Merging the Health System and Education Silos to Better Educate Future Physicians

Collaboration between maternal-fetal medicine and family planning: a survey of Northeast US academic medical centers

OBJECTIVES

To explore how complex family planning (CFP) and maternal-fetal medicine (MFM) in Northeast academic medical centers work together to provide abortion care.

METHODS

We distributed an exploratory cross-sectional online survey to CFP and MFM faculty and fellows at academic medical centers in the Northeast between July and September of 2020. The survey included demographic information, assessment of practice patterns, hospital/administration support and assessment of collaboration. Likert scale questions examined opinions about collaboration and an open-ended question solicited ideas for improvement. We performed bivariate analysis to examine the association between subspecialty and practice location regarding provision of abortion care and perceived barriers to care.

RESULTS

The response rate was 31 % and was similar by specialty. Of the 69 respondents, 83 % were MFMs, 75 % were faculty, and 54 % practiced in New York. More than 85 % reported personal participation in some portion of abortion care. The two most common perceived barriers to care were "lack or reluctance of physicians/staff" and state laws prohibiting termination. Nearly all (95 %) stated there was a good working relationship between CFP and MFM divisions; however, almost one-third agreed with or were neutral to the statements "MFM and CFP are siloed in terms of work/patient care."

CONCLUSIONS

Academic MFM and CFP providers in the Northeast collaborate well in providing abortion care, though our findings highlight areas that would benefit from improvement. Optimizing collaboration in the Northeast is important given its regional role for ensuring abortion access in the current national landscape. Improved education of all members of the patient care team on the importance of abortion access may also help provide optimal patient care where abortion services still legally exist.

Frameworks for Integrating Learning Analytics With the Electronic Health Record

The information systems designed to support clinical care have evolved separately from those that support health professions education. This has resulted in a considerable digital divide between patient care and education, one that poorly serves practitioners and organizations, even as learning becomes ever more important to both. In this perspective, we advocate for the enhancement of existing health information systems so that they intentionally facilitate learning. We describe three well-regarded frameworks for learning that can point toward how health care information systems can best evolve to support learning. The Master Adaptive Learner model suggests ways that the individual practitioner can best organize their activities to ensure continual self-improvement. The PDSA cycle similarly proposes actions for improvement but at a health care organization's workflow level. Senge's Five Disciplines of the Learning Organization, a more general framework from the business literature, serves to further inform how disparate information and knowledge flows can be managed for continual improvement. Our main thesis holds that these types of learning frameworks should inform the design and integration of information systems serving the health professions. An underutilized mediator of educational improvement is the ubiquitous electronic health record. The authors list learning analytic opportunities, including potential modifications of learning management systems and the electronic health record, that would enhance health professions education and support the shared goal of delivering high-quality evidence-based health care.

Toward High-Value, Cost-Conscious Care - Supporting Future Doctors to Adopt a Role as Stewards of a Sustainable Healthcare System

PHENOMENON

In order to tackle the persistent rise of healthcare costs, physicians as "stewards of scarce resources" could be effective change agents, extending cost containment efforts from national policy to the micro level. Current programs focus on educating future doctors to deliver "high-value, cost-conscious care" (HVCCC). Although the importance of HVCCC education is increasingly recognized, there is a lag in implementation. Whereas recent efforts generated effective interventions that promote HVCCC in a local context, gaps persist in the examination of system factors that underlie broader successful and lasting implementation in educational and healthcare practices.

APPROACH

We conducted a realist evaluation of a program focused on embedding HVCCC in postgraduate education by encouraging and supporting residents to set up "HVCCC projects" to promote HVCCC delivery. We interviewed 39 medical residents and 10 attending physicians involved in such HVCCC projects to examine HVCCC implementation in different educational and healthcare contexts. We held six reflection sessions attended by the program commissioners and educationalists to validate and enrich the findings.

