2010 APDIM Spring Conference April 25-29, 2010 Baltimore Marriott Waterfront Baltimore, MD. Poster Abstracts

Transcription

1 2010 APDIM Spring Conference April 25-29, 2010 Baltimore Marriott Waterfront Baltimore, MD Poster Abstracts Research Abstracts Poster Number Submitting Author Submitting Author Poster Title 1 Christopher Nabors, MD christopher_nabors@nymc.edu Faculty Supervision of Transitions of Care: The Time Has Come 2 Alec B. O Connor, MD alec_oconnor@urmc.rochester.edu 3 Armand Kriorian, MD armand.krikorian@uhhospitals.org 4 Dean Bricker, MD dean.bricker@wright.edu 5 Jami Foreback, MD JamiF@mclaren.org Intern Cap Reduction Associated with Decreased Length of Stay and Greater Resident Enjoyment of an Inpatient Rotation Conflict Resolution in Health Care: Dominant Negotiation Styles among Internal Medicine Residents Night Float Teaching and Learning: Perceptions of Residents and Faculty How Do Academic Primary Care Faculty Spend Their Time? 6 Andrew J. Halvorsen halvorsen.andrew@mayo.edu Subspecialty Choice: Roles of Gender, Medical School Training, and Future Salary Programmatic Innovations Abstracts Poster Number Submitting Author Submitting Author Poster Title 7 Patricia McNally, MD mcnallyp@trinity-health.org Minimizing the Conflict between Inpatient and Outpatient Duties: An Innovation in Clinic Scheduling 8 Lia Logio, MD llogio@iupui.edu 9 Leonard Feldman, MD LF@jhmi.edu 10 Liza Icayan, MD licayan@northshore.org The Planned Visit: Teaching Residents How to Promote Self-Management in Diabetic Patients An Evaluation of a Transitions Orientation for Interns Improving Morbidity and Mortality Conferences and Addressing the Systems-Based Competency: The Merits of Teamwork 11 Jeanne M. Farnan, MD jfarnan@medicine.bsd.uchicago. edu The Observed Simulated Hand-off Experience (OSHE): Two-Site Experience 12 William Gustin, MD billgust@uci.edu 13 William Gustin, MD billgust@uci.edu Patients Satisfaction with Bedside Education in a Novel Teaching Curriculum Ensuring Broad-Based Ambulatory Resident Patient Panels

2 14 Michael J. Rosenblum, MD 15 Michael Aylward, MD 16 Michael Aylward, MD 17 Alexander M. Djuricich, MD 18 Rand A. David, MD 19 Curtis Mirkes, DO 20 Andrew Adams, MD 21 Colleen Christmas, MD 22 Thomas Y. Tom, MD 23 Joshua D. Lenchus, DO 24 Cyrus R. Kapadia, MD 25 Christian Cable, MD Evening Clinic: A Tool to Improve Work-Life Balance Passing on the Handoff: An Interactive Resident Handoff Workshop The University of Minnesota Continuity Clinic Dashboard The Impact of a Dedicated Quality Improvement Chief Resident Integration of Residency Program Quality Improvement and Departmental Quality Improvement Activities: ACGME Competencies Impact upon Medical Residents Research The End of the Beginning: Residents Teach Interns ICU Supervisory Skills through High- Fidelity Simulation Team-Based Learning in Residency: How to Create Journal Clubs which Residents Value Outcomes From 10 Years Experience with a Junior Resident Teaching Skills Retreat Who's My Doctor? A Flyer with Photographs to Improve Patient Identification of their Doctors- In-Charge Standardized Invasive Bedside Procedural Training Improves Self-Assessed Confidence and Competence Hypothesis-Driven Research: A Feasible and Successful Initiative in Internal Medicine Residency Training Intern Needs Assessment in a Nascent Resident Advising Program 26 Diana B. McNeill, MD; Suzanne K. Woods, MD mcnei006@mc.duke.edu The Effect of Advising Program Changes on Residents Perception: The ILP Effect 27 Diana B. McNeill, MD; Saumil Chudgar, MD mcnei006@mc.duke.edu Implementing a Resident-Driven 360 Peer Review System 2010 APDIM Spring Conference Poster Abstracts Page 2

