Junior doctors

Innovative Health Systems Projects Michael Green1, Mansoor Amad2 and Mark Woodland3 1

Department of Anaesthesiology Department of Surgery 3 Department of Obstetrics & Gynaecology, Drexel University College of Medicine, Hahnemann University Hospital, Philadelphia, Pennsylvania, USA 2

SUMMARY Background: Residency programmes struggle with the systems-based practice and improvement competency promoted by the Accreditation Council for Graduate Medical Education. The development of Innovative Health Systems Projects (IHelP) was driven by the need for better systemsbased initiatives at an institutional level. Our objective was to develop a novel approach that successfully incorporates systems-based practice in our Graduate Medical Education (GME) programmes, while tracking our impact on health care delivery as an academic medical centre.

Methods: We started the IHelP programme as a ‘volunteer initiative’ in 2010. A detailed description of the definition, development and implementation of the IHelP programme, along with our experience of the first year, is described. Residents, fellows and faculty mentors all played an important role in establishing the foundation of this initiative. Following the positive response, we have now incorporated IHelP into all curricula as a graduating requirement. Results: A total of 123 residents and fellows, representing 26 specialties, participated. We reviewed 145 projects that addressed topics ranging from administrative and departmental

improvements to clinical care algorithms. The projects by area of focus were: patient care – clinical care, 38 per cent; patient care – quality, 27 per cent; resident education, 21 per cent; and a cumulative 16 per cent among pharmacy, department activities, patient education, medical records and clinical facility. Discussion: We are pleased with the results of our first year of incorporating a systems-based improvement programme into the GME programmes. This initiative has promoted scholarly activity and faculty mentorship, has improved aspects of patient care and safety, and has led to the development of many practical innovations.

IHelP has promoted scholarly activity and faculty mentorship, [and] has improved aspects of patient care and safety

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We made IHelP voluntary, and did not mandate a project during its first year

INTRODUCTION

T

he culture of graduate medical education has significantly shifted over the last decade from being process driven to the current outcomesbased system. In 1999, the Accreditation Council of Graduate Medical Education (ACGME) launched its outcome project that sought to redefine the goals of graduate medical education (GME). This initiative identified six quantifiable domains: patient care; medical knowledge; practice-based learning and improvement; interpersonal and communication skills; professionalism, and systems-based practice. Development in each of these categories ensures residents are well prepared to provide optimal patient care, while better appreciating the complex systems that intertwine in health care delivery.

The implementation of systems-based practice (SBP) in health care has been a challenging task.1 Some of the challenges have been a lack of time to carry out initiatives in busy schedules, lack of quality improvement knowledge, and simply questioning its utility in health care. While there have been reports of SBP initiatives at a programme level across various specialties,2,3 there has not been any approach at an institutional level. Institutional efforts to work together and address systemslevel issues and initiatives will enable all programmes to improve and meet the needs of training outcomes for learners. The future of GME is geared towards measuring outcomes in order to improve areas of weakness and aligning strong programmes for innovation. At Drexel University College of Medicine (DUCOM), we have striven to develop a novel approach of implementing an SBP initiative into the academic curricula of all GME programmes

at our institution: Innovative Health Systems Projects (IHelP). While numerous studies describe the challenges and rewards of SBP on a departmental level, we have not seen the advancement of SBP on an institution scale. In order to establish a baseline level of interest in SBP amongst our faculty members and residents, we made IHelP voluntary, and did not mandate a project during its first year. The goals set prior to implementing IHelP were to highlight the value of GME to our administration, promote a culture of ‘giving back’ via critical analysis of our systems, monitor and analyse the utility and impact of faculty member–resident mentorship, and to incorporate SBP into busy curricula.

