Resident-led Quality Improvement Project Research Articles

Resident-led improvement project to screen for primary hyperaldosteronism in patients with resistant hypertension in an outpatient clinic

Clinical practice guidelines recommend screening for primary hyperaldosteronism (PH) in patients with resistant hypertension. However, screening rates are low in the outpatient setting. We sought to increase screening rates for...

S1746 A Resident-Led Quality Improvement Project to Increased Internal Medicine Resident Comfort With Performing Timely Diagnostic Paracentesis

S1746 A Resident-Led Quality Improvement Project to Increased Internal Medicine Resident Comfort With Performing Timely Diagnostic Paracentesis

COVID-19 and practice transformation: Building an office-based opioid treatment program in a family medicine residency practice.

This brief report describes how a family medicine residency practice (FMRP) leveraged a resident-led quality improvement project and a grant-funded Addiction Integrated Care Team (AICT) to initiate an office-based opioid treatment (OBOT) program to provide medications for opioid use disorder during the COVID-19 pandemic. In 2020, the practice experienced four disruptors that shifted motivation for practice development: (a) The COVID-19 pandemic demanded rapid change in primary care processes/staffing, including pivoting to telehealth/remote practice. (b) The practice's transition to a federally qualified community health center model meant a shift in organizational priorities that required offering OBOT services. (c) External grant resources became available through the AICT program to support practice core for OBOT, and 10 implementation strategies were utilized. (d) A resident champion implemented an OBOT quality improvement project. These efforts resulted in the practice offering the OBOT program and 18 patients receiving OBOT from January 2020 to February 2021, with 10 of 18 patients engaged for 12 months or longer. Further, the cumulative adoption and reach from January 2020 through September 2022 was 15 faculty and 14 residents becoming prescribers and 101 patients served within the OBOT program, respectively. FMRPs striving for significant practice transformation, such as implementing an OBOT program during a pandemic, may benefit from synergistic guidance and resources including established theory, strategies from the implementation science literature, and resident-led quality improvement efforts. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Experiences with targeting inpatient advance care planning for emergency general surgery patients: A resident-led quality improvement project

BackgroundFor patients who may permanently or temporarily lose their ability to communicate preferences, advance care planning is a critical mechanism to guide medical decision-making but is currently underused among surgical patients. MethodsA resident-led quality improvement project, including education and performance measurement, was conducted on an emergency general surgery service to increase the completion of inpatient advance care planning notes using a specialized template in the electronic health record. Advance care planning documentation was defined as either preadmission advance care planning documentation (eg, advance directive) or inpatient advance care planning (use of the electronic health record template). Data from patients admitted to the emergency general surgery service for 12+ hours were analyzed, and baseline data (July 2020 to June 2021) were compared with data from the intervention period (July 2021 to June 2022). The chart review evaluated the content of the inpatient advance care planning documentation from the intervention period. ResultsThe frequency of inpatient advance care planning documentation increased (9.3%, n = 56 to 16.6%, n = 92, P < .001) with a greater contribution of inpatient advance care planning notes by the surgery team (16.7% to 55.4%) in the intervention period. Content analysis indicated that 79.0% of inpatient advance care planning notes listed preferences for life-sustaining therapy, 78.3% listed surrogacy, 57.3% listed overall health goals, and 50.3% listed treatment goals specific to the surgical encounter. ConclusionAlthough a resident-led quality improvement project contributed to greater adoption of standardized inpatient advance care planning documentation on an emergency general surgery service, progress was slow, and integration into standard work was not achieved. Future efforts are needed to better understand the integration of essential advance care planning elements into workflows and to establish inclusive educational programming to prepare all team members for conducting and documenting advance care planning conversations.

Getting Ahead: A Resident Led Quality Improvement Project to Increase Diabetic Nephropathy Screening in an Underserved Hispanic-Predominant Population.