3 Research Abstracts Poster Number: 1 Submitting Author: Christopher Nabors, MD Poster Title: Faculty Supervision of Transitions of Care: The Time Has Come Hand offs of patient information have been associated with medical errors and adverse events. Recent studies show that information passed from primary to covering teams at shift changes is often flawed. Faculty supervision of the sign-out process has received little attention. We believe that the time has come for hospitalist faculty to assume the supervisory role of all transitions of care. Our computerized sign-out system has attending oversight, by which faculty hospitalists must rate and correct each patient s sign-out information on the general internal medicine service prior to sign-out, and an adverse events reporting module to encourage house staff to disclose untoward events, allowing for timely feedback and system-changes. Data collected from the modules were supplemented with information gathered from surveys of the faculty hospitalists and interns who used the system on the general internal medicine service. Sixty-three percent of interns felt that the PDTS system was either good or excellent in managing sign-out information. Eighty-four percent of interns believed that the quality of their sign-out information was improved by attending oversight and 67% believed that PDTS software improved patient safety. Twenty-four percent of interns believed that having readily available information through PDTS prevented an adverse event from occurring on more than 10 occasions per month. Of 1225 sign-outs reviewed by faculty during a one month time period (February, 2009), 7% were found to be deficient with respect to the each of the following categories of information: on call plan (33%), deviation from expected clinical behavior (25%), deficient present illness/past medical history (21%) and medication lists (15%). Faculty estimated that they correct 13% of sign-outs, and of those sign-outs 7% of the total represent a serious matter related to patient safety or quality of care. Faculty estimated that on 1-2 occasions per month their oversight of PDTS sign-out information prevented the occurrence of a serious medical error or adverse event. This study supports the importance of faculty supervision of all transitions of care in any serious attempt to reduce errors and improve safety. Poster Number: 2 Submitting Author: Alec B. O Connor, MD Poster Title: Intern Cap Reduction Associated with Decreased Length of Stay and Greater Resident Enjoyment of an Inpatient Rotation Background: Beginning in July 2009, the RRC-IM reduced the intern cap, or maximum number of inpatients per intern, from 12 to 10. Little is known about the effects of changing the number of inpatients per intern. Purpose: To assess the possible effects of changes in resident team structure, including reduced numbers of patients per intern, on patient and resident outcomes. Methods: Following the academic year we converted four of five 1-resident:1-intern teams to 1- resident:2-intern teams. The census cap for the 1-resident:1-intern teams decreased from 11 patients/intern in (pre-intervention) to 10 patients/intern in (post-intervention), and the 2-intern teams had a cap of 14 patients (7 patients/intern). The intervention also emphasized pairing each team with a hospitalist teaching attending. The residents signout program database was linked to a hospital database to provide patient outcome data and the results of post-discharge surveys (Press Ganey and Hospital CAHPS). Resident end-of-rotation electronic surveys were also compared before vs. after these changes. Results: In the pre-intervention year, resident teams cared for 2332 patients; in the post-intervention year, residents cared for 3142 patients (2670 patients on 2-intern teams and 472 patients on 1-intern teams). Basic patient demographics were similar pre- and post-intervention, but post-intervention there were more hospitalist patients on

4 the 2-intern teams (69.2% vs. 53.7% during the pre-intervention year, P<0.001) and less patients spent time in the ICU (11.4% vs. 16.1%,P<0.001). Length of stay (LOS) was significantly shorter in the post-intervention period (median 6.0 days for 11 patient/intern teams, 5.0 days for 10 patient/intern teams, and 4.0 days for 7 patient/intern teams, P<0.001). We performed a sub-analysis on the patient subset consisting of hospitalist patients who did not require ICU care (coverage assignments before and after an ICU stay are not linked if the patient stays in the ICU for more than a few days); after adjusting for severity of illness, we still found an association between lower intern cap and shorter length of stay (average adjusted LOS for 11 patient/intern teams 6.8 days, for 10 patient/intern teams 5.9 days, and for 7 patient/intern teams 5.5 days; P<0.001 for 7 vs. 11 comparison). Similar LOS differences were found for non-hospitalist patients using the same analysis. Only 778 patients completed post-discharge surveys (14%). There were no significant associations between the patient survey results and intern caps. Resident ratings of their satisfaction with different aspects of the rotation were similar across the two years, but overall enjoyment of the rotation was higher post-intervention for both R1s (4.26 vs on a 1-5 scale, P<0.001) and R2s (4.05 vs. 3.83, P<0.05). Conclusions: We found associations between lower intern caps and both shorter LOS and greater resident enjoyment of the rotations. We did not find associations between intern cap and patient satisfaction, but were limited by the sample size due to a low survey response rate. Whether smaller intern caps increase or decrease resident learning deserves future study. Poster Number: 3 Submitting Author: Armand Krikorian, MD Poster Title: Conflict Resolution in Health Care: Dominant Negotiation Styles Among Internal Medicine Residents Background and Purpose: Medical residents are exposed to different levels of workplace-related conflicts with faculty, colleagues, nursing staff, patients and their families. Effective resolution of such conflicts is part of Interpersonal and Communication Skills, a core competency of Internal Medicine training programs. Certain negotiation styles are more suited to effective conflict resolution and the unsatisfactory resolution of workplace conflicts has been linked to job dissatisfaction and poor team morale. To our knowledge, there are no published data on negotiation styles of physicians-in-training. In this study, we examined the negotiating styles of housestaff in a department of medicine at a large academic medical center. Methods: We used the 30-question Thomas-Kilmann Conflict Mode Instrument (TKI) a tool that has been extensively validated in various populations. It identifies the subject s dominant negotiating style (Accommodating, Avoiding, Compromising, Collaborating or Competing) and also measures the willingness to adapt one s negotiating style to different situations. We administered the TKI using the REDCAP online survey tool, together with a questionnaire that gathered demographic data. Participation was voluntary and restricted to housestaff in the Department of Medicine at Case Western Reserve University. All data were collected anonymously and were analyzed using SPSS version Results: The response rate was 36% (n=52). The median age of respondents was 28 years and the gender distribution was 1.12:1 (M:F). Sixty-six percent were single and 68% had no prior exposure to conflict resolution training. The most common negotiating style among housestaff was Accomodating (44%), followed by Competing (25%), Compromising (15.4%) and Avoiding (13.4%), while Collaborating was the least favored style (1.9%). There was a high resistance to change among styles, with only 9 individuals (17%) showing adaptation of their style to different situations. Using Pearson s chi-square, there was no statistically significant difference among styles by gender, age, marital status, type of program (categorical vs. preliminary), or year of training. Discussion: The dominant negotiating style among surveyed housestaff was Accomodating, with high resistance to 2010 APDIM Spring Conference Abstract Summaries Page 2

