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Schnipper JL, Reyes Nieva H, Yoon C, Mallouk M, Mixon AS, Rennke S, Chu ES, Mueller SK, Smith GR, Williams MV, Wetterneck TB, Stein J, Dalal AK, Labonville S, Sridharan A, Stolldorf DP, Orav EJ, Gresham M, Goldstein J, Platt S, Nyenpan CT, Howell E, Kripalani S. What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study. BMJ Qual Saf 2023; 32:457-469. [PMID: 36948542 PMCID: PMC11046420 DOI: 10.1136/bmjqs-2022-014806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 01/31/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND The second Multicenter Medication Reconciliation Quality Improvement Study demonstrated a marked reduction in medication discrepancies per patient. The aim of the current analysis was to determine the association of patient exposure to each system-level intervention and receipt of each patient-level intervention on these results. METHODS This study was conducted at 17 North American Hospitals, the study period was 18 months per site, and sites typically adopted interventions after 2-5 months of preintervention data collection. We conducted an on-treatment analysis (ie, an evaluation of outcomes based on patient exposure) of system-level interventions, both at the category level and at the individual component level, based on monthly surveys of implementation site leads at each site (response rate 65%). We then conducted a similar analysis of patient-level interventions, as determined by study pharmacist review of documented activities in the medical record. We analysed the association of each intervention on the adjusted number of medication discrepancies per patient in admission and discharge orders, based on a random sample of up to 22 patients per month per site, using mixed-effects Poisson regression with hospital site as a random effect. We then used a generalised linear mixed-effects model (GLMM) decision tree to determine which patient-level interventions explained the most variance in discrepancy rates. RESULTS Among 4947 patients, patient exposure to seven of the eight system-level component categories was associated with modest but significant reductions in discrepancy rates (adjusted rate ratios (ARR) 0.75-0.97), as were 15 of the 17 individual system-level intervention components, including hiring, reallocating and training personnel to take a best possible medication history (BPMH) and training personnel to perform discharge medication reconciliation and patient counselling. Receipt of five of seven patient-level interventions was independently associated with large reductions in discrepancy rates, including receipt of a BPMH in the emergency department (ED) by a trained clinician (ARR 0.40, 95% CI 0.37 to 0.43), admission medication reconciliation by a trained clinician (ARR 0.57, 95% CI 0.50 to 0.64) and discharge medication reconciliation by a trained clinician (ARR 0.64, 95% CI 0.57 to 0.73). In GLMM decision tree analyses, patients who received both a BPMH in the ED and discharge medication reconciliation by a trained clinician experienced the lowest discrepancy rates (0.08 per medication per patient). CONCLUSION AND RELEVANCE Patient-level interventions most associated with reductions in discrepancies were receipt of a BPMH of admitted patients in the ED and admission and discharge medication reconciliation by a trained clinician. System-level interventions were associated with modest reduction in discrepancies for the average patient but are likely important to support patient-level interventions and may reach more patients. These findings can be used to help hospitals and health systems prioritise interventions to improve medication safety during care transitions.
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Affiliation(s)
- Jeffrey L Schnipper
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Hospital Medicine Unit, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Harry Reyes Nieva
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Catherine Yoon
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Meghan Mallouk
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Amanda S Mixon
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephanie Rennke
- UCSF Health and Department of Medicine, Division of Hospital Medicine, University of California San Francisco Medical Center, San Francisco, California, USA
| | - Eugene S Chu
- Parkland Health and Hospital System and Hospital Medicine Service, Department of Internal Medicine, University of Texas Southwestern School of Medicine, Dallas, Texas, USA
| | - Stephanie K Mueller
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Hospital Medicine Unit, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - G Randy Smith
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Mark V Williams
- Division of Hospital Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Tosha B Wetterneck
- Department of Medicine, Center for Quality and Productivity Improvement, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison College of Engineering, Madison, Wisconsin, USA
| | - Jason Stein
- Section of Hospital Medicine, Emory University Hospital and 1Unit, Atlanta, Georgia, USA
| | - Anuj K Dalal
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Hospital Medicine Unit, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Stephanie Labonville
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anirudh Sridharan
- Department of Medicine, Howard County General Hospital, Columbia, Maryland, USA
| | - Deonni P Stolldorf
- Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - Endel John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Marcus Gresham
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Jenna Goldstein
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Sara Platt
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | | | - Eric Howell
- Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
- Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Sunil Kripalani
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Conner SM, Choi N, Fuller J, Daya S, Barish P, Rennke S, Harrison JD, Narayana S. Trainee Autonomy and Supervision in the Modern Clinical Learning Environment: A Mixed-Methods Study of Faculty and Trainee Perspectives. Res Sq 2023:rs.3.rs-2982838. [PMID: 37333324 PMCID: PMC10275050 DOI: 10.21203/rs.3.rs-2982838/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Background Balancing autonomy and supervision during medical residency is important for trainee development while ensuring patient safety. In the modern clinical learning environment, tension exists when this balance is skewed. This study aimed to understand the current and ideal states of autonomy and supervision, then describe the factors that contribute to imbalance from both trainee and attending perspectives. Methods A mixed-methods design included surveys and focus groups of trainees and attendings at three institutionally affiliated hospitals between May 2019-June 2020. Survey responses were compared using chi-square tests or Fisher's exact tests. Open-ended survey and focus group questions were analyzed using thematic analysis. Results Surveys were sent to 182 trainees and 208 attendings; 76 trainees (42%) and 101 attendings (49%) completed the survey. Fourteen trainees (8%) and 32 attendings (32%) participated in focus groups. Trainees perceived the current culture to be significantly more autonomous than attendings; both groups described an "ideal" culture as more autonomous than the current state. Focus group analysis revealed five core contributors to the balance of autonomy and supervision: attending-, trainee-, patient-, interpersonal-, and institutional-related factors. These factors were found to be dynamic and interactive with each other. Additionally, we identified a cultural shift in how the modern inpatient environment is impacted by increased hospitalist attending supervision and emphasis on patient safety and health system improvement initiatives. Conclusions Trainees and attendings agree that the clinical learning environment should favor resident autonomy and that the current environment does not achieve the ideal balance. There are several factors contributing to autonomy and supervision, including attending-, resident-, patient-, interpersonal-, and institutional-related. These factors are complex, multifaceted, and dynamic. Cultural shifts towards supervision by primarily hospitalist attendings and increased attending accountability for patient safety and systems improvement outcomes further impacts trainee autonomy.