METHODS System development The concept of implementing IHelP into the curriculum of GME programmes was initiated in the autumn of 2010. Our initial inspiration stemmed from the Affordable Care Act’s concept of Health Innovation Zones, which in part aims to improve quality while controlling cost in academic medical centres (AMCs). We developed a model that would incorporate all aspects of patient care, research and medical education, while meeting the educational outcome needs of our trainees. The focus is more on establishing a database that tracks our impact on health care delivery. Phase 1 was initiated by presenting the proposal to the Dean of the College of Medicine for approval. The process was further enhanced by recommendations of the vice dean and Designated Institutional Official (DIO). We then presented the initiative to the Graduate Medical Education Committee (GMEC) for feedback and final considerations before roll out to the chief residents of our residency programmes. The next step was the development of data-collection software, completed by our in-house IT

department. In July 2011 IHelP was introduced to the curricula on a volunteer basis, encouraging each resident to complete at least one project prior to the culmination of their residency. We thought it would be interesting to gauge a level of interest in SBP amongst our residents by not mandating projects during our first year. With the infrastructure complete, phase 2 – identifying mentors and performing a trial run – ensued. The programme director for each department was responsible for identifying faculty members who were eager to mentor resident-led initiatives. At the discretion of the programme director, residents could work alone or in groups. The objective was to design an innovative project that served to improve the quality of care to patients, decrease morbidity and mortality, increase efficiency, improve communication, reduce the cost of health care expenses or achieve any other goal approved by the programme director. We then completed the implementation process by training residency programme coordinators to maintain and regulate data entry for projects in their respective departments. All projects are evaluated by the programme directors and forwarded to the vice dean of GME for further review. The vice dean prepares an annual report for the DIO, the Executive Committee of the Faculty (EOC) and the Clinical Chairs Committee (CCC) to mark the progress of the programme. Project review The review is department dependent and varies. We will use predetermined guidelines to evaluate the quality of projects submitted for consideration.4 The evaluation system is a graded five-tier scale (levels 1–5) highlighting skill sets in SBP that should be reached, and improved upon, throughout

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Table 1. Next Accreditation System (NAS) systemsbased practice evaluation scale Level 1

• Can describe systems theory and the characteristics of high-reliability organisations. • Understands the epidemiology of medical errors and the differences between medical errors, near misses and sentinel events. • Can define human-factors engineering.

Level 2

• Reports problematic devices, architecture and processes (including errors and near misses) to supervisor, institution or programme, as appropriate. • Illustrates with examples how human-factors engineering promotes patient safety (e.g. Stroop effect, perceptual illusions, easily confused medications).

Level 3

• Analyses the causes of adverse events through root cause analysis. • Demonstrates basic usability testing and critique design of devices, architecture and processes on the basis of principles of human-factors engineering.

Level 4

• Can compare and contrast failure modes and effects analysis with root-cause analysis as a patient safety tool in health care. • Develops content for and facilitates a morbidity and mortality presentation or conference, focusing on systemsbased errors in patient care.

Level 5

• Recommends and justifies characteristics of high-reliability organisations (e.g. reporting adverse events, root cause analysis, and failure modes and effects analysis) to organisational leadership to promote patient safety. • Develops and works with multidisciplinary teams (e.g. human-factors engineers, reference librarians, and cognitive and social scientists) to find solutions to patient-safety problems.

part of this initiative. Projects were completed in various areas of focus, including: patient care – quality of care; patient care – actual clinical care; resident education; hospital administration; medical records; pharmacy; medical school administration; department activities; programme activities; and clinical facility.

Some of our stronger projects clearly identified a systematic problem, and provided a feasible solution

Continuing evaluation Projects are reviewed and evaluated by programme directors on an annual basis. In our department we found it was most suitable for the programme director to discuss projects with residents during biannual scheduled meetings. Once learning objectives are met and the project deemed acceptable they are forwarded to the programme coordinators for inclusion into the institutional database. At the culmination of each academic year, the vice dean receives a summary of all projects that were submitted. This report includes the following information for each project: name of resident, level of training, department, project title, name of mentor and area of focus. Projects that led to institutional change are discussed in GME meetings.

RESULTS the course of training (Table 1). We expect that as our residents matriculate from postgraduate year 1 of training, and beyond, their understanding of and ability to improve upon systems also strengthens. For example, a level–1 project demonstrates a basic knowledge of systems, identifies ways to improve upon medical errors and can suggest changes in processes that stem from human-factors engineering. A level–5 project is expected to include multidisciplinary teams and implement change at the level of organisational leadership, using root cause analysis in improving patient safety. During the programme director’s review and grading

of submitted projects, the level of training of authors will be taken into consideration. If a senior resident’s project does not demonstrate an appropriate level of understanding of SBP, it will be recommended that the resident meet with their mentor for further analysis and re-submit. Some of our stronger projects clearly identified a systematic problem, and provided a feasible solution, using rootcause analysis or other quality improvement (QI) modalities, such as Plan–Do–Study–Act, Lean Methodology and Balance Scorecard.5–7 The residents were not given any supplemental QI training as

