Together, Eugene Lin, MD, a second year Internal Medicine resident, and Kara Chenitz, MD, a fellow in Nephrology, knocked, then gently pushed open the door of the patient room on Silverstein 7.
Hooked up to several monitors, the patient was sitting in a chair next to her bed. She seemed happy to have the company. After introducing themselves, and explaining the reason for their visit, the physicians began asking the patient questions about her experience in the hospital with the call bells.
Throughout the Penn Medicine hospitals, small groups of residents were visiting patients and asking the same questions. “They were all taking part in an exercise to observe how care is delivered in the hospital in real life -- to collect information, to understand what it is like to be a patient, and begin to think about ways that the process could be improved,” said Jennifer Myers, MD, director of Quality and Safety Education at the Perelman School of Medicine and a recipient of a Macy Faculty Scholars grant from the Josiah Macy Jr. Foundation.
After each group collected data on how long patients feel it takes a nurse to respond to a call button and related questions, the residents shared the information with the nurses and unit clerks on the floor. Then, at the end of the day, the data were collected and provided to hospital leaders who plan to use it to make changes. “We are learning a systematic way to identify a problem and then develop a way to improve it,” explained Yevgeniy Gitelman, MD, a second year Internal Medicine resident.
This exercise is actually a component of the Health System Leadership in Quality Track, a new program aimed for doctors in training that is aimed at improving quality and safety across the Health System. It was born out of the Penn Medicine Blueprint for Quality and the new realities of health care.
“One of the first things we had to do was change the culture,” Myers said. Although slightly difficult at first, experiences like the one above get residents to think about the hospital and the quality and safety of care in a whole new way. “In order to change the culture, we had to enhance training for residents and get them more involved in quality and safety activities,” she said.
“When a resident begins training at Penn, we set the expectations about quality and safety on day one,” said Lisa Bellini, MD, vice dean of Faculty Affairs for the Perelman School of Medicine and program director for Medicine residents.
Training the teachers in quality and safety education is another component of these efforts, which starts this month. Each residency program has begun sending one or two of its faculty for skills training to learn how to teach residents key quality areas. The training will cover on some of the most basic issues that involve the hospital patient. This year they will focus on the handoff between doctors, eg, transferring a patient from the operating room to the ICU, the best way to safely relay information between doctors when they change shifts at night, and all the components of patient discharge when patients are “handed off” to their primary care provider.
Changes throughout the hospitals have already resulted from involving residents in quality improvement. The Discharge Time-Out that that was created three years ago on Founders 12 and 14 is an example. It ensures each patient has an accurate medication discharge list. According to Jodi Savitz, MD, medical director of Founders 12, before the new policy was instituted, the discharge process was not clearly defined. There were no double-checks in the system, which can lead to medication errors – one of the most dangerous complications of a hospital discharge that can result in return hospitalizations. Under the Discharge Time-Out, a core group consisting of a medicine resident, the patient’s primary nurse and a pharmacist conduct a medication reconciliation together. They compare the proposed discharge medication list with both the admission medications and the current hospital medications.
When completed, the nurse brings the document and discusses it with the patient. “Now, the nurse and pharmacist are actually is involved in the process,” said Neha Patel, MD, director of the Healthcare Leadership in Quality Track.
Another patient benefit also resulted. There are now unit-based pharmacists on the floors. During the initial four-month study to gauge the effectiveness of the Discharge Time Out, it was determined that the readmission rate for patients in the pilot group was 4.76 percent as compared with the overall rate of 14.37 percent.
To continue resident involvement in hospital quality initiatives “we created a resident-led Quality and Safety Leadership Council to work on initiatives that are closely aligned with the Penn Medicine Blueprint for Quality. This Council is open to all residents from all specialties,” Myers said. The Council comprises two resident co-chairs, 18 residents, four advanced nurse practitioners, two nurses, and faculty and quality improvement advisors. This year, over 40 residents have signed up. “Before this council was created, there was no forum to have such conversations.”
The residents find value in the collaboration and like being exposed to other areas of medicine. “We learn to look at the bigger picture,” explained Amana Akhtar, MD, a third year Radiology resident. “We are learning to be integrated with hospital quality initiatives,” added Alice Goyanes, MD, a second year Internal Medicine resident.
Residents were also involved the design of an initiative to help maintain the momentum in Radiology. All reports produced by the on-call resident must be read by the attending. This process is being measured to find how long it takes for the attending to read the report, how long it takes for the attending to get back to the resident and the quality of the report.
The Council also took up other communications issues that affect the safety and coordination of patient care. For example, as different residents are responsible for patients throughout their hospital stay, it can be confusing to know who is taking care of a patient at any given time. The Council worked with Information Services to make changes to a centralized computer where this information could be displayed and updated. This way everyone involved with that patient’s care knows which resident to contact when there is a change in the plan.
Back on Founders, the residents developed a brochure to explain to patients who everyone is. “We use terms like residents, interns and nurse managers and figure everyone knows what we mean,” Patel said. It also contains a list of questions for patients to ask. “Our message is that this is a safe place and we encourage patients to ask specific questions.”
“The ACGME [Accreditation Council for Graduate Medical Education] requirements, which specify the quality and safety of the learning environment for patient care and call for institutions to be monitored and held accountable for their program, will propel all medical schools to include these components in their curriculum,” Bellini said. “We’ve been working on this for four or five years because we recognized early that it is the right thing to do and helps us make better physicians.”
Top photo: As part of their introduction into the world of quality and safety at Penn, a group of residents from multiple specialties worked together to “save” members of a Mr. Potato Head family who were involved in a bus crash. The scenario required teamwork and taught the residents key communication strategies that are necessary for successful health-care teams.
Bottom photo: Nephrology fellow Kara Chenitz, MD, (c) and Internal Medicine resident Eugene Lin, MD, discuss the data they collected from patients about the call button response time with Anna Fontanilla, unit secretary on Silverstein 7.