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Misky GJ, Sharpe B, Weaver AC, Niranjan-Azadi A, Gupta A, Rennke S, Ludwin S, Piper C, Mlis, Sun VK, Brotman DJ, Frank M. Faculty Development in Academic Hospital Medicine: a Scoping Review. J Gen Intern Med 2023; 38:1955-1961. [PMID: 36877213 PMCID: PMC10271943 DOI: 10.1007/s11606-023-08089-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/07/2023] [Indexed: 03/07/2023]
Abstract
This scoping review sought to identify and describe the state of academic faculty development programs in hospital medicine and other specialties. We reviewed faculty development content, structure, metrics of success including facilitators, barriers, and sustainability to create a framework and inform hospital medicine leadership and faculty development initiatives. We completed a systematic search of peer-reviewed literature and searched Ovid MEDLINE ALL (1946 to June 17, 2021) and Embase (via Elsevier, 1947 to June 17, 2021). Twenty-two studies were included in the final review, with wide heterogeneity in program design, program description, outcomes, and study design. Program design included a combination of didactics, workshops, and community or networking events; half of the studies included mentorship or coaching for faculty. Thirteen studies included program description and institutional experience without reported outcomes while eight studies included quantitative analysis and mixed methods results. Barriers to program success included limited time and support for faculty attendance, conflicting clinical commitments, and lack of mentor availability. Facilitators included allotted funding and time for faculty participation, formal mentoring and coaching opportunities, and a structured curriculum with focused skill development supporting faculty priorities. We identified heterogeneous historical studies addressing faculty development across highly variable program design, intervention, faculty targeted, and outcomes assessed. Common themes emerged, including the need for program structure and support, aligning areas of skill development with faculty values, and longitudinal mentoring/coaching. Programs require dedicated program leadership, support for faculty time and participation, curricula focused on skills development, and mentoring and sponsorship.
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Affiliation(s)
- Gregory J Misky
- Division of Hospital Medicine, University of Colorado, P.O. Box 6510, 12605 E. 16th Ave., Aurora, CO, 80045, USA.
| | - Bradley Sharpe
- Division of Hospital Medicine, University of California, San Francisco (UCSF), 450 Stanyan St, San Francisco, CA, 94117, USA
| | - A Charlotta Weaver
- Division of Hospital Medicine, Northwestern University, 251 E Huron St Ste 16-738, Chicago, IL, 60611, USA
| | - Ashwini Niranjan-Azadi
- Division of Hospital Medicine, Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Ashwin Gupta
- Division of Hospital Medicine, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Stephanie Rennke
- Division of Hospital Medicine, University of California, San Francisco (UCSF), 450 Stanyan St, San Francisco, CA, 94117, USA
| | - Steve Ludwin
- Division of Hospital Medicine, University of California, San Francisco (UCSF), 450 Stanyan St, San Francisco, CA, 94117, USA
| | - Christi Piper
- Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus, 12950 E. Montview Boulevard, Aurora, CO, 80045, USA
| | | | - Vivien K Sun
- Division of Pediatric Hospital Medicine, Stanford University, 300 Pasteur Dr. MC 5776, Stanford, CA, 94305, USA
| | - Daniel J Brotman
- Division of Hospital Medicine, Johns Hopkins School of Medicine, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Maria Frank
- Division of Hospital Medicine, University of Colorado, P.O. Box 6510, 12605 E. 16th Ave., Aurora, CO, 80045, USA
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Rennke S, Warren R, Sims W, Menon S, Binford S, Rathfon M, Wallhagen M. CAN YOU HEAR ME? A MEDICAL STUDENT-LED QUALITY IMPROVEMENT INITIATIVE FOR HOSPITALIZED PATIENTS WITH HEARING LOSS. Innov Aging 2022. [PMCID: PMC9766242 DOI: 10.1093/geroni/igac059.2279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
In acute care settings hearing loss (HL) is associated with impaired patient-provider communication, increased length of stay, and increased mortality. COVID-19 has exacerbated this problem with the widespread use of masks and eye shields which muffle speech and prevent lip reading. Our 800-bed tertiary care medical center lacked a standardized approach to identify patients with HL and address communication barriers. Three first year medical students spearheaded the initiative as part of a health systems improvement curriculum with support from a faculty coach and a faculty researcher. From September 2020 to October 2021, the students met with stakeholders, leadership and champions and unit staff, identified the current state and completed a gap analysis through interviews, surveys, and direct observation. The pilot in May 2021 included two week-long PDSA cycles on one hospital unit to: 1) screen patients aged 65 and older using the validated 10-item HHIE-S questionnaire, 2) implement an education and awareness campaign with bedside signage, posters, and conferences and 3) provide a personal amplifier (purchased in bulk by the medical center) with verbal and written instructions. A total of 29 patients screened positive and were given personal amplifiers. Post-pilot interviews reported increased provider awareness and knowledge around best communication practices. Patients and staff reported limited amplifier use due to poor sound quality, small dials, poorly fitting ear buds and a short battery life. Based on these results the team recommended discontinuing the personal amplifiers and identifying other communication tools including higher quality personal amplifiers and speech to text applications.
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Affiliation(s)
- Stephanie Rennke
- University of California, San Francisco, San Francisco, California, United States
| | - Rachel Warren
- University of California, San Francisco, San Francisco, California, United States
| | - Wynton Sims
- University of California, San Francisco, San Francisco, California, United States
| | - Shreya Menon
- University of California, San Francisco, San Francisco, California, United States
| | - Sasha Binford
- University of California, San Francisco, San Francisco, California, United States
| | - Megan Rathfon
- University of California, San Francisco, San Francisco, California, United States
| | - Margaret Wallhagen
- University of California, San Francisco, San Francisco, California, United States
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Leep Hunderfund AN, Kumbamu A, O'Brien BC, Starr SR, Dekhtyar M, Gonzalo JD, Rennke S, Ridinger H, Chang A. "Finding My Piece in That Puzzle": A Qualitative Study Exploring How Medical Students at Four U.S. Schools Envision Their Future Professional Identity in Relation to Health Systems. Acad Med 2022; 97:1804-1815. [PMID: 35797546 DOI: 10.1097/acm.0000000000004799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE Health systems science (HSS) curricula equip future physicians to improve patient, population, and health systems outcomes (i.e., to become "systems citizens"), but the degree to which medical students internalize this conception of the physician role remains unclear. This study aimed to explore how students envision their future professional identity in relation to the system and identify experiences relevant to this aspect of identity formation. METHOD Between December 2018 and September 2019, authors interviewed 48 students at 4 U.S. medical schools with HSS curricula. Semistructured interviews were audiorecorded, transcribed, and analyzed iteratively using inductive thematic analysis. Interview questions explored how students understood the health system, systems-related activities they envisioned as future physicians, and experiences and considerations shaping their perspectives. RESULTS Most students anticipated enacting one or more systems-related roles as a future physician, categorized as "bottom-up" efforts enacted at a patient or community level (humanist, connector, steward) or "top-down" efforts enacted at a system or policy level (system improver, system scholar, policy advocate). Corresponding activities included attending to social determinants of health or serving medically underserved populations, connecting patients with team members to address systems-related barriers, stewarding health care resources, conducting quality improvement projects, researching/teaching systems topics, and advocating for policy change. Students attributed systems-related aspirations to experiences beyond HSS curricula (e.g., low-income background; work or volunteer experience; undergraduate studies; exposure to systems challenges affecting patients; supportive classmates, faculty, and institutional culture). Students also described future-oriented considerations promoting or undermining identification with systems-related roles (responsibility, affinity, ability, efficacy, priority, reality, consequences). CONCLUSIONS This study illuminates systems-related roles medical students at 4 schools with HSS curricula envisioned as part of their future physician identity and highlights past/present experiences and future-oriented considerations shaping identification with such roles. These findings inform practical strategies to support professional identity formation inclusive of systems engagement.