During the 2010–2011 academic year, a total of 123 residents and fellows, across 26 medical specialties/subspecialties, completed a total of 145 IHelP projects. The number of projects per area of focus is outlined in Figure 1. All projects were completed individually with the exception of one. Three projects had dual mentorship. Having a focused SBP curriculum enables us to effectively monitor faculty mentorship throughout the various GME programmes. Prior to IHelP, mentorship was governed departmentally, with no way of comparing or analysing its value across the college. From an administrative standpoint, we now

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We now benefit from the large volume of sustainable change that occurred towards patient safety

benefit from the large volume of sustainable change that occurred towards patient safety as a result of various IHelP projects. IHelP continues to promote a culture of inquisitiveness, and challenges our residents to identify and improve upon areas that are less than ideal. Furthermore, the IHelP initiative has helped emphasise the value of GME in our complex heath care system. Resident education has traditionally centred upon the mastery of the knowledge and skill sets required to become a competent clinician. SBP management encourages residents to demonstrate an awareness of the larger systems in which they interact, and to use the available resources to deliver optimal patient care. Checklists are well recognised for minimising error and reducing the cost of heath care.8 Although the shortcomings of processes vary from department to department, resident physicians are at the front line, and are able to recognise these failed processes. A collaborative effort from our departments of Anaesthesiology and Obstetrics and Gynaecology was able to recognise a weak process that affected both groups. A large number of patients requiring anaesthesia procedures had essential

information missing or located on multiple consult forms. The end product of this realisation was a labour and delivery pre-procedure checklist (Figure S1), which is currently in place. Another example of an implemented IHelP project was the creation of a clinical care pathway (CCP). CCPs have been shown to decrease morbidity and mortality, as well as the length of hospital stay.9 A resident created a consolidated preoperative pathway for hip fracture patients (Figure S2). It works on the same premise of having vital information at hand in a concise format that allows for the identification of potential areas of concern. In this pathway, areas of concern for anaesthesia are approached systemically – cardiovascular, pulmonary, nephrology and neurology – and are addressed preoperatively to minimise error.

DISCUSSION We are pleased to report an overwhelmingly positive response to our SBP programme during its inaugural year. The completion of a project was not mandated during its inaugural year, and all of our 145 submissions were selfmotivated. We now have hundreds of resident physicians/fellows

Figure 1. Projects in each area of focus

who are at the front line of health care delivery identifying and critically analysing areas for improvement. Furthermore, we continue to collect invaluable data for our institutions that will be of benefit when the next accreditation system (NAS) is in effect. Programmes in the past have used various strategies for teaching SBP. The most commonly reported were didactics, grand round presentations, discussion in journal clubs and reflective analysis.10 Our approach to the integration of this competency has been much more independent when compared with those described. Time and financial constraints are often cited as the most important barrier when implementing any aspect of the outcome project.11 IHelP has proven successful because of the minimal set-up required and its flexibility in incorporating IHelP in the busy schedules of faculty members and residents. Most discussions between residents, mentors and the programme directors occur in scheduled meetings. This is an essential contributing factor in compliance from residents and faculty staff alike. It is important to note that IHelP serves as a supplemental SBP initiative to existing requirements that individual GME programmes have in place. The positive response to IHelP during its first year by residents, mentors and programme directors encouraged us to incorporate an SBP project as a graduation requirement. The premise of evaluating the bigger picture in health care delivery has been around for more than a decade on the international platform.12,13 We hope to align our residents to better understand these dynamic processes. Simply making them aware of SBP is not enough. The successful completion of an IHelP project demonstrates fundamental skills in the critical analysis of various aspects of health care delivery.

