College of Medicine PO Box Gainesville, FL Graduate Medical Education fax October 17, 2016

Transcription

1 College of Medicine PO Box Gainesville, FL Graduate Medical Education fax October 17, Dear Colleagues: The Accreditation Council for Graduate Medical Education (ACGME) requires that the Designated Institutional Official (DIO) provide an annual report to the Organized Medical Staff and governing body of the major participating Joint Commission accredited hospitals involved in graduate medical education. This report must include notification of each ACGME accredited programs accreditation status and self-studies, results of ACGME Faculty and Resident surveys, and monitoring procedures for action plans. This report covers activities between January 1, 2015 and June 30,. The University of Florida College of Medicine sponsors 69 ACGME accredited programs based in Gainesville, 3 ACGME accredited programs at the Arnold Palmer Children s Hospital in Orlando and 2 ACGME accredited programs at Sacred Heart - Pensacola. For 2015, there 4 programs with Initial Accreditation Status; Emergency Medical Services, Internal Medicine Advanced Heart Failure, Pediatric Rheumatology, and Psychiatry Geriatric. Two programs moved from Initial Accreditation to Continued Accreditation, Surgery Plastics Integrated and Child Neurology. There are 859 residents in all 74 programs. There are 63 fellows and post doctorial fellows currently training in 44 programs that the ACGME does not accredit. The primary participating institutions include Shands Hospital at the University of Florida, the North Florida/South Georgia Veterans Health System, Arnold Palmer Hospital in Orlando, Florida, and Sacred Heart Pensacola. Addendum 1 shows the current status of all ACGME-accredited training programs sponsored by the University of Florida. All programs will have a self-study site visit modeled after the LCME self-study visits every 10 years. Appendix 1 also shows the targeted self-study dates scheduled for each program and for the University of Florida College of Medicine which is the sponsoring institution for all 68 programs. Past program site visits occurring every 1-5 years based on accreditation status have been replaced by an annual data review of each program by the appropriate residency review committee. Data for these reviews come from resident surveys, faculty surveys, ACGME Case Logs, ABMS board pass rates as well as other data by each program to the ACGME s Accreditation Data System (ADS). There are no programs on probation. Self-Study and Site Visit: ACGME requires each program to conduct a self-study. Per the ACGME, The self-study is an objective, comprehensive evaluation of the residency or fellowship program, with the aim of improving it. Underlying the self-study is a longitudinal evaluation of the program and its learning environment, facilitated through The Foundation for The Gator Nation An Equal Opportunity Institution

2 sequential annual program evaluations that focus on the required components, with an emphasis on program strengths and self-identified areas for improvement ( selfidentified is used to distinguish this dimension of the self-study from areas for improvement the Review Committee identifies during accreditation reviews). The following programs have received ACGME notification to begin their self-studies: Date to begin the self-study Initial Site Visit Date set by the Review Committee Program Name Obstetrics Gynecology May 1, December Endovascular Surgical Neuroradiology June 1, January 2017 Neurological Surgery January 2017 Orthopaedic Surgery June 1, January 2017 Orthopaedic Hand Surgery June 1, January 2017 Orthopaedic Musculoskeletal Oncology June 1, January 2017 In preparation for the CLER visit, on-going and work is being done on core issues such as: Who and what form the infrastructure of a Sponsoring Institution s (SI) clinical learning environment? How integrated is the GME leadership and faculty within the SI s current clinical learning environment infrastructure? How engaged are the residents and fellows in using the SI s current clinical learning environment infrastructure? How does the SI determine the success of its efforts to integrate GME into the quality of infrastructure? What areas have the Sponsoring Institution identified as opportunities for improvement? A summary of issues identified in the December 2014 CLER site visit, as well as the results in the ACGME s National Report are detailed in Addendum 2, and documentation of our ongoing quality improvement efforts are detailed in Addendum 3. 2

3 Addendum 1 ACGME Accredited Programs University of Florida, Gainesville Program Director (Bold = New PD) Current ACGME Accreditation Status Next ACGME Action Next ACGME Action Date Anesthesiology (Core) Timothy Martin, MD Continued Accreditation SS 05/01/2017 Anes-Critical Care Brenda Fahy, MD Continued Accreditation SS 05/01/2017 Anes-Adult Cardiovascular Anesthesiology William Smith, MD Continued Accreditation SS 05/01/2017 Anes- Critical Care Medicine Brenda Fahy, MD Continued Accreditation SS 5/1/2017 Anes-Pain Medicine (Multidisciplinary) Rene Przkora Continued Accreditation SS 5/1/2017 Dermatology (Core) Stanton Wesson, MD Continued Accreditation SS 05/01/2019 Derm-Dermatopathology Ann Church, MD Continued Accreditation SS 05/01/2019 Emergency Medicine (Core) Lars Beattie, MD Continued Accreditation SS 09/01/2020 EM-Emergency Med Services Christine VanDillen, MD Initial Accreditation SV Pending Family Medicine (Core) Karen L. Hall, MD Continued Accreditation SS 09/01/2022 FM-Sports Medicine Guy W. Nicolette, MD Continued Accreditation SS 09/01/2022 Internal Medicine (Core) N. Lawrence Edwards, MD Continued Accreditation SS 10/01//2017 IM-Cardiovascular Disease Thomas Burkart, MD Continued Accreditation SS 10/01//2017 IM-Endocrinology & Metab Catherine Edwards, MD Continued Accreditation SS 10/01//2017 IM-Gastroenterology Virginia Clark, MD Continued Accreditation SS 10/01//2017 IM-Infectious Diseases Jennifer Janelle, MD Continued Accreditation SS 10/01//2017 IM-Nephrology JogiRaju Tantravahi, MD Continued Accreditation SS 10/01//2017 IM-Rheumatology Eric Sobel, MD Continued Accreditation SS 10/01//2017 IM-Geriatric Medicine John Meuleman, MD Continued Accreditation SS 10/01//2017 IM-Interventional Cardiology Russell Anderson, MD Continued Accreditation SS 10/01//2017 IM-Cardiac Electrophysiology William Miles, MD Continued Accreditation SS 10/01//2017 IM-Hematology/Oncology Julia Close, MD Continued Accreditation SS 10/01//2017 IM-Pulmonary/Critical Care Ibrahim Faruqi, MD Continued Accreditation SS 10/01//2017 IM-Transplant Hepatology Roberto J. Firpi, MD Continued Accreditation SS 10/01//2017 IM-Sleep Medicine Richard Berry, MD Continued Accreditation SS 10/01//2017 IM-Advanced Heart Failure & Transplant Cardiology Juan Aranda, MD Initial Accreditation SV 06/15/ Neurological Surgery George Murad, MD Continued Accreditation SS 01/01/2017 NS-Endovascular Surgical Neuroradiology W. Christopher Fox, MD Continued Accreditation SS 01/01/2017 Neurology Christina Wilson, MD Continued Accreditation SS 11/01/2018 3