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Affiliation(s)
- Andrea N Leep Hunderfund
- A.N. Leep Hunderfund is associate professor of neurology and director, Learning Environment and Educational Culture, Mayo Clinic Alix School of Medicine, Rochester, Minnesota
| | - Ashok Kumbamu
- A. Kumbamu is assistant professor of biomedical ethics, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Bridget C O'Brien
- B.C. O'Brien is professor of medicine and education scientist, Center for Faculty Educators, University of California, San Francisco, San Francisco, California
| | - Stephanie R Starr
- S.R. Starr is associate professor of pediatrics, Mayo Clinic College of Medicine and Science, and director, Science of Health Care Delivery Education, Mayo Clinic Alix School of Medicine, Rochester, Minnesota
| | - Michael Dekhtyar
- M. Dekhtyar is research associate, Department of Medical Education, University of Illinois College of Medicine at Chicago; ORCID: https://orcid.org/0000-0002-8548-3624
| | - Jed D Gonzalo
- J.D. Gonzalo is professor of medicine and public health sciences and associate dean for health systems education, Penn State College of Medicine, Hershey, Pennsylvania; ORCID: https://orcid.org/0000-0003-1253-2963
| | - Stephanie Rennke
- S. Rennke is professor of medicine, Division of Hospital Medicine, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California
| | - Heather Ridinger
- H. Ridinger is assistant professor of medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anna Chang
- A. Chang is professor of medicine, Division of Geriatrics, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California
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Schnipper JL, Reyes Nieva H, Mallouk M, Mixon A, Rennke S, Chu E, Mueller S, Smith GRR, Williams MV, Wetterneck TB, Stein J, Dalal A, Labonville S, Sridharan A, Stolldorf DP, Orav EJ, Levin B, Gresham M, Yoon C, Goldstein J, Platt S, Nyenpan CT, Howell E, Kripalani S. Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study. BMJ Qual Saf 2022; 31:278-286. [PMID: 33927025 PMCID: PMC10964422 DOI: 10.1136/bmjqs-2020-012709] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 03/26/2021] [Accepted: 04/10/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The first Multicenter Medication Reconciliation Quality Improvement (QI) Study (MARQUIS1) demonstrated that mentored implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals, but results varied by site. The objective of this study was to determine the effects of a refined toolkit on a larger group of hospitals. METHODS We conducted a pragmatic quality improvement study (MARQUIS2) at 18 North American hospitals or hospital systems from 2016 to 2018. Incorporating lessons learnt from MARQUIS1, we implemented a refined toolkit, offering 17 system-level and 6 patient-level interventions. One of eight physician mentors coached each site via monthly calls and performed one to two site visits. The primary outcome was number of unintentional medication discrepancies in admission or discharge orders per patient. Time series analysis used multivariable Poisson regression. RESULTS A total of 4947 patients were sampled, including 1229 patients preimplementation and 3718 patients postimplementation. Both the number of system-level interventions adopted per site and the proportion of patients receiving patient-level interventions increased over time. During the intervention, patients experienced a steady decline in their medication discrepancy rate from 2.85 discrepancies per patient to 0.98 discrepancies per patient. An interrupted time series analysis of the 17 sites with sufficient data for analysis showed the intervention was associated with a 5% relative decrease in discrepancies per month over baseline temporal trends (adjusted incidence rate ratio: 0.95, 95% CI 0.93 to 0.97, p<0.001). Receipt of patient-level interventions was associated with decreased discrepancy rates, and these associations increased over time as sites adopted more system-level interventions. CONCLUSION A multicentre medication reconciliation QI initiative using mentored implementation of a refined best practices toolkit, including patient-level and system-level interventions, was associated with a substantial decrease in unintentional medication discrepancies over time. Future efforts should focus on sustainability and spread.
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Affiliation(s)
- Jeffrey L Schnipper
- Hospital Medicine Unit, Brigham Health, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Harry Reyes Nieva
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Meghan Mallouk
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, PA, USA
| | - Amanda Mixon
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research, Education, and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Stephanie Rennke
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Eugene Chu
- Division of Hospital Medicine, Parkland Health and Hospital System and Department of Internal Medicine, University of Texas Southwestern School of Medicine, Dallas, TX, USA
| | - Stephanie Mueller
- Hospital Medicine Unit, Brigham Health, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Gregory Randy R Smith
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark V Williams
- Division of Hospital Medicine, Department of Internal Medicine, University of Kentucky Medical Center, Lexington, KY, USA
| | - Tosha B Wetterneck
- Division of General Internal Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | | | - Anuj Dalal
- Hospital Medicine Unit, Brigham Health, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | | | | | - E John Orav
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA
| | - Brian Levin
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Marcus Gresham
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Cathy Yoon
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jenna Goldstein
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, PA, USA
| | - Sara Platt
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, PA, USA
| | | | - Eric Howell
- Society of Hospital Medicine, Philadelphia, PA, USA
- Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Center for Clinical Quality and Implementation Research, Nashville, TN, USA
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Castro MR, Calthorpe LM, Fogh SE, McAllister S, Johnson CL, Isaacs ED, Ishizaki A, Kozas A, Lo D, Rennke S, Davis J, Chang A. Lessons From Learners: Adapting Medical Student Education During and Post COVID-19. Acad Med 2021; 96:1671-1679. [PMID: 33951675 PMCID: PMC8603439 DOI: 10.1097/acm.0000000000004148] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
In response to the COVID-19 pandemic, many medical schools suspended clinical clerkships and implemented newly adapted curricula to facilitate continued educational progress. While the implementation of these new curricula has been described, an understanding of the impact on student learning outcomes is lacking. In 2020, the authors followed Kern's 6-step approach to curricular development to create and evaluate a novel COVID-19 curriculum for medical students at the University of California San Francisco School of Medicine and evaluate its learning outcomes. The primary goal of the curriculum was to provide third- and fourth-year medical students an opportunity for workplace learning in the absence of clinical clerkships, specifically for students to develop clerkship-level milestones in the competency domains of practice-based learning and improvement, professionalism, and systems-based practice. The curriculum was designed to match students with faculty-mentored projects occurring primarily in virtual formats. A total of 126 students enrolled in the curriculum and completed a survey about their learning outcomes (100% response rate). Of 35 possible clerkship-level milestones, there were 12 milestones for which over half of students reported development in competency domains including practice-based learning and improvement, professionalism, and interpersonal and communication skills. Thematic analysis of students' qualitative survey responses demonstrated 2 central motivations for participating in the curriculum: identity as physicians-in-training and patient engagement. Six central learning areas were developed during the curriculum: interprofessional teamwork, community resources, technology in medicine, skill-building, quality improvement, and specialty-specific learning. This analysis demonstrates that students can develop competencies and achieve rich workplace learning through project-based experiential learning, even in virtual clinical workplaces. Furthermore, knowledge of community resources, technology in medicine, and quality improvement was developed through the curriculum more readily than in traditional clerkships. These could be considered as integral learning objectives in future curricular design.
