- Email: [email protected]
15. Applying Lean Initiatives to Inpatient Rounds to Improve Discharge Delays
e8
ABSTRACTS
12. SUCCESSFUL SELF-DIRECTED LIFE-LONG LEARNING IN MEDICINE: A CONCEPTUAL MODEL DERIVED FROM QUALITATIVE ANALYSIS OF A NATIONAL SURVEY OF PEDIATRIC RESIDENTS Su-Ting T. Li, MD, MPH, Debora A. Paterniti, PhD, University of California Davis, Sacramento, CA, John Patrick T. Co, MD, MPH, Harvard Medical School, Boston, MA, Daniel C. West, MD, University of California San Francisco, San Francisco, CA Background: Self-directed lifelong learning is recognized as an integral component of medical professionalism, yet how best to encourage its development during clinically intensive training is unknown. We developed a model for successful self-directed learning by analyzing qualitative data from a national survey of residents collected in 2008-2009. Methods: Pediatric and medicine/pediatric residents at 46 training programs completed a web-based survey. Self-reported barriers to and strategies for achieving self-directed learning goals were systematically analyzed through inductive iterative review. Results: 57% (992/1738) responded. Barriers to achieving selfdirected learning goals were categorized into: difficulty with personal reflection, environmental strain, competing demands, difficulty with goal generation, and problems with plan development and implementation. Strategies for achieving self-directed learning goals included creating goals that were important (relevant to the learner and prioritized by the learner as important to achieve), specific (with broad goals broken down into incremental steps and a specific plan for each step), measurable, accountable (with reminder and tracking systems and building in internal and external accountability), realistic (achievable goals which utilize existing opportunities and constant self-adjustment), and included a timeline for completion of the goal (and incorporation of goal into their daily routine). Conclusions: Based on the data, we propose a conceptual model for self-directed lifelong learning that involves creation of learning goals and plan development based on individual reflection and self-assessment and continual revision of goals and/or plans based on degree of goal attainment. This model could be broadly applicable across the continuum of medical education. 13. ASSESSING ‘CENTEREDNESS’ OF PEDIATRIC RESIDENTS PRIOR TO A NEW CURRICULUM Keith J. Mann, MD, Children’s Mercy Hospital, Sheryl A. Chadwick, BS, Deedra J. Miller, AAS, Children’s Mercy Hospitals and Clinics, Sarah C. Petersen, MD, University of Missouri Kansas City Pediatric Resident, Kansas City, MO Objectives: The Patient-Practitioner Orientations Scale (PPOS) measures physicians’ attitudes towards the doctor-patient relationship on a scale ranging from patient- to physician/disease-centered. We aim to document a baseline measure of centeredness in pediatric interns, and compare that baseline to third year residents, prior to implementing a patient- and family-centered curriculum. Methods: A non-randomized control group pretest-posttest design will be used to assess the curriculum. This abstract summarizes the pre-test data. The PPOS was given to both 2009 interns and graduating residents. The 18 item PPOS assesses two domains of ‘‘centeredness’’, caring and sharing. Scores ranges from 6, patient centered, to 1, physician/disease centered. Mean scores were compared by two-tailed t test; P values <0.05 are statistically significant. Results: 32/32 interns and 18/26 senior residents completed the PPOS. The mean ( SD) score for the interns was 4.6 ( 0.42). Interns scored similarly in the sharing domain, mean 4.5 ( 0.52), compared to the caring domain, mean 4.7 ( 0.4). Female interns (4.7 0.39) were slightly more patient-centered than male interns (4.4 0.42) (P ¼ 0.06). Female interns (4.64 0.49) scored significantly higher than males (4.19 0.48) in the sharing domain (P <.05). For third year residents, mean total PPOS (4.5 0.40) and mean caring domain scores (4.7 0.46) were statistically similar to interns. The difference in the sharing domain (PL-3, 4.27 0.51 vs Pl-1, 4.5 0.52) approached statistical significance (P ¼ 0.12). Conclusion: Pediatric residents in our program have a patient centered attitude that is consistent throughout training. Females are more patient and family centered than males, especially in their comfort sharing information and decisions with families. Third year residents scored lower than interns in the sharing domain. While this difference was not statistically significant, one would expect that experience would lead to more, not less, comfort in sharing information and decisions with families.