4 ACGME Accredited Programs University of Florida, Gainesville Program Director (Bold = New PD) Current ACGME Accreditation Status Next ACGME Action Next ACGME Action Date Neuro-Clinical Neurophysiology Stephen Eisenschenk, MD Continued Accreditation SS 11/01/2018 Neuro-Vascular Neurology Christina Wilson, MD Continued Accreditation SS 11/01/2018 Obstetrics/Gynecology John Davis, MD Continued Accreditation SS 12/01/ Obstetrics/Gynecology (Pensacola) Julie DeCesare, MD Continued Accreditation SS 06/01/2022 Ophthalmology Sonal Tuli, MD Continued Accreditation SS 11/01/2019 Orthopedic Surgery Robert Decker, MD Continued Accreditation SS 01/01/2017 Ortho-Hand Surgery Paul C. Dell, MD Continued Accreditation SS 01/01/2017 Ortho-Musculoskeletal Oncology Mark Scarborough, MD Continued Accreditation SS 01/01/2017 Otolaryngology William Collins, MD Continued Accreditation SS 02/01/2018 Pathology Anthony Yachnis, MD Continued Accreditation SS 04/01/2022 Path-Cytopathology Edward J. Wilkinson, MD Continued Accreditation SS 04/01/2022 Path-Hematology Ying Li, MD Continued Accreditation SS 04/01/2022 Path-Neuropathology Anthony Yachnis, MD Continued Accreditation SS 04/01/2022 Pediatrics (Core) Nicole Black, MD Continued Accreditation SS 10/01/2020 Pediatrics (Orlando) Jerome Chen, MD Continued Accreditation SS 04/01/2017 Pediatrics (Pensacola) Peter Jennings, MD Continued Accreditation SS 07/01/2019 Peds-Critical Care Torrey Baines, MD Continued Accreditation SS 10/01/2020 Peds-Cardiology F. Jay Fricker, MD Continued Accreditation SS 10/01/2020 Peds-Child Neurology Peter Kang, MD Continued Accreditation SS 11/01/2018 Peds-Endocrinology Michael Haller, MD Continued Accreditation SS 10/01/2020 Peds-Nephrology Lawrence Shoemaker, MD Continued Accreditation SS 10/01/2020 Peds-Hematology-Oncology Tung Wynn, MD Continued Accreditation SS 10/01/2020 Peds-Neonatal-Perinatal Josef Neu, MD Continued Accreditation SS 10/01/2020 Peds-Pulmonology Mutasim N Abu-Hasan, MD Continued Accreditation SS 10/01/2020 Peds-Gastroenterology Genie Beasley, MD Continued Accreditation SS 10/01/2020 Peds-Gastroenterology (Orlando) Karoly Horvath, MD Continued Accreditation SS 04/01/2017 Peds-Rheumatology Akaluck Thatayaikom, MD Initial Accreditation SV 06/04/ Peds Sports Medicine (Orlando) Harrison Youmans, MD Continued Accreditation SS 04/01/2017 Psychiatry Jacqueline Hobbs, MD Continued Accreditation SS 04/01/2019 Psych-Child & Adolescent Mariam Rahmani, MD Continued Accreditation SS 04/01/2019 Psych Geriatric Uma Suryadevara, MD Initial Accreditation SV Pending 4