FINDINGS

A realist evaluation was used to unravel the facilitators and barriers that underlie the implementation of HVCCC in a variety of healthcare practices. Whereas research activities regularly stop after the identification of facilitators and barriers, we used these insights to formulate four high-value, cost-conscious care carriers: (1) continue to promote HVCCC awareness, (2) create an institutional structure that fosters HVCCC, (3) continue the focus on projects for embedding HVCCC in practice, (4) generate evidence. The carriers support residents, attendings and others involved in educating physicians in training to develop and implement innovative HVCCC projects.

INSIGHTS

Strategies to promote physician stewardship go beyond the formal curriculum and require a transformation in the informal educational system from one that almost exclusively focuses on medical discussions to one that also considers value and cost as part of medical decision-making. The HVCCC carriers propose a set of strategies and system adaptations that could aid the transformation toward a HVCCC supporting context.

Prevalence and Characteristics of House Staff Quality and Safety Councils Within Clinical Learning Environments: Results of a National Survey

House Staff Quality and Safety Councils (HQSCs) are relatively new multispecialty groups led by residents and fellows that focus on quality and safety activities at their training site. The authors sought to estimate the prevalence of HQSCs, describe their common characteristics and determine any perceived impacts. A national survey was conducted with Designated Institutional Officers (DIO) of graduate medical education programs in 2019. For institutions with an HQSC, a second survey was sent to program leaders to obtain additional details. Responses were obtained from 204 DIOs, 47% of whom currently have an HQSC. Forty-five percent of sites provided details about HQSC membership, leadership, funding, activities/initiatives, facilitators, and barriers. The majority reported positive program outcomes. This study found that HQSCs are common and share key characteristics, yet at the same time have many unique features tailored to their clinical learning environment. Participants report positive outcomes associated with these groups.

Establishing a Multi-Institutional Quality and Patient Safety Consortium: Collaboration Across Affiliates in a Community-Based Medical School

The landscape of health care delivery and medical education is evolving. Institutions must continually reassess priorities, strategies, and partnerships to align the knowledge and skills of the health care workforce with the delivery of quality, socially accountable, collaborative health care that meets the needs of diverse populations in communities. This article describes the development, implementation, and early outcomes of the University of Missouri-Kansas City's Health Care Quality and Patient Safety Consortium. Inspired by an actual patient safety event, the consortium aimed to improve patient outcomes by establishing quality improvement and patient safety (QIPS) education and scholarship as foundational within its unique, horizontal-matrix academic health center, which comprises 6 affiliated hospitals and 4 university-based health sciences schools. The consortium established a governance structure with leaders who, collectively, represent the diverse members and stakeholders of the consortium. The members share a common agenda and mutual goals. The consortium measures success by applying published conceptual frameworks for evaluating the outcomes of educational programs on learners (Kirkpatrick) and patients (Bzowyckyj and colleagues). Consortium learner and patient outcomes span all levels of these frameworks. Undergraduate and graduate QIPS-based projects with meaningful health system or improved individual health outcomes signify a Level 4 outcome (the highest level) for learners and patients alike. Factors critical to success include a financial gift, leadership buy-in and support, a clear champion, shared goals and a united vision, a willingness to collaborate across health systems with varied strengths and priorities, and a stable communication platform. Aspirational goals of the consortium include increasing involvement across health professional schools, incorporating simulation into QIPS activities, and aligning the consortium's projects with broader community needs.

General Internists as Change Agents: Opportunities and Barriers to Leadership in Health Systems and Medical Education Transformation

Health systems are increasingly engaging in mission development around the quadruple aim of patient experience of care, population health, cost of care, and work-life balance of clinicians. This integrated approach is closely aligned with the education principles and competencies of health systems science (HSS), which includes population health, high-value care, leadership, teamwork, collaboration, and systems thinking. Influenced by health outcomes research, the systems-based practice competency, and the Clinical Learning Environment Review, many medical schools and residency programs are taking on the challenge of comprehensively incorporating these HSS competencies into the education agenda. General internal medicine physicians, inclusive of hospitalists, geriatricians, and palliative and primary care physicians, are at the frontlines of this transformation and uniquely positioned to contribute to and lead health system transformation, role model HSS competencies for trainees, and facilitate the education of a new workforce equipped with HSS skills to accelerate change in healthcare. Although GIM faculty are positioned to be early adopters and leaders in evolving systems of care and education, professional development and changes with academic health systems are required. This Perspective article explores the conceptualization and opportunities to effectively link GIM with healthcare and medical education transformation.

