Gripes Gripes and and

Performance ImprovementPerformance ImprovementIn ResidencyIn Residency

Auxford Burks, MD

Albert Einstein College of Medicine

Department of Pediatrics/ Jacobi Medical Center

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

Aim

Measures

Ideas

Act Plan

Study Do

A PDSA Cycle

Will encounter forms facilitate severity classification? Dr. X will try form with severity class Qs with 3 patients on Thurs

Dr. X tried with two patients. Couldn’t find a form for third patient.

Dr. X found the form helpful for prompting; thought items on form should be in a different order. Need better process for getting form to provider.

Revise form. Try new form with 3 patients tomorrow; MA will put form on chart.

PDSA Objective: Test the use of encounter form to facilitate visit

PDSA Cycles

“Negative results on the fish…Let’s try rubbing two sticks together.”

PI initiatives at Jacobi

• Network Emergency preparedness• Stroke Center• Transforming ambulatory care• Surgical Care improvement project• DVT task force• NYC Chronic Disease Collaborative On Diabetes• Pediatric Emergency Department Asthma Initiatives• Obstetrical Patient Safety Monitoring• Near Miss hotline• Rapid Response teams

So, how can we involve residents?

Jacobi PI initiatives

• Good Catch

• Resident Gripes

Good Catch

• “Problem” identified

• Anonymous, confidential form completed

• Submitted to the chief residents – The residents were assured that the hospital

operates as a just culture and that individual blame would not be assigned to anyone guilty of making an error

Errors identified:

• Misdiagnosis/poor judgment: 36%

• Poor communication between clinical units: 24%

• Poor communication among staff: 8%

• Medication: 12

• Administrative: 12

• Medical procedure: 8

This work resulted in a poster at the Pediatric Academic Societies meeting….

Resident Gripes

Chief residents supervised “gripe” sessions with residents with the goal of discovering potential QI projects. Such gripes were used to identify system wide problems in re: patient care and quality of resident education. Chief residents functioned as project leaders, educating residents on how to implement the Plan, Do, Study, and Act cycles (PDSA).

Outcomes:

1. Improving peripheral IV line (PIV) care and replacement

– Gripe: Number of hours spent by residents maintaining and replacing PIV's.

– Patient Care issue: Delays in care, time to admission, and reductions in time available for patient care planning.

– Outcome: Increased cooperation with nursing to manage PIV issues. Overall 32% mean decrease in the time residents spent replacing PIVs on the inpatient service over 1 yr period.

2. Improving hospital discharge follow-up process

– Gripe: Amount of time spent by residents on phone making follow-up appointments.

– Patient Care issues: Loss of resident time available for patient care planning.

– Outcome: Initiation of an alternate system for discharge planning. Relative 45% decrease in amount of working time spent by residents making follow-up appointments.

This work resulted in another poster at the Pediatric Academic Societies meeting….