An evaluation of a medical student international service-learning experience in Southeast Asia.

Background: International service-learning trips (ISLTs) are structured experiences in a different country where students interact and engage in cross-cultural dialog with others. Month-long ISLTs originating from North American or European medical schools enhance clinical acumen, cultural awareness, and global health familiarity. The impact of experiences shorter than 1 month or those that originate from Asia is unknown. We aimed to determine the impact of a short-term ISLT on medical students' clinical and cultural competence. Methods: At Duke-National University Singapore, we developed an ISLT incorporating peer-assisted learning and a 1-week on-site experience delivering supervised primary care, health screening, and health education in an underserved Southeast Asian community. Using a prospective controlled design, we assessed its impact on medical students' clinical and cultural competency using validated surveys. We compared medical students who participated in the ISTL (intervention group) to a control group of students before and after the ISTL experience. We analyzed responses using univariate analysis and the Kruskal-Wallis test. Results: : Sixty-six students responded to the survey (100%). After the ISTL, the intervention group (n = 32) showed an increase in their ratings of clinical competency (preexperience mean = 3.39, postexperience mean = 3.81, P < 0.01) as well as an increase in their cultural competency domains (preexperience mean = 3.61, postexperience mean = 4.12, P < 0.01). Post the ISTL, students in the intervention group rated their clinical and cultural competency higher than the control group (n = 34) (clinical: intervention postexperience mean = 3.81, control postexperience mean = 3.30, P < 0.01; cultural: intervention postexperience mean = 4.12, control postexperience mean = 3.50, P < 0.01). After the ISTL, the intervention group reported increased ratings of self-efficacy (pre mean = 3.99, post mean = 4.29, P = 0.021), which were higher than the control group (pre mean = 4.29, post mean = 3.57, P < 0.01). Discussion: : This short-term ISLT in an Asian medical school improved students' clinical and cultural competency and self-efficacy. Our findings suggest a positive impact of short-term ISLTs if designed and implemented with a student learning focus.

Engaging GME Learners in Health System-Aligned Improvement Work in the Clinical Learning Environment.

Alignment between graduate medical education (GME) and health system priorities is foundational to meaningful engagement of residents and fellows in systems improvement work within the clinical learning environment. The Residents and Fellows Leading Interprofessional Continuous Improvement Teams program at the University of California San Francisco was designed over a decade ago to address barriers to trainee participation in health system-based improvement work. The program provides structure and support for health system-aligned trainee-led improvement projects in the clinic learning environment. Project champions (residents/fellows) from GME programs attend workshops where they learn improvement methodologies and develop proposals for health system-based improvement projects for their training programs. Proposals are supported by local faculty mentors and are reviewed and approved by GME and health systems' leaders. During the academic year, teams share their progress using visual management boards and interactive leader rounds. The health system provides a modest financial incentive for successful projects. Since the program's inception, thousands of trainees from 58 residency and fellowship programs have participated either as champions or participants in the program at least once, and in total over 300 projects have been implemented. Approximately three-quarters of the specific improvement goals were met, all projects meaningfully engaged residents and fellows, and many projects continued after the learners graduated. This active partnership between GME and a health system created a symbiotic relationship; trainees received education and support to complete improvement projects, while the health system reaped additional benefits from the alignment and impact of the projects. This partnership continues to grow with steady increases in participating programs, spread to partner health systems, and scholarship for trainees and faculty.

Inability of providers to predict unplanned readmissions.

BACKGROUND: Readmissions cause significant distress to patients and considerable financial costs. Identifying hospitalized patients at high risk for readmission is an important strategy in reducing readmissions. We aimed to evaluate how well physicians, case managers, and nurses can predict whether their older patients will be readmitted and to compare their predictions to a standardized risk tool (Probability of Repeat Admission, or P(ra)). METHODS: Patients aged ≥ 65 discharged from the general medical service at University of California, San Francisco Medical Center, a 550-bed tertiary care academic medical center, were eligible for enrollment over a 5-week period. At the time of discharge, the inpatient team members caring for each patient estimated the chance of unscheduled readmission within 30 days and predicted the reason for potential readmission. We also calculated the P(ra) for each patient. We identified readmissions through electronic medical record (EMR) review and phone calls with patients/caregivers. Discrimination was determined by creating ROC curves for each provider group and the P(ra). RESULTS: One hundred sixty-four patients were eligible for enrollment. Of these patients, five died during the 30-day period post-discharge. Of the remaining 159 patients, 52 patients (32.7%) were readmitted. Mean readmission predictions for the physician providers were closest to the actual readmission rate, while case managers, nurses, and the P(ra) all overestimated readmissions. The ability to discriminate between readmissions and non-readmissions was poor for all provider groups and the P(ra) (AUC from 0.50 for case managers to 0.59 for interns, 0.56 for P(ra)). None of the provider groups predicted the reason for readmission with accuracy. CONCLUSIONS: This study found (1) overall readmission rates were higher than previously reported, possibly because we employed a more thorough follow-up methodology, and (2) neither providers nor a published algorithm were able to accurately predict which patients were at highest risk of readmission. Amid increasing pressure to reduce readmission rates, hospitals do not have accurate predictive tools to guide their efforts.

Potential unintended consequences due to Medicare's "no pay for errors" rule? A randomized controlled trial of an educational intervention with internal medicine residents.

