NSQIP-Based Quality Improvement Curriculum for Surgical Residents

Tracking Residents' Surgical Outcomes Using Data from the Quality In-Training Initiative

OBJECTIVES

Monitoring resident trainees' patient outcomes is essential to improving surgical performance; however, resident-specific follow-up is rarely provided in the current surgical training environment. Whether there is a correlation between individual resident's surgical performance and patients' clinical outcomes remains undefined. In this study, we aimed to use risk-adjusted patient outcomes as an educational tool to track individual surgical trainee performance.

STUDY DESIGN

American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) appendectomy and partial colectomy operations (2013-2021) were examined. Residents performing ≥25 operations were included. The primary outcome was ACS NSQIP-defined morbidity adjusted using estimated probability of morbidity. Observed-to-expected ratios (O/E) of morbidity measured overall performance and risk-adjusted cumulative sum (RA-CUSUM) methodology represented surgical resident's performance over time.

SETTING

Academic quaternary care institution.

PARTICIPANTS

Highest-ranking surgical resident participating in an operation and included in Quality In-Training Initiative.

RESULTS

A total of 449 operations were examined. 12 residents performed 343 appendectomy operations. 7 residents (29.3 ± 5.1 operations each) did not have any postoperative morbidity and demonstrated better-than-expected patient outcomes. Three residents did not have morbidity after their seventh/eleventh/fifteenth appendectomies. Two residents (case volume 29, 33) had an O/E ratio > 3. Partial colectomy (n = 106) performed by 4 residents had 2 residents (case volume 30, 26) with better-than-expected outcomes and 2 with worse-than-expected (case volume 25, 25).

CONCLUSION

Longitudinal monitoring of postoperative patient outcomes provides an opportunity for trainee self-reflection and system examination. RA-CUSUM methodology offers sequential monitoring allowing for early evaluation and intervention when RA-CUSUM results for a trainee demonstrate higher-than-expected morbidity.

Education Research: Sustained Implementation of Quality Improvement Practices Is Observed in Early Career Physicians Following a Neurology Resident QI Curriculum

Background and Objectives

The Accreditation Council for Graduate Medical Education and American Board of Psychiatry and Neurology expect engagement in quality improvement (QI) activities for all residents and practicing neurologists. Our neurology residency program instituted an experiential Neurology Residency QI Curriculum in 2015 for all residents. In this study, we aimed to characterize the role of QI engagement in the early-career paths of program graduates.

Methods

We distributed an online survey evaluating QI training, scholarship, and leadership (before, during, and after residency training) to all individuals who graduated from our residency program (graduation years 2017-2021). Primary outcomes were QI project leadership or mentorship and QI scholarship (projects, posters, and publications) after residency. Predictors of these outcomes were also evaluated using Fisher exact test.

Results

Twenty-nine of 50 graduates (58%) completed the survey. Median time from residency graduation was 3 years. Of the respondents, 14% actively participated in a QI project before residency, 83% during residency, and 48% after graduating. In addition, 41% had led or mentored a QI project and 34% had performed QI scholarship since residency. Fourteen percent of participants held formal roles in QI or patient safety, while 24% received formal full-time equivalents for QI work. Significant predictors (p < 0.05) of QI leadership included older age, time since graduation, rank, and participation in Clinical Effectiveness Leadership Training (CELT-an institutional QI faculty development course). Significant predictors (p < 0.05) of QI scholarship included older age, time since graduation, participation in CELT, and participation in QI scholarship during residency. QI training, participation, and/or project leadership before residency did not predict either QI leadership or scholarship after residency.

Discussion

Many neurology residency graduates continued to lead QI projects and produce QI scholarship in the early years after graduation. However, receiving protected time for leadership and academic work in this area is uncommon. Our findings suggest that more infrastructure, including training, career development, and mentorship, can foster neurologists interested in leading in quality and patient safety. In academic models, promotion pathways that support academic advancement for faculty leading in QI are needed.

