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EDU 08-426 – HSR&D Study

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EDU 08-426
Improving Patient Outcomes via the Clinical Improvement Work of Learners
Gregory Simon Ogrinc MD MS
White River Junction VA Medical Center, White River Junction, VT
White River Junction, VT
Funding Period: July 2010 - June 2013

BACKGROUND/RATIONALE:
This study proposed to improve care for veterans and provide a benchmark for educational programs linking educational activities and patient outcomes. The project sought to identify what works for resident-led improvement and under what circumstances. This would inform all residency training programs - both VHA and non-VHA - and help them improve the delivery of care in their own programs, thus strengthening VHA's leadership in developing novel educational programs.

OBJECTIVE(S):
1) Determine impact of an educational intervention for inpatient internal medicine residents focusing on systems knowledge, quality improvement, and interprofessional care.
2) Create a system of education that integrates patient care with quality improvement and system knowledge for resident physicians.


METHODS:
Randomized, clustered design, with early and late intervention groups. The interventions and the analysis of clinical outcomes occurred at the microsystem level. Individual resident physicians were the level of analysis for educational outcomes. The project occurred in three phases: Phase 1 - preparation of educational intervention, component pilot testing, and developing the team reports; Phase 2 - resident enrollment, intervention delivery, updates to the data reports, and analysis of midpoint data; Phase 3 - preparing manuscripts and integrating effective elements. Analysis was done through statistical process control charts for clinical data and interrupted time series for educational knowledge, satisfaction, and self-efficacy. Qualitative techniques were used to assess information from key stakeholders (resident physicians, nurses, QI teachers) through semi-structured interviews.

FINDINGS/RESULTS:
Since April 2011, inpatient resident teams have increased pneumococcal vaccine rates from 87 - 95%; increased appropriate VTE prophylaxis from 83% to 96%; decreased time from order to initiation for Heparin from 58 minutes to <30 minutes; increased physician hand hygiene in the ICU from 55% to 80%; increased evidence based smoking cessation interventions from 20% to 75%; created a new follow-up appointment system for discharge from the hospital; improved the reliability and validity of using hospital bed to weigh patients; and revised "comfort measures only" orders for patients. All QI projects now include nursing staff from WRJ VA. Some projects have included pharmacists and administrators.
Our interim semi-structured interviews identified important educational processes that facilitate integrated QI teaching. Three domains emerged from our qualitative analysis: setting, learner, and teacher. In the setting domain, a constant presence of the QI material on a white board in the team room was a facilitating mechanism. Routine updates on the white board provide a visible chronology of the QI work. In the learner domain, because residents change clinical duties every four weeks, we explicitly recognized that the residents require formal hand-off of the QI work to the next team. This hand-off was facilitated by the QI teachers. In the teacher domain, two factors of success were identified. First, having QI teachers seen as clinical leaders with QI expertise provided excellent role modeling for the residents. Second, the faculty's knowledge of the local system was crucial for implementing changes and navigating organizational issues.
Resident learning was evaluated using the Quality Improvement Knowledge Application Tool (QIKAT). These data have been gathered from 80 pre-intervention residents, 47 mid-point residents, and 48 endpoint residents and is being analyzed. We have also completed semi-structure interviews with resident physicians and nurses.

IMPACT:
As listed in the Findings section, our resident physician interventions have improved the quality and efficiency of care for veterans at the WRJ VA. Three of our resident QI projects received recognition from VISN 1 for excellence as engaged work teams. As residency programs face a new accreditation system that includes site visits, our model of integrating QI into the regular work of resident teams will important for both VA and non-VA residency programs.

PUBLICATIONS:

Journal Articles

  1. Ogrinc G, Ercolano E, Cohen ES, Harwood B, Baum K, van Aalst R, Jones AC, Davies L. Educational system factors that engage resident physicians in an integrated quality improvement curriculum at a VA hospital: a realist evaluation. Academic Medicine. 2014 Oct 1; 89(10):1380-5.
Conference Presentations

  1. Ogrinc GS. Helping Learners Ask and Answer Questions for the Future of Healthcare Delivery. Paper presented at: Yale-New Haven Hospital Transforming Medicine Grand Rounds; 2014 Jul 8; New Haven, CT.
  2. Ogrinc GS. Helping Learners Ask and Answer Questions for the Future of Healthcare Delivery. Paper presented at: University of Minnesota School of Medicine Education Faculty Development Day; 2014 May 7; Minneapolis, MN.
  3. Ogrinc GS. Helping Learners Ask and Answer Questions for the Future of Healthcare Delivery. Paper presented at: PeaceHealth Sacred Heart Medical Center University District Annual Clinical Faculty Appreciation Dinner; 2014 Feb 27; Eugene, OR.
  4. Ogrinc GS. Educational System Factors that Activate Resident Physician Participation in an Integrated Quality Improvement Curriculum: A Realist Evaluation. Presented at: Academy for Healthcare Improvement Annual International Scientific Symposium on Improving the Quality and Value of Health Care; 2012 Dec 10; Orlando, FL.
  5. Ogrinc GS. Teaching about QI and Systems at Geisel School of Medicine. Paper presented at: Medical College of Wisconsin Grand Rounds; 2012 Jun 5; Madison, WI.
  6. Ogrinc GS. Teaching about QI and Systems along the Developmental Continuum. Paper presented at: University of Wisconsin Hospital and Clinics Medical Education Grand Rounds; 2012 Jun 4; Madison, WI.
  7. Ogrinc GS. Teaching about QI and Systems along the Developmental Continuum. Paper presented at: University of South Florida Grand Rounds; 2012 Mar 7; Tampa, FL.


DRA: Health Systems
DRE: Treatment - Comparative Effectiveness
Keywords: Knowledge Integration, Outcomes - Patient, Provider Education
MeSH Terms: none

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