How to Teach Laboratory Stewardship in the Undergraduate Medical Curriculum?

OBJECTIVES

Promotion of high-quality care at a lower cost requires educational initiatives across the continuum of medical education. A needs assessment was performed to inform the design of an educational tool with the goal of teaching laboratory stewardship to medical students.

METHODS

The needs assessment consisted of semistructured interviews with core clerkship directors and residency program directors at our institution, a national survey to the Undergraduate Medical Educators Section (UMEDS) of the Association of Pathology Chairs, and a review of existing online resources that teach high-value care.

RESULTS

Two major themes emerged regarding opportunities to enhance laboratory stewardship education: appropriate ordering (knowledge of test indications, pretest/posttest probability, appropriateness criteria, recognition of unnecessary testing) and correct interpretation (understanding test specifications, factors that affect the test result, recognizing inaccurate results).

CONCLUSIONS

The online educational tool will focus on the curricular needs identified, using a multidisciplinary approach for development and implementation.

The Sooner the Better: High-Value Care Education in Medical School

Over the last decade in the United States, a national emphasis on controlling health care costs has prompted the medical community to embrace the ideal of high-value care (HVC), with value defined as health outcomes achieved per dollar spent. Despite increasing recognition of its importance as a skill for the modern physician, the practice of HVC remains a relatively new concept. Integrating HVC into medical education has been heterogeneous at best, with the majority of current HVC education thus far implemented at the postgraduate level. The authors present the unique benefits of the earlier introduction of HVC training at the medical school level, including ease of standardization across programs, a synergy in learning the value of an intervention alongside its other innate qualities, and the establishment of a foundational HVC education to allow for specialty-specific value training during residency. In this Invited Commentary, the authors offer practical recommendations for the incorporation of HVC training into medical schools' curricula, with special attention to correlating specific education strategies with the preclerkship, clerkship, and elective years of medical school.

High-Value Care Culture Among the Future Physician Workforce in Internal Medicine

PURPOSE

Training in high-spending regions correlates with higher spending patterns among practicing physicians. This study aimed to evaluate whether trainees' exposure to a high-value care culture differed based on type of health system in which they trained.

METHOD

In 2016, 517 internal medicine residents at 12 California graduate medical education programs (university, community, and safety-net medical centers) completed a cross-sectional survey assessing perceptions of high-value care culture within their respective training program. The authors used multilevel linear regression to assess the relationship between type of medical center and High-Value Care Culture Survey (HVCCS) scores. The correlation between mean institutional HVCCS and Centers for Medicare and Medicaid Services' Value-Based Purchasing (VBP) scores was calculated using Spearman rank coefficients.

RESULTS

Of 517 residents, 306 (59.2%), 83 (16.1%), and 128 (24.8%) trained in university, community, and safety-net programs, respectively. Across all sites, the mean HVCCS score was 51.2 (standard deviation [SD] 11.8) on a 0-100 scale. Residents reported lower mean HVCCS scores if they were from safety-net-based training programs (β = -4.4; 95% confidence interval: -8.2, -0.6) with lower performance in the leadership and health system messaging domain (P < .001). Mean institutional HVCCS scores among university and community sites positively correlated with institutional VBP scores (Spearman r = 0.71; P < .05).

CONCLUSIONS

Safety-net trainees reported less exposure to aspects of high-value care culture within their training environments. Tactics to improve the training environment to foster high-value care culture include training, increasing access to data, and improving open communication about value.