Supporting a culture of patient safety: Resident-led patient safety event reviews in a pathology residency training program

Patient safety is a critical component of quality patient care at any healthcare institution. In order to support a culture of patient safety, and in the context of a hospital-wide patient safety initiative at our institution, we have created and implemented a new patient safety curriculum within our training program. The curriculum is embedded in an introductory course for first-year residents, in which residents gain an understanding of the multifaceted role of the pathologist in patient care. The patient safety curriculum is a resident-centered event review process and includes 1) identification and reporting of a patient safety event, 2) event investigation and review, and 3) presentation of findings to the residency program including core faculty and safety champions for the consideration of implementation of the identified systems solution. Here we discuss the development of our patient safety curriculum, which was trialed over a series of seven event reviews conducted between January 2021 and June 2022. Resident involvement in patient safety event reporting and patient safety event review outcomes were measured. All event reviews conducted thus far have resulted in the implementation of the solutions discussed during event review presentations based on cause analysis and identification of strong action items. Ultimately this pilot will serve as the basis by which we implement a sustainable curriculum in our pathology residency training program centered on supporting a culture of patient safety, and in line with ACGME requirements.

30-day postoperative sepsis risk factors following laminectomy for intradural extramedullary tumors

BACKGROUND

Posterior laminectomy (LA) for resection of intradural extramedullary tumors (IDEMTs) is associated with postoperative complications, including sepsis. Sepsis is an uncommon but serious complication that can lead to increased morbidity and mortality, prolonged hospital stays, and greater costs. Given the susceptibility of a solid tumor patients to sepsis-related complications, it is important to recognize IDEMT patients as a unique population when assessing the risk factors for sepsis after laminectomy.

METHODS

The study design was a retrospective cohort study. Adult patients undergoing LA for IDEMTs from 2012 to 2018 were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Baseline patient characteristics/comorbidities, operative and hospital variables, and 30-day postoperative complications were collected.

RESULTS

Of 2,027 total patients undergoing LA for IDEMTs, 38 (2%) had postoperative sepsis. On bivariate analysis sepsis was associated with superficial surgical site infection [odds ratio (OR) 11.62, P<0.001], deep surgical site infection (OR 10.67, P<0.001), deep vein thrombosis (OR 10.75, P<0.001), pulmonary embolism (OR 15.27, P<0.001), transfusion (OR 6.18, P<0.001), length of stay greater than five days (OR 5.41, P<0.001), and return to the operating room within thirty days (OR 8.72, P<0.001). Subsequent multivariate analysis identified the following independent risk factors for sepsis and septic shock: operative time ≥50th percentile (OR 2.11, P=0.032), higher anesthesia class (OR 1.76, P=0.046), dependent functional status (OR 2.23, P=0.001), diabetes (OR 2.31, P=0.037), and chronic obstructive pulmonary disease (OR 3.56, P=0.037).

CONCLUSIONS

These findings can help spine surgeons identify high-risk patients and proactively deploy measures to avoid this potentially devastating complication in individuals who may be more vulnerable than the general elective spine population.

Show Me the Money, I'll Show You My Complications: Impacts of Incentivized Incident Self-Reporting Among Surgeons

INTRODUCTION

Trial and error have the propensity to generate knowledge. Near misses and adverse event reporting can improve patient care. Professional ridicule or litigation risks after an incident may lead to decreased reporting by physicians; however, the lack of incident reporting can negatively affect patient safety and halt scientific advancements. This study compares reporting patterns after distribution of financial incentives to surgeons for self-reporting quality incidents.

METHODS

Retrospective review of an internal incident reporting system, RL6, from September 2018 to September 2019 was performed. Incident reporting patterns after incentive distributions across professional classifications and surgical specialties were evaluated. Engagement surveys on incident reporting were completed by physicians. The primary outcomes were changes in reporting patterns and perceptions after distribution of incentives.