Diabetes is the leading cause of end-stage renal disease (ESRD) in the United States (US), with 37 million having chronic kidney disease. Despite national guidelines recommendations for diabetic nephropathy screening with urine albumin-to-creatinine ratio (UACR), less than 50% receive full screening.Our Internal Medicine residents led a quality improvement project to increase diabetic nephropathy screening rate with UACR in our resident clinic by 50% in one academic year. We conducted the resident-led quality improvement project from July 2021 to April 2022. We reviewed the electronic medical records (EMR) from our clinic pre-intervention July 2020 to June 2021 and compared this to post intervention July 2021 to March 2022 determining the nephropathy screening rates in patients with diabetes. Our interventions included resident education, pre and post surveys to test foundational knowledge, adding UACR in the affordable laboratory order form and establishing normal reference range of UACR in the EMR. We collected 217 patients with diabetes, 27% were uninsured, 38% had Medicare/Medicaid and 90% identified as Hispanic. Comparing pre to post intervention, there was a significant change of 45 (20.7%) vs 71 (32.7%) patients screened for diabetic nephropathy with a UACR. The correct average score of knowledge-based questions was 82% on the pre survey, which increased to 88% in the post survey. Our study showed promising results on improving diabetic nephropathy screening. The comprehensive approach including resident education about diabetic nephropathy screening with UACR and more so facilitating the order set in the EMR were key to achieve this goal.

Improving Utilization of an After-Hours Phone Triage Service: A Resident Quality Improvement Initiative.

Phone triage systems are increasingly used by primary care clinics to improve patient satisfaction and direct low-acuity patients to appropriate care settings. Despite the prevalence of telephone triage, the majority of pediatric training programs do not include this practice in their curricula. Our aim was to increase the volume of after-hours patient phone calls per week by 25% and to secondarily reduce "treat and release" emergency department (ED) visits by 5% over the course of a 9-month quality improvement (QI) study. A resident-led QI project was conducted from 2017 to 2019 at a mixed faculty-resident pediatric primary care practice providing care for an urban, primarily immigrant, underserved population. Eight Plan-Do-Study-Act cycles were developed on the basis of identified key drivers and included efforts to increase the visibility of the call service to patient families. After-hours calls were tracked and compared with similar practices, and ED visits for the first week of each month were reviewed using the electronic medical record system. After promoting the service via various modalities, the number of after-hours calls increased by 30%, from an average of 6.5 calls per week to 8.5. Treat and release ED visits decreased by 6%, from a baseline of 64.3 to 60.3 visits per week. The increased patient awareness of and availability of a reliable after-hours call service in pediatric practices are promising tools for reducing unnecessary ED visits, leveraging resident direction and implementation to promote the service through varying modalities.

A Resident-Led QI Project to Improve Dental Health at a Primary Care Pediatric Practice.

Dental caries are the most common chronic condition of childhood and have significant medical, psychological, and financial consequences. The American Academy of Pediatrics (AAP) recommends primary care physicians apply fluoride varnish (FV) every 3 to 6 months from tooth emergence through age 5. Through a resident-led quality improvement (QI) project, we aimed to provide FV to 50% of patients ages 1 through 5 who did not have a dental visit in the preceding 6 months or receive FV elsewhere in the past month. From May 2017 through April 2018, we conducted 7 monthly plan-do-study-act cycles to improve our primary outcome measure (FV application), secondary outcome measure (percentage of patients who had routine dental care), and process measure (percentage of dental referrals). Balancing measures included time taken away from other clinical priorities and reimbursement rates. Fluoride varnish application improved from 3.6% to 44% with a 54% peak. The percentage of patients under 6 who had seen a dentist in the past 6 months increased from 30% to 47%. The percentage of dental referrals increased from 17% to 33%. Application of FV is a quick, cost-effective way for primary care providers to improve dental health. This resident-led QI project increased rates of FV application, dental referrals, and dental visits while meeting ACGME guidelines for experiential learning in QI. By adapting to state-specific guidelines and workflows of each clinic, this QI project could be nationally reproduced to improve adherence to AAP and United States Preventive Services Task Force guidelines.

Closing the Gap: A Resident-Led Quality Improvement Project to Improve Colorectal Cancer Screening in Primary Care Community Clinics.

Despite the prevalence and mortality associated with colorectal cancer (CRC), 67.4% of US adults aged 50 to 75 years received recommended screening tests in 2016. We created a quality improvement project in resident-run outpatient clinics to increase CRC screening rates to ≥ 50% from 2016 to 2018, with emphasis on vulnerable patient populations. We applied a comprehensive, multidisciplinary approach involving internal medicine and family medicine residents and staff from various hospital network departments, selecting 4 clinics to participate whose screening rates were below our network's average of 41%. Our intervention consisted of a needs assessment, resident-led educational sessions for clinicians, staff, and patients, use of fecal immunochemical tests as a first screening option, and application of care gap analysts at each clinic to answer patients' screening questions and to follow up regarding their screening status. We obtained approximately 100 patient surveys from each clinic, a 100% staff completion rate (68 of 68), and a 90% clinician completion rate (85 of 94). Staff and clinician surveys revealed concerns about reducing patient screening fears, inconsistent documentation of screening outcomes, and need for education about CRC prevention, early detection, and screening recommendations. Patient surveys revealed educational deficits and concerns about perceived screening obstacles (eg, transportation and insurance). While CRC screening rates increased across all participating clinics, one clinic experienced an increase from 23% to 48%. Our multitargeted approach in primary care residency practices yielded increased CRC screening rates in vulnerable patient populations.