Aligning Delivery System and Training Missions in Academic Medical Centers to Promote High-Value Care

Academic medical centers (AMCs) are transforming to improve their care delivery and learning environments so that they build a culture that fosters high-value care. However, AMCs struggle to create learning environments where trainees are part of the reason for institutional success and their initiatives have high impact and are sustainable. The authors believe that AMCs can reach these goals if they codevelop strategic priorities and provide infrastructure to support alignment between the missions of health delivery systems and graduate medical education (GME).They outline four steps for AMCs and policy makers to create an infrastructure that supports this alignment to deliver value-based care. First, AMCs can align strategic priorities between delivery systems and educators by creating a common understanding of why initiatives require priorities within the health care system. Second, AMCs can support alignment with data from multiple sources that are reliable, valid, and actionable for trainees. Third, resident initiatives can create sustained impact by linking trainees to the institutional staff and infrastructure supporting value improvement efforts. Fourth, incentive payment programs through medical education could augment current system incentives to propel further alignment between education and delivery systems. The authors support their recommendations with concrete examples from emerging models created by GME and health delivery system leaders at AMCs across the country.

Exemplary Learning Environments for the Health Professions: A Vision

In this article, the authors propose a vision for exemplary learning environments in which everyone involved in health professions education and health care collaborates toward optimal health for individuals, populations, and communities. Learning environments in the health professions can be conceptualized as complex adaptive systems, defined as a collection of individual agents whose actions are interconnected and follow a set of shared "simple rules." Using principles from complex adaptive systems as a guiding framework for the proposed vision, the authors postulate that exemplary learning environments will follow four such simple rules: Health care and health professions education share a goal of improving health for individuals, populations, and communities; in exemplary learning environments, learning is work and work is learning; exemplary learning environments recognize that collaboration with integration of diverse perspectives is essential for success; and the organizations and agents in the learning environments learn about themselves and the greater system they are part of in order to achieve continuous improvement and innovation. For each of the simple rules, the authors describe the details of the vision and how the current state diverges from this vision. They provide actionable ideas about how to reach the vision using specific examples from the literature. In addition, they identify potential targets for assessment to monitor the success of learning environments, including outcome measures at the individual, team, institutional, and societal levels. Such measurements can ensure optimal alignment between health professions education and health care and inform ongoing improvement of learning environments.

Defining and Adopting Clinical Performance Measures in Graduate Medical Education: Where Are We Now and Where Are We Going?

Assessment and evaluation of trainees' clinical performance measures is needed to ensure safe, high-quality patient care. These measures also aid in the development of reflective, high-performing clinicians and hold graduate medical education (GME) accountable to the public. Although clinical performance measures hold great potential, challenges of defining, extracting, and measuring clinical performance in this way hinder their use for educational and quality improvement purposes. This article provides a way forward by identifying and articulating how clinical performance measures can be used to enhance GME by linking educational objectives with relevant clinical outcomes. The authors explore four key challenges: defining as well as measuring clinical performance measures, using electronic health record and clinical registry data to capture clinical performance, and bridging silos of medical education and health care quality improvement. The authors also propose solutions to showcase the value of clinical performance measures and conclude with a research and implementation agenda. Developing a common taxonomy of uniform specialty-specific clinical performance measures, linking these measures to large-scale GME databases, and applying both quantitative and qualitative methods to create a rich understanding of how GME affects quality of care and patient outcomes is important, the authors argue. The focus of this article is primarily GME, yet similar challenges and solutions will be applicable to other areas of medical and health professions education as well.

New Educator Roles for Health Systems Science: Implications of New Physician Competencies for U.S. Medical School Faculty

To address gaps in U.S. health care outcomes, medical education is evolving to incorporate new competencies, as well as to align with care delivery transformation and prepare systems-ready providers. These new health systems science (HSS) competencies-including value-based care, quality improvement, social determinants of health, population health, informatics, and systems thinking-require formal education and role modeling in both classroom and clinical settings. This is challenging because few faculty had formal training in how to practice or teach these concepts. Thus, these new competencies require both expanding current educators' skills and a new cohort of educators, especially interprofessional clinicians. Additionally, because interprofessional teams are the foundation of many clinical learning environments, medical schools are developing innovative experiential activities that include interprofessional clinicians as teachers. This combination of a relative "expertise vacuum" within the current cohort of medical educators and expanding need for workplace learning opportunities requires a reimagining of medical school teachers. Based on experiences implementing HSS curricula at two U.S. medical schools (Penn State College of Medicine and University of California, San Francisco, School of Medicine, starting in 2013), this Perspective explores the need for new educator competencies and the implications for medical education, including the need to identify and integrate "new" educators into the education mission, develop faculty educators' knowledge and skills in HSS, and acknowledge and reward new and emerging educators. These efforts have the potential to better align the clinical and education missions of academic health centers and cultivate the next generation of physician leaders.