5 ACGME Accredited Programs University of Florida, Gainesville Program Director (Bold = New PD) Current ACGME Accreditation Status Next ACGME Action Next ACGME Action Date Psych-Forensic Psychiatry Joel Silberberg, MD Continued Accreditation SS 04/01/2019 Radiology - Diagnostic David Wymer, MD Continued Accreditation SS 11/01/2018 Rad-Neuroradiology Jeffrey Bennett, MD Continued Accreditation SS 11/01/2018 Rad-Vascular & Interventional Darren Postoak, MD Continued Accreditation SS 11/01/2018 Radiation Oncology Robert J. Amdur, MD Continued Accreditation SS 03/01/2020 Surgery - General George A. Sarosi, Jr, MD Continued Accreditation SS 11/01/2018 Surg-Vascular Surgery Robert Feezor, MD Continued Accreditation SS 11/01/2018 Surg-Pediatrics Saleem Islam, MD Continued Accreditation SS 11/01/2018 Surg-Critical Care Alicia Mohr, MD Continued Accreditation SS 11/01/2018 Surg-Thoracic Surgery Thomas Beaver, MD Continued Accreditation SS 1/10/2024 Surg-Plastic Surgery Bruce Mast, MD Continued Accreditation SS 04/01/2021 Surg-Plastic Surgery Integrated Bruce Mast, MD Continued Accreditation SS 04/01/2021 Urology Louis Moy, MD Continued Accreditation SS 06/01/2019 Sponsoring Institution (University of Florida College of Medicine) Lisa Dixon, MD Continued Accreditation SS 4/1/2021 Abbreviations Key: SS = Self- Study; SV = ACGME Site Visit Programs in Process of Obtaining Accreditation Internal Medicine (Pensacola) John Retzloff, MD Initial Application SV 08/04/ Orthopedics Adult Reconstructive Hari Parvataneni, MD Initial Application SV Pending 5

6 Central Questions asked by the initial round of CLER visits included: Who and what form the infrastructure of a Sponsoring Institution s clinical learning environment? What organizational structures and administrative and clinical processes do the Sponsoring Institution (SI) and its major participating sites have in place to support GME learning in each of the six focus areas? [See Appendix A] How integrated is the GME leadership and faculty within the SI s current clinical learning environment infrastructure? What is the role of GME leadership and faculty to support resident and fellow learning in each of the six areas? [See Appendix A] How engaged are the residents and fellows in using the SI s current clinical learning environment infrastructure? How comprehensive is the involvement of residents and fellows in using these structures and processes to support their learning in each of the six areas? [See Appendix A] How does the SI determine the success of its efforts to integrate GME into the quality infrastructure? From the perspective of the SI and its major participating sites, what are the measures of success in using this infrastructure and what was the level of success? [See Appendix A] What areas have the Sponsoring Institution identified as opportunities for improvement? From the perspective of the SI and its major participating sites (if different), what are seen as the opportunities for improving the quality and value of the current clinical learning environment infrastructure to support the six focus areas? [See Appendix B] Collated Summary of Needs Identified in the December 2014 UF CLER Site Visit Results and in the National Report Patient Safety 1. Increase focus on institutional (in addition to departmental) patient safety priorities 2. Increase knowledge and application of PS/QI principles, terminology and methods 3. Submit PSRs from multiple perspectives involved (nursing, housestaff, faculty, etc.) 4. Report near misses/close calls 5. Educate housestaff and faculty on what constitutes a reportable patient safety event, including near misses/close calls, events without harm, unexpected deteriorations or procedural complications 6. Disseminate information on how PSRs have improved patient safety both broadly and departmentally 7. Educate housestaff and faculty on what constitutes a patient safety event investigation 8. Implement consistent, standardized time-outs 9. Engage housestaff in formulating strategies for institution-wide initiatives Healthcare Quality and Healthcare Disparities The Foundation for The Gator Nation An Equal Opportunity Institution

7 1. Involve housestaff in one or more PDSA cycles when participating in QI projects 2. Access organized systems to collect and analyze data in order to develop dashboards (aka clinical effectiveness/daily clinical habits) 3. Include housestaff when conducting needs assessments for health disparities and healthcare disparities 4. Implement UF Health/VA patient population specific cultural competency education 5. Indicate how housestaff level projects relate to institution-wide initiatives Transitions in Care 1. Implement a standardized, organization wide effort for care transition types (end of shift, site to site) 2. Implement a standardized templates and standardized level of relayed detail for handoffs 3. Include contingency planning and read back or clarifying questions during handoffs 4. Include other health care professionals during handoffs 5. Include other healthcare professionals during rounds (interprofessional) 6. Formally assess handoffs Supervision 1. Reduce situations with inadequate supervision 2. Be cognizant of over-supervision, particularly in procedural specialties 3. Develop a system to identify resident procedural competence (which housestaff can do what) Duty Hours/Fatigue 1. Be cognizant of factors other than duty hours that may result in fatigue such as financial or emotional stress or caring for a family member or young infant (resident wellbeing) 2. Be vigilant regarding moonlighting reporting 3. Report safety events that appear to be related to fatigue even if death or serious harm to a patient did not occur Professionalism 1. Report all moonlighting 2. No cutting and pasting from another note 3. Report disruptive or disrespectful behavior 4. Review GME mistreatment policy with all faculty, housestaff and staff 7

8 Appendix A Comparison of December 2014 UF CLER Site Visit Results compared to May National Report of Findings Notes: CLER Site Visitor Descriptive Terms: few (<10%), some (10 49%), most (50 90%), and nearly all (>90%) --% or blank: Data not provided in 2014 UF CLER Site Visit Report CLER NATIONAL REPORT (CLE NR) OF FINDINGS - blue italicized font, national data reported o Robin Wagner, Nancy J. Koh, Carl Patow, Robin Newton, Baretta R. Casey, and Kevin B. Weiss () Detailed Findings from the CLER National Report of Findings. Journal of Graduate Medical Education: May, Vol. 8, No. 2s1, pp When possible, shading of topics indicates the following: o Equal to or higher than national data (green shading), o lower than national data (yellow shading) Resident refers to residents and/or fellows Information shaded in orange indicates processes that were either on-going at the time of or started after the December 2014 CLER site visit 8