RESULTS

Two hundred and eighteen surgical patients were identified in the incidents reported. Financial incentives significantly increased incidents reported (35 to 183) by physicians (37.1% to 67.8%; P < 0.001) and physician assistants (2.9% to 18.6%; P < 0.001). Acute care surgery displayed the largest increase in incidents reported among surgical specialties (5.7% to 20.2%; P = 0.040). Surgeons exhibited an increase in reporting (60.0% to 94.5%; P < 0.001) compared with witnesses after incentivization (2.9% to 1.6%).

CONCLUSIONS

Financial incentives were associated with increased incident reporting. After the establishment of incentives, physicians were more likely to report their incidents, which may dispel professional embarrassment and display incident ownership. Institutions must encourage reporting while supporting providers. Future quality-improvement studies targeting reporting should incorporate incentives aimed to engage and empower health-care providers.

Implementation and Evaluation of Quality Improvement Training in Surgery: A Systematic Review

OBJECTIVE

The aim of this study was to review and appraise how quality improvement (QI) skills are taught to surgeons and surgical residents.

BACKGROUND

There is a global drive to deliver capacity in undertaking QI within surgical services. However, there are currently no specifications regarding optimal QI content or delivery.

METHODS

We reviewed QI educational intervention studies targeting surgeons or surgical trainees/residents published until 2017. Primary outcomes included teaching methods and training materials. Secondary outcomes were implementation frameworks and strategies used to deliver QI training successfully.

RESULTS

There were 20,590 hits across 10 databases, of which 11,563 were screened following de-duplication. Seventeen studies were included in the final synthesis. Variable QI techniques (eg, combined QI models, process mapping, and "lean" principles) and assessment methods were found. Delivery was more consistent, typically combining didactic teaching blended with QI project delivery. Implementation of QI training was poorly reported and appears supported by collaborative approaches (including building learning collaboratives, and coalitions). Study designs were typically pre-/post-training without controls. Studies generally lacked clarity on the underpinning framework (59%), setting description (59%), content (47%), and conclusions (47%), whereas 88% scored low on psychometrics reporting.

CONCLUSIONS

The evidence suggests that surgical QI training can focus on any well-established QI technique, provided it is done through a combination of didactic teaching and practical application. True effectiveness and extent of impact of QI training remain unclear, due to methodological weaknesses and inconsistent reporting. Conduct of larger-scale educational QI studies across multiple institutions can advance the field.

Problem-Based Learning Discussion to Introduce Quality Improvement to Residents in the Perioperative Setting

INTRODUCTION

Quality improvement (QI) is a growing and critical part of perioperative medical practice. However, there are few examples of educational tools to introduce new learners from anesthesiology to QI. This may contribute to a lack of enthusiasm to learn about and apply these concepts.

METHODS

This problem-based learning discussion (PBLD) was designed to teach anesthesiology residents about QI in a way allowing for the application of core concepts in a group setting. We created this PBLD using available literature on QI in the perioperative setting. Basic concepts and terminology necessary for new learners to communicate about QI were specifically addressed. Feedback from staff anesthesiologists and resident participants in the PBLD was used to tailor it to the needs of the target learners and to reach the educational objectives.

RESULTS

We delivered this PBLD in two separate learning sessions both to board-certified anesthesiologists (N = 10) and to resident anesthesiologists (N = 19) at our institution. The exercise was reviewed anonymously, and qualitative feedback was used to improve updated versions. Respondents felt that the PBLD would be improved by avoiding jargon-based humor, considering the systemic implications of QI, and limiting the overall length of the learning tool. The PBLD has been adopted as a starting point for discussions about QI in our training program.

DISCUSSION

We feel this PBLD can introduce new learners to the learning objectives. This tool has provided an alternative to lectures or computer-based modules for teaching QI.