ACADEMIC PEDIATRICS 14. A QUALITY IMPROVEMENT (QI) PROJECT TO DECREASE PAGES DURING RESIDENT CONFERENCES Keith J. Mann, MD, Mary Hamm, MD, Lory Harte, PharmD, Children’s Mercy Hospital, Kansas City, MO Objectives: 1) Identify the volume and character of the pages that disrupt residents during noon conference; and 2) Decrease non-urgent pages during noon conferences by 75% within 6 months. Methods: The study is a resident driven single site quality improvement (QI) study. We created a fishbone diagram identifying causes for nonurgent pages and held focus groups to identify possible solutions. A multidisciplinary group created a nursing communication card documenting vital information including times of resident availability. We collected data through tally sheets filled out by residents answering pages during conference. Information collected included the nursing unit, nature of the call, the caller’s occupation, and call urgency. The data was coded and entered into an Excel spreadsheet. We collected 23 days of pre-intervention data. We then began to distribute the nurse communication card while continuing data collection. We plotted the data on a control chart (x-axis ¼ day #, y axis ¼ number of pages) and used Excel QI Macros for analysis. A statistically significant change, based on standard QI methodology, exists when 8 consecutive post-intervention points fall on one side of the pre-intervention mean. Results: Prior to our intervention, there were 121 pages recorded over 23 days. The mean number of pages was 5.26 with an upper control limit (UCL) of 12.16 and a lower control limit (LCL) of 0.5. 17/121 (14%) of pages were considered urgent. After the implementation of the nursing communication card, there were 29 pages over 16 consecutive days (mean ¼ 1.81, UCL ¼ 5.85, LCL ¼ 0). After a peak of 6 paging interruptions 5 days post-intervention, there were 11 consecutive days where there were less than 5 pages (the mean pre-intervention was 5.26) suggesting statistical significance. Conclusion: The vast majority of pages during noon conference are non-urgent in nature. A simple nurse communication card can significantly decrease the number of non-urgent pages during resident noon conference.
15. APPLYING LEAN INITIATIVES TO INPATIENT ROUNDS TO IMPROVE DISCHARGE DELAYS Beatriz M. Cunill-De Sautu, MD, Marcos Mestre, MD, Antonio Rodriguez, MD, Nikole Sanchez-Rubiera, RN, BSM, MBA, Miami Children’s Hospital, Miami, FL Background: The Pediatric RRC’s system-based practice requirement calls for residents to participate in quality improvement projects aimed at identifying opportunities in patient care and hospital processes. Resident feedback in our program suggests that the lack of standardization of inpatient rounds and multidisciplinary care coordination hampers efficiency in executing patient care duties, such as discharges. This leaves them less time for educational activities and self-directed learning. Methods: Lean concepts were utilized to analyze the activities of a typical day on the inpatient wards. A value stream map was developed to measure the duration of the discharge process. The medical team’s improvement intervention consisted of the 1) standardization of rounding schedules; 2) identification of potential discharges 24 hours in advance to facilitate document preparation; 3) prioritization of discharges on rounds; and 4) completion of discharge orders on rounds. A ‘try-storm’ or pilot of the interventions was conducted, and times were compared. Results: The discharge process from decision to discharge to admission of a new patient took up to 8 hours with variation amongst process steps. Discharge decision to time of discharge order written (a resident function) took up to 4 hours. 80% of discharge orders were processed after 1 pm. After the intervention implementation, the discharge process time decreased by 60% to 3.25 hours. Discharge decision to time of discharge order written decreased by 88% from 3 hours to 12 minutes. Conclusions: Resident participation in this QI project aimed at improving the discharge process yielded multiple benefits. The intervention by the medical team led to a significant reduction in discharge delays and improved patient flow. Additionally, multidisciplinary communication, care coordination, and patient satisfaction all indirectly benefited from the intervention. Efficiencies in rounding and the discharge process benefited the resident by increasing the likelihood of attending educational activities and decreasing the likelihood of duty hour violations due to inpatient service obligations.