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Affiliation(s)
- Maria R.H. Castro
- M.R.H. Castro is a third-year medical student, University of California San Francisco School of Medicine, San Francisco, California; ORCID: https://orcid.org/0000-0002-2085-4893
| | - Lucia M. Calthorpe
- L.M. Calthorpe is a third-year medical student, University of California San Francisco School of Medicine, San Francisco, California; ORCID: https://orcid.org/0000-0002-0496-9471
| | - Shannon E. Fogh
- S.E. Fogh is associate professor, Department of Radiation Oncology, University of California San Francisco School of Medicine, San Francisco, California
| | - Sophie McAllister
- S. McAllister is a third-year medical student, University of California San Francisco School of Medicine, San Francisco, California
| | - Christopher L. Johnson
- C.L Johnson is a third-year medical student, University of California San Francisco School of Medicine, San Francisco, California
| | - Eric D. Isaacs
- E.D. Isaacs is professor of emergency medicine, Department of Emergency Medicine, University of California San Francisco, San Francisco, California
| | - Allison Ishizaki
- A. Ishizaki is manager, Clinical Microsystems Clerkship, University of California San Francisco School of Medicine, San Francisco, California
| | - Anna Kozas
- A. Kozas is curriculum coordinator, Clinical Microsystems Clerkship, University of California San Francisco School of Medicine, San Francisco, California
| | - Daphne Lo
- D. Lo is assistant professor of medicine, Division of Geriatrics, Department of Medicine, University of California San Francisco School of Medicine and Department of Geriatrics and Extended Care, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Stephanie Rennke
- S. Rennke is professor of medicine, Division of Hospital Medicine, Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California
| | - John Davis
- J. Davis is professor of medicine and associate dean for curriculum, University of California San Francisco School of Medicine, San Francisco, California
| | - Anna Chang
- A. Chang is professor of medicine, Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California
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Deardorff WJ, Binford SS, Cole I, James T, Rathfon M, Rennke S, Wallhagen M. COVID-19, masks, and hearing difficulty: Perspectives of healthcare providers. J Am Geriatr Soc 2021; 69:2783-2785. [PMID: 34228350 PMCID: PMC8447172 DOI: 10.1111/jgs.17349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 06/19/2021] [Indexed: 11/25/2022]
Affiliation(s)
- William James Deardorff
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Sasha S Binford
- Center for Nursing Excellence and Innovation, University of California, San Francisco, San Francisco, California, USA
| | - Irene Cole
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, San Francisco, California, USA
| | - Todd James
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Megan Rathfon
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Stephanie Rennke
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Margaret Wallhagen
- Department of Physiological Nursing, School of Nursing, University of California, San Francisco, San Francisco, California, USA
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Mixon AS, Smith GR, Mallouk M, Nieva HR, Kripalani S, Rennke S, Chu E, Sridharan A, Dalal A, Mueller S, Williams M, Wetterneck T, Stein JM, Stolldorf D, Howell E, Orav J, Labonville S, Levin B, Yoon C, Gresham M, Goldstein J, Platt S, Nyenpan C, Schnipper JL. Design of MARQUIS2: study protocol for a mentored implementation study of an evidence-based toolkit to improve patient safety through medication reconciliation. BMC Health Serv Res 2019; 19:659. [PMID: 31511070 PMCID: PMC6737715 DOI: 10.1186/s12913-019-4491-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 08/28/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The first Multi-center Medication Reconciliation Quality Improvement Study (MARQUIS1) demonstrated that implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals. We sought to implement the MARQUIS toolkit in more diverse hospitals, incorporating lessons learned from MARQUIS1. METHODS MARQUIS2 is a pragmatic, mentored implementation QI study which collected clinical and implementation outcomes. Sites implemented a revised toolkit, which included interventions from these domains: 1) best possible medication history (BPMH)-taking; 2) discharge medication reconciliation and patient/caregiver counseling; 3) identifying and defining clinician roles and responsibilities; 4) risk stratification; 5) health information technology improvements; 6) improved access to medication sources; 7) identification and correction of real-time discrepancies; and, 8) stakeholder engagement. Eight hospitalists mentored the sites via one site visit and monthly phone calls over the 18-month intervention period. Each site's local QI team assessed opportunities to improve, implemented at least one of the 17 toolkit components, and accessed a variety of resources (e.g. implementation manual, webinars, and workshops). Outcomes to be assessed will include unintentional medication discrepancies per patient. DISCUSSION A mentored multi-center medication reconciliation QI initiative using a best practices toolkit was successfully implemented across 18 medical centers. The 18 participating sites varied in size, teaching status, location, and electronic health record (EHR) platform. We introduce barriers to implementation and lessons learned from MARQUIS1, such as the importance of utilizing dedicated, trained medication history takers, simple EHR solutions, clarifying roles and responsibilities, and the input of patients and families when improving medication reconciliation.