Concerns and Responses for Integrating Health Systems Science Into Medical Education

With the aim of improving the health of individuals and populations, medical schools are transforming curricula to ensure physician competence encompasses health systems science (HSS), which includes population health, health policy, high-value care, interprofessional teamwork, leadership, quality improvement, and patient safety. Large-scale, meaningful integration remains limited, however, and a major challenge in HSS curricular transformation efforts relates to the receptivity and engagement of students, educators, clinicians, scientists, and health system leaders. The authors identify several widely perceived challenges to integrating HSS into medical school curricula, respond to each concern, and provide potential strategies to address these concerns, based on their experiences designing and integrating HSS curricula. They identify two broad categories of concerns: the (1) relevance and importance of learning HSS-including the perception that there is inadequate urgency for change; HSS education is too complex and should occur in later years; early students would not be able to contribute, and the roles already exist; and the science is too nascent-and (2) logistics and practicality of teaching HSS-including limited curricular time, scarcity of faculty educators with expertise, lack of support from accreditation agencies and licensing boards, and unpreparedness of evolving health care systems to partner with schools with HSS curricula. The authors recommend the initiation and continuation of discussions between educators, clinicians, basic science faculty, health system leaders, and accrediting and regulatory bodies about the goals and priorities of medical education, as well as about the need to collaborate on new methods of education to reach these goals.

Measuring Value in Internal Medicine Residency Training Hospitals Using Publicly Reported Measures

Graduate medical education (GME) lacks measures of resident preparation for high-quality, cost-conscious practice. The authors used publicly reported teaching hospital value measures to compare internal medicine residency programs on high-value care training and to validate these measures against program director perceptions of value. Program-level value training scores were constructed using Centers for Medicare & Medicaid Services Value-Based Purchasing (VBP) Program hospital quality and cost-efficiency data. Correlations with Association of Program Directors in Internal Medicine Annual Survey high-value care training measures were examined using logistic regression. For every point increase in program-level VBP score, residency directors were more likely to agree that GME programs have a responsibility to contain health care costs (adjusted odds ratio [aOR] 1.18, P = .04), their faculty model high-value care (aOR 1.07, P = .03), and residents are prepared to make high-value medical decisions (aOR 1.07, P = .09). Publicly reported clinical data offer valid measures of GME value training.

US Internal Medicine Program Director Perceptions of Alignment of Graduate Medical Education and Institutional Resources for Engaging Residents in Quality and Safety

Alignment between institutions and graduate medical education (GME) regarding quality and safety initiatives (QI) has not been measured. The objective was to determine US internal medicine residency program directors’ (IM PDs) perceived resourcing for QI and alignment between GME and their institutions. A national survey of IM PDs was conducted in the Fall of 2013. Multivariable linear regression was used to test association between a novel Integration Score (IS) measuring alignment between GME and the institution via PD perceptions. The response rate was 72.6% (265/365). According to PDs, residents were highly engaged in QI (82%), but adequate funding (14%) and support personnel (37% to 61%) were lower. Higher IS correlated to reports of funding for QI (76.3% vs 54.5%, P = .012), QI personnel (67.3% vs 41.1%, P < .001), research experts (70.5% vs 50.0%, P < .001), and computer experts (69.0% vs 45.8%, P < .001) for QI assistance. Apparent mismatch between GME and institutional resources exists, and the IS may be useful in measuring GME–institutional leadership alignment in QI.

Pediatric Training Faculty and Resident Perceptions on Teaching High-Value, Cost-Conscious Care: A Multi-Institutional Study

BACKGROUND AND OBJECTIVES

High-value, cost-conscious care (HVCCC) is care that promotes optimal patient outcomes while reducing unnecessary costs. Teaching to promote HVCCC is essential, yet little research has assessed the dual perspectives of residents and faculty on this topic. Our aim was to investigate pediatric resident and faculty perspectives of HVCCC training and role modeling to more effectively promote curriculum and faculty development on this subject.

