Background: The American College of Graduate Medical Education requires resident involvement in patient safety and quality improvement (PS/QI) but it remains difficult to engage house officers (HOs) in meaningful and sustainable projects. In 2011, the University of Michigan created a multidisciplinary committee called the House Officer Quality and Safety Council (HOQSC). The goal of the HOQSC is to increase direct involvement of HOs in multidisciplinary institutional PS/QI work and leverage institutional resources to support those initiatives. Our hospital’s 2014-2015 Patient Safety Plan identified hand over improvement, particularly HO sign out, as a critical safety priority and the HOQSC took ownership of this task.
Purpose: This report aims to demonstrate the HOQSC’s successful evaluation of an institutional problem and implementation of an impactful PS/QI initiative.
Description: In March 2015, the HOQSC queried all HOs on hand over safety using a subset of questions from the Agency for Healthcare Research and Quality (AHRQ) Hospital Safety Culture survey and open-ended questions regarding satisfaction with and usability of our existing electronic medical record (EMR) sign out tools. Safety specific concerns identified were: variable functionality of the multiple tools, lack of standardization of tools used across services, limited user control over the amount and accuracy of free text and auto-populated information, inability to simultaneously view the chart and update the tools, format of the printed sign out, and lack of designated space for consultant sign out. Additionally, many services were using tools outside of the EMR (e.g. email) which risk HIPPA non-compliance. HOQSC representatives presented the findings to an institutional PS/QI committee where hospital leaders agreed to endorse and allocate resources to this project.
EMR specialists and HOs reviewed the survey results and deemed that existing options in our EMR were insufficient to address the concerns. HOs from medical and surgical specialties brainstormed with colleagues about an ideal sign out template for their service. Representatives then met and formed a consensus on layout and content of the tool. An alternative tool was found, added to our EMR platform and tailored to HOs recommendations. The final product contains a mix of pre-populated patient information and free text areas allowing the tool to be modified for individual services. It can be edited while viewing the patient chart to facilitate accuracy of information. Every service, including consultants, has access to a unique space for their sign out. User acceptance testing was performed to vet the design and dissemination of education around its use was done through email and peer-to-peer education. Since its launch, at least 25 services use the tool daily. HOs will be surveyed again this Spring to evaluate for improved satisfaction and continued enhancements are made to the tool to facilitate safer sign out of patient information.
Conclusions: The HOQSC is a valuable asset for the evaluation of institutional patient safety issues and engaging HOs in impactful PS/QI work to improve safety and efficiency of patient care workflow.
As public and private stakeholders demand higher quality of care in the hospital setting, hospitalists play a critical role in leading performance improvement. As hospitalists seek ways to improve quality and lower costs, malnutrition among hospitalized patients – particularly older adults – offers a prime opportunity. Evidence suggests that 20-50% of patients are at-risk for or are malnourished at hospital admission (Barker et al., 2011), but only 7% are diagnosed by medical providers (Weiss et al., 2016). In turn, malnutrition is associated with higher rates of infection, pressure ulcers, length of stay and readmissions, leading to hospital costs of $42 billion annually (Weiss et al., 2016).
To address malnutrition care gaps, Avalere and the Academy of Nutrition and Dietetics established the Malnutrition Quality Improvement Initiative (MQii), a multi-stakeholder effort to identify tools to support hospital-based care teams in improving malnutrition quality standards. Given the multidisciplinary nature of malnutrition care, hospitalists are centrally positioned to deploy these tools for quality improvement (QI) efforts.
Hospitalists are critical to ensure timely malnutrition diagnosis, care plan implementation, and care transition to next-in-line providers. The MQii interdisciplinary malnutrition Toolkit was designed to help clinicians reduce clinical practice variability in malnutrition care and advance evidence-based, patient-driven care for malnourished or at-risk hospitalized older adults.
The Toolkit and related resources were tested in a three-month intervention at Vanderbilt University Medical Center (VUMC). Additionally, 5 Learning Collaborative sites implemented it with limited support to reflect real-world circumstances. At the pilot’s conclusion, VUMC found that the Toolkit successfully improved malnutrition care (Table 1).
To accompany the Toolkit, 4 electronic clinical quality measures (eCQMs) evaluating malnutrition screening, assessment, care plan development, and diagnosis rates were created to assess malnutrition care quality provided by the multidisciplinary care team. The eCQMs offer care teams the ability to identify where care gaps remain and when they have successfully implemented best practices.
Hospitalists are increasingly held accountable for achievement of performance measures to demonstrate the value of care they provide. As malnutrition is an often overlooked risk factor, hospitalists can use the MQii Toolkit and eCQMs to help attain patient safety, patient engagement/satisfaction and resource use targets through clinical performance improvement and optimize patients’ chance at rapid recovery.