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Affiliation(s)
- Amanda S Mixon
- GRECC, VA Tennessee Valley Healthcare System and Section of Hospital Medicine, Vanderbilt University Medical Center, Suite 450, 2525 West End Avenue, Nashville, TN, 37203, USA.
| | - G Randy Smith
- Hospital Medicine, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - Meghan Mallouk
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, PA, USA
| | - Harry Reyes Nieva
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sunil Kripalani
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephanie Rennke
- Division of Hospital Medicine, University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Eugene Chu
- Division of Hospital Medicine, Parkland Health and Hospital System and Department of Internal Medicine, University of Texas Southwestern School of Medicine, Dallas, TX, USA
| | | | - Anuj Dalal
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephanie Mueller
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark Williams
- Department of Internal Medicine, University of Kentucky, Lexington, KY, USA
| | - Tosha Wetterneck
- Division of General Internal Medicine, University of Wisconsin, Madison, WI, USA
| | | | | | - Eric Howell
- Division of Collaborative Inpatient Medicine Service, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - John Orav
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephanie Labonville
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian Levin
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Catherine Yoon
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcus Gresham
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jenna Goldstein
- Center for Hospital Innovation and Improvement, Society of Hospital Medicine, Philadelphia, PA, USA
| | - Sara Platt
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, PA, USA
| | - Christopher Nyenpan
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, PA, USA
| | - Jeffrey L Schnipper
- Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Harman SM, Blankenburg R, Satterfield JM, Monash B, Rennke S, Yuan P, Sakai DS, Huynh E, Chua I, Hilton JF. Promoting Shared Decision-Making Behaviors During Inpatient Rounds: A Multimodal Educational Intervention. Acad Med 2019; 94:1010-1018. [PMID: 30893066 PMCID: PMC6594883 DOI: 10.1097/acm.0000000000002715] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
PURPOSE To estimate the effectiveness of a multimodal educational intervention to increase use of shared decision-making (SDM) behaviors by inpatient pediatric and internal medicine hospitalists and trainees at teaching hospitals at Stanford University and the University of California, San Francisco. METHOD The 8-week Patient Engagement Project Study intervention, delivered at four services between November 2014 and January 2015, included workshops, campaign messaging, report cards, and coaching. For 12-week pre- and postintervention periods, clinician peers used the nine-point Rochester Participatory Decision-Making Scale (RPAD) to evaluate rounding teams' SDM behaviors with patients during ward rounds. Eligible teams included a hospitalist and at least one trainee (resident, intern, medical student), in addition to nonphysicians. Random-effects models were used to estimate intervention effects based on RPAD scores that sum points on nine SDM behaviors per patient encounter. RESULTS In total, 527 patient encounters were scored during 175 rounds led by 49 hospitalists. Patient and team characteristics were similar across pre- and postintervention periods. Improvement was observed on all nine SDM behaviors. Adjusted for the hierarchical study design and covariates, the mean RPAD score improvement was 1.68 points (95% CI, 1.33-2.03; P < .001; Cohen d = 0.82), with intervention effects ranging from 0.7 to 2.5 points per service. Improvements were associated with longer patient encounters and a higher percentage of trainees per team. CONCLUSIONS The intervention increased behaviors supporting SDM during ward rounds on four independent services. The findings recommend use of clinician-focused interventions to promote SDM adoption in the inpatient setting.
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Affiliation(s)
- Stephanie M Harman
- S.M. Harman is clinical associate professor, Department of Medicine, Stanford University School of Medicine, Stanford, California; ORCID: http://orcid.org/0000-0002-1356-9314. R. Blankenburg is clinical associate professor, Department of Pediatrics, Stanford University School of Medicine, Stanford, California; ORCID: http://orcid.org/0000-0002-1938-6113. J.M. Satterfield is professor, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California; ORCID: http://orcid.org/0000-0002-2765-3701. B. Monash is associate professor, Departments of Medicine and Pediatrics, University of California, San Francisco School of Medicine, San Francisco, California. S. Rennke is professor, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California; ORCID: http://orcid.org/0000-0002-2004-8496. P. Yuan is research assistant, Department of Epidemiology and Biostatistics, University of California, San Francisco School of Medicine, San Francisco, California; ORCID: http://orcid.org/0000-0002-8472-0739. D.S. Sakai is clinical associate professor, Department of Pediatrics, Stanford University School of Medicine, Stanford, California; ORCID: https://orcid.org/0000-0002-2345-9856. E. Huynh is an MBA student, University of California, Berkeley, Haas School of Business, Berkeley, California. I. Chua is assistant professor, Department of Pediatrics, Children's National Medical Center, Washington, D.C., and clinical instructor, Department of Pediatrics, Stanford University School of Medicine, Stanford, California. J.F. Hilton is professor, Department of Epidemiology and Biostatistics, University of California, San Francisco School of Medicine, San Francisco, California; ORCID: http://orcid.org/0000-0003-2452-4274
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11
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Blankenburg R, Hilton JF, Yuan P, Rennke S, Monash B, Harman SM, Sakai DS, Hosamani P, Khan A, Chua I, Huynh E, Shieh L, Xie L. Shared Decision-Making During Inpatient Rounds: Opportunities for Improvement in Patient Engagement and Communication. J Hosp Med 2018; 13:453-461. [PMID: 29401211 PMCID: PMC6392000 DOI: 10.12788/jhm.2909] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Shared decision-making (SDM) improves patient engagement and may improve outpatient health outcomes. Little is known about inpatient SDM. OBJECTIVE To assess overall quality, provider behaviors, and contextual predictors of SDM during inpatient rounds on medicine and pediatrics hospitalist services. DESIGN A 12-week, cross-sectional, single-blinded observational study of team SDM behaviors during rounds, followed by semistructured patient interviews. SETTING Two large quaternary care academic medical centers. PARTICIPANTS Thirty-five inpatient teams (18 medicine, 17 pediatrics) and 254 unique patient encounters (117 medicine, 137 pediatrics). INTERVENTION Observational study. MEASUREMENTS We used a 9-item Rochester Participatory Decision-Making Scale (RPAD) measured team-level SDM behaviors. Same-day interviews using a modified RPAD assessed patient perceptions of SDM. RESULTS Characteristics associated with increased SDM in the multivariate analysis included the following: service, patient gender, timing of rounds during patient's hospital stay, and amount of time rounding per patient (P < .05). The most frequently observed behaviors across all services included explaining the clinical issue and matching medical language to the patient's level of understanding. The least frequently observed behaviors included checking understanding of the patient's point of view, examining barriers to follow-through, and asking if the patient has any questions. Patients and guardians had substantially higher ratings for SDM quality compared to peer observers (7.2 vs 4.4 out of 9). CONCLUSIONS Important opportunities exist to improve inpatient SDM. Team size, number of learners, patient census, and type of decision being made did not affect SDM, suggesting that even large, busy services can perform SDM if properly trained.