METHODS

Pediatric residents and teaching faculty in 2 academic medical centers were surveyed during the 2015-2016 academic year. Questions addressed comfort with HVCCC, current teaching practices, barriers to teaching HVCC, and desired curriculum. Descriptive statistics were used to summarize data, and Fisher's exact or χ² tests were used to assess for associations between responses. Institutional review board approval was obtained at both participating institutions.

RESULTS

We received responses from 51% of faculty (128 of 249) and 60% of residents (73 of 123). Most faculty and residents agreed that HVCCC training is important, but only 26% of residents (18 of 69) felt comfortable practicing HVCCC. Faculty and residents identified lack of training or knowledge (50%, 61 of 121 and 53%, 37 of 70, respectively) and lack of hospital support (73%, 88 of 121 and 69%, 47 of 68, respectively) as the largest barriers. Of residents, >85% (60 of 69) reported a lack of attending physician role modeling. Most faculty (83%, 102 of 123) desired faculty development.

CONCLUSIONS

Residents and faculty agree that HVCCC is important and that training institutions have a responsibility to address it. However, most residents were not comfortable with HVCCC. Faculty development in HVCCC as well as hospital support for access to pricing data will be key for programs to develop effective resident training in this area.

Disseminating Innovations in Teaching Value-Based Care Through an Online Learning Network

BACKGROUND

A national imperative to provide value-based care requires new strategies to teach clinicians about high-value care.

OBJECTIVE

We developed a virtual online learning network aimed at disseminating emerging strategies in teaching value-based care.

METHODS

The online Teaching Value in Health Care Learning Network includes monthly webinars that feature selected innovators, online discussion forums, and a repository for sharing tools. The learning network comprises clinician-educators and health system leaders across North America. We conducted a cross-sectional online survey of all webinar presenters and the active members of the network, and we assessed program feasibility.

RESULTS

Six months after the program launched, there were 277 learning community members in 22 US states. Of the 74 active members, 50 (68%) completed the evaluation. Active members represented independently practicing physicians and trainees in 7 specialties, nurses, educators, and health system leaders. Nearly all speakers reported that the learning network provided them with a unique opportunity to connect with a different audience and achieve greater recognition for their work. Of the members who were active in the learning network, most reported that strategies gleaned from the network were helpful, and some adopted or adapted these innovations at their home institutions. One year after the program launched, the learning network had grown to 364 total members.

CONCLUSIONS

The learning network helped participants share and implement innovations to promote high-value care. The model can help disseminate innovations in emerging areas of health care transformation, and is sustainable without ongoing support after a period of start-up funding.

Swimming Upstream: Creating a Culture of High-Value Care

As health system leaders strategize the best ways to encourage the transition toward value-based health care, the underlying culture-defined as a system of shared assumptions, values, beliefs, and norms existing within an environment-continues to shape clinician practice patterns. The current prevailing medical culture contributes to overtesting, overtreatment, and health care waste. Choosing Wisely lists, appropriateness criteria, and guidelines codify best practices, but academic medicine as a whole must recognize that faculty and trainees are all largely still operating within the same cultural climate. Addressing this culture, on both local and national levels, is imperative for engaging clinicians in reforms and creating sustained changes that will deliver on the promise of better health care value. This Perspective outlines four steps for health system leaders to understand, cultivate, and maintain cultural changes toward value-based care: (1) Build the will for change through engaging frontline providers and communicating patient-centered motivations for health care value; (2) create necessary infrastructure to support value improvement efforts; (3) expose physicians to value-based payment structures; and (4) demonstrate leadership commitment and visibility to shared goals. The authors support their recommendations with concrete examples from emerging models and leaders across the country.

Barriers and facilitators of Canadian quality and safety teams: a mixed-methods study exploring the views of health care leaders

BACKGROUND

Health care organizations are utilizing quality and safety (QS) teams as a mechanism to optimize care. However, there is a lack of evidence-informed best practices for creating and sustaining successful QS teams. This study aimed to understand what health care leaders viewed as barriers and facilitators to establishing/implementing and measuring the impact of Canadian acute care QS teams.