9 Patient Safety Knowledge of UF Health s PS priorities (Big AIMS/Strive for Five) alth.org/qualitypatientsafety/quality-andpatient-safetystrategic-mission / Knowledge of patient safety formal education or training Resident (UF %, %, 73.9% knew institution s priorities %, 92%, 81.4% 89%, 83.3% Need to focus on overarching CLE priorities versus departmental priorities (CLE NR) 2014: January 2014 Joint meeting between program PDs and departmental Physician Directors of Quality (PDQ) regarding CLER Big AIMS and Strive for Five distributed to all housestaff via badge buddies 2014 to present: Monthly Quality Grand Rounds The Q Report published quarterly: Annual Patient and Quality Week Housestaff Quality and Patient Safety Committee (HQPSC) data dissemination at GMEC AY : Housestaff Quality and Patient Safety Committee (HQPSC) developed three required online modules with quizzes for every housestaff to address institutional safety needs: Advanced Directives Nursing Communication Orders Google Translate (Don t Use) June : "OSCE & Limited English Proficiency Patient Safety" was accepted as a storyboard at the Institute for Healthcare Improvement (IHI), 28 th Annual National Forum on Quality Improvement in Health Care in December in Orlando. Due to the intern OSCEs, one of the cases which used translators via phone through an external company to UF Health served not only to assessing resident skills in use of translators, but also served as a quality check for the institution. The Intern OSCE identified an institution-wide patient safety issue. UF Health and the translation company are now working together to address this issue. August : UF Health Shands 2017 Quality goals are included as part of follow-up OSCE1 presentation to all incoming interns %, 96.8% received formal education Discrepancy between provided education and knowledge (CLE NR) Across most CLE s, (82.6%) residents had limited knowledge of principles, terminology and methods (CLE NR) 9

10 Patient Safety Culture of Safety: Belief of safe, non-punitive environment for PS reporting Resident (UF %, %, 2014: North Florida/South Georgia Veterans Health System, UF Health and UF College of Medicine Interdisciplinary Patient Safety Faculty Development Workshop presented by the VA National Center for Patient Safety All incoming housestaff must complete the following prior to July 1 st o UF Patient Safety/Quality Improvement Video o Bloodborne Pathogen (BBP) and Biomedical Waste (BMW) Training done annually o IHI PS100: Introduction to Patient Safety o IHI PS101: Fundamentals of Patient Safety o IHI PS103: Teamwork and Communication o IHI PS104: Root Cause and Systems Analysis 2014 to present: Quality Grand Rounds: Just Culture Training: Dr. Stalvey presents Intern OSCE results to each program s interns and PD highlighting institution-wide patient safety initiatives such as use of enhanced precautions for patients with C. difficile and handwashing 2015 to present: TeamSTEPPS 2.0 training ComNet/SPOK: Secure messaging phone app. SPOK committee and nursing were heavily involved. Tip sheets on accessing SPOK was developed and disseminated. Housestaff were provided training sessions in their lounge : Teaching for Quality (Te4Q) Workshop by AAMC A subcommittee has been formed to begin working on an institution-wide QI/PS curriculum Developing a new patient safety module that relates to risk management Safer Gator Newsletter: %, 95.5% felt there was a safe environment in which to report patient safety events Not clear if there is enough experience for residents to learn as others (nursing) tended to file majority of reports (CLE NR) 10

11 Patient Safety Frequency for resident/ fellow PSR reporting Resident (UF %, %, 2014 See chart below --%, 81% believe fewer than half of residents submitted PSR --%, 49.4% believe residents would use CLE s reporting system --%, 83% believe fewer than half of residents submitted PSR --%, 51.5% believe residents would use CLE s reporting system Only 32% of CLEs could track if PSRs submitted by residents (CLE NR) Develop a learning module for what constitutes PSR (and let them know it is ok for more than one person to submit) 11

12 Patient Safety Resident (UF %, %, : EMS vendor implemented feature to now track data by hospital service June : The Quality Department provides a quarterly risk report to GMEC including a summary of a high reliability organization, patient safety report data, and a summary of RCAs attended by residents. 12

13 Patient Safety Number that experienced an adverse event or near miss Resident/ fellow process for reporting PSRs Resident (UF %, %, 68.0% % of the 85% (or 52% of total) reported, 46.8% 27%, 29.8% relied on supervisor to report 6%, 15.0% relied on nurse to report 4%, 8.9% chose not to report %, 18.2% of residents reporting a near miss, %, 67%, --% believed less than 50% of residents report 67%, --% believe residents would report 20%, --% would rely on supervisor to report 5%, --% would rely on nurse to report 8%, --% would choose not to report 73%, --% believed less than 50% of residents report 73%, --% believe residents would report 9%, --% would rely on supervisor to report 9%, --% would rely on nurse to report 9%, --% would choose not to report Nurses submit majority of PSRs 2014 to present: Nurses submit majority : Icon for express PSR reporting changed based upon resident feedback to make it less intimidating Residents have limited understanding of range of safety events that should be reported. (CLE NR) Educate residents and nurses on near misses/close calls, events without harm, unexpected deteriorations or procedural complications as reportable events (CLE NR) 87% of walking rounds indicated that residents infrequently enter PSRs (CLE NR) Track PSRs by: role (resident, housestaff, attending, nurse, etc.) by near miss vs adverse event 13