5 change. This style emphasizes self sacrifice and placing the importance of a relationship above one s own goal. While this style may be appropriate in dealing with patients and families, it is not always suited to interactions with colleagues, faculty or allied health care workers. More alarming, Collaborating was the least favored style, reflecting an unwillingness to work through differences to strengthen relationships and engender win-win situations. The high resistance to change that was measured reflects unwillingness to change style despite being confronted with varying situations. Conclusions: Internal Medicine residents may not possess negotiating styles conducive to effective conflict resolution in health care settings. A more in-depth examination of these traits is necessary. Confirmation of these findings would inform curricular development strategies focused on changing negotiating styles to better confront problems in the healthcare environment. Poster Number: 4 Submitting Author: Dean Bricker, MD Poster Title: Night Float Teaching and Learning: Perceptions of Residents and Faculty Background: Most internal medicine training programs use a night float system to meet resident work hour regulations. The amount of time spent on night float is often 10 to 15 % of total time spent in post graduate training (3 to 4 months out of 36). Some regulatory bodies have suggested that new night float hour restrictions are needed in the interest of better patient safety. If adopted, those changes could result in even more night float rotations. Frequently the number of night time new patient encounters equals or exceeds that of daytime duty. Despite the significant impact night float rotations are likely to continue playing in the developmental education of housestaff, few studies have assessed the adequacy of current learning opportunities and better bedside teaching during this core curriculum rotation 1,2. Purpose: This study was designed to assess internal medicine resident physicians perceptions about teaching effectiveness and learning opportunities during their night float hospital rotations. It was intended to compare residents opinions about night float with their impression of day time rotations, and to assess any differences in perception between residents and their faculty attendings. Methods: A 25-question anonymous, voluntary survey was given to all Wright State University, Boonschoft School of Medicine internal medicine residents and to their faculty who regularly attend on the inpatient teaching service. A 5-point Likert scale was used to assess perceived quantity and quality of various educational opportunities including: delineation of teacher expectations, direct attending discussions, feedback, conferences and direct bedside teaching. Results: Response rate was 52% (n=85). Resident physicians had statistically significant negative opinions about the teaching and learning opportunities of night vs day rotations for 17 of 25 (68%) areas surveyed. Faculty attendings held statistically significant negative opinions about night float compared with day rotations on 25 of 25 (100%) of areas assessed. Residents held statistically different views from faculty in 6 areas. Concerning night rotations, residents: 1) believe they attend adequate didactic conferences 2) feel they learn from following patient s daily progress 3) do not feel they have adequate opportunity to teach junior learners 4) do not discuss detailed clinical reasoning with their attending 5) do not find the attending available for teaching or to guide clinical decisions 6) do not feel adequately rested. Conclusions: Compared with dayshift rotations, relatively little time is spent in direct bedside teaching, case discussion, education conferences, and learner feedback during night float rotations. Despite the substantial influence of night float rotations on resident s overall education, there are many lost teaching and learning opportunities in the current night float system. Modification of the existing night float format may be able to improve the overall educational value of night float rotations. A new format is proposed and currently being tested. References 1. Jasti H, Hanusu B, Switzer G, et al. Residents perceptions of a night float system. BMC Medical 2010 APDIM Spring Conference Abstract Summaries Page 3

6 Education 2009;9: Aki E, Bais A, Rich E, et al. Brief report: internal medicine residents, attendings, and nurses perceptions of the night float system. JGIM 2006;21: Poster Number: 5 Submitting Author: Jami Foreback, MD Poster Title: How Do Academic Primary Care Faculty Spend Their Time? Introduction: Academic primary care physicians have multiple demands on their time and achieving a satisfactory balance can be difficult. The overall goal of this study was to describe how primary care physician faculty allocate time for their academic responsibilities. Three research questions guided this study: 1) How do academic primary care faculty allocate their time; 2) Are there differences between their actual and preferred time allocations? and 3) Are there differences in time allocation among primary care specialties? Methods: Data were collected from using a curricular needs assessment completed by 87 clinicianeducator fellows participating in the Primary Care Faculty Development Fellowship at Michigan State University. Of the 87 fellows, 14 were general internists, 27 were pediatricians, and 46 were family medicine faculty. Data were manually collected and analyzed using descriptive statistics. This study was approved by the Institutional Review Board at Michigan State University (NO ) Results: 91% of the subjects were from community-based residency programs, all had been in academic medicine less than 5 years, 47% were male, and 29% were underrepresented minority faculty. The results by research question were: 1) The nine-year average of how primary care physician faculty allocate their time was: Clinical Teaching & Curriculum Development: 43.05%; Patient Care: 35.1%; Administration & Management: 14.3%; Research & Scholarship: 4.7%; and Professional Organization & Community Service: 2.9%. 2) When comparing the fellow s Actual and Preferred time allocations, they preferred additional time for Research (11.3% preferred vs. 4.7% actual); less time for Patient Care (26.0% preferred vs. 35.1% actual); and more time for Professional Organization & Community Service (6.6% preferred vs. 3.3% actual). 3) When comparing general internists to the other specialties, they devoted less time to Clinical Teaching & Curriculum Development (39.5% vs. 43.0%), more time for Research & Scholarship (7.3% vs. 4.7%), less time for Professional Organization and Community Service (1.6% vs. 2.9%), and slightly more time to Administration & Management (15.8% vs. 14.3%). There were no major differences among the specialties in their preferred time allocations. Discussion: The results of this study may be limited by the small number of subjects, how representative the fellows were of all primary care faculty, and the use of self-report data. Based upon the results, we draw the following conclusions: 1) Overall, there are remarkable similarities in the distribution of actual time spent by these primary care faculty. The preferred distribution of time was also similar across disciplines. The results of this study were similar to those of other studies of clinician-educator effort. 2) All respondents preferred more time for Research and Scholarship. The actual amount of time spent in this category (4.7%) was significantly less than the time reported in the literature for clinical-educators, generally 10-20% effort. 3) With the challenges of recruiting and retaining faculty in primary care academic medicine, program directors are encouraged to address discrepancies between how faculty allocate their time and how they prefer to allocate their time. These discrepancies may ultimately lead to dissatisfaction and a lower commitment to a career in academic medicine. Poster Number: 6 Submitting Author: Andrew J. Halverson Poster Title: Subspecialty Choice: Roles of Gender, Medical School Training, and Future Salary 2010 APDIM Spring Conference Abstract Summaries Page 4

