Summary: Residents at a New York hospital established a quality and patient safety organization with the support of hospital administration to help engage their peers in identifying and solving issues related to medication reconciliation, communication between administration and residents, and other safety concerns. The organization has made significant strides in addressing these issues, especially by improving communication among residents.
By Sarah Klein
Residents play a key role in patient care at academic medical centers. As trainees, they spend many hours in the hospital and have unique insights into problems that occur there. Yet, as the junior-most members of the medical team, they are not optimally involved in efforts to improve care. More frequently, hospital administrators, nurses, and attending physicians study the outcomes of care, assess root causes when adverse events occur, and develop corrective action plans as necessary. Resident input may not always be included in policy changes and as a result, residents may not be engaged in adopting these policy changes. To address these issues, the Accreditation Council for Graduate Medical Education and American Board of Medical Specialties have recommended that institutions engage residents more fully in quality improvement activities.
The Housestaff Quality Council (HQC) at the New York-Presbyterian Hospital/Weill Cornell Medical Center aims to improve patient care and safety by engaging residents in a culture of quality improvement and by enhancing communication between hospital administrators and clinical departments. The HQC also provides a vehicle to survey house staff attitudes and behaviors related to patient safety and to encourage best practices. Its mission statement is to "improve patient care and safety at New York-Presbyterian Hospital by creating a culture that promotes greater house staff participation."
New York-Presbyterian Hospital (NYPH) is a large academic medical center that consists of five main facilities, including two campuses with more than 2,298 beds. The medical center is affiliated with two medical schools: Weill Medical College of Cornell University and Columbia University College of Physicians and Surgeons. The campuses share a common electronic health record system, which has been customized to meet the needs of patient populations at NYPH's clinical sites.
NYPH has two house staff quality councils: one at New York-Presbyterian Hospital/Weill Cornell Medical Center and the other at NYPH's uptown campus, which is affiliated with Columbia University College of Physicians and Surgeons. This case study focuses solely on the HQC on the Weill Cornell campus.
The Housestaff Quality Council on the Cornell campus was founded in December 2007 by Peter M. Fleischut, M.D., and Adam S. Evans, M.D., M.B.A., two residents working in close collaboration with Gregory E. Kerr, M.D., M.B.A, the medical director of the cardiothoracic intensive care unit at the Weill Cornell campus, who came up with the idea for the council and continues to serve as its faculty advisor.
Its membership includes approximately 30 residents, representing each clinical department on the Weill Cornell campus. Departments with large numbers of residents, such as medicine, nominate more than one representative.
The leadership of the organization changes from year to year, as residents graduate. Each year, one resident serves as chair of the organization and another as vice-chair, with the expectation that the vice-chair will succeed the chair—a system that ensures the sustainability of the organization and continuity of programming as residents graduate and pursue other employment.
The HQC receives guidance and support from both Weill Cornell Medical College and the New York-Presbyterian Hospital. Its faculty advisor, who is employed by the medical school, provides guidance and mentoring, while the quality and patient safety administrator in the department of anesthesiology, Susan L. Faggiani, R.N., C.P.H.Q., serves as the quality and patient safety liaison to the Council. The hospital provides financial and administrative support (such as maintaining a listserv, creating flyers, and sending e-mails), as well as guidance. NYPH's division of quality and patient safety, which provides oversight of the organization, pays the HQC chair an annual stipend of $5,000 to compensate for his/her time and effort.
Origin and Development of the Council
In 2007, Fleischut and Evans, then residents in the anesthesiology program, approached Kerr about working on a project to improve the quality of care in the cardiothoracic intensive care unit based upon quality and patient safety trends they observed in the unit. The residents suggested using information technology such as the creation of dashboard to monitor trends. "I said we need something more basic. We need to change the culture of this place and the culture of the house staff – to engage them in quality improvement," says Kerr, who suggested the two form a council that would bring together representatives from every department to address hospital-wide problems.
The founders of the HQC liked the idea and presented a proposal to form such an organization to senior administrators of the hospital in December 2007, suggesting that the group could help engage residents in quality improvement, information dissemination, and enforcement of policy changes. The organization was quickly approved by NYPH. By April 2008, its leaders had developed a strategic plan and held the group's first meeting. The HQC continues to meet monthly for one-hour meetings.
The HQC began to focus on solving problems that had broad appeal to residents from a wide range of departments. To ensure ongoing interest in the group, its leaders also felt it would be important to select projects with a reasonable chance of success. Our goal is "showing it's really possible to make change," Fleischut says.