14 Patient Safety Feedback received on PSRs Resident (UF %, %, 46.9% received feedback whether selfreported, nurse or supervisor reported %, Residents unaware of how CLE use PSRs to improve broadly and departmentally (CLE NR) Residents rarely involved in CLE s process of reviewing PSRs for further investigation (CLE NR) Most common feedback was for receipt of PSR or request for more information (CLE NR) RCA participation %, 41.3% participated in activities such as RCA or M&Ms Need to review how feedback is determined and/or disseminated June 2014 to present: incoming interns have been required to report a PSR as follow-up to a medication dosage error case as part of the OSCE1 prior to July 1st June 2015 to present: Resident orientation includes how to enter a Patient Safety Report (PSR) -- when, how, why April : o Automated to those who submit PSRs has been revised o Vendor asked to make M&M category from IDInc non-visible; o Vendor asked to place an M&M code on the risk closure page of PSR June : PSR Checklist developed and used at Intern OSCEs1 during June to provide incoming residents with feedback July : incoming housestaff shown how to enter PSRs by UF Health s Quality Department leadership for current patients with data pre-population within EPIC during EPIC training 80%, --% of 60%, --% of 50 residents had residents had performed of opportunity to opportunity to which 33 participate in participate in involved RCA RCA resident --%, 66.7% had participated in an investigation such as an RCA --%, 71.4% had participated in an investigation such as an RCA Residents varied widely in what constitutes a patient safety event investigation (CLE NR) Track RCA participation by role Education needed on what constitutes an investigation Need mock or simulated RCAs use a medical error that could be generic. Do with Risk Management, where video and stop and start for discussion afterwards. Jan 2015 If M&M identified patient safety issue, unclear whether entered as a PSR M&Ms should include near miss discussions M&Ms need to include PDSA cycle 14

15 Patient Safety Resident (UF %, PS/QI Data: 25 RCAs: 7/1/2015 6/30/ 19/749 (2.5 %) Residents %, PS/QI Data: 25 RCAs: 7/1/2015 6/30/ 71/1326 (5.4 %) Faculty New Innovations Data: New Innovations Data: Psychiatry RCAs: (attended by some residents/fellows) 2015: 1/28, 6/3, 6/16, 8/28, 9/3 : 1/7, 2/1, 3/9, 5/25, 6/8 Psychiatry RCAs: (attended by some faculty) 2015: 1/28, 6/3, 6/16, 8/28, 9/3 : 1/7, 2/1, 3/9, 5/25, 6/8 Anes-Pain Med Grand Rounds- Mock RCA: 6/6/ Mock RCAs: 1/2015 6/ (26% of residents) Anes: 3/25/15 (n=88) Anes-CCM: 6/6/ (n=6) Anes-Pain Med: 5/18/ (n=4) EM: 3/12/15 (n=24) IM-Hem/Onc: (n=15) OB/Gyn: 5/16/16 (n=16) Psych: 4/8/2015 (n=40) 15

16 Patient Safety Time-outs performed prior to patient procedures Resident (UF %, 2014 Usually conducted throughout floors and units of hospital (confirmed by housestaff and nursing on walk arounds) %, Consistent standardized time-outs not conducted prior to performing procedures and indicated lack of clarity as to the role of residents in performing these processes (CLE NR) Engagement of Strategies to Improve Patient Care Need to review how feedback is determined and/or disseminated %, 89.8% Residents most commonly described their role as implementers of hospital or medical-center wide initiatives (CLE NR) Resident engagement in formulating strategies was uncommon (CLE NR) 2014 CLER Site Visit Patient Safety Suggestions by Participants In the resident, faculty member, and program director group interviews, the participants were asked for recommendations to improve resident and fellow engagement in the hospital s patient safety efforts. Suggestions included: Providing more feedback than the automated message with more detail on outcome. Simplifying & streamlining the PSR entry process. Receiving better information on the outcomes of RCAs. Improving identification of who was involved in a case and who should attend an RCA. Scheduling RCAs at times when residents are able to attend. Is this something the department chair could require coverage so they can attend? Nursing coverage as well? Organizing data around patient safety reports and making it more specific to resident activity. Having more interdisciplinary meetings on patient safety. Assuring all residents complete the IHI modules. Conducting simulations on units and floors where care is provided and with full team participation. Having more collaboration among the teaching faculty. Giving the faculty protected time to teach quality and patient safety. Including residents in the annual patient safety/quality improvement retreat. Making more grants available to residents and fellows for quality work. Facilitating more interdisciplinary patient safety work. Involving quality improvement and patient safety staff as active participants in departmental and institutional quality & safety activities. 16

17 Healthcare Quality Resident knowledge of UF Shands quality priorities Faculty knowledge of UF Shands quality priorities Resident engaged with leadership for quality Resident participated in quality activity directed by hospital administration Resident (UF %, %, %, 74.4% knew priorities 82%, --% believed residents knew priorities 59%, --% believed residents knew Priorities often reported tended to focus on departmental priorities versus CLE priorities (CLE NR) priorities %, 74.3% 82%, 73.5% Priorities often reported tended to focus on departmental priorities versus CLE priorities (CLE NR) %, 27.3% felt they were engaged with quality leadership to present: HQPSC asked to disseminate updates at monthly GMEC meeting AY -2017: HQPSC asked to provide brief update presentations at monthly GMEC meeting %, 50.8% felt they participated in a hospital administration s quality activity Residents often described as implementers for examples such as reducing hospital acquired infections, improving medication reconciliation, and reducing 30-day readmission (CLE NR) Examples include hand hygiene, use of translators, enhanced contact precautions AY The Peer Review Committee composed of housestaff, led by Quality administration and by the DIO, reviewed cases that involved patient safety and quality issues or processes that did not require a RCA. These cases and resultant changes have been presented to the HQPSC and to GMEC. 17