7 Background: The percent of U.S. medical school graduates training in a medical specialty increases as the specialty s mean salary increases. The relationship between future salary and subspecialty choice for internal medicine residents is unknown. Purpose: To determine if internal medicine subspecialty choice is associated with future salary and if it differs by gender and medical school origin (U.S. vs international). Methods: Published data on 8,898 subspecialty fellows in training during the 2007 academic year and mean salaries from a national physician survey were used to assess the linear relationships between salary and percent of fellows who were U.S. graduates and percent who were women. A cross-sectional survey of 17,015 third-year internal medicine residents, representing 69.9% of all third year U.S. categorical internal medicine residents from 2003 to 2006, was used to assess interactions between medical school origin and gender. The outcome variables obtained from these sources were the percentages of fellows training in subspecialties and reported career choice by third-year residents, based on medical school origin and gender, paired with mean salaries for those subspecialties. Results: Percent of fellows in a subspecialty who were U.S. medical school graduates (USMG) showed a positive association with mean salary (R=0.67, P=.05). Geriatric medicine had the lowest mean salary ($177,392) and percent USMG fellows (28.9%), while cardiology and gastroenterology had the highest mean salaries ($370,295 and $356,388 respectively) and percent USMG fellows (both 65.3%). The percent of fellows in a subspecialty who were women showed a strong negative association with mean salary (R=-.83, P=.005). Endocrinology had the highest percent of women fellows (67.4%) and second lowest mean salary ($204,217), while cardiology had the lowest percent of women fellows (18.8%). Inclusion of international medical graduate status and it s interaction with gender did not significantly alter the associations of gender and salary with reported career choice. Discussion: Higher paid subspecialties are pursued at higher rates by men than women, regardless of whether they trained in U.S. or international medical schools. Our data are unable to address several interesting questions: Are women systematically paid less, decreasing the overall salaries of the subspecialties they prefer? Do gender biases exist toward certain subspecialties for non-monetary reasons, such as perceived lifestyle? Does a lack of female role models in certain subspecialties perpetuate a lower number of female trainees? We believe these questions frame important areas to explore and warrant further research. Programmatic Innovation Abstracts Poster Number: 7 Submitting Author: Patricia McNally, MD Poster Title: Minimizing the Conflict Between Inpatient and Outpatient Duties: An Innovation in Clinic Scheduling Background: On July 1, 2008, our program implemented a novel system for scheduling continuity clinic, to minimize the conflicts between inpatient and outpatient responsibilities. We implemented an Intensive Clinic Month, where residents spend one month exclusively seeing patients in their continuity clinic. Additionally, inpatient/outpatient scheduling was altered to minimize conflicts between inpatient and outpatient responsibilities: during elective months, residents were given 2 continuity clinics per week. During inpatient months, clinic was minimized such that residents had abbreviated clinics which were only 1 and 1/2 hours in length, and were scheduled only twice during the month. The purpose of these abbreviated clinics was for the residents to maintain continuity with patients needing short-term interval follow-up (i.e. patients who could not wait for the resident s next elective month.) Successes: We formed a focus group mid-year to review the new system, consisting of residents, outpatient faculty, and inpatient faculty. The innovation was unanimously felt to be an improvement over the old system. Outpatient faculty noticed that when residents were in clinic, they were much more engaged in both patient care 2010 APDIM Spring Conference Abstract Summaries Page 5