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One of the limitations to this report is that these are initial findings. Follow-up data are warranted over the course of the next few years to help confirm our findings. Furthermore, we do not have a system in place that tracks the number of local and national presentations, and publications that result from IHelP projects. These data could be used as a metric of evaluating the success of our initiative. Another shortcoming of our approach is that our IHelP programme does not provide residents and fellows with rigorous training in quality improvement and SBP when compared with other programmespecific initiatives. This is much more difficult to achieve on a larger scale for the same time, cost and logistic issues that individual programmes face. It is also important to note that we currently do not have a process in place that tracks the specific changes that resulted from all IHelP projects. We are working to include this in our database, as it is essential in measuring clinical change. To the best of our knowledge, this is the first report of an SBP educational model that encompasses every training programme within an academic medical centre. This initiative requires limited resources to set up infrastructure, and has proven to be fruitful on many fronts. It is our hope that our findings serve as a starting point for other institutions to take innovative approaches to incorporate SBP into GME programmes.

REFERENCES 1. Johnson JK, Miller SH, Horowitz SD. Systems-Based Practice: Improving the Safety and Quality of Patient Care by Recognizing and Improving the Systems in Which We Work. In Advances in Patient Safety: New Directions and Alternative Approaches. Vol. 2: Culture and Redesign. Henriksesn K, Battles JB, Keyes MA, Grady ML (eds). Rockville, MD: Agency for Healthcare Research and Quality; 2008. Available at http://www. ahrq.gov/downloads/pub/advances2/vol2/Advances-Johnson_90. pdf. Accessed on 10 October 2012. 2. Soto RG, Cormican DS, Gallagher CJ, Seidman PA. Teaching Systems-Based Competency in Anesthesiology Residency: Development of an Education and Assessment Tool. J Grad Med Educ 2010;2:250–259. 3. Eiser AR, Connaughton-Storey J. Experiential learning of systems-based practice: a hands-on experience for firstyear medical residents. Acad Med 2008;83:916–923. 4. The Accreditation Council of Graduate Medical Education. Milestone Project. Available at http://www.acgme.org/ acgmeweb/tabid/430/Programand InstitutionalAccreditation/ NextAccreditationSystem/ Milestones.aspx. Accessed on 8 October 2012. 5. Nakayama DK, Bushey TN, Hubbard I, Cole D, Brown A, Grant TM, Shaker IJ. Using a Plan–Do– Study–Act cycle to introduce a new OR service line. AORN J 2010;92:335–343. 6. Kimsey DB. Lean methodology in health care. AORN J 2010;92: 53–60. 7. Kocakülâh MC, Austill AD. Balanced scorecard application in the health care industry: a case study. J Healthc Finance Manage 2007;34:72–99.

8. Haynes AB, Weiser TG, Berry WR, et al. Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491–499. 9. Numan RC, Klomp HM, Li W, Buitelaar DR, Burgers JA, Van Sandick JW, Wouters MW. A clinical audit in a multidisciplinary care path for thoracic surgery: An instrument for continuous quality improvement. Lung Cancer 2012;78:270–275.

This initiative requires limited resources to set up, and has proven to be fruitful on many fronts

10. Tomolo A, Caron A, Perz ML, Fultz T, Aron DC. The outcomes card: development of a systems-based practice educational tool. J Gen Intern Med 2005;20:769–771. 11. Malik MU, Diaz Voss Varela DA, Stewart CM, Laeeq K, Yenokyan G, Francis HW, Bhatti NI. Barriers to Implementing the ACGME Outcome Project: A Systematic Review of Program Director Surveys. J Grad Med Educ 2012;4:425–433. 12. Plsek P, Greenhalgh T. Complexity science: The challenge of complexity in health care. BMJ 2001;13:625–628. 13. Kernick D. Complexity and healthcare organisation. Oxford: Radcliffe Medical Press; 2004.

SUPPORTING INFORMATION Additional supporting information may be found in the online version of this article at http://onlinelibrary.wiley.com/ doi/10.1111/tct.12218/suppinfo Figure S1. Quality and process improvement: Innovative Health Systems Project (IHeLP). Figure S2. Preoperative pathway: hip fracture patients.

Corresponding author’s contact details: Michael S. Green, DO, Interim Chair/Program Director, Associate Professor, Drexel University College of Medicine, 245 N. 15th Street, Suite 7502, MS 310, Philadelphia, PA, 19102, USA. E-mail: [email protected]

Funding: None. Conflict of interest: None. Acknowledgements: None. Ethical approval: Ethical approval was obtained from Drexel University College of Medicine Institutional Review Board. doi: 10.1111/tct.12218

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Innovative health systems projects.

Residency programmes struggle with the systems-based practice and improvement competency promoted by the Accreditation Council for Graduate Medical Ed...
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