Improving Care Transitions From Inpatient to Primary Care Pediatric Settings: A Resident-Led Quality Improvement Project

Background: Breakdowns in the coordination of care across the health care continuum, such as poor transition and miscommunication among providers, may cause confusion regarding treatment plans, duplicate testing, medication discrepancies, missed physician follow-up, and ultimately, fragmented care, patient dissatisfaction and even adverse patient outcomes. We aimed to identify gaps in the current transition of care process from pediatric inpatient to outpatient …

Improving Care Transitions From Inpatient to Primary Care Pediatric Settings: A Resident-Led Quality Improvement Project

Improving Care Transitions From Inpatient to Primary Care Pediatric Settings: A Resident-Led Quality Improvement Project

A Resident-Led Quality Improvement Project to Improve Obesity Recognition and Treatment within a Pediatric Continuity Clinic

BACKGROUND: Obesity now affects 1 in 6 children and adolescents in the United States and is a major risk factor for development of significant comorbidities in adolescence and adulthood, including hypertension, hyperlipidemia, diabetes, and cardiovascular disease. Within a pediatric continuity clinic, residents sought to improve clinical management of patients with obesity by aiming to improve rates of obesity recognition, nutritional counseling, offering of additional resources for support of lifestyle changes, and laboratory screening for comorbidities in accordance with American Academy of Pediatrics (AAP) guidelines …

A Resident-Led Quality Improvement Project to Improve Obesity Recognition and Treatment within a Pediatric Continuity Clinic

A Resident-Led Quality Improvement Project to Improve Obesity Recognition and Treatment within a Pediatric Continuity Clinic

Residents as Key Effectors of Change in Improving Opioid Prescribing Behavior

There is a national imperative to curb the flow of opioids into our communities. In academic medical centers, the majority of discharge opioid prescriptions are written by residents who receive predominantly ad hoc, peer-to-peer education on perioperative analgesia. We aimed to reduce opioid overprescribing after common general surgical operations through a resident led quality improvement project that involved formal educational interventions and feedback on prescribing habits. A transdisciplinary team was formed to identify how current prescribing habits differed from best practices, and to identify the educational needs to bridge this gap. We then focused on multiple educational interventions, including department-wide grand rounds, case-based conferences with residents, and dedicated didactic sessions on opioid prescribing. Feedback reports of opioid prescribing habits of the residents were developed. Residents' attitudes toward opioid prescribing were assessed using an anonymous survey before and after our interventions. Actual opioid prescribing data were abstracted from the electronic health record. A single academic medical center. A surgical resident led a transdisciplinary team consisting of faculty, anesthesiologists, pharmacists, advanced practice providers, and health informaticians within the Department of Surgery. After our educational intervention, residents' impression of the appropriate number of opioid pills necessary after common general surgical operations decreased significantly, as measured by surveys pre- and postintervention. Electronic health record data regarding actual opioid prescribing behavior show significant discrepancy from the survey responses, but does show a significant decrease in the quantity of opioids prescribed for most evaluated operations following the educational intervention. Opioid prescribing is an ideal target for resident led education and quality improvement. Residents' attitudes toward appropriate opioid prescribing tend to differ from actual prescribing habits. Our results demonstrate that a well-scoped, resident-driven quality improvement program can lead to change in both attitudes and practice surrounding opioid prescribing.