8 and in learning. This improved job satisfaction for outpatient preceptors. Inpatient faculty noticed that on the wards, the decreased clinic demands allowed the residents to be much more present for patient care responsibilities. Residents are very pleased with the new system, because they feel that when they are in the outpatient clinic, they can be more fully committed to their outpatient responsibilities, with less distractions. Similarly, when they are on inpatient rotations, they feel that they are more able to be fully incorporated in the care of their inpatients, without the distraction of a full four-hour continuity clinic each week. Lessons learned and future directions: When residents have multiple inpatient months in a row, it causes prolonged periods when the resident has minimal clinic presence, and the residents primary patients cannot get timely appointments to see them. To combat this, we switched our block scheduling policy to require an every other month schedule: inpatient months alternate with elective months in a one-on, one-off fashion. This dictates that a resident is rarely away from the office for more than one month at a time. Another barrier to continuity occurred due to the way the abbreviated schedules were utilized by ancillary staff: the intention had been for these abbreviated clinics to be used solely to maintain continuity while residents were on inpatient months. However, many residents abbreviated schedules were used by office staff for add-ons, urgent visits, and new patient visits. Our intervention is that we no longer keep open schedules for abbreviated clinics, but rather, we have devised a mechanism by which residents can self-schedule add-ons. Residents will still be expected to see continuity patients at least twice per inpatient month, but with this intervention, the residents will have full control over which patients get scheduled during their service months. Overall, we feel that this innovation has been successful in improving the educational process, and we are excited to develop it further. Poster Number: 8 Submitting Author: Lia Logio, MD Poster Title: The Planned Visit: Teaching Residents How to Promote Self-Management in Diabetic Patients Introduction: The Chronic Care Model identifies six key elements of care to support best practice chronic disease management. One of these components is self-management support with evidence that this approach fosters productive interactions between informed patients who become more actively engaged in their care leading to healthier patients and more satisfied providers. We developed an intensive week-long curriculum for all PGY2 residents to learn and apply these skills to their continuity clinic patients. The Planned Visit Activity has provided deep understanding of these concepts. Purpose: Immersion Week Two was developed to introduce the important concept of self-management for patients with chronic disease. The weekly activities provide each resident with an overview of individual characteristics and quality metrics of his own continuity clinic patients with diabetes mellitus. A Planned Visit at the end of the week provides an opportunity for the resident to practice the new skills and apply what is learned. Methods: Within the continuity clinic, residents spend time learning motivational interviewing skills, working with pharmacists during patient consultations, and attending an interdisciplinary diabetes class. Additional time during the week is assigned for self-study using the ACP Diabetic Care Guide, performing a chart audit, and preparing for and implementing a planned visit on a challenging patient with diabetes. The Planned Visit requires the resident to identify and schedule an extended appointment with a diabetic patient from his panel. Four goals are outlined for this appointment with the focus on assessing compliance and identifying what barriers exist. In addition to these goals, residents are asked to explore at least two additional health education activities with the patient. These might include health literacy assessment, exploration of meal habits and social factors, exercise and diet plan, sick day plan, foot care education, modification of insulin/medications based on blood sugars, or introduction of aspirin, statin, ACE/ARB. Results: Immersion Week (PGY2) is evaluated using four tools; an overall evaluation, a pre-rotation survey ( APDIM Spring Conference Abstract Summaries Page 6

9 items), the planned visit activity and reflection, and the chart audit reflection. The overall evaluation includes selfratings on four key concepts before and after the rotation: medical knowledge, health literacy, doctor role in changing self care and effective collaboration. During , residents showed greatest change in knowledge (5.26 pre to 7.33 post, 2.07) second to health literacy (5.11 pre to 6.93 post, 1.82). The doctor role moved from 6.11 to 7.52 while the effective collaboration moved from 6.04 to The Planned Visit Activity and Reflection asks three open-ended questions about the resident experience. Our most valuable and discerning information has come from the resident responses to these three questions including insightful recognition of patient-centered issues and the efficacy of a collaborative approach to care of a diabetic patient. Conclusion: This one-week model provides an effective mechanism to teach residents how to promote patient self-management within the chronic care model. The planned visit component provides an opportunity to evaluate residents understanding of patient-centered care, team-based diabetes care. Poster Number: 9 Submitting Author: Leonard Feldman, MD Poster Title: An Evaluation of a Transitions Orientation for Interns Background: The Joint Commission on Accreditation of Healthcare Organizations, hospitalists, hospital leadership, and quality improvement specialists all agree that transitions in care pose a serious threat to patient safety. Patients cared for by residents are likely to be particularly vulnerable given their lack of experience. These transitions include sign-outs from the primary daytime physician to either night teams or on-call residents, discharges to home or other health care facilities, and hand-offs when a resident rotates off a service. Evening signouts suffer when there are important content omissions, like the clinical condition of a patient or tasks that needed to be performed, and when failure-prone communication processes are used. 1, 2 The consequences of failures in the home discharge process have been quantified. Twenty percent of patients discharged home have an adverse event within 3 weeks, of which 66% were drug-related adverse events. 3 Direct communication between hospital physicians and PCPs occurs in only 3%-20%of cases studied and the discharge summary is available at the first post-discharge visit less than 35% of the time. 3 These worrisome statistics and our own personal experiences prompted us to devote one day of intern orientation to a transitions workshop. The two-hour morning session focused on the transition created when the primary daytime physician signs-out to an on-call housestaff member. The morning session started with the housestaff signing-out to a partner without any instruction. After debriefing the activity, the housestaff were taught how to sign-out, watched a video where the process was demonstrated, and reviewed the computerized sign-out system used in our hospital. The session ended with the housestaff signing-out two new cases to each other. The second two-hour session started with a role play where the residents had to discharge a patient with CHF or COPD. After debriefing the exercise, we reviewed the keys to discharging patients safely, including how to use the teach back method. They then viewed the 23-minute AMA Foundation video Help Your Patients Understand, which highlights health literacy as a patient safety issue. The session ended with another discharge role play. Methods: After the workshop, the housestaff were asked to fill out a 14-question survey using a 5-point Likert scale. Results: Thirty-six incoming interns to Johns Hopkins University Internal Medicine residency program participated in the workshop. A post then pre survey design was used to measure self-reported change in knowledge and confidence levels in areas pertaining to workshop objectives. There was a consistent trend of improved ratings on all post-workshop survey questions compared to pre-workshop. A Mann Whitney test was performed, and all differences were found to be statistically significant (p<0.05). Fig 1 shows the average rating for each of the survey questions before and after workshop. (see table below for question text) 2010 APDIM Spring Conference Abstract Summaries Page 7

