Creating a Quality Improvement Course for Undergraduate Medical Education: Practice What You Teach

PROBLEM

More than half of U.S. medical schools have implemented curricula addressing quality improvement (QI); however, the evidence on which pedagogical methods are most effective is limited.

APPROACH

As of January 2015, students at Vanderbilt University School of Medicine are required to take a QI course consisting of three 1-month-long (4 hours per week) blocks during their third or fourth year, in which student-identified faculty sponsors are paired with highly trained QI professionals from Vanderbilt University Medical Center. The three blocks of the course include didactic instruction using Institute for Healthcare Improvement Open School modules, readings, weekly assignments, and experiential learning activities (i.e., students develop and implement a QI project with two Plan-Do-Study-Act cycles using a systematic approach that employs the principles of improvement science, which they present as a poster on the last day of the third block).

OUTCOMES

From January 2015 to January 2017, 132 students completed all three blocks, resulting in 110 completed QI projects. On evaluations (distributed after each completed block), a majority of students rated the clinical relevance of the blocks highly (191/273; 70%), agreed the blocks contributed to their development as physicians (192/273; 70%), and reported the blocks motivated them to continue to learn more about QI (168/273; 62%).

NEXT STEPS

The authors have applied QI methods to improve the course and will aim to assess the sustainability of the course by tracking clinical outcomes related to the projects and students' ongoing involvement in QI after graduation.

Potentially Avoidable Readmissions of Patients Discharged to Post-Acute Care: Perspectives of Hospital and Skilled Nursing Facility Staff

BACKGROUND

Hospital readmissions from skilled nursing facilities (SNFs) are common. Previous research has not examined how assessments of avoidable readmissions differ between hospital and SNF perspectives.

OBJECTIVES

To determine the percentage of readmissions from post-acute care that are considered potentially avoidable from hospital and SNF perspectives.

DESIGN

Prospective cohort study.

SETTING

One academic medical center and 23 SNFs.

PARTICIPANTS

We included patients from a quality improvement trial aimed at reducing hospital readmissions among patients discharged to SNFs. We included Medicare patients who were discharged to one of 23 regional SNFs between January 2013 and January 2015, and readmitted to the hospital within 30 days.

MEASUREMENTS

Hospital-based physicians and SNF-based staff performed structured root-cause analyses (RCA) on a sample of readmissions from a participating SNF to the index hospital. RCAs reported avoidability and factors contributing to readmissions.

RESULTS

The 30-day unplanned readmission rate to the index hospital from SNFs was 14.5% (262 hospital readmissions of 1,808 discharges). Of the readmissions, 120 had RCA from both the hospital and SNF. The percentage of readmissions rated as potentially avoidable was 30.0% and 13.3% according to hospital and SNF staff, respectively. Hospital and SNF ratings of potential avoidability agreed for 73.3% (88 of the 120 readmissions), but readmission factors varied between settings. Diagnostic problems and improved management of changes in conditions were the most common avoidable readmission factors by hospitals and SNFs, respectively.

CONCLUSION

A substantial percentage of hospital readmissions from SNFs are rated as potentially avoidable. The ratings and factors underlying avoidability differ between hospital and SNF staff. These data support the need for joint accountability and collaboration for future readmission reduction efforts between hospitals and their SNF partners.

The effect of reducing maximum shift lengths to 16 hours on internal medicine interns' educational opportunities

PURPOSE

To evaluate educational experiences of internal medicine interns before and after maximum shift lengths were decreased from 30 hours to 16 hours.

METHOD

The authors compared educational experiences of internal medicine interns at Vanderbilt University Medical Center before (2010; 47 interns) and after (2011; 50 interns) duty hours restrictions were implemented in July 2011. The authors compared number of inpatient encounters, breadth of concepts in notes, exposure to five common presenting problems, procedural experience, and attendance at teaching conferences.

RESULTS

Following the duty hours restrictions, interns cared for more unique patients (mean 118 versus 140 patients per intern, P = .005) and wrote more history and physicals (mean 73 versus 88, P = .005). Documentation included more total concepts after the 16-hour maximum shift implementation, with a 14% increase for history and physicals (338 versus 387, P < .001) and a 10% increase for progress notes (316 versus 349, P < .001). There was no difference in the median number of selected procedures performed (6 versus 6, P = 0.94). Attendance was higher at the weekly chief resident conference (60% versus 68% of expected attendees, P < .001) but unchanged at morning report conferences (79% versus 78%, P = .49).

CONCLUSIONS

Intern clinical exposure did not decrease after implementation of the 16-hour shift length restriction. In fact, interns saw more patients, produced more detailed notes, and attended more conferences following duty hours restrictions.