In less than two years, the group had developed educational programs targeting safety priorities, and made progress increasing rates of medication reconciliation for hospital patients and reducing use of paper-based laboratory orders,
To develop and implement solutions to these problems, members of the HQC worked closely with liaisons from the hospital, including representatives from quality and patient safety, communications, infection control, and information technology, as well as performance improvement specialists employed by the hospital, often suggesting unique approaches to problems that have resisted other solutions. The residents "have come up with some incredibly creative solutions to some safety concerns we have," says Eliot J. Lazar, M.D., M.B.A., senior vice-president and chief quality and patient safety officer of NYPH. "They also serve as an extraordinarily good conduit for sharing information with house staff more broadly," he says.
Finding methods of getting the attention and input of busy residents is a key feature of the group's strategy. Residents who serve on the council are expected to relay the details of the council's initiatives to colleagues within their own departments, and distribute materials the HQC has developed to inform residents of pressing issues. The group also relies on alphanumeric paging, poster boards, and a once-a-month e-mail alert, which succinctly summarize key issues for residents. By using this multi-modal peer-to-peer approach to communication, the group has been able to convey messages effectively and efficiently. HQC's medication reconciliation project—its first project—is a good example.
NYPH sought input from the resident's group to improve the rate of medication reconciliation. The rate of medication reconciliation at the Weill Cornell campus was then below target for patients who were hospitalized. The HQC recommended that the NYPH's electronic health record system be modified to provide residents with a series of reminders of the need to perform medication reconciliation, beginning six hours after a patient's admission. If the reconciliation did not occur within 18 hours of admission, the residents suggested that the hospital's system institute a "hard stop," which would prevent a physician from writing another order until the reconciliation was performed. The hospital's paging system would notify house staff carrying pagers of the creation of the hard stop and the importance of complying with medication reconciliation.
Because the residents had suggested the change and communicated its importance to other residents, the introduction of a hard stop generated little to no resistance. "If you tell them there are these significant events, here's the data, and this is why we are working on this, they are much more likely to buy-in and disseminate that to their peers," Fleischut says.
Within two months of the intervention, the rate of medication reconciliation at the Weill Cornell campus was 97 percent, up from a baseline rate of 48 percent (Exhibit 1). At six months, the rate remained at 96 percent. "That was our first big win in terms of being able to demonstrate a measurable change within a quick period of time," Fleischut says.
The success of the medication reconciliation initiative impressed the administration as well. "We might have come up with the same thing, but I think they embraced it and therefore it happened much more quickly than if we had suggested it," Lazar says.
The organization then turned its focus to dosing of narcotics—at the recommendation of residents of the anesthesiology department. They began with a review of Dilaudid (hydromorphone) prescriptions by residents and found that lower dosing ranges (e.g 0.2 -0.8 mg) were prescribed less frequently than doses of 1 and 2 mg, doses that are more typical for morphine, a drug that is less potent than Dilaudid.
The HQC then recommended employing an information campaign to educate residents about the differences between the two drugs and explain that while a dose of 1-2 mg of Dilaudid might be indicated under certain circumstances (i.e. in the care of patients with sickle cell anemia), smaller doses were often effective for other types of pain. The residents also encouraged the hospital to add an alert to the electronic health record system about the drugs and change doses available for each drug to avoid confusion. Finally, the council highlighted the issue in a monthly e-mail, which was sent to inform residents about these new recommendations. With this campaign, the rate of 0.8-2 mg doses dropped by 50 percent and the rate of 0-0.2 mg doses increased by 50 percent (Exhibit 2).
Combining notices of quality and patient safety issues in a single, monthly e-mail was critical to the organization's success, Fleischut says. "We said once a month we are going to send one e-mail and that e-mail will have some key information you need to know, such as central line checklist information, access to rapid response teams, and vaccination information."
In February 2009 the HQC, partnering with the departments of pathology and nursing, sought to reduce the use of paper-based laboratory orders after discovering that 700,000 paper-based requisitions were generated each year for laboratory work. The paper-based requests were handwritten, cost more to execute, and delayed performance of tests because they required a staff person to input the order into the electronic health records so that it could be processed. To gain the attention of residents, the HQC conveyed to residents that electronic laboratory orders benefit everyone—including residents. "No one wants to change their workflow, but if you can show them how it works to everyone's benefit…if you explain to them you can get your labs back faster…" they will stop doing it. Indeed, within eight months, the rate of paper-based orders from the intensive care unit dropped by 75 percent.
To generate interest in the group and awareness of its efforts, the council hosts an annual event to welcome new residents. At that event, the group launched a patient safety awareness campaign that focused on 10 potential medical errors that new house staff need to avoid. Members of the council attached their names to fictionalized descriptions of these errors, which helped to draw attention to them. "They …are fictionalized, but frankly the kind of situation that every house officer could find themselves in," Lazar says.