10 Discussion: We found that a four-hour workshop improved self-reported knowledge and confidence levels in an important and often overlooked area of education for new housestaff. We had taught an abridged form of the content in We were pleased that the results are both statistically and clinically significant. We had not previously formally discussed the impact of health literacy issues, and we were impressed with the importance the housestaff placed on the issue. Our next step is to follow-up with an additional survey to assess whether the housestaff are using the techniques that we taught them and whether they think more training is necessary. 5 Average rating on 1 5 Likert scale Before After 0 Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 1= Disagree strongly 2= Disagree slightly 3= Neutral 4= Agree slightly 5= Agree strongly Ave Rating BEFORE Ave Rating AFTER Q1 I am confident that I can effectively sign out my patients to others on my team Q2 I can deliver a clear and organized verbal sign out Q3 I know the four basic steps for sign out Q4 I can prepare a complete written sign out APDIM Spring Conference Abstract Summaries Page 8

11 Q5 Q6 Q7 Q8 Q9 Q10 I am confident that I can clearly communicate the discharge instructions to my patients I know how to prepare my COPD patients to take care of their medical condition upon discharge I know how to prepare my CHF patients to take care of their medical condition upon discharge I know how to ensure that my patients understood my discharge instructions I am confident of my ability to use the Teach Back communication method I m aware of the problem of health literacy and how it can impact patient care Q11 The sign out approach I learned today can improve my patients safety 4.9 Q12 Q13 Q14 The discharge approach I learned today can improve my patients safety I plan to use the sign out approach I learned today as I sign out to my colleagues I plan to use the Teach back method I learned today to ensure that my patients understood my instructions Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. Dec 2005;14(6): Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Consequences of inadequate sign-out for patient care. Arch Intern Med. Sep ;168(16): Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College Of Emergency Physicians, and Society for Academic Emergency Medicine. J Hosp Med. Jul 2009;4(6): Poster Number: 10 Submitting Author: Liza Icayan, MD Poster Title: Improving Morbidity and Mortality Conferences and Addressing the Systems-Based Competency: The Merits of Teamwork 2010 APDIM Spring Conference Abstract Summaries Page 9

12 Problem: Several years ago we discovered that our morbidity & mortality (M&M) conferences were increasingly difficult to sustain. Residents who were asked to present a case for the conference were routinely fearful and felt unfairly isolated from their colleagues. When there were no apparent cases to choose from, residents rarely volunteered any of their own cases. At around the same time, the six competencies for residency education was introduced by the ACGME. One of these was the Systems-Based Practice competency and our residency needed to more directly address how this competency would fit into our curriculum. Innovation: In order to address our residents fears we created resident teams. We divided our 76 residents into ten teams. Teams consisted of equal numbers of PGy-3s, PGy-2s, Internal Medicine PGY-1s, Preliminary Year PGY-1s, and Transitional year PGY-1s. They were given the freedom to choose a case from any of its members and to decide on how the presentation should be formatted. Residents were encouraged to share duties. Two cocaptains were assigned to each team. These conferences were rated and the team with the highest rating was formally recognized at the end of the year. Each of the 10 teams was also assigned a Systems-Based Improvement project. Nurses were added to the teams. Pertinent administrative and hospital personnel were invited to hear about these projects during Grand Rounds in order to promote further discussion or possibly implement the recommendations. Results: Since 2004 the fear and loathing that was consistently present for M&M conferences has been replaced by excitement and a drive to produce a great conference. Conference participants have routinely praised the quality of these conferences. Many resident teams chose to additionally give an in depth presentation on a particular topic relevant to the M&M case which enhanced these conferences further. Residents have also been motivated to ensure attendings involved in the case or who have expert commentary were in attendance which enriched the discussions. To date there have been 50 Systems-Based Projects presented. 80% of these have been fully or partially implemented. One example involves the overuse of proton pump inhibitors (PPIs) in routine patient care. One team presented data regarding proper indications for prescribing PPIs, proposed possible reasons for overuse, and recommended potential solutions. As a result PPIs were removed from the standard order set in our electronic medical record system and specific guidelines for their use was disseminated across our hospital system. These guidelines continue to be in use today. Implications of the Innovation: M&M presentations are no longer dreaded by residents. The team format has also produced higher quality conferences. Residents have also learned skills in leadership, delegation, teamwork, and presentation. Another positive byproduct has been the formation of natural mentorships between PGY classes. Systems-Based improvement projects involving multiple people, including nursing, have been creative and progressive. These projects have simultaneously empowered our residents to recommend improvements for the betterment of patient care and these improvements have been, in many situations, implemented to benefit our patients and hospitals. Poster Number: 11 Submitting Author: Jeanne M. Farnan, MD Poster Title: The Observed Simulated Hand-off Experience (OSHE): Two-Site Experience Description of the Problem: Few trainees receive formal training in communication during patient handoffs. In addition, tools to assess hand-off performance are lacking. Based on a successful model of training medical students using standardized patients, we created the OSHE (observed simulated hand-off experience) to evaluate student and intern performance using a real-time assessment tool based on the Mini-CEX (Clinical Examination) called the Hand-off CEX. Description of the Intervention: Senior students (33) and incoming interns in all specialties (125) at two Midwestern schools participated in the OSHE experience. Static information, including a mock patient history and physical examination transcript, created by teaching faculty and based upon an actual clinical case, was provided to the trainees. A five minute interval patient events video highlighting important clinical updates (increasing 2010 APDIM Spring Conference Abstract Summaries Page 10