A longitudinal course pilot to improve surgical resident acquisition of quality improvement skills

Problem

Despite mounting evidence that incorporation of QI curricula into surgical trainee education improves morbidity and outcomes, surgery training programs lack standardized QI curricula and tools to measure QI knowledge. In the current study, we developed, implemented, and evaluated a quality improvement curriculum for surgical residents.

Intervention

Surgical trainees participated in a longitudinal, year-long (2019–2020) curriculum based on the Institute for Healthcare Improvement’s online program. Online curriculum was supplemented with in person didactics and small group projects. Acquisition of skills was assessed pre- and post- course via self-report on a Likert scale as well as the Quality Improvement Knowledge Application Tool (QIKAT). Self-efficacy scores were assessed using the General Self-Efficacy Scale. 9 out of 18 total course participants completed the post course survey. This first course cohort was analyzed as a pilot for future work.

Context

The project was developed and deployed among surgical residents during their research/lab year. Teams of surgical residents were partnered with a faculty project mentor, as well as non-physician teammates for project work.

Impact

Participation in the QI course significantly increased skills related to studying the process (p = 0.0463), making changes in a system (p = 0.0167), identifying whether a change leads to an improvement (p = 0.0039), using small cycles of change (p = 0.0000), identifying best practices and comparing them to local practices (p = 0.0020), using PDSA model as a systematic framework for trial and learning (p = 0.0004), identifying how data is linked to specific processes (p = 0.0488), and building the next improvement cycle upon success or failure (p = 0.0316). There was also a significant improvement in aim (p = 0.037) and change (p = 0.029) responses to one QIKAT vignette.

Lessons learned

We describe the effectiveness of a pilot longitudinal, multi component QI course based on the IHI online curriculum in improving surgical trainee knowledge and use of key QI skills.

Physical Medicine and Rehabilitation Residency Quality Improvement and Research Curriculum: Design and Implementation

ABSTRACT

Physical medicine and rehabilitation residency programs do not demonstrate a uniform level of training and mentorship for resident scholarly activities related in part to variable utilization of standardized curricula. The aim of this study was to design, develop, implement, and evaluate a structured Quality Improvement and Research Curriculum for a physical medicine and rehabilitation residency program in academic year 2015 using standardized methodology. A combination of five-phase project-lifecycle and six-step medical-curriculum development methodologies was used to integrate existing resources into five institutional domains: (1) Patient Safety and Quality Improvement Program; (2) Research Mentorship Program; (3) Rehab in Review; (4) Publication and Presentation Resources, and (5) Research and QI Lecture Series. Dedicated resident-faculty teams were created for individual domains and for the overall curriculum. Written materials developed included scope documents, reporting forms, and tracking tables. A dedicated webpage on the department website served as an accessible resource. A bimonthly Updates newsletter highlighted ongoing resident achievements. Program and resident outcome metrics were evaluated at the mid and end of academic year 2015. Excellent resident and good faculty participation in the curriculum was observed. Resident publication and presentation productivity improved. Time was the biggest barrier to success. Key factors for success included phased implementation, dedicated teams, scope clarity, accessible resources, personnel support, resident champions, and faculty mentorship.

Bundle interventions including nontechnical skills for surgeons can reduce operative time and improve patient safety

OBJECTIVE

This study aimed to determine if introducing nontechnical skills to surgical trainees during surgical education can reduce the operation time and contribute to patient safety.

DESIGN

Quality improvement initiatives using the KAIZEN as a problem-solving method.

SETTING

Department of surgery in a referral and educational hospital.

PARTICIPANTS

Surgical team and quality management team.

INTERVENTION

The KAIZEN was used as a problem-solving method between 2015 and 2018 to reduce the operation time. First, baseline measurement was performed to understand the current situations in our department. To achieve continuous improvement, periodical feedback of the current status was obtained from all staff. Bundles, including nontechnical skills, were established. Briefing and debriefing were performed by the surgical team.

MAIN OUTCOME MEASURES

Excessively long operation rates with a standard procedure.

