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Leveraging Front-Line Work

Graduate Medical Education: Focusing on Quality

and Safety in a Clinical Learning Environment

November 2013

Diane M. Hartmann, MD

Professor of Obstetrics & Gynecology

Senior Associate Dean for Graduate Medical Education

University of Rochester School of Medicine

Robert J. Panzer, MD

Georgia & Thomas Gosnell Professor of Quality & Safety

Chief Quality Officer

University of Rochester School of Medicine

NEW-NAS –Jan_2013

University of

Rochester

University of Rochester Medical

Center

HealthSciencesDivision

School ofMedicine

and Dentistry

URMFG

StrongMemorial Hospital

VisitingNurse

Service

EastmanInstitute of Oral Health

University of Rochester Medical Center Divisions

Highlands At

Brighton

StrongPartners

Highland Hospital

Highlandsat

Pittsford

HighlandLiving Center

ThompsonHealth System

Schoolof

Nursing

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CLER Focus Areas

• Patient Safety

• Health Care Quality

• Care Transitions

• Supervision

• Duty Hours/Fatigue Management and Mitigation

• Professionalism

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Intersection of QS and GME Leadership

• CQO active participant in GMEC

• DIO active participant in Quality Council

• Leadership Team meetings with individual training programs

• Resident Quality/Safety Council

• Trainee Education

• Safety Culture Survey

• Med Center-wide Quality Safety Initiatives

• Harm Reports

• Multidisciplinary CLER Team

• Collaboration with IT and I-CARE Groups

• Departmental Activities

• Quantros Reporting System

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Chief Quality Officer and DIOactive participants on GMEC &

Quality Council

DIO, CQO, COO Meetings with Individual Training Programs

“What Hospital-Based issues are preventing you from delivering quality

care/getting a good education?”

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Resident Quality and Safety Council

Resident Quality and Safety CouncilConsult Guidelines

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Trainee Education Institutional

• Six On-line Quality/Safety Modules

• Institutional Orientation

• Annual Mandatory Sessions (ID,

QS, Communication)

On-line Quality/Safety Modules

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Institutional Orientation

Topics:

Quality & safety prioritiesAsking for help

Rapid response team

Annual Mandatory SessionsInfections

Each August:

Update on hospital acquired infections

Special topics:

Central line placement

Occupational blood exposure (needlesticks)

Sepsis detection & early managemetn

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Annual Mandatory SessionsQuality & Safety

Annual Mandatory Session-Quality & SafetyFocus on “measures that matter”

• Necessary to promoting high reliability and a

culture of safety

• Maintain professionalism and earn respect

As in clinical care

Beware of unintended consequences

Overtreatment of ED patients with bronchitis

Beware of unintended messages

Cleveland conference story

Scramble to document rather than improve

“Clicking is caring”

• Emphasize measuring doing the right “bundle” of best

practices

clicking is caring-bottom.jpg

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Annual Mandatory Session-Quality & SafetySMH – Current Year Top Safety Priorities

•Preventing harm from complications

CLABSI, SSI, C Diff, CAUTI

Falls, pressure ulcers

Hospital acquired severe sepsis (deployed with ED sepsis)

•Medications

Home medication lists

Reconciliation on admission, transfer(s), discharge

Ordering

•Handoffs

Shift to shift (and nights, weekends, holidays)

Unit to unit (and service to service, to or from OR, ICU, etc)

Wayne Gretzky

“I skate to where the puck is

going to be, not where it has

been.”

“A good hockey player plays

where the puck is. A great

hockey player plays where the

puck is going to be.”

RJP

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Annual Mandatory Session-Quality & Safety Vision of the Future

• Quality measures derived from good clinical data, not bills

• Abstraction from paper records fully shifts to extraction from

EMR’s

• EMR data is codified and accurate

• Convergence of Meaningful Use and P4P measures

• EMR data created during the normal process of care, not

distorted by act of measurement

• Shift from measurement of hospital and outpatient episodes -

to population health, prevention, and chronic disease

processes and outcomes over time17

Annual Mandatory SessionsPatient & Family Centered Care

Introduced by Medical Center CEO

Special Topics

Patient & Family experiences at SMH

Managing acute and chronic pain

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Session Title 2013 DatesDiagnostic Error in Medical Decision Making: A Growing Risk January 29