ABSTRACTS
12. SUCCESSFUL SELF-DIRECTED LIFE-LONG LEARNING IN MEDICINE: A CONCEPTUAL MODEL DERIVED FROM QUALITATIVE ANALYSIS OF A NATIONAL SURVEY OF PEDIATRIC RESIDENTS Su-Ting T. Li, MD, MPH, Debora A. Paterniti, PhD, University of California Davis, Sacramento, CA, John Patrick T. Co, MD, MPH, Harvard Medical School, Boston, MA, Daniel C. West, MD, University of California San Francisco, San Francisco, CA Background: Self-directed lifelong learning is recognized as an integral component of medical professionalism, yet how best to encourage its development during clinically intensive training is unknown. We developed a model for successful self-directed learning by analyzing qualitative data from a national survey of residents collected in 2008-2009. Methods: Pediatric and medicine/pediatric residents at 46 training programs completed a web-based survey. Self-reported barriers to and strategies for achieving self-directed learning goals were systematically analyzed through inductive iterative review. Results: 57% (992/1738) responded. Barriers to achieving selfdirected learning goals were categorized into: difficulty with personal reflection, environmental strain, competing demands, difficulty with goal generation, and problems with plan development and implementation. Strategies for achieving self-directed learning goals included creating goals that were important (relevant to the learner and prioritized by the learner as important to achieve), specific (with broad goals broken down into incremental steps and a specific plan for each step), measurable, accountable (with reminder and tracking systems and building in internal and external accountability), realistic (achievable goals which utilize existing opportunities and constant self-adjustment), and included a timeline for completion of the goal (and incorporation of goal into their daily routine). Conclusions: Based on the data, we propose a conceptual model for self-directed lifelong learning that involves creation of learning goals and plan development based on individual reflection and self-assessment and continual revision of goals and/or plans based on degree of goal attainment. This model could be broadly applicable across the continuum of medical education. 13. ASSESSING ‘CENTEREDNESS’ OF PEDIATRIC RESIDENTS PRIOR TO A NEW CURRICULUM Keith J. Mann, MD, Children’s Mercy Hospital, Sheryl A. Chadwick, BS, Deedra J. Miller, AAS, Children’s Mercy Hospitals and Clinics, Sarah C. Petersen, MD, University of Missouri Kansas City Pediatric Resident, Kansas City, MO Objectives: The Patient-Practitioner Orientations Scale (PPOS) measures physicians’ attitudes towards the doctor-patient relationship on a scale ranging from patient- to physician/disease-centered. We aim to document a baseline measure of centeredness in pediatric interns, and compare that baseline to third year residents, prior to implementing a patient- and family-centered curriculum. Methods: A non-randomized control group pretest-posttest design will be used to assess the curriculum. This abstract summarizes the pre-test data. The PPOS was given to both 2009 interns and graduating residents. The 18 item PPOS assesses two domains of ‘‘centeredness’’, caring and sharing. Scores ranges from 6, patient centered, to 1, physician/disease centered. Mean scores were compared by two-tailed t test; P values <0.05 are statistically significant. Results: 32/32 interns and 18/26 senior residents completed the PPOS. The mean ( SD) score for the interns was 4.6 ( 0.42). Interns scored similarly in the sharing domain, mean 4.5 ( 0.52), compared to the caring domain, mean 4.7 ( 0.4). Female interns (4.7 0.39) were slightly more patient-centered than male interns (4.4 0.42) (P ¼ 0.06). Female interns (4.64 0.49) scored significantly higher than males (4.19 0.48) in the sharing domain (P <.05). For third year residents, mean total PPOS (4.5 0.40) and mean caring domain scores (4.7 0.46) were statistically similar to interns. The difference in the sharing domain (PL-3, 4.27 0.51 vs Pl-1, 4.5 0.52) approached statistical significance (P ¼ 0.12). Conclusion: Pediatric residents in our program have a patient centered attitude that is consistent throughout training. Females are more patient and family centered than males, especially in their comfort sharing information and decisions with families. Third year residents scored lower than interns in the sharing domain. While this difference was not statistically significant, one would expect that experience would lead to more, not less, comfort in sharing information and decisions with families.