RESULTS

We included 1573 operations in this initiative. Excessively long operation rates were reduced in all types of surgeries, from 27.1% to 15.2% for herniorrhaphy (P = 0.005), 58.3-40.0% for gastrectomy (P = 0.03), 50.0-4.1% for total gastrectomy (P = 0.12), 65.6-45.0% for colectomy (P = 0.004), 67.8-43.2% for high anterior resection (P = 0.02) and 69.6-47.9% for low anterior resection (P = 0.03). The adherence to briefing and debriefing were improved, and majority of the surgeons favored the bundle elements.

CONCLUSIONS

The KAIZEN initiative was effective in clinical healthcare settings. In the event of scaling-up this initiative, the educational program for physicians should include project management strategies and leadership skills.

A realist synthesis of quality improvement curricula in undergraduate and postgraduate medical education: what works, for whom, and in what contexts?

BACKGROUND

With the integration of quality improvement (QI) into competency-based models of physician training, there is an increasing requirement for medical students and residents to demonstrate competence in QI. There may be factors that commonly facilitate or inhibit the desired outcomes of QI curricula in undergraduate and postgraduate medical education. The purpose of this review was to synthesise attributes of QI curricula in undergraduate and postgraduate medical education associated with curricular outcomes.

METHODS

A realist synthesis of peer-reviewed and grey literature was conducted to identify the common contexts, mechanisms, and outcomes of QI curricula in undergraduate and postgraduate medical education in order to develop a programme theory to articulate what works, for whom, and in what contexts.

RESULTS

18854 records underwent title and abstract screening, full texts of 609 records were appraised for eligibility, data were extracted from 358 studies, and 218 studies were included in the development and refinement of the final programme theory. Contexts included curricular strategies, levels of training, clinical settings, and organisational culture. Mechanisms were identified within the overall QI curricula itself (eg, clear expectations and deliverables, and protected time), in the didactic components (ie, content delivery strategies), and within the experiential components (eg, topic selection strategies, working with others, and mentorship). Mechanisms were often associated with certain contexts to promote educational and clinical outcomes.

CONCLUSION

This research describes the various pedagogical strategies for teaching QI to medical learners and highlights the contexts and mechanisms that could potentially account for differences in educational and clinical outcomes of QI curricula. Educators may benefit from considering these contexts and mechanisms in the design and implementation of QI curricula to optimise the outcomes of training in this competency area.

Implementation and Evaluation of a Novel High-Value Care Curriculum in a Single Academic Surgery Department

BACKGROUND

High value care (HVC), maximizing quality while minimizing cost, has become a major focus of surgical practice. Effective education in healthcare value concepts is critical during residency to ensure graduates are able to deliver high value surgical care and participate in interprofessional teams to improve the system.

STUDY DESIGN

An HVC curriculum was implemented at a single academic medical center. Sixty-six residents from general surgery, plastic surgery, otolaryngology, and urology completed the curriculum over 3 academic years (2016 to 2019). The 1-year curriculum taught residents the concepts of HVC before participating in a value improvement project the following year. Residents' knowledge of value was assessed pre- and post-participation using a validated assessment tool, the Quality Improvement Knowledge Application Tool Revised (QIKAT-R), and a curriculum-specific assessment tool. The overall success of the program was evaluated by assessing residents' skills in completing value improvement projects using a novel scoring rubric.

RESULTS

After completing the program, residents expressed improved confidence in their ability to complete a value improvement project. Residents also demonstrated improved knowledge on the curriculum-specific assessment (4.7/13 to 10.9/13) and the scenario assessment using the QIKAT-R tool (8.5/27 to 16.4/27). As the program underwent iterative improvements each year, the quality of the residents' projects also improved, as assessed by the novel scoring rubric.

CONCLUSIONS

Multimodal assessment demonstrated improvement in residents' objective knowledge of HVC principles, residents' ability to design and lead clinical value improvement projects, and residents' confidence they could use HVC principles in their current and future practice.