METHODS

Organizational senior leaders (SLs) and QS team leaders (TLs) participated. A mixed-methods sequential explanatory design included surveys (n=249) and interviews (n=89). Chi-squared and Fisher's exact tests were used to compare categorical variables for region, organization size, and leader position. Interviews were digitally recorded and transcribed for constant comparison analysis.

RESULTS

Five qualitative themes overlapped with quantitative data: (1) resources, time, and capacity; (2) data availability and information technology; (3) leadership; (4) organizational plan and culture; and (5) team composition and processes. Leaders from larger organizations more often reported that clear objectives and physician champions facilitated QS teams (p<0.01). Fewer Eastern respondents viewed board/senior leadership as a facilitator (p<0.001), and fewer Ontario respondents viewed geography as a barrier to measurement (p<0.001). TLs and SLs differed on several factors, including time to meet with the team, data availability, leadership, and culture.

CONCLUSION

QS teams need strong, committed leaders who align initiatives to strategic directions of the organization, foster a quality culture, and provide tools teams require for their work. There are excellent opportunities to create synergy across the country to address each organization's quality agenda.

Residents' self-report on why they order perceived unnecessary inpatient laboratory tests

Resident physicians routinely order unnecessary inpatient laboratory tests. As hospitalists face growing pressures to reduce low-value services, understanding the factors that drive residents' laboratory ordering can help steer resident training in high-value care. We conducted a qualitative analysis of internal medicine (IM) and general surgery (GS) residents at a large academic medical center to describe the frequency of perceived unnecessary ordering of inpatient laboratory tests, factors contributing to that behavior, and potential interventions to change it. The sample comprised 57.0% of IM and 54.4% of GS residents. Among respondents, perceived unnecessary inpatient laboratory test ordering was self-reported by 88.2% of IM and 67.7% of GS residents, occurring on a daily basis by 43.5% and 32.3% of responding IM and GS residents, respectively. Across both specialties, residents attributed their behaviors to the health system culture, lack of transparency of the costs associated with health care services, and lack of faculty role models that celebrate restraint. Journal of Hospital Medicine 2015;11:869-872. © 2015 Society of Hospital Medicine.

Development of a high-value care culture survey: a modified Delphi process and psychometric evaluation

BACKGROUND

Organisational culture affects physician behaviours. Patient safety culture surveys have previously been used to drive care improvements, but no comparable survey of high-value care culture currently exists. We aimed to develop a High-Value Care Culture Survey (HVCCS) for use by healthcare leaders and training programmes to target future improvements in value-based care.

METHODS

We conducted a two-phase national modified Delphi process among 28 physicians and nurse experts with diverse backgrounds. We then administered a cross-sectional survey at two large academic medical centres in 2015 among 162 internal medicine residents and 91 hospitalists for psychometric evaluation.

RESULTS

Twenty-six (93%) experts completed the first phase and 22 (85%) experts completed the second phase of the modified Delphi process. Thirty-eight items achieved ≥70% consensus and were included in the survey. One hundred and forty-one residents (83%) and 73 (73%) hospitalists completed the survey. From exploratory factor analyses, four factors emerged with strong reliability: (1) leadership and health system messaging (α=0.94); (2) data transparency and access (α=0.80); (3) comfort with cost conversations (α=0.70); and (4) blame-free environment (α=0.70). In confirmatory factor analysis, this four-factor model fit the data well (Bentler-Bonett Normed Fit Index 0.976 and root mean square residual 0.056). The leadership and health system messaging (r=0.56, p<0.001), data transparency and access (r=0.15, p<0.001) and blame-free environment (r=0.37, p<0.001) domains differed significantly between institutions and positively correlated with Value-Based Purchasing Scores.

CONCLUSIONS

Our results provide support for the reliability and validity of the HVCCS to assess high-value care culture among front-line clinicians. HVCCS may be used by healthcare groups to identify target areas for improvements and to monitor the effects of high-value care initiatives.