Hospital Quality and Safety
  initiatives
• More Work
• Self evaluation

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Elements of the PGY3 RotationQuality Champion

• Quality improvement project
• Senior residents will be expected to work on
  their previously selected hospital wide patient
  safety or quality improvement project
• Projects pertinent to the patients located in the
  ExCEL will be most important
• Post hoc abstraction of quality data
• Twice monthly residents will use structured
  medical chart audit forms that focus on quality
  elements (IHI, NQF, JCAHO and internal metrics)
  for patients being discharged from both the ExCEL
  and a non ExCEL general medical floors
• This activity will allow comparisons of care
  provided relative to the above measures
• Rapid Response Team Case Review
• All MET (Medical Emergency Team- our rapid
  response team) calls and codes will be analyzed
  to determine potential areas for improvement in
  the care process prior to the MET call

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Elements of the PGY3 RotationQuality Champion

• Concurrent interface with case management and
  department of social work
• Senior residents will be in constant contact with
  case managers to both assist teams in assembling
  the optimal services at time of discharge and to
  track utilization and length of stay
• Quality Work Rounds
• Daily rounding with care teams to provide
  feedback and guidance relative to quality indices
• For example teams may receive feedback concerning
  patients that do not have appropriate DVT
  prophylaxis, etc
• Quality and Safety Conference
• Senior residents will be responsible for leading
  a weekly conference focusing on quality and
  safety
• In attendance will be residents, attendings and
  other staff rotating or primarily stationed in
  the EXCEL laboratory
• Discussions will center on quality issues and
  gaps found on the unit in the past week

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Elements of the PGY3 RotationQuality Champion

• Concurrent quality endpoint chart review
• Utilizing a structured chart abstraction tool
  residents will examine ongoing care delivery for
  gaps in delivery of evidenced based care
• Metrics include those generated externally (IHI,
  JCAHO, NQF etc) and internally (appropriate
  utilization of specialists, efficiency and
  efficacy of test ordering, etc)
• Concurrent computer system audits
• Utilizing structured abstraction tools senior
  residents will catalogue and review all clinical
  alerts generated on patients in the teaching unit
  
• Senior residents will assist with the timely
  management and extinguishments of all alerts
• Concurrent pharmacy intervention database review
  
• Senior residents will review all interventions
  made by the department of pharmacy on patients
  located in the teaching units
• Interventions will be catalogued and reviewed
  with care teams on a daily basis

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Primary Hypotheses

• The end-of-rotation performance will be better
  for residents on the EXCEL rotations versus the
  residents who have yet to have the rotation. (see
  table of assessment tools)
• Resident and Faculty satisfaction will be greater
  on the EXCEL rotation compared to traditional
  rotations.
• Nursing, case management, and social work
  evaluations of resident performance will be
  better on the EXCEL rotation
• Quality performance of residents will be better
  at the end of EXCEL rotations versus those
  residents who have not yet had the rotations.
• Resident evaluations and performance on quality
  measures will increase on non-EXCEL rotations
  equaling their performance on EXCEL rotations.

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Table of Assessment Tools

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Timeline Initial Phase

• 2/06- Preliminary Discussions about
  Implementation
• Faculty retreat- 2/28/06
• Rotational schedules- 2/06
• 3/06- Physical Plant Changes
• Planning session- 3/27/06
• 4/06-6/06- Coordinating Meetings
• Nursing, Case Management, Social Work
• Computer systems analysts
• Bed Control
• 4/06-6/06- Physical Plant Changes
• 7/06- Implementation

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Excellent Clinical Educational Laboratory EXCEL

• Create designated learning lab within the
  hospital
• Resident Complement
• PGY1- 2
• PGY2- 1
• PGY3- 2
• PGY3- Quality Champion
• Curriculum in patient safety and quality
• Quality advocate for each patient
• Chart audits

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Table of Assessment Tools

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Impact on.

• Residents
• Increased resident satisfaction
• Improved communication and empathy skills
• Better feedback on performance across the six
  competencies

• Faculty
• Professional growth and clinical development
• Integration with Hospital Quality and Safety
  initiatives

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Abstract

• The ACGME challenged all residency programs to
  rethink every aspect of our programs when it
  championed a competency-based curriculum. Our
  core faculty believes that this challenge
  requires bold new initiatives as opposed to
  tinkering at the margins. Using different
  evaluation forms to focus and assess learners and
  faculty without changing the content and process
  of education falls far short of the desired
  competency outcomes. The centerpiece of our
  proposal is the development of clinical
  educational laboratories in both the inpatient
  and outpatient settings where residents and
  faculty can truly embrace the challenges of the
  six competencies. Removing competing agendas and
  priorities will allow faculty (physicians,
  behavioralists, case managers, nurse managers,
  patients) to observe and evaluate resident
  performance to a degree never before possible.
  Residents will be taught how to deliver care
  while continually evaluating the details and the
  ultimate outcome of that care. Residents will
  be integrated directly into the hospitals
  award-winning patient safety program and will be
  expected to become proficient in process and
  performance improvement. To that end, residents
  will use the entire hospital as a learning
  laboratory for systems of care and to participate
  in the process of program improvement when the
  outcomes fall short of the desired quality goals.
  Residents will spend approximately 25 of their
  36 months in these educational laboratories and
  even more time if chosen as electives. An
  essential component of the rotations will be the
  need to bootstrap the faculty and residents into
  the Abington Memorial Hospital Patient Safety and
  Quality Program. The patient safety curriculum
  embraces all of the competencies in an
  outcome-oriented manner that will prepare our
  faculty and residents to be significant
  contributors to performance improvement projects.
  The major resource requirement for the redesign
  is the faculty commitment to play even greater
  roles in championing these initiatives and their
  protection from responsibilities.

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Current Rotations EIP Rotation

• High patient volume
• Little time to reflect on care
• Multiple attendings
• Little direct observation
• Rare meaningful evaluation
• from all staff
• Rare direct patient evaluation
• Faculty learning sporadic
• Residents sometimes follow
• hospital quality agenda
• Retrospective audits of performance

• Patient volume lessened
• Frequent care based discussions
• Few attendings
• Frequent direct observation
• High quality evaluations through staff education
• Frequent patient evaluation
• Faculty development integral
• Residents help lead hospital quality agenda
• Concurrent audit of performance helps drive
  quality and safety