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Affiliation(s)
- Rebecca Blankenburg
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California, USA.
| | - Joan F Hilton
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Patrick Yuan
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Stephanie Rennke
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Brad Monash
- Division of Hospital Medicine, Department of Medicine, and Division of Hospital Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Stephanie M Harman
- Division of Primary Care and Population Health, Department of Medicine, School of Medicine, Stanford University, Stanford, California, USA
| | - Debbie S Sakai
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California, USA
| | - Poonam Hosamani
- Division of Hospital Medicine, Department of Medicine, School of Medicine, Stanford University, Stanford, California, USA
| | - Adeena Khan
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Ian Chua
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California, USA
- Division of Hospital Medicine, Department of Pediatrics, Children's National Medical Center, Washington, DC, USA
| | - Eric Huynh
- Department of Medicine, School of Medicine, Stanford University, Stanford, California, USA
| | - Lisa Shieh
- Division of Hospital Medicine, Department of Medicine, School of Medicine, Stanford University, Stanford, California, USA
| | - Lijia Xie
- Medicine Residency Program, Department of Medicine, Stanford School of Medicine, USA
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Rennke S, Yuan P, Monash B, Blankenburg R, Chua I, Harman S, Sakai DS, Khan A, Hilton JF, Shieh L, Satterfield J. The SDM 3 Circle Model: A Literature Synthesis and Adaptation for Shared Decision Making in the Hospital. J Hosp Med 2017; 12:1001-1008. [PMID: 29073314 PMCID: PMC5709161 DOI: 10.12788/jhm.2865] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patient engagement through shared decision-making (SDM) is increasingly seen as a key component for patient safety, patient satisfaction, and quality of care. Current SDM models do not adequately account for medical and environmental contexts, which may influence medical decisions in the hospital. We identified leading SDM models and reviews to inductively construct a novel SDM model appropriate for the inpatient setting. A team of medicine and pediatric hospitalists reviewed the literature to integrate core SDM concepts and processes and iteratively constructed a synthesized draft model. We then solicited broad SDM expert feedback on the draft model for validation and further refinement. The SDM 3 Circle Model identifies 3 core categories of variables that dynamically interact within an "environmental frame." The resulting Venn diagram includes overlapping circles for (1) patient/family, (2) provider/team, and (3) medical context. The environmental frame includes all external, contextual factors that may influence any of the 3 circles. Existing multistep SDM process models were then rearticulated and contextualized to illustrate how a shared decision might be made. The SDM 3 Circle Model accounts for important environmental and contextual characteristics that vary across settings. The visual emphasis generated by each "circle" and by the environmental frame direct attention to often overlooked interactive forces and has the potential to more precisely define, promote, and improve SDM. This model provides a framework to develop interventions to improve quality and patient safety through SDM and patient engagement for hospitalists.
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Affiliation(s)
- Stephanie Rennke
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Patrick Yuan
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Brad Monash
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca Blankenburg
- Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California, USA
| | - Ian Chua
- Division of Hospital Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine, Washington, DC, USA
| | - Stephanie Harman
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Debbie S Sakai
- Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California, USA
| | - Adeena Khan
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Joan F Hilton
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Lisa Shieh
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Jason Satterfield
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA.
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Larson C, O'Brien B, Rennke S. GeriWard Falls: An Interprofessional Team-Based Curriculum on Falls in the Hospitalized Older Adult. MedEdPORTAL 2016; 12:10410. [PMID: 31008190 PMCID: PMC6464557 DOI: 10.15766/mep_2374-8265.10410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 04/14/2016] [Indexed: 05/26/2023]
Abstract
INTRODUCTION Interprofessional (IP) collaboration is key in caring for older adults and a critical part of health professions education. Falls are a source of significant morbidity and mortality in older adults. GeriWard, an innovative curriculum, emphasizes IP collaboration during a clinical encounter with a hospitalized older adult. GeriWard Falls expands on the existing GeriWard curriculum, allowing medical, pharmacy, physical therapy, and nursing students to conduct a comprehensive falls risk evaluation at the bedside. METHODS The 2-hour exercise consists of participation in a team-based falls risk assessment at the bedside of a hospitalized older adult, development of a falls care plan and communication with the patient and primary inpatient physicians, and completion of clinical questions focused on systems-based interventions to reduce fall risk. RESULTS A total of 39 students participated in two sessions. Ninety-seven percent of students were likely to change their clinical activities as a result of the session. Faculty facilitators cited the students' ability to effectively collaborate, identify risk factors for falls, and propose systems-based interventions to reduce falls risk. Seventy-eight percent of primary inpatient physicians planned to implement at least one of the IP team recommendations; 89% agreed that the IP team recommendations were helpful. DISCUSSION The activity was engaging for students and helped them achieve competency with fall risk assessment. Communication of the students' assessment to the primary medical team not only was useful to the primary team but also helped students understand how systems can affect patient care.
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Affiliation(s)
- Claire Larson
- Assistant Clinical Professor of Medicine, University of California, San Francisco, School of Medicine
| | - Bridget O'Brien
- Associate Adjunct Professor, the Office of Medical Education, Research and Development in Medical Education, University of California, San Francisco, School of Medicine
| | - Stephanie Rennke
- Associate Clinical Professor of Medicine, Division of Hospital Medicine, University of California, San Francisco, School of Medicine
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Abstract
Hospitals are challenged with reevaluating their hospital's transitional care practices, to reduce 30-day readmission rates, prevent adverse events, and ensure a safe transition of patients from hospital to home. Despite the increasing attention to transitional care, there are few published studies that have shown significant reductions in readmission rates, particularly for patients with stroke and other neurologic diagnoses. Successful hospital-initiated transitional care programs include a "bridging" strategy with both predischarge and postdischarge interventions and dedicated transitions provider involved at multiple points in time. Although multicomponent strategies including patient engagement, use of a dedicated transition provider, and facilitation of communication with outpatient providers require time and resources, there is evidence that neurohospitalists can implement a transitional care program with the aim of improving patient safety across the continuum of care.
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Affiliation(s)
- Stephanie Rennke
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Sumant R. Ranji
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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Satterfield JM, Bereknyei S, Hilton JF, Bogetz AL, Blankenburg R, Buckelew SM, Chen HC, Monash B, Ramos JS, Rennke S, Braddock CH. The prevalence of social and behavioral topics and related educational opportunities during attending rounds. Acad Med 2014; 89:1548-57. [PMID: 25250747 PMCID: PMC4213280 DOI: 10.1097/acm.0000000000000483] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
PURPOSE To quantify the prevalence of social and behavioral sciences (SBS) topics during patient care and to rate team response to these topics once introduced. METHOD This cross-sectional study used five independent raters to observe 80 inpatient ward teams on internal medicine and pediatric services during attending rounds at two academic hospitals over a five-month period. Patient-level primary outcomes-prevalence of SBS topic discussions and rate of positive responses to discussions-were captured using an observational tool and summarized at the team level using hierarchical models. Teams were scored on patient- and learner-centered behaviors. RESULTS Observations were made of 80 attendings, 83 residents, 75 interns, 78 medical students, and 113 allied health providers. Teams saw a median of 8.0 patients per round (collectively, 622 patients), and 97.1% had at least one SBS topic arise (mean = 5.3 topics per patient). Common topics were pain (62%), nutrition (53%), social support (52%), and resources (39%). After adjusting for team characteristics, the number of discussion topics raised varied significantly among the four services and was associated with greater patient-centeredness. When topics were raised, 38% of teams' responses were positive. Services varied with respect to learner- and patient-centeredness, with most services above average for learner-centered, and below average for patient-centered behaviors. CONCLUSIONS Of 30 SBS topics tracked, some were addressed commonly and others rarely. Multivariable analyses suggest that medium-sized teams can address SBS concerns by increasing time per patient and consistently adopting patient-centered behaviors.