18 Healthcare Quality Resident activities: participation in QI project Resident (UF %, 2014 Nearly all, 76.0% participated in own design or designed by program/department 67%, 52.3% linked to hospital goals 11%, 30.0% did not know if linked to hospital goals %, Most residents described participating in part of QI cycle (planning or implementing) but no involvement in formally reviewing outcome and adjusting efforts accordingly (CLE NR) Need to be involved in 1 or more PDSA cycles most were not involved in 1 or more complete PDSA cycles 2014: Documentation available in Projects and Teams feature in New Innovations Participate in inter-professional QI teams Familiarity with QI terminology & methods; e.g. PDSA cycles 2015 to present: BMJ Quality: 100 institution wide licenses purchased Developing QI Project Approver and Data Registry in conjunction with Clinical and Translational Science Institute ( CTSI) with anticipated target date of November %, 74.5% 2014 Limited familiarity, 59.1% with limited knowledge to present: All incoming housestaff must complete the following prior to July 1 st UF Patient Safety/Quality Improvement Video Compliance Training for Incoming Residents / Fellows / Post-Doctoral Associates o IHI QI102: The Model for Improvement: Your Engine for Change o IHI QI103: Measuring for Improvement Limited residents could articulate CLE s methods and tools for QI (CLE NR) 18

19 Healthcare Quality Access to organized system to collect and analyze data Resident (UF %, %, %, 65.5% 70% 61% Most common sources of data were local or regional quality dashboards, specialty-specific registries, and HER (CLE NR) This is both an institutional and departmental issue : Custom HIPAA compliant operative log Crystal Reports from EPIC data now available for residents and fellows (in surgical specialties). This is dependent upon nurses entering each resident/fellow in op time report. : An EPIC person has been assigned to track GME report requests May : All reports for data from GME programs must include that the report is for GME related data for tracking purposes 2014 CLER Site Visit Healthcare Quality Suggestions by Participants When asked for recommendations to improve resident engagement in healthcare quality improvement at UF Health Shands Hospital, physicians in the group interviews suggested: Providing better access to data. Having statisticians available to analyze data. Providing resources to make changes based on QI project recommendations. Improving resident education as to the hospital s priorities. Making sure the residents know the hospital s goals. Improving resident participation in committees. 19

20 Healthcare Disparities Knowledge of priorities for HC disparities Resident (UF %, %, %, 55.1% 64%, 62.0% 47%, 60.1% Under development Rural communiti es Low SES Dual diagnoses (psychiatri c and medical) Limited English proficiency to present: Uncommon for CLEs to include residents when conducting needs assessments (CLE NR) Most resident participated in community outreach centers (CLE NR) Few specialties engaged in free or low-cost care and clinics for the underserved (CLE NR) Dr. Stalvey presents Intern OSCE results to each program s interns and PD highlighting healthcare disparity concepts such as how using translators helps to provide safer care and reduces healthcare disparities Systematic approach to identifying variability in care Cultural competency education 2014 Less than 5% of CLE leaders described a specific set of strategies or systematic approach to identifying variability in care provided or the clinical outcomes (CLE NR) UF needs development per CLER site visitors % of residents across all CLE s described this as generic (CLE NR) Too generic not tailored to UF Shands patient populations per CLER site visitors 20

21 Transitions in Care Knowledge of hospital s priorities for improving transitions in care Resident (UF %, %, %, 82.4% 89%, --% 86%, --% Improvement in this focus area is focused on handoffs to present: UF Health Shands Hospital is developing a common approach to managing resident patient care handoffs across programs and service areas There was often a mismatch in alignment of priorities residents, nurses and other clinical staff described vulnerable transitions regarding patient safety not mentioned by executive leaders (CLE NR) Dr. Stalvey presents Intern OSCE results to each program s interns and PD comparing how the interns did in general on the OSCE handoff cases compared to I-PASS components to promote safer handoffs. Inpatient Transitions: Use of a standardized process for handoffs between floors or units : The institution-wide I-PASS project has been placed on hold until further notice 2014 Most, 84.0% used a standardized process when transferring inpatient care; Most, 80.0% use standardized process from inpatient to outpatient Across CLEs, 80.0% reported using both a standardized process and a written template, but varied widely across programs (CLE NR) During walking rounds, several handoff sessions observed varied in use of templates, style of template, and level of detail relayed 21

22 Transitions in Care Resident (UF %, %, May : All programs were asked to review their handoff policies and update as needed for core faculty and residents to confirm in New Innovations Change of shift transitions June : "The Intern Handover: The Gap between Expectations and Performance", an article written by faculty who administer OSCEs to incoming interns was accepted for publication to Medical Science Educator. The article was based on data gathered during the Intern OSCE1 written hand-off case that demonstrated that even though the handover is a newly identified EPA for LCMEaccredited medical schools, over 70% of the incoming interns failed the written handoff station %, 90.0% used a standardized process during change of shift -- of which 83%, 77.8% used a written template Across CLEs, 80.0% reported using both a standardized process and a written template, but varied widely across programs (CLE NR) During walking rounds, several handoff sessions observed varied in use of templates, style of template, and level of detail relayed 2014 to present: Pediatrics has implemented I-PASS and has several faculty members trained to use I-PASS standardized evaluation tools. August October 2015: Introduction to I-PASS provided during required Resident as Teacher (RasT) sessions Interprofessional rounding May : all programs were asked to review their handoff policies and update as needed for core faculty and residents to confirm in New Innovations 2014 Interprofessional rounds varied across and within organizations. These most commonly occurred in ICUs or during discharge planning. (CLE NR) Noted during walking rounds to occur in some service areas 22