Resident-Championed Quality Improvement Provides Value: Confronting Prolonged Mechanical Ventilation

BACKGROUND

The Quality In-Training Initiative (QITI) provides hands-on quality improvement education for residents. As our institution has ranked in the bottom quartile for prolonged mechanical ventilation (PMV) according to the National Surgical Quality Improvement Program (NSQIP), we sought to illustrate how our resident-led QITI could be used to determine perioperative contributors to PMV.

MATERIALS AND METHODS

The Model for Improvement framework (developed by Associates in Process Improvement) was used to target postoperative ventilator management. However, baseline findings from our 2016 NSQIP data suggested that preoperative patient factors were more likely contributing to PMV. Subsequently, a retrospective one-to-one case-control study was developed, comparing preoperative NSQIP risk calculator profiles for PMV patients to case-matched patients for age, sex, procedure, and emergent case status. Chart review determined ventilator time, 30-d outcomes, and all-cause mortality.

RESULTS

Forty-five patients with PMV (69% elective) had a median ventilator time of 134 h (interquartile range 87-254). The NSQIP calculator demonstrated increased preoperative risk percentages in PMV patients when compared to case-matched patients for any complication (includes PMV), predicted length of stay, and death (all P < 0.05). Thirty-day outcomes were worse for the PMV group in categories for sepsis, pneumonia, unplanned reoperation, 30-d mortality, rehab facility discharge, and length of stay (all P < 0.05). All-cause mortality was also significantly higher for PMV patients (P < 0.05).

CONCLUSIONS

Resident-led QITI projects enhance resident education while exposing opportunities for improving care. Preoperative patient factors play a larger-than-anticipated role in PMV at our institution. Ongoing efforts are aimed toward preoperative identification and optimization of high-risk patients.

Education Research: A novel resident-driven neurology quality improvement curriculum

OBJECTIVE

To describe and assess the effectiveness of a neurology resident quality improvement curriculum focused on development of practical skills and project experience.

METHODS

We designed and implemented a quality improvement curriculum composed of (1) a workshop series and (2) monthly resident-led Morbidity, Mortality, & Improvement conferences focused on case analysis and project development. Surveys were administered precurriculum and 18 months postcurriculum to assess the effect on self-assessed confidence with quality improvement skills, attitudes, and project participation. Scholarship in the form of posters, presentations, and manuscripts was tracked during the course of the study.

RESULTS

Precurriculum, 83% of neurology residents felt that instruction in quality improvement was important, but most rated their confidence level with various skills as low. Following implementation of the curriculum, residents were significantly more confident in analyzing a patient case (odds ratio, 95% confidence interval) (2.4, 1.9-3.1), proposing system changes (3.1, 2.3-3.9), writing a problem statement (9.9, 6.2-13.5), studying a process (3.1, 2.3-3.8), identifying resources (3.1, 2.3-3.8), identifying appropriate measures (2.5, 1.9-3.0), collaborating with other providers to make improvements (4.9, 3.5-6.4), and making changes in a system (3.1, 2.3-3.8). Project participation increased from the precurriculum baseline (7/18, 39%) to the postcurriculum period (17/22, 77%; p = 0.023). One hundred percent of residents surveyed rated the curriculum positively.

CONCLUSIONS

Our multifaceted curriculum was associated with increased resident confidence with quality improvement skills and increased participation in improvement projects. With adequate faculty mentorship, this curriculum represents a novel template for preparing neurology residents for meeting the expectations of improvement in practice and offers scholarship opportunities.

Defining the Content for a Quality and Safety in Surgery Curriculum Using a Nominal Group Technique

OBJECTIVE

There is growing awareness of the need to provide surgical residents with training in quality and safety. Previous studies have revealed a need for a formal curriculum, but the content and structure of such a curriculum has not been defined. Our objective was to develop a surgery resident curriculum using a consensus, team-building approach.