13 oxygenation requirement, pending labs) that had occurred throughout the day was designed to trigger critical anticipatory guidance and to-do items. Participants were then given 10 minutes to complete a written sign-out, incorporating the dynamic information from the video with the static information, and hand-off this patient to a standardized receiver. Receivers were housestaff and fellows trained on the case a priori and on hand-off expectations using a curriculum developed by the investigators, received the hand-off, and provided trainees with feedback. The Hand-off CEX asked receivers to rate overall hand-off performance and its components, organization, communication skills, clinical judgment and humanistic qualities on a 9-point scale. Senior students at one site also complete pre and post-surveys which assessed self-reported hand-off preparedness. Interns at the second site were surveyed on previous hand-off education and experience. Data were analyzed using descriptive statistics and, where appropriate, Wilcoxon-signrank tests. Cronbach s alpha was calculated to evaluate the internal consistency of the Hand-off CEX instrument. All encounters were videotaped for future review to assess inter-rater reliability. Results to date: 60.8% of incoming interns at one site reported they had not received hand-off education during medical school training and 20.4% reported feeling somewhat or not at all prepared to perform an effective handoff. In addition, 80.6% stated they were aware of an adverse patient event secondary to a poor hand-off. Senior students at the second site reported statistically significant improvement in self-perceived hand-off preparedness (67% post vs. 27% pre reporting well-prepared, p<0.009) after the OSHE experience. All participants, at both sites, received the following mean scores for: organization/efficiency [5.80; range 1-9, max 9]; communication skills [6.24; range 1-9, max 9]; content [5.72; range 1-9, max 9]; clinical judgment [5.80; range 1-9, max 9] and professionalism [7.23; range 5-9, max 9]. Standardized receivers rated the overall student and intern performance with a mean score of 5.97 [range 2-9, max 9]. 79.8% of interns stated the difficulty of the experience was appropriate. Cronbach s α was calculated as 0.90, demonstrating internal consistency of the Hand-off CEX instrument. Implications: The OSHE is a potential way to teach and assess handoff quality in medical trainees that has been successfully adapted to 2 teaching settings. Future work focuses on establishment of validity and reliability of the Hand-off CEX for further dissemination. Poster Number: 12 Submitting Author: William Gustin, MD Poster Title: Patients Satisfaction with Bedside Education in a Novel Teaching Curriculum Introduction: Several studies have evaluated the bedside teaching experience from the learners perspective and some literature has shown generally enhanced patient satisfaction with increased time and teaching at the bedside. This current study evaluates patients perception of bedside teaching while conducting a novel curricular program, the Doctoring Skills Rotation (DSR). DSR focuses on communication and physical examination. Does a single teaching intervention at the bedside translate into a change in patient s satisfaction with their medical care? Methods: The study employed a convenience sample of inpatients in an academic medical center being cared for on the medical-surgical ward services. Patients were screened and consented by a single research volunteer and then placed on a daily list of patients available for DSR teaching-team interviews. All patients received a presurvey to assess their baseline characteristics and satisfaction. Patients who were seen by the DSR team participated in faculty DSR teaching rounds and feedback at the bedside. Those patients not seen by the team were control patients. Post-encounter surveys were administered to all of the DSR participant patients immediately after the DSR interview and a final survey was given to DSR patients and controls at the time of discharge. Basic demographics and length of stay data were also collected. Regular primary care teams were unaware of the patients participation in the study. The patients were surveyed using standardized Likert-scale questions on: 1) satisfaction with current care, 2) understanding of the medical plan, 3) satisfaction with daily teaching at the bedside by the primary care 2010 APDIM Spring Conference Abstract Summaries Page 11