23 Transitions in Care Handoffs in nonpatient care area with no interruptions Monitoring of handoffs Residents engaged in Improving Care Transitions Resident (UF %, %, 2014 Many handoffs observed in areas that facilitated good communication, some did not (CLE NR) A limited number of handoffs included other health care professionals (CLE NR) Handoffs varied in use of contingency planning and read back or clarifying questions (CLE NR) Noted during walking rounds to occur in some service areas (not conducive to good communication) -- this may need to be reviewed by hospital senior leadership 2014 Varying degrees of monitoring resident skills during change of shift handoffs. (CLE NR) A limited number used formal criteria to assess (CLE NR) Noted during walking rounds to vary by specialty to present: Intern OSCE1 and Intern OSCE2 cases contain both written and verbal handoffs with feedback Executive leaders occasionally described efforts for a standardized, organization wide effort for types of care transitions. They varied in degree in resident involvement in designing and testing these processes. (CLE NR) Most commonly, residents were involved in efforts to standardize their program s processes for transferring care at change of shift (CLE NR) GMEC agreed to use I-PASS as a standardized handoff tool investigated use of e-handoff for use by the institution, but chose not too as it was not able to be integrated into EPIC investigating use of a standardized handoff tool in EPIC s multiple services tool based upon KUMC s and Standford s adaptations 23

24 Supervision Perceived potential vulnerabilities: Placed in situation where inadequate supervision (attending not available) Competency in procedures objective way to know if resident can perform with or without supervision Resident (UF %, %, 19.0% reported placed in situation or witnessed peers with inadequate supervision; %, Vulnerable during high volume patient care need times Availability of some service areas attending coverage Supervision from afar not available for hands-on training Over-supervision impeding transition to autonomy Vulnerabilities experienced during evenings & weekends (CLE NR) Vulnerabilities for over-confident residents, those unaware they need supervision, those hesitant to request supervision (CLE NR) Over-supervision at times, particularly for procedural specialties (CLE NR) This will need to be handled by department chairs May, all programs were asked to review their supervision policies and update as needed for core faculty and residents to confirm in New Innovations %, 33.2% have objective way to know if other resident is able to perform a procedure with or without direct supervision --%, 96.6% of residents knew what they were allowed to do with and without direct supervision 79% 84.0% have an objective way to know which procedures a particular resident was allowed to perform with or without direct supervision, 94% 92.6% have an objective way to know which procedures a particular resident was allowed to perform with or without direct supervision, --%, 98.2% felt residents knew what they were allowed to do with and without direct supervision --%, 99.3% felt residents knew what they were allowed to do with and without direct supervision 24

25 Supervision Supervision issue that resulted in PS event handled by PD System for nursing etc. to identify resident procedural competence Resident (UF %, %, : A supervision database will be entered by level and by person with each PD adjusting individual resident supervision needs as necessary. Surgery will pilot this and post on The Bridge during July %, 22.0% managed and supervision related PS event during past year PS/QI did not recall any events Most PS/QI leaders only recalled those that resulted in a serious safety event (CLE NR) Limited number of CLEs have an organized system of active surveillance to detect and address emerging vulnerabilities to minimize patient harm (CLE NR) --%, 47.4% managed one or more issues related to supervision within past year 2014 Most CLEs have paper or online methods for nurses and others to check. These most often consist of listing each program s competencies by year of training (CLE NR) Limited CLEs provided detailed information to check specific residents. (CLE NR) Most nurses relied on familiarity, trust, year of training, or presence of an attending physician (CLE NR) UF does not appear to have a system in place 25

26 Supervision Patient awareness of different roles of resident vs. faculty Resident (UF %, %, --% thought patients could identify differences in roles %, 31%,, --% 42%,, --% This is both a department chair and a program director issue Specified in: CP Patient Safety Evaluation System (PSES) This is outlined in the resident orientation video (provides background for why it is everyone s duty to report safety events high reliability organization) It is also covered in the IHI patient safety modules that residents are required to take 26

27 Duty Hours/Fatigue Education on fatigue management and mitigation Awareness and use of resources: Maximally fatigued resident scenario what would resident do? Reporting of moonlighting time Fatigue and patient safety: Recall of PS event related to resident fatigue Resident (UF %, 2014 Nearly all, 96.9% received education, %, Most, 67.0% received education, Most, received education, In general, this education primarily consisted of an initial session at orientation, followed by required annual online modules (CLE NR) 2014 to present: Sleep Alertness and Fatigue Education in Residency (SAFER) required of all incoming housestaff prior to July 1 st each academic year and for all faculty members %, 29.4% would power through, 41%, 42.0% notify supervisor and go off duty 12%, 10.6% approach other resident for them to take over 8%, --% notify supervisor and asked to stay 4%, --% take other action 20%, 20.0% would power through 53%, 53% notify supervisor and go off duty 18%, 15.7% would power through 62%, 60% notify supervisor and go off duty %, 33.3% felt that it was under-reported %, 8% recalled an event PS/QI were not aware of this, 6% Residents felt current duty hour requirements were effective in mitigating fatigue. However, they often noted the potential for non-duty hour fatigue such as financial or emotional stress, caring for a family member or young infant. Faculty members and nurses reported observing resident fatigue that appeared to be related to factors other than the number of hours worked (CLE NR) Nurses who were interviewed appeared to vary widely in their awareness of resident and fellow fatigue and strategies to assist them in managing fatigue Program directors and faculty members indicated they diligently avoided exceptions to the rules,4 even those permitted by ACGME policy, to avoid the potential of a citation from a Residency Review Committee External moonlighting appears to be the issue need review of GME policy Occasionally across CLEs, the program directors were aware of patient safety events related to resident or fellow fatigue that appeared to be unknown to the patient safety and quality leaders especially if the events did not result in death or serious harm to a patient 27