Severe Sepsis and Septic Shock: Lessons from the Rory Staunton Story

February 19 & 26

Ensuring Comprehensive Hand-Offs at URMC: New Standards, New Tools March 5

Care Management Strategies for Integrated Health Systems March 21

Listening with a Stethoscope II April 23

Communication and Collaboration – Acute Pain in the Hospitalized Patient May 30

Raising the Bar on Performance: Accountability in a Just Culture June 3

Preventing Harm from Infections and Severe Sepsis August 23

Quality of Care – The Measurement Tsunami Continues September 13

Changing Safety Culture in a Hospital:Improving Use of Perioperative Antibiotics to Prevent Surgical Site Infection

October 9

Physician Stress, Burnout, and Compassion Fatigue November 18

Patient Safety Grand Rounds

AHRQ Safety Culture Survey Response Rate - Spring 2013

Residents

Attending Physicians

Staff

34%

100%

28%

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Minimal Handoff Standards

1. A hand-off communication will occur between the sender and receiver for all transfers of patient care responsibility.

2. The hand-off process will include use of an on-screen clinical summary, a printable report and/or verbal communication between the sender and receiver of the hand-off information.

3. Hand-offs will occur with minimal interruptions.

4. Hand-offs will occur in an appropriate environment conducive to good communication.

5. The sender of the hand-off communication will have sufficient knowledge of the patient to effectively communicate the key and pertinent information to the receiver.

Patient Story

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Weekly Report of Harm:Focusing Attention on the Front Lines

• Johns Hopkins Model – 2008

• Selling the idea – Fall 2008

• Mock report

• Gathering the data

• Start January 2009

• Expansion to affiliated community hospital25

Culture ChangeWeekly “Report of Harm”

Since Jan 3, 2009

• Updated each Wednesday through the previous Saturday

•Raw numbers for each of past 8 weeks

•Central line associated blood stream infections

•Hospital acquired C. difficile infections

•MRSA bacteremia

•Surgical site infections (NHSN cardiac, colon)

•Serious hospital acquired pressure ulcers

•Fall with fracture or head bleed

•Serious safety event stories or improvement story of the

month

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Culture ChangeWeekly “Report of Harm”

Since Jan 3, 2009

•Leadership responses:

•Board quality committee chair

• “Bob - Greetings from nyc.......why so many c diff? We

were doing well and this seems very high. Thoughts?

Thanks, DC”

•Board chair

• “Ray. Any understanding of CLABSI increases the last

few weeks?”

•Cardiology chief (8 minutes after report emailed)

•“I hold my breath as a I page down through the

results, scanning for the CCU and Cardiac rows...”

Harm Report – Handoff Data

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Multidisciplinary CLER Team

• Operational • Aspirational/Idea Generating

“integrating safety practices, ICARE behaviors, and lean strategies into daily work”

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“ever better, every day across the six aims of healthcare improvement – safe, effective,

patient-centered, timely, efficient, and equitable”

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Collaboration with ITand I-Care Teams

• Professionalism in the use of Electronic Records

• Building a culture of Respect

Professionalism

• EMR Guidelines• Cultural Respect

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Electronic Use Guidelines

Provider eRecord Etiquette Overview

Purpose and Rationale

eRecord is a powerful patient‐centric tool, shared across ambulatory and inpatient settings. Effective and

safe use of eRecord requires careful adherence to URMC guidelines. While many clinical workflows are changing, the fundamental responsibilities of independent patient evaluation, original documentation and individualized patient care remain the centerpiece of our professional obligations to the patient and the health care system. In addition, there are many robust and interactive portions of this electronic patient record that now demand all providers consider the impact of their documentation on others in the health care system. Many patient-specific databases will be populated by individual providers and shared with other professionals throughout eRecord. Some documents and data will be shared with patients and their families. There are shared functionalities (e.g. Problem Lists, Handoff templates, Medical History) that will be edited by many different providers at different times. More than ever, this collective, evolving record will be co-managed and co-owned by many providers and the patient. This reality necessitates the development of a set of rules and guidelines to ensure that appropriate evaluation, documentation, communication and record-sharing occur, to allow for the best outcomes for our patients and for the professional satisfaction of all members of the health care team.

This document is not intended to be a final product nor an explicit piece of policy. It is not a step by step account of how to use the record. This document contains the current expectations and workflows that should encourage the best use of eRecord and support our professional missions of patient care, teaching and research. As we become more experienced and facile as an organization with eRecord, and as the software evolves, we expect this etiquette document to evolve as well.

Building a Culture of Respect

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Building a Culture of Respect (cont.)

Departmental/Program Activities

• PCMH Ambulatory Quality Council

• Resident QS Projects• Data driven and “Systems”

approach to M&M• “Team drills” via simulation

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To Do

• Improve alignment with departmental quality leader, program director and trainees

• Consistent attendance by trainees at RCA’s, quality rounds, system redesign activities

• Better reporting system

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