14 team, 4) perception of time the medical team spent at bedside, 5) participation in teaching and care plan, and 6) overall satisfaction with the hospital experience. Results: When comparing patient values before and after undergoing the teaching exercise, the DSR team was found to be easier to understand (p=0.03), listened more carefully (p= 0.02) and tended to involve patients more when teaching students (p=0.01) compared to the patient s normal primary care team. The DSR team was also perceived to spend more time at the bedside (p<0.001) and sufficient time teaching students about patient s illness (p=0.02). The perception of increased teaching time at the bedside persisted to discharge (p=0.01) and the total minutes spent at bedside by the primary care team were also perceived to be longer in the intervention group (p=0.02). Conclusion: A single DSR teaching session at the bedside positively enhanced patient s perception of their care and increased the perceived time spent at the bedside by the primary care team. Poster Number: 13 Submitting Author: William Gustin, MD Poster Title: Ensuring Broad-Based Ambulatory Resident Patient Panels Introduction: Patient diversity within a continuity clinic patient panel and reasonable similarity across panels in a residency ambulatory practice is of paramount concern for Internal Medicine training programs. However, it is difficult to track and ensure every resident has every type of patient within his or her panel. The authors propose the possibility that tracking a minimum number of diabetic patients within each resident panel can serve as a proxy diagnosis for multiple coexisting chronic conditions. As a first step in this process the authors wished to first analyze the current demographics and coexisting diseases of the diabetics in the outpatient resident clinics to evaluate if a diabetic population distributed across each resident panel could serve as a foundation in chronic disease management by offering multiple coexisting conditions. Methods: The charts of 400 diabetic patients from the residents clinical practice were reviewed. Basic demographic data as well as 42 coexisting diseases were selected for review based upon likely comorbidities found in diabetics as well as chronic diseases of high educational value in a resident clinical practice. All data were deidentified and all patients were analyzed by resident provider. Results: 73% of the patients in the resident practices were type II on oral medications, 23% were type II who required insulin, and 4% were type I. 91% of the patients had at least 2 additional coexisting illnesses and 85% of the patients were over 50 years old. Interestingly, only 64 patients (16%) had undergone a coronary or other vascular surgery. Hypertension (87% of all patients) and hyperlipidemia (79% of all patients) were clearly the 2 highest coexisting conditions in the patient cohort. However, there was more than a 1 in 5 chance for diabetic patients to also have each of the following chronic diseases: osteoarthritis, obesity, depression, neuropathy, chronic kidney disease, anemia, or coronary artery disease. When categorized by resident, on average, 4.6 (range 1-14) diabetic patients were clearly identified as seen by residents on a regular basis. While significant variability existed amongst the resident panels, we noted that residents with at least 5 diabetics in their panel would, on average, care for patients with 26 (range 14-46) common coexisting conditions in their practice while those with less than 5 diabetics demonstrated a significant loss in panel diversity. Conclusion: In this feasibility pilot study of diabetics as a primary educational cohort in an internal medicine resident continuity clinic the data suggests that ensuring that each resident provides care for at least 5 type II diabetics may also ensure the residents panels will include a relatively broad range of chronic medical diseases. Poster Number: 14 Submitting Author: Michael J. Rosenblum, MD Poster Title: Evening Clinic: A Tool to Improve Work-Life Balance 2010 APDIM Spring Conference Abstract Summaries Page 12

15 Background: The resident ambulatory block experience has historically been Monday-Friday leaving little or no time accessible for personal needs during daytime hours. Residents report great difficulty in scheduling appointments for their healthcare and other essentials. Satisfaction with work-life balance suffers as a result of this routine scheduling paradigm that challenges residents in getting to the dentist, the bank or the post-office. Many patients are frustrated by the limited hours that most health centers offer them as evening and weekends are typically unavailable. Full time students and workforce often have the greatest limitation to healthcare access. Hypothesis: We believe that an evening continuity care session at Baystate High Street Health Center that creates a free half-day (either AM or PM) will improve resident work-life balance and craft an opportunity to manage personal needs more successfully. We also hypothesize that patient satisfaction will advance as a result of improved access and opportunities for care. Methodology: Ambulatory block residents were assigned to a consistent weekly evening session from 5:00 PM to 7:30 PM on either Tu, Wed or Th. Each resident received a compensatory morning or afternoon session off to maintain educational and patient care opportunities. Scheduling templates are based on the individual competence of each learner. There are a maximum of three residents per preceptor during these sessions to guarantee appropriate education and enhance efficiency. An anonymous pre-intervention survey was utilized to evaluate the current sentiment of our 2nd and 3rd year medicine residents. Key themes: Our pre-intervention survey of work-life balance was eye-opening and concerning. 77% of the twenty-six 2nd and 3rd year respondents had neglected their health and wellness as a result of their schedule. One of three felt it was impossible to take care of a DDS or MD appointment in our classic scheduling model. 88% welcomed an opportunity to have an evening continuity session for compensatory weekday time off. Preliminary data suggests that opportunities for resident healthcare and other needs are markedly improved (a post-test survey is ongoing). Overall satisfaction with patient care, education and efficiency for residents who have participated in the evening sessions is uniformly high. Many patients who struggle with daytime appointments have expressed great satisfaction in this novel opportunity to connect with their healthcare provider. Lessons Learned: Innovative evening continuity sessions have positively impacted the resident work-life balance and improved the access for many of our patients. Open weekday time affords residents the opportunity to schedule appointments and take care of personal/familial issues that cannot as a rule be accomplished during inpatient or ambulatory rotations. Developing efficient evening sessions requires creative scheduling for faculty, residents, and complimentary healthcare resources. The financial impact of extended hours (utilities, security and staff) must be balanced by productivity. The opportunity for evening urgent clinics and the potential for weekend sessions are subjects for future discourse. Poster Number: 15 Submitting Author: Michael Aylward, MD Poster Title: Passing On the Handoff: An Interactive Resident Handoff Workshop Problem: Hand-offs exist at the intersection of patient care, communication, and professionalism. Finding ways to provide smooth transitions of care between housestaff teams may improve patient care and addresses regulatory and core competency requirements. We sought to design an efficient, effective way to improve interns knowledge and readiness to perform handoffs between covering teams. Description: In 2008 and 2009 we iteratively (using a Plan, Do, Study, Act approach) created a 90 minute workshop for intern orientation. A total of 92 internal medicine and internal medicine/pediatric residents have completed the workshop in small groups of The workshop was an interactive, small group session using multi-media, discussion, and role-playing to identify and reinforce the ideal components of a hand-off. Content of the workshop was grounded in the handoff literature and utilized adult learning techniques. Content was modified 2010 APDIM Spring Conference Abstract Summaries Page 13