DESIGN

This study consisted of moderated, structured focus groups using a nominal group technique to guide discussion. Participants generated rank lists of topics to be included and answered questions regarding structure and design of teaching and assessment modalities.

SETTING

Two separate focus groups among 9 surgical residents and 10 faculty experts in quality and safety were held in conjunction with the American College of Surgeons Quality and Safety Conference in July 2017. A total of 16 institutions were represented.

RESULTS

A total of 35 topics were initially proposed by the resident group and a total of 41 topics were proposed by the expert group. After discussion, each group reached consensus on a final list of 9 topics. Most topics in the final lists fell into the broad areas of improvement science and nontechnical skills. Residents indicated that most topics were, on average, poorly covered by their current training program, however, a wide range was noted within each topic. Faculty indicated a preference for didactic instructional methods and assessment using multiple-choice questions.

CONCLUSIONS

Quality and safety are integral components of surgical training. Learners and experts agreed that topics within the domains of improvement science and nontechnical skills should be included in a formal curriculum. Learners reported wide variation on how well these topics are currently included in graduate medical education training programs.

Focused Resident Education and Engagement in Quality Improvement Enhances Documentation, Shortens Hospital Length of Stay, and Creates a Culture of Continuous Improvement

PURPOSE

System-based practice with an emphasis on quality improvement (QI) is a recent initiative for the American College of Surgeons and a core-competency for surgical trainees. Few surgical training programs have a curriculum for hospital-based QI.

METHODS

Our vascular surgery service implemented several QI initiatives focused on decreasing length of stay (LOS) by targeting resident education and engagement. Residents were educated on terminology and processes impacting hospital and CMS QI metrics such as Medicare geometric mean LOS (CMS GMLOS) and diagnostic-related groups (DRG) with complication or comorbidity (CC/MCC) coding. LOS initiatives focused on identifying, tracking and removing avoidable perioperative delays, and improving accuracy of clinical documentation. Residents were given specific roles in QI initiatives and the impact on LOS was quantified. Patients' CMS GMLOS were compared to actual LOS during daily rounds, with confirmation that resident progress notes contained thorough and accurate documentation of diagnoses, comorbidities, and complications. Ten minutes during weekly preoperative conferences were dedicated to ongoing QI, with LOS metrics for the inpatient census presented by trainees and reviewed by attendings. Feedback was given addressing barriers to avoidable delays and impact on LOS. Data for July 2016-June 2017 (FY17) was compared to preimplementation baseline data (FY16) for vascular discharges overall. Accurate documentation of acuity was evaluated with in-depth review of notes and overall case mix index.

RESULTS

Within the first year of implementation, overall vascular admissions demonstrated a 21% reduction in LOS, closing the gap between observed LOS and expected CMS GMLOS, from 2.1days to 0.5days on average. Documentation improved, with a shift in 24% of DRGs to accurately reflect CC/MCC. Overall case mix index increased by 10%, from 3.07 to 3.37.

CONCLUSIONS

A culture of continuous quality improvement can be created with the establishment of a QI infrastructure that educates and involves trainees as stakeholders. Assigning discrete roles to increase resident accountability supports both formal and informal resident education that can substantially impact hospital benchmarking metrics.

Quantitative Analysis of Surgical Residency Reform: Using Case-Logs to Evaluate Resident Experience

BACKGROUND

Curricular changes at a mid-sized surgical training program were developed to rebalance clinical rotations, optimize education over service, decrease the size of service teams, and integrate apprenticeship-type experiences. This study quantifies the operative experience before and after implementation as part of a mixed-methods program evaluation.

STUDY DESIGN

Retrospective review of case-log data and data from the Accreditation Council for Graduate Medical Education (ACGME) and the American College of Surgeons National Surgical Quality Improvement Program: quality in-training initiative to evaluate case volume pre- and postintervention.