Standardization of Oncology Resident Handover Notes in Order to Improve Patient Safety

Communication errors are a leading cause of adverse events in healthcare. Resident handover notes are not standardized. This resident led quality improvement project aimed to produce a standardized patient handover note with goal of 100% compliance at 12 months. We implemented a standardized handover note using Advancing Safety for Patients in Residency Education (ASPIRE) sessions. In the first session the residents reviewed sample weekend and holiday handover notes with the ASPIRE attending. This was followed by take home project where the residents reviewed data elements that are crucial to a safe handover note. In the following ASPIRE session the residents used consensus based recommendations regarding data elements that were deemed essential in a handover document. The standardized handover document was distributed to all staff and off service residents. The intervention was evaluated by reviewing compliance over the first 10 months. Compliance with the standardized handover note was 75% in the first three months of implementation. Compliance was 100% in the most recent three months. The average compliance is 90% in the first 10 months. Patient code status was addressed on average 48% of the time. Patient location was stated on average 79% of the time. Using ASPIRE sessions we were able to produce a standardized handover note. Our aim was to reduce communication errors and improve patient safety. Compliance increased in the first 10 months. Code status and patient location can be further optimized. This project can be adapted at other programs to improve patient safety.

Meet your surgical team: The impact of a resident-led quality improvement project on patient satisfaction

BackgroundPatients often have an incomplete understanding of the levels of training and roles of the various surgical providers in teaching hospitals, leading to patient confusion and dissatisfaction. MethodsPre-intervention discharge surveys were administered to gastrointestinal surgery inpatients (10/2016–02/2017) to evaluate sentiments regarding their surgical team. During the intervention period (02/2017–05/2017), patients at admission received “facesheets” containing team member profiles, photos, training level, and roles. These patients were evaluated using the survey, and pre- and post-intervention scores compared. Results153 pre- and 100 post-intervention surveys were collected. There was a significant increase in patients reporting it was important to know the surgical team members and that they knew team member roles (p ≤ 0.05). Scores in every domain of the satisfaction survey improved in the post-intervention period, although not reaching statistical significance. ConclusionsImproving how patients perceive their interactions with their surgical team has implications on patient satisfaction and hospital quality metrics.

Impact of Quality Improvement on Care of Chronic Obstructive Pulmonary Disease Patients in an Internal Medicine Resident Clinic.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality. Guideline-discordant care of COPD is not uncommon. Further, there is a push to incorporate quality improvement (QI) training into internal medicine (IM) residency curricula. This study compared quality of care of COPD patients in an IM residents’ clinic and a pulmonary fellows’ clinic and, subsequently, the results of a quality improvement program in the residents’ clinic. Pre-intervention rates of quality measure adherence were compared between the IM teaching clinic (n = 451) and pulmonary fellows’ clinic (n = 177). Patient encounters in the residents’ teaching clinic after quality improvement intervention (n = 119) were reviewed and compared with pre-intervention data. Prior to intervention, fellows were significantly more likely to offer smoking cessation counseling (p = 0.024) and document spirometry showing airway obstruction (p < 0.001). Smoking cessation counseling, pneumococcal vaccination, and diagnosis of COPD by spirometry were targets for QI. A single-cycle, resident-led QI project was initiated. After, residents numerically improved in the utilization of spirometry (66.5% vs. 74.8%) and smoking cessation counseling (81.8% vs. 86.6%), and significantly improved rates of pneumococcal vaccination (p = 0.024). One cycle of resident-led QI significantly improved the rates of pneumococcal vaccination, with numerical improvement in other areas of COPD care.

The Importance of Standardization in Workflow Enhancement and Patient Safety

Continuous quality improvement is a priority of radiation oncology practice given the many complexities in the treatment process. Incident forms (IFs) are completed by caregivers who observe workflow or process flaws. Our workflow enhancement (WE) team reviews IFs related to radiation simulation procedures. A resident led quality improvement project was undertaken to standardize simulation request forms using templates based on common setups for each disease site. We examined IFs collected by our WE team to evaluate if introducing standardized templates resulted in a reduction of incidents. We identified the number of simulations performed in 2015 along with IF reports as recorded by our WE team preceding the implementation of standardized simulation request templates, and then again in 2016 after implementation of standardized templates. IFs were analyzed by type: informed consent (proper documentation or not), treatment setup (e.g., as respiratory management, mask, bolus, contrast, positioning, scan type or length), treatment modality (electrons, fields), treatment site (additional sites or wrong site marked on simulation request form), and miscellaneous (form not signed by physician, medication or scheduling error). A Chi-square analysis was utilized to evaluate for a reduction in reported IFs after implementation of standardized simulation templates. Overall, there were 2224 simulations completed in 2015 and 2241 in 2016. The number of IFs generated regarding simulation processes decreased from 68 in 2015 to 29 in 2016, for a relative decrease of 57% (p<0.0001). The reduction in IFs following utilization of standardized simulation request forms is summarized by type in Table 1 below:Abstract 3324; Table 1Process Related IFs20152016% changeTotal Incident Forms682957%Informed consent9367%Treatment setup331458%Treatment modality5340%Treatment site11645%Miscellaneous10370% Open table in a new tab Introduction of standardized simulation request templates resulted in a 57% reduction in the number of reported IFs. Continuous quality improvement processes can result in fewer errors potentially impacting patient care.

