NAS in a Community Hospital

Transcription

1 NAS in a Community Hospital Best Practices with Limited Resources Presented By: Susan Greenwood-Clark, RN, MBA, FACHE Director, Medical Education St. Mary Mercy Hospital Date: May 13, 2015

2 Goals At the conclusion of this session, the learner should be able to: Identify key areas where traditional structures could be changed to more efficiently meet oversight requirements necessary for institutional accreditation Learn strategies for simplifying processes to meet the standards Identify opportunities where innovation could be used to redeploy resources to "high value" activities Describe ways to partner with program leadership to meet new requirements (i.e., milestone evaluations) 2

3 Survey Results 3

4 Overall Results of Teaching Hospital Survey Conducted in April, institutions responded Add range Answer Options Response Average Range Response Count ACGME AOA Other answered question 54 4

5 Role of Organization of Responder: Comparison between Larger and Smaller Organizations Larger Smaller Larger organizations may have a deeper bench to get some work done on behalf of DIO???? 5

6 Institutional Composition of Programs by Size 100% 90% 80% 70% 25% 20% 2% 60% 50% 40% 30% 33% 78% Other AOA ACGME 20% 42% 10% 0% Smaller Larger 6

7 Current Number of Trainees Under Sponsored Programs 14 Frequency of Institutions by Number of Trainees # of Institutions # of Trainees in Institution 7

8 How frequently does your Graduate Medical Education Committee (GMEC) meet? Quarterly 7% Other 4% Every 2 months 20% Monthly 69% 8

9 Frequency of GMEC Meetings- Comparison Larger Smaller Smaller organizations have a slightly higher percentage of meetings every 2 months 9

10 How many voting members on the GMEC? Answer Options Response Average Response Count Total # of Voting Members # of Program Directors # of Residents # of GME/Hospital Leadership answered question 52 10

11 GMEC Voting Members by Size Larger Smaller 11

12 Do you have subcommittees of the GMEC? No 34% Yes 66% 12

13 Do you have subcommittees of GMEC? 100% 90% 80% 70% 60% 50% 40% No Yes 30% 20% 10% 0% Smaller Larger 13

14 Listing of Subcommittees 14

15 Does GME leadership review the program's Annual WebADS updates prior to submission? No No, 46.2% Yes Yes, 53.8% 42.0% 44.0% 46.0% 48.0% 50.0% 52.0% 54.0% 56.0% 15

16 Review of WebADS before Submission Larger Smaller 16

17 Have you implemented dashboard reports for GMEC review? 47.2% 52.8% Yes No 17

18 Implementation of Dashboards for GME review? 100% 90% 80% 70% % 50% 40% No Yes 30% 20% % 0% Smaller Larger 18

19 How does GME leadership and/or GMEC utilize resident and faculty survey results? At Program Level: Used for Annual Program Evaluation and Program Evaluation Committee Reviewed by CCC Top Three goals identified with action plans submission At Institutional Level: Annual Institutional Review with action plans developed and monitored Incorporated into Special Review Criteria Used in dashboards- with yellow (at or slightly below national mean or red (5% below national mean) highlights. Action plans are submitted for items below the national mean (or below 85%) Reviewed by Resident Education and Work Environment Subcommittee Resident survey of faculty used by GME leadership to identify faculty members who are not promoting a safe and effective learning and working environment Reviewed by accredited subcommittee or AIR subcommittee 19

20 Have you been able to streamline processes to more effectively meet institutional accreditation requirements? 20

21 What processes/committees have you implemented to address/enhance Clinical Learning Environment 21

22 Patient Safety Initiatives 1-large organizations 2-smaller organizations CLER Coordinator (1) / CLER Steering Committee (2) Resident Quality and Pt Safety Committee- both Asst Dean, QIPS, Asst Dir (1) Enhanced reporting of near misses/areas of concern (2) Use of online education/ihi (2) QI/PS subcommittee of GMEC (2) All campus/system committees have residents (2) Include Dashboard reports for resident meetings, discussed RCA (2) 22

23 Health Care Quality- additional items Bedside Procedure Committee & Privileging (1)/ Online access for nurses to view resident s are certified for bedside procedures (2) Hired a GME-specific Quality/PS director (1) DIO serves on institution s Quality Subcommittee of Board (2) QI mentors (2) Online educational modules (2) Team rounding, multidisclinary teams, bundles (2) 23

24 Care Transitions Participating in AIAMC National Quality Improvement Initiative to standardize handoff practices (2) Didactic instruction/formal evaluation of TOC Monitor TOC for each program and report to GMEC on a regular basis (2) Implementation of I-PASS Joint activity with nursing re: handoff (2) Standardize EMR template for Handoff Faculty development on evaluating TOC (2) Workflow Committee (1) 2 handover task forces created (1) ½ day orientation focused on TOC (1) 24

25 Supervision Workflow Committee (1) Enhance hospital staff awareness of credentials/supervision site (1) and (2) Use feedback on ACGME survey Didactic instruction/faculty development (2) PEC reviews resident supervision (2) Reaffirmed/updated pre-cler policies Completion of SAFER module (2) Content expert (1) (1and 2) 25

26 Duty Hours/Fatigue Management and Mitigation Engage content expert (1) SAFER Module (2) Annual well-being survey (2)/ residency and wellness (1) DIO meets twice yearly with each program s residents to discuss compliance with supervision and DH reqts (2) Monthly review by GMEC Administer e-module annually to residents and faculty (2) Using Culture of Safety Reports/ action plans 26

27 Professionalism Annual Johns Hopkin module (2) Content expert responsible for collecting info on where all depts are with this, identify gaps and share best practice (1) IPM module (1) Created questions related to workplace intimidation on the annual evaluation of program (1) On-line education LIFE curriculum (2) 27

28 Sharing of best practices organizations have utilized for GME oversight 28

29 Best Practices- Larger Organizations Added quarterly dinners with the DIO for Program Directors Established annual Program Director review with DIO and Dept Chair Created web-based QIP project tracking form. Planning to create web-based APE report that can be integrated at the institutional level CMO highly engaged at many areas of GME GMEC and GME office to increase support for program self-study Providing professional development opportunities for PDs and PCs to develop skills needed for transitions to NAS and Milestones When subcommittee or GMEC refers to another body, cover/summary sheet is drafted compiles section of minutes, possible impact to programs, GME office impact, if resources (even time) is needed to implement, who will make final decision This helps to get everyone on the same page Use of NI for duty hours tracking and reporting 29

30 Best Practice- Smaller Organizations COO and CSO attend each GMEC Sends staff out to each program to personally go over APE template CLER champion for hospital (c-suite)- VP who communicates to other depts. Increased feedback on incident reporting: RM attends monthly resident meetings Nurse/Resident Council to establish better communication between groups-results in joint QI projects Strategy board with top 3 GME goals and metrics in GME office- weekly meetings to keep on task Dashboard- include most important measures: Board pass rate, ACGME resident and faculty survey, Milestones on-time, grad requirements, % QI/Research residents/faculty, PD succession plan Most work of GMEC is done by subcommittees opened the eyes of the committee members to oversight of all programs and helped programs understand this oversight is for benefit Quarterly reports at GMEC from VP Risk Mgmt/Pt Safety 30

31 Questions? 31