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Affiliation(s)
- Jason M Satterfield
- Dr. Satterfield is professor of clinical medicine, Division of General Internal Medicine, University of California, San Francisco, San Francisco, California. Dr. Bereknyei is a research scholar, Stanford Center for Medical Education Research and Innovation, Stanford University, Stanford, California. Dr. Hilton is professor, Division of Biostatistics, University of California, San Francisco, San Francisco, California. Ms. Bogetz is project coordinator, Division of General Internal Medicine, University of California, San Francisco, San Francisco, California. Dr. Blankenburg is clinical assistant professor, General Pediatrics, Stanford University, Stanford, California. Dr. Buckelew is associate clinical professor, Department of Pediatrics, University of California, San Francisco, San Francisco, California. Dr. Chen is professor, Department of Pediatrics, University of California, San Francisco, San Francisco, California. Dr. Monash is assistant professor, Division of Hospital Medicine, University of California, San Francisco, San Francisco, California. Ms. Ramos is program coordinator, Stanford Center for Medical Education Research and Innovation, Stanford University, Stanford, California. Dr. Rennke is assistant professor, Division of Hospital Medicine, University of California, San Francisco, San Francisco, California. Dr. Braddock is vice dean for medical education, University of California, Los Angeles, Los Angeles, California
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16
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Ranji SR, Rennke S, Wachter RM. Computerised provider order entry combined with clinical decision support systems to improve medication safety: a narrative review. BMJ Qual Saf 2014; 23:773-80. [DOI: 10.1136/bmjqs-2013-002165] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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17
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Tasaka CL, Burg C, VanOsdol SJ, Bekeart L, Anglemyer A, Tsourounis C, Rennke S. An interprofessional approach to reducing the overutilization of stress ulcer prophylaxis in adult medical and surgical intensive care units. Ann Pharmacother 2014; 48:462-9. [PMID: 24473490 DOI: 10.1177/1060028013517088] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Overutilization of stress ulcer prophylaxis (SUP) in the intensive care unit (ICU) is common. Acid-suppressive therapies routinely used for SUP are best reserved for patients with greatest risk of clinically important bleeding as they have been associated with nosocomial pneumonia, Clostridium difficile infection and increased hospital cost. OBJECTIVE The primary objective was to reduce inappropriate utilization of SUP in 2 adult medical and surgical ICU settings at the University of California, San Francisco Medical Center. Secondary objectives included reduction of inappropriate continuation of SUP at ICU and hospital discharge. METHODS To attain the study objective, an interprofessional team developed a bundled quality improvement initiative, including an institution SUP guideline, pharmacist-led intervention, and an education and awareness campaign. To assess the impact of these interventions, we conducted a retrospective cohort study comparing data on prescribing practices at baseline before and after the intervention. Since computerized prescriber order entry (CPOE) was implemented during this time frame, preintervention data collection consisted of 2 periods, one before and one after CPOE implementation. RESULTS The incidence of the inappropriate use of SUP was not significantly different between the pre-CPOE and post-CPOE groups (20 and 19 per 100 patient-days, respectively; P = .88), but the incidence of inappropriate use of SUP was significantly lower in the postintervention group versus the post-CPOE group (9 and 19 per 100 patient-days, respectively; P = .03). At ICU discharge, 4% of patients in the post-intervention group were discharged inappropriately on SUP compared with 8% in the post-CPOE group (P = .54). At hospital discharge, none of the patients in the postintervention group were discharged inappropriately on SUP compared with 7% in the post-CPOE group (P = .22). CONCLUSIONS Implementation of an interprofessional bundled quality improvement initiative is effective in decreasing inappropriate use of SUP in adult medical and surgical ICUs at a university-affiliated, tertiary care academic medical center.
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Rennke S, Nguyen OK, Shoeb MH, Magan Y, Wachter RM, Ranji SR. Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review. Ann Intern Med 2013; 158:433-40. [PMID: 23460101 DOI: 10.7326/0003-4819-158-5-201303051-00011] [Citation(s) in RCA: 167] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Hospitals now have the responsibility to implement strategies to prevent adverse outcomes after discharge. This systematic review addressed the effectiveness of hospital-initiated care transition strategies aimed at preventing clinical adverse events (AEs), emergency department (ED) visits, and readmissions after discharge in general medical patients. MEDLINE, CINAHL, EMBASE, and Cochrane Database of Clinical Trials (January 1990 to September 2012) were searched, and 47 controlled studies of fair methodological quality were identified. Forty-six studies reported readmission rates, 26 reported ED visit rates, and 9 reported AE rates. A "bridging" strategy (incorporating both predischarge and postdischarge interventions) with a dedicated transition provider reduced readmission or ED visit rates in 10 studies, but the overall strength of evidence for this strategy was low. Because of scant evidence, no conclusions could be reached on methods to prevent postdischarge AEs. Most studies did not report intervention context, implementation, or cost. The strategies hospitals should implement to improve patient safety at hospital discharge remain unclear.
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Affiliation(s)
- Stephanie Rennke
- University of California, San Francisco, San Francisco, California, USA.
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Shekelle PG, Wachter RM, Pronovost PJ, Schoelles K, McDonald KM, Dy SM, Shojania K, Reston J, Berger Z, Johnsen B, Larkin JW, Lucas S, Martinez K, Motala A, Newberry SJ, Noble M, Pfoh E, Ranji SR, Rennke S, Schmidt E, Shanman R, Sullivan N, Sun F, Tipton K, Treadwell JR, Tsou A, Vaiana ME, Weaver SJ, Wilson R, Winters BD. Making health care safer II: an updated critical analysis of the evidence for patient safety practices. Evid Rep Technol Assess (Full Rep) 2013:1-945. [PMID: 24423049 PMCID: PMC4781147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To review important patient safety practices for evidence of effectiveness, implementation, and adoption. DATA SOURCES Searches of multiple computerized databases, gray literature, and the judgments of a 20-member panel of patient safety stakeholders. REVIEW METHODS The judgments of the stakeholders were used to prioritize patient safety practices for review, and to select which practices received in-depth reviews and which received brief reviews. In-depth reviews consisted of a formal literature search, usually of multiple databases, and included gray literature, where applicable. In-depth reviews assessed practices on the following domains: • How important is the problem? • What is the patient safety practice? • Why should this practice work? • What are the beneficial effects of the practice? • What are the harms of the practice? • How has the practice been implemented, and in what contexts? • Are there any data about costs? • Are there data about the effect of context on effectiveness? We assessed individual studies for risk of bias using tools appropriate to specific study designs. We assessed the strength of evidence of effectiveness using a system developed for this project. Brief reviews had focused literature searches for focused questions. All practices were then summarized on the following domains: scope of the problem, strength of evidence for effectiveness, evidence on potential for harmful unintended consequences, estimate of costs, how much is known about implementation and how difficult the practice is to implement. Stakeholder judgment was then used to identify practices that were "strongly encouraged" for adoption, and those practices that were "encouraged" for adoption. RESULTS From an initial list of over 100 patient safety practices, the stakeholders identified 41 practices as a priority for this review: 18 in-depth reviews and 23 brief reviews. Of these, 20 practices had their strength of evidence of effectiveness rated as at least "moderate," and 25 practices had at least "moderate" evidence of how to implement them. Ten practices were classified by the stakeholders as having sufficient evidence of effectiveness and implementation and should be "strongly encouraged" for adoption, and an additional 12 practices were classified as those that should be "encouraged" for adoption. CONCLUSIONS The evidence supporting the effectiveness of many patient safety practices has improved substantially over the past decade. Evidence about implementation and context has also improved, but continues to lag behind evidence of effectiveness. Twenty-two patient safety practices are sufficiently well understood, and health care providers can consider adopting them now.