28 Professionalism (focused on honesty, integrity, mistreatment) GME-related incidents involving honesty or integrity Institutional training on professionalism and ethics Resident (UF %, %, %, 66.4% %, 95.3% received institutional training, Nearly all, 12.7% received this training during orientation --%, 75% stated training periodically continued throughout length of program to present: Onboarding required of all incoming housestaff prior to July 1 st each academic year: Shands Confidentiality and Security Agreement HIPAA & Privacy General Awareness training in myufl Compliance Training for Incoming Residents / Fellows / Post-Doctoral Associates EPIC training Program specific professionalism education Supportive, nonpunitive environment for reporting 2015 to present: Hospitality Training required of every resident fellow, faculty member, and staff % participated in required program specific sessions %, 93% 28

29 Professionalism (focused on honesty, integrity, mistreatment) At least one occasion where pressured to compromise integrity for authority figure Resident cutting and pasting from another note Observing or encountering physicians or nurses who were disruptive or disrespectful Resident (UF %, %, 14.3% %, %, 34% 50%, 23.1% believed majority of residents engage in this practice 2014 Nearly all reported safe and respectful working environment At times, it was noted that the behavior of a few attending physicians and nurses has been perceived as being disruptive or disrespectful 50%, 20.7% believed majority of residents engage in this practice Observed in 50% of CLEs across multiple areas 29

30 Professionalism (focused on honesty, integrity, mistreatment) How to handle physician mistreatment of colleague Resident (UF %, %, 58.6% discuss with Chief Resident or PD If GME chain of command failed, follow-up to this was varied for UF --%, 40% report to HR or EEOC --%, 9% report via anonymous hotline --%, 23.7% complain to ACGME %, 77% discuss with Chief Resident or PD, If GME chain of command failed, followup to this was varied for UF --%, 28% report to HR or EEOC 77% discuss with Chief Resident or PD, If GME chain of command failed, followup to this was varied for UF --%, 33% report to HR or EEOC Implement Chief Resident Training for mistreatment MyTraining on this for both faculty and residents Jan %, 14% tell colleague to submit incident report --%, 9.9% other course of action Resident/ fellows/ nurses indicated instances of disruptive or disrespectful behavior by physicians and nurses across several units --%, 12% report via anonymous hotline --%, 9% complain to ACGME --%, 28% tell colleague to submit incident report --%, 12% report via anonymous hotline --%, 8% complain to ACGME --%, 25% tell colleague to submit incident report --%,22% other course --%,22% other course of action 30

31 Professionalism (focused on honesty, integrity, mistreatment) Resident (UF %, %, of action 31

32 Appendix B Areas Identified by the Sponsoring Institution as Opportunities for Improvement High Impact Low Impact Effort/Impact grid for prioritized projects developed by CLE Council Low Effort High Effort High Impact/Low Effort High Impact/High Effort Quarterly PD/PDQ/HQPSC beginning 9/14/ Education on supervision for attendings Assigned EPIC person for GME* completed QI/PS Database Registry -- targeted availability of November Housestaff PSR Outcome Reports changes made due to PSR dissemination o Separate near miss reports Resident AHRQ Survey in New Innovations [implement Spring 2017] Faculty AHRQ Survey in Qualtrics or MyTraining [implement Spring 2017] Low Impact/Low Effort Professionalism Concerns Reporting Process complete/no additional work needed Online Disclosure training for Housestaff based on SIP modules Institution-wide QI/PS curriculum [in process] o Disclosure training with simulation QI/PS Housestaff participation documentation [in process] Hospital staff ability to access database regarding needed supervision by specific housestaff for procedures [in process] Practice Habits Dashboard/Reports through EPIC* - Piloting in Neurosurgery, next will be Neurology, etc. Standardized Handoff tool in EPIC* Cultural Competency/Disparities in Healthcare Training Mock RCAs Low Impact/High Effort 32

33 The Graduate Medical Education Committee welcomes feedback about the quality of our GME Programs from the Organized Medical Staff and governing bodies of the participating hospitals. Regular communication about the safety and quality of patient care and education of the residents is an important part of our mission and is welcomed. If there are any concerns or questions, please feel free to call. Respectfully submitted, Lisa Dixon, MD Associate Dear for Graduate Medical Education Designated Institutional Official CC: Bradley Bender, MD, Chief of Staff, NF/SG Veterans Health System Thomas Wisnieski, MPA, FACHE, Director NF/SG Veterans Health System Joseph C. Fantone, MD, Senior Associate Dean for Educational Affairs Timothy C. Flynn, MD, Senior Associate Dean for Clinical Affairs and Chief Medical Officer, UF Health - Shands Mr. Edward Jimenez, Chief Executive Officer, UF Health Shands Michael Good, MD, Dean, UF College of Medicine David Guzick, MD, PhD., Vice President for Health Affairs, President for UF Health Shands Linda Edwards, MD, Senior Associate Dean for Educational Affairs, Jacksonville W. Kent Fuchs, PhD., President, University of Florida Daniel Wilson, MD, Ph.D., Vice President for Health Affairs; Dean, College of Medicine Jacksonville; Senior Vice President for Academic Affairs, UF Health Shands Jacksonville Ms. Cindy Seidman, Director, Medical Staff Services, UF Health Shands Ms. Nancy Reissener, Deputy Director, NF/SG Veterans Health System Department Chairs Faculty Council Program Directors Faculty Housestaff The Foundation for The Gator Nation An Equal Opportunity Institution