RESULTS

11,365 cases, excluding "first-assistant" and "endoscopic" cases, were logged for an average of 291 and 263 cases/resident pre- and postintervention, respectively. Average case volume increased significantly for postgraduate year (PGY) 3 residents and decreased significantly for PGY 4 residents between the two time periods. Variability was observed among residents at the same PGY level both pre- and postintervention, with coefficients of variation of 6.0% to 34.1% in 2014 to 2015 and 11.2% to 66.8% in 2015 to 2016. Inter-resident variability persisted when comparing a specific procedure between ACGME case-log and quality in-training initiative data sets.

CONCLUSION

The data suggest that inter-resident variability in case load is not an artifact of case logging behavior alone, but may reflect personal preferences and choices in case selection that are not impacted by curriculum change. Logging behavior and accuracy of case-logs may contribute to variability. The shift in case load from PGY 4 to PGY 3 after curriculum implementation requires validation by ongoing analysis of ACGME case-log data.

Resident-Specific Morbidity Reduced Following ACS NSQIP Data-Driven Quality Program

BACKGROUND

The Accreditation Council for Graduate Medical Education Milestone Project for general surgery provided a more robust method for developing and tracking residents' competence. This framework enhanced systematic and progressive development of residents' competencies in surgical quality improvement.

STUDY DESIGN

A 22-month interactive, educational program based on resident-specific surgical outcomes data culminated in a quality improvement project for postgraduate year 4 surgery residents. Self- assessment, quality knowledge test, and resident-specific American College of Surgeons National Surgical Quality Improvement Program Quality In-Training Initiative morbidity were compared before and after the intervention.

RESULTS

Quality in-training initiative morbidity decreased from 25% (82/325) to 18% (93/517), p = 0.015 despite residents performing more complex cases. All participants achieved level 4 competency (4/4) within the general surgery milestones improvement of care, practice-based learning and improvement competency. Institutional American College of Surgeons National Surgical Quality Improvement Program general surgery morbidity improved from the ninth to the sixth decile. Quality assessment and improvement self-assessment postintervention scores (M = 23.80, SD = 4.97) were not significantly higher than preintervention scores (M = 19.20, SD = 5.26), p = 0.061. Quality Improvement Knowledge Application Tool postintervention test scores (M = 17.4, SD = 4.88), were not significantly higher than pretest scores (M = 13.2, SD = 1.92), p = 0.12.

CONCLUSION

Sharing validated resident-specific clinical data with participants was associated with improved surgical outcomes. Participating fourth year surgical residents achieved the highest score, a level 4, in the practice based learning and improvement competency of the improvement of care practice domain and observed significantly reduced surgical morbidity for cases in which they participated.

Incision Classification Accuracy: Do Residents Know How to Classify Them?

BACKGROUND

It is unclear whether surgical residents understand how to classify incisions, which may impact how closure is handled in the operating room. We hypothesized that surgical residents define incision class (IC) accurately compared with an attending NSQIP surgeon champion (SC).

METHODS

We evaluated our NSQIP database from April 1, 2015, to December 31, 2016, including cases in which a resident was present and IC was documented. Cases in which the resident, circulator, or surgical clinical rater disagreed on the IC were then reviewed by a blinded SC.

RESULTS

Residents were correct in 83.6% of the cases, with PGY 5 persons having the lowest accuracy. Class 3 incisions were most often misclassified (36%). A disproportionate number of misclassifications by PGY4 and PGY5-7 residents occurred in incision classes 2 and 3. Surgical site infections occurred in 7.4% of cases, ranging from 2.4% in IC 1 to 15.7% in IC 4 cases.

CONCLUSIONS

Although overall accuracy appears reasonable, it is of concern that incisions at higher risk of infection (contaminated) were least likely to be classified appropriately. Chief residents, who often are making the decisions on incision closure, were the least accurate in determining IC. This may have a deleterious impact on incision management, suggesting a need for directed resident education on IC and further investigation to determine its impact on site infection risk and patient outcomes.