A resident-led quality improvement project evaluating patient outcomes following biopsy diagnosis of malignancy

A resident-led quality improvement project evaluating patient outcomes following biopsy diagnosis of malignancy

Validity and Reliability of a Tool to Assess Quality Improvement Knowledge and Skills in Pediatrics Residents.

Residency programs are expected to educate residents in quality improvement (QI). Effective assessments are needed to ensure residents gain QI knowledge and skills. Limitations of current tools include poor interrater reliability and requirement for scorer training. To provide evidence for the validity of the Assessment of Quality Improvement Knowledge and Skills (AQIKS), which is a new tool that provides a summative assessment of pediatrics residents' ability to recall QI concepts and apply them to a clinical scenario. We conducted a quasi-experimental study to measure the AQIKS performance in 2 groups of pediatrics residents: postgraduate year (PGY) 2 residents who participated in a 1-year longitudinal QI curriculum, and a concurrent control group of PGY-1 residents who received no formal QI training. The curriculum included 20 hours of didactics and participation in a resident-led QI project. Three faculty members with clinical QI experience, who were not involved in the curriculum and received no additional training, scored the AQIKS. Complete data were obtained for 30 of 37 residents (81%) in the intervention group, and 36 of 40 residents (90%) in the control group. After completing a QI curriculum, the intervention group's mean score was 40% higher than at baseline (P < .001), while the control group showed no improvement (P = .29). Interrater reliability was substantial (κ = 0.74). The AQIKS detects an increase in QI knowledge and skills among pediatrics residents who participated in a QI curriculum, with better interrater reliability than currently available assessment tools.

Let’s Talk About Sex: Improving the Adoption of Pre-exposure Prophylaxis by Internal Medicine Resident Physicians in New Orleans

BackgroundAn estimated 1.2 million adults in the US have an indication for pre-exposure prophylaxis (PrEP). However, the practice of prescribing PrEP by primary care providers (PCPs) continues to be low and ranges from 17–35% in recent studies. PCPs are best positioned to provide PrEP as a prevention tool before referral to an HIV specialist. New Orleans has the third highest incidence of HIV in the US; therefore, PCPs need to be adequately trained in providing PrEP. We implemented a resident-led quality improvement project to evaluate knowledge of PrEP and implement a training program to increase adoption of PrEP in internal medicine resident clinics.MethodsAn anonymous, online survey to assess PrEP knowledge and practices was conducted among resident and attending physicians in an internal medicine training program in New Orleans, Louisiana in 2017. We used SAS 9.4 for descriptive analyses and to evaluate variables associated with higher survey scores.ResultsWe received 111 responses out of 153 (72.5%) physicians invited to participate, 100/140 (71.4%) of resident physicians and 11/13 (84.6%) of attending physicians. 93.6% of respondents had heard of PrEP and 75.2% were aware of published guidelines. Few had discussed (41.4%) or prescribed (14.4%) PrEP with at least 1 patient and 62.5% of those prescribing had done so only within an infectious disease clinic rotation (Figure 1). 50 (45.9%) respondents reported only taking a sexual history when in relation to a patient’s chief complaint and 9 (8.3%) rarely asked about sexual history. Being unsure of patient eligibility, medication management, monitoring requirements and limitations in clinic were cited as barriers to adoption of PrEP (Figure 2). Respondents scored an average of 7.9 out of a possible 13 points (61%) regarding knowledge about PrEP based on CDC prescribing guidelines. There was a significant association between reported familiarity with PrEP (P < 0.01) and survey score.ConclusionFew internal medicine resident physicians who practice in New Orleans, a high-risk community for HIV, have experience prescribing PrEP, and there are opportunities to address gaps in knowledge that are the reported barriers to prescribing.Disclosures J. Halperin, Gilead Sciences: Investigator, Research grant