In many ways the HQC's first projects represent low-hanging fruit. That was purposeful. The projects served as a means of demonstrating the potential effectiveness of the group to solve problems, says Evans, the council's co-founder. The discipline of the group, and its willingness to measures its results and hold itself accountable to those results, increased the willingness of the institution to support the group. "It was a very organized, data-driven, professional approach that was bent on demonstrating improvement, collegiality, and teamwork," Evans says.
As result, the group forged relationships with staff in departments across the hospital. "There's a lot more collaboration between the house staff and various clinical departments," Fleischut says. For example, the HQC worked with the information technology department to change order sets. "The leadership of the council now knows how to get those done and expedited," he says. The group's ties to the hospital's quality improvement department are even stronger. The chair of the HQC at the Weill Cornell campus and the chair of the HQC at the Columbia campus now are welcome to attend weekly meetings of NYPH's quality and patient safety officers. In fact, the hospital has established the position of resident quality & patient safety officer, which is given to the HQC chair from each campus. "They have an equal seat at the table," Lazar says. "We respect their opinion. They have a tremendous amount to offer."
The HQC monitors the impact of its initiatives in multiple ways. It tests not only whether the intervention addresses the identified problem, as noted above, but it also measures to what extent residents absorb the message. When e-mail alerts are sent to residents, it monitors the percentage of residents in each department who read the alert and this information is trended.
To gauge the impact of this program on residents' attitudes and behavior, the organization is using a Safety Attitudes Survey developed by J. Bryan Sexton, Ph.D., at the Duke University Health System. "We wanted to try and find out…if we are reaching out to everyone," Fleischut says. "The initial responses …basically showed that the house staff was really neutral in regards to quality and patient safety and weren't very engaged in the process, which we were kind of expecting. That was our baseline," Fleischut says. Data are collected in 9-month intervals. "We hope to see an improvement in the attitudes of house staff in relation to quality and patient safety matters," he says.
The HQC at the NYPH demonstrates the effectiveness of harnessing the untapped resource of medical residents and the validity of the approach. Giving residents a proactive role in quality improvement has the potential to improve care and engage residents in quality improvement even after their residencies are complete.
The HQC has highlighted the important role of residents play in quality and patient safety among the leaders of NYPH. Not only do administrators value their input, they compete to present to the group at meetings.
Achieving this culture required significant institutional support, which was critical to persuading residents that hospital leadership took their concerns and suggestions seriously. Anyone considering replicating this program in a hospital must ensure the hospital "gives it the appropriate recognition and gravitas within the institution," Lazar says. At NYPH, the HQC reports annually to the quality and performance improvement committee of the board of trustees, which enhances its credibility and increases accountability, Evans says.
Success also requires institutions to ensure they identify and encourage residents interested in quality improvement. Given the natural turnover in residency programs, finding residents with a high level of interest and motivation is essential to launching and sustaining such efforts. Some residents may be drawn to the opportunity to publish the results of their work. Others may desire the benefit of quality improvement training. For residents who choose to engage in quality improvement programs, it can be professionally rewarding. Serving as the vice-chair and chair of HQC amounted to an apprenticeship in leadership and quality improvement for Fleischut, who has finished his residency and is now a deputy quality & patient safety officer for NYPH's division of quality and patient safety, as well as an attending physician.
Fleischut believes there's no shortage of residents like him. "We have people coming to the institution with master's in public health, public policy, and M.B.A.s. I think it provides an opportunity and a venue for people to utilize those degrees," Fleischut says.
For Further Information: Peter M. Fleischut, MD, assistant professor of anesthesiology, Weill Cornell Medical College and deputy quality and patient safety officer at New York-Presbyterian Hospital, [email protected]
A. S. Evans, E. J. Lazar, V. L. Tiase et al., The Role of Housestaff in Implementing Medication Reconciliation on Admission at an Academic Medical Center, American Journal of Medical Quality, published online May 25, 2010.
This study was based on publicly available information and self-reported data provided by the case study institution(s). The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund’s case studies series is not an endorsement by the Fund for receipt of health care from the institution.
The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied institutions’ experience that will be helpful in their own efforts to become high performers. It is important to note, however, that even the best-performing organizations may fall short in some areas; doing well in one dimension of quality does not necessarily mean that the same level of quality will be achieved in other dimensions. Similarly, performance may vary from one year to the next. Thus, it is critical to adopt systematic approaches for improving quality and preventing harm to patients and staff.