ACADEMIC PEDIATRICS 14. A QUALITY IMPROVEMENT (QI) PROJECT TO DECREASE PAGES DURING RESIDENT CONFERENCES Keith J. Mann, MD, Mary Hamm, MD, Lory Harte, PharmD, Children’s Mercy Hospital, Kansas City, MO Objectives: 1) Identify the volume and character of the pages that disrupt residents during noon conference; and 2) Decrease non-urgent pages during noon conferences by 75% within 6 months. Methods: The study is a resident driven single site quality improvement (QI) study. We created a fishbone diagram identifying causes for nonurgent pages and held focus groups to identify possible solutions. A multidisciplinary group created a nursing communication card documenting vital information including times of resident availability. We collected data through tally sheets filled out by residents answering pages during conference. Information collected included the nursing unit, nature of the call, the caller’s occupation, and call urgency. The data was coded and entered into an Excel spreadsheet. We collected 23 days of pre-intervention data. We then began to distribute the nurse communication card while continuing data collection. We plotted the data on a control chart (x-axis ¼ day #, y axis ¼ number of pages) and used Excel QI Macros for analysis. A statistically significant change, based on standard QI methodology, exists when 8 consecutive post-intervention points fall on one side of the pre-intervention mean. Results: Prior to our intervention, there were 121 pages recorded over 23 days. The mean number of pages was 5.26 with an upper control limit (UCL) of 12.16 and a lower control limit (LCL) of 0.5. 17/121 (14%) of pages were considered urgent. After the implementation of the nursing communication card, there were 29 pages over 16 consecutive days (mean ¼ 1.81, UCL ¼ 5.85, LCL ¼ 0). After a peak of 6 paging interruptions 5 days post-intervention, there were 11 consecutive days where there were less than 5 pages (the mean pre-intervention was 5.26) suggesting statistical significance. Conclusion: The vast majority of pages during noon conference are non-urgent in nature. A simple nurse communication card can significantly decrease the number of non-urgent pages during resident noon conference.
15. APPLYING LEAN INITIATIVES TO INPATIENT ROUNDS TO IMPROVE DISCHARGE DELAYS Beatriz M. Cunill-De Sautu, MD, Marcos Mestre, MD, Antonio Rodriguez, MD, Nikole Sanchez-Rubiera, RN, BSM, MBA, Miami Children’s Hospital, Miami, FL Background: The Pediatric RRC’s system-based practice requirement calls for residents to participate in quality improvement projects aimed at identifying opportunities in patient care and hospital processes. Resident feedback in our program suggests that the lack of standardization of inpatient rounds and multidisciplinary care coordination hampers efficiency in executing patient care duties, such as discharges. This leaves them less time for educational activities and self-directed learning. Methods: Lean concepts were utilized to analyze the activities of a typical day on the inpatient wards. A value stream map was developed to measure the duration of the discharge process. The medical team’s improvement intervention consisted of the 1) standardization of rounding schedules; 2) identification of potential discharges 24 hours in advance to facilitate document preparation; 3) prioritization of discharges on rounds; and 4) completion of discharge orders on rounds. A ‘try-storm’ or pilot of the interventions was conducted, and times were compared. Results: The discharge process from decision to discharge to admission of a new patient took up to 8 hours with variation amongst process steps. Discharge decision to time of discharge order written (a resident function) took up to 4 hours. 80% of discharge orders were processed after 1 pm. After the intervention implementation, the discharge process time decreased by 60% to 3.25 hours. Discharge decision to time of discharge order written decreased by 88% from 3 hours to 12 minutes. Conclusions: Resident participation in this QI project aimed at improving the discharge process yielded multiple benefits. The intervention by the medical team led to a significant reduction in discharge delays and improved patient flow. Additionally, multidisciplinary communication, care coordination, and patient satisfaction all indirectly benefited from the intervention. Efficiencies in rounding and the discharge process benefited the resident by increasing the likelihood of attending educational activities and decreasing the likelihood of duty hour violations due to inpatient service obligations.