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Affiliation(s)
- Stephanie Rennke
- Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, CA 94143, USA
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Melman L, Cao ZF, Rennke S, Marzolo MP, Wardell MR, Bu G. High affinity binding of receptor-associated protein to heparin and low density lipoprotein receptor-related protein requires similar basic amino acid sequence motifs. J Biol Chem 2001; 276:29338-46. [PMID: 11382778 DOI: 10.1074/jbc.m103717200] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The 39-kDa receptor-associated protein (RAP) is a specialized chaperone for members of the low density lipoprotein receptor gene family, which also binds heparin. Previous studies have identified a triplicate repeat sequence within RAP that appears to exhibit differential functions. Here we generated a series of truncated and site-directed RAP mutants in order to define the sites within RAP that are important for interacting with heparin and low density lipoprotein receptor-related protein (LRP). We found that high affinity binding of RAP to heparin is mediated by the carboxyl-terminal repeat of RAP, whereas both the carboxyl-terminal repeat and a combination of amino and central repeats exhibit high affinity binding to LRP. Several motifs were found to mediate the binding of RAP to heparin, and each contained a cluster of basic amino acids; among them, an intact R(282)VSR(285)SR(287)EK(289) motif is required for high affinity binding of RAP to heparin, whereas two other motifs, R(203)LR(205)R(206) and R(314)ISR(317)AR(319), also contribute to this interaction. We also found that intact motifs of both R(203)LR(205)R(206) and R(282)VSR(285)SR(287)EK(289) are required for high affinity binding of RAP to LRP, with the third motif, R(314)ISR(317)AR(319), contributing little to RAP-LRP interaction. We conclude that electrostatic interactions likely contribute significantly in the binding of RAP to both heparin and LRP and that high affinity interaction with both heparin and LRP appears to require mostly overlapping sequence motifs within RAP.
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Affiliation(s)
- L Melman
- Department of Pediatrics Washington University School of Medicine, St. Louis, Missouri 63110, USA
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Abstract
The 39 kDa receptor-associated protein (RAP) is a receptor antagonist that interacts with several members of the low density lipoprotein (LDL) receptor gene family. Upon binding to these receptors, RAP inhibits all ligand interactions with the receptors. Our recent studies have demonstrated that RAP is an endoplasmic reticulum (ER) resident protein and an intracellular chaperone for the LDL receptor-related protein (LRP). The HNEL sequence at the carboxyl terminus of RAP represents a novel ER retention signal that shares homology with the well-characterized KDEL signal. In the present study, using immunoelectron microscopy we demonstrate that cells stably transfected with human growth hormone (GH) tagged with either KDEL (GH + KDEL) or HNEL (GH + HNEL) signals exhibit ER and cis-Golgi localization typical of ER-retained proteins. Overexpression of not only GH + HNEL but also GH + KDEL cDNA in transfected cells results in saturation of ER retention receptors and secretion of endogenous RAP indicating that the two signals interact with the same ER retention receptor(s). The role of RAP in the maturation of LRP is further supported by the observation that functional LRP is reduced about 60% as a result of decreased intracellular RAP. Pulse-chase labeling and immunolocalization studies of ERD2.1 and ERD2.2 proteins in transfected cells demonstrate a long half-life and Golgi localization for both receptors. Finally, overexpression of either ERD2.1 or ERD2.2 proteins significantly increases the capacity of cells to retain both KDEL and HNEL-containing proteins. Taken together, our results thus demonstrate that ERD2 proteins are capable of retaining the novel ER retention signal associated with RAP.
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Affiliation(s)
- G Bu
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri 63110, USA.
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Abstract
The 39-kDa receptor-associated protein (RAP) is a receptor antagonist that inhibits ligand interactions with the receptors that belong to the low density lipoprotein receptor gene family. Our previous studies have demonstrated that RAP interacts with the low density lipoprotein receptor-related protein (LRP) within the endoplasmic reticulum and prevents premature interaction of ligands with the receptor. To analyze whether RAP is also involved in the folding of LRP during receptor biosynthesis, we generated anchor-free, soluble minireceptors that represent each of the four putative ligand-binding domains of LRP (SLRP1, -2, -3, and -4, corresponding to the clusters with 2, 8, 10, and 11 cysteine-rich complement-type repeats, respectively). When these SLRPs were overexpressed by cell transfection, only SLRP1 was secreted. Little or no secretion was observed for SLRP2, -3, and -4. However, when RAP cDNA was cotransfected with SLRP2, -3, and -4 cDNAs, each of these SLRPs was secreted. The cellular retention of SLRPs in the absence of RAP coexpression appeared to be a result of the formation of SDS-resistant, oligomeric aggregates observed under nonreducing conditions. Such oligomers of the SLRPs likely resulted from formation of intermolecular disulfide bonds since they were reduced to monomers when analyzed under reducing conditions. The oligomers were formed not only among molecules of a given SLRP, but also between different SLRPs. The role of RAP in the process of LRP folding was shown by the reduction in aggregated SLRP oligomers upon RAP coexpression. A similar role of RAP in preventing the aggregation of newly synthesized receptor was also observed using membrane-containing minireceptor of LRP. Coimmunoprecipitation and ligand binding studies demonstrated that RAP binds avidly to SLRP2, -3, and -4, but not to SLRP1. These results suggest that these interactions may be important for proper folding of LRP by ensuring the formation of proper intradomain, but not intermolecular or interdomain, disulfide bonds. Thus, our results strongly suggest that, in addition to the prevention of premature binding of ligands to LRP, RAP also plays an important role in receptor folding.
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Affiliation(s)
- G Bu
- Edward Mallinkrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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