BACKGROUND: Medicare has selected 10 hospital-acquired conditions for which it will not reimburse hospitals unless the condition was documented as "present on admission." This "no pay for errors" rule may have a profound effect on the clinical practice of physicians. OBJECTIVE: To determine how physicians might change their behavior after learning about the Medicare rule. DESIGN: We conducted a randomized trial of a brief educational intervention embedded in an online survey, using clinical vignettes to estimate behavioral changes. PARTICIPANTS: At a university-based internal medicine residency program, 168 internal medicine residents were eligible to participate. INTERVENTION: Residents were randomized to receive a one-page description of Medicare's "no pay for errors" rule with pre-vignette reminders (intervention group) or no information (control group). Residents responded to five clinical vignettes in which "no pay for errors" conditions might be present on admission. MAIN MEASURES: Primary outcome was selection of the single most clinically appropriate option from three clinical practice choices presented for each clinical vignette. KEY RESULTS: Survey administered from December 2008 to March 2009. There were 119 responses (71%). In four of five vignettes, the intervention group was less likely to select the most clinically appropriate response. This was statistically significant in two of the cases. Most residents were aware of the rule but not its impact and specifics. Residents acknowledged responsibility to know Medicare documentation rules but felt poorly trained to do so. Residents educated about the Medicare's "no pay for errors" were less likely to select the most clinically appropriate responses to clinical vignettes. Such choices, if implemented in practice, have the potential for causing patient harm through unnecessary tests, procedures, and other interventions.

I-CaRe: a case review tool focused on improving inpatient care.

I-CaRe, an inpatient case review tool that walks individual physician reviewers through the details of a patient case, facilitates the collection and assessment of quality and safety data both for internal quality improvement initiatives and external reporting.

Factors associated with intern fatigue.

BACKGROUND: Prior data suggest that fatigue adversely affects patient safety and resident well-being. ACGME duty hour limitations were intended, in part, to reduce resident fatigue, but the factors that affect intern fatigue are unknown. OBJECTIVE: To identify factors associated with intern fatigue following implementation of duty hour limitations. DESIGN: Cross-sectional confidential survey of validated questions related to fatigue, sleep, and stress, as well as author-developed teamwork questions. SUBJECTS: Interns in cognitive specialties at the University of California, San Francisco. MEASUREMENTS: Univariate statistics characterized the distribution of responses. Pearson correlations elucidated bivariate relationships between fatigue and other variables. Multivariate linear regression models identified factors independently associated with fatigue, sleep, and stress. RESULTS: Of 111 eligible interns, 66 responded (59%). In a regression analysis including gender, hours worked in the previous week, sleep quality, perceived stress, and teamwork, only poorer quality of sleep and greater perceived stress were significantly associated with fatigue (p < 0.001 and p = 0.02, respectively). To identify factors that may affect sleep, specifically duty hours and stress, a secondary model was constructed. Only greater perceived stress was significantly associated with diminished sleep quality (p = 0.04), and only poorer teamwork was significantly associated with perceived stress (p < 0.001). Working >80 h was not significantly associated with perceived stress, quality of sleep, or fatigue. CONCLUSIONS: Simply decreasing the number of duty hours may be insufficient to reduce intern fatigue. Residency programs may need to incorporate programmatic changes to reduce stress, improve sleep quality, and foster teamwork in order to decrease intern fatigue and its deleterious consequences.

A multidisciplinary teamwork training program: the Triad for Optimal Patient Safety (TOPS) experience.

INTRODUCTION: Communication and teamwork failures are a common cause of adverse events. Residency programs, with a mandate to teach systems-based practice, are particularly challenged to address these important skills. AIM: To develop a multidisciplinary teamwork training program focused on teaching teamwork behaviors and communication skills. SETTING: Internal medicine residents, hospitalists, nurses, pharmacists, and all other staff on a designated inpatient medical unit at an academic medical center. PROGRAM DESCRIPTION: We developed a 4-h teamwork training program as part of the Triad for Optimal Patient Safety (TOPS) project. Teaching strategies combined didactic presentation, facilitated discussion using a safety trigger video, and small-group scenario-based exercises to practice effective communication skills and team behaviors. Development, planning, implementation, delivery, and evaluation of TOPS Training was conducted by a multidisciplinary team. PROGRAM EVALUATION: We received 203 evaluations with a mean overall rating for the training of 4.49 +/- 0.79 on a 1-5 scale. Participants rated the multidisciplinary educational setting highly at 4.59 +/- 0.68. DISCUSSION: We developed a multidisciplinary teamwork training program that was highly rated by all participating disciplines. The key was creating a shared forum to learn about and discuss interdisciplinary communication and teamwork.

Understanding Singaporean medical students' stress and coping.

Medical school is intrinsically stressful, and high levels of stress have untoward effects. Although surveys have revealed some sources of stress among medical students, little is known about the qualitative aspects of these stressors and their associated coping behaviours, particularly among medical students in Singapore. Our exploratory pilot study found that relationship issues and examinations were the major sources of stress for medical students. The respondents described multiple context-sensitive coping styles, as well as reported 'avoidance' or 'wishful thinking' coping strategies as ineffective. Their stress-and-coping process suggests the influence of Asian culture and medical school culture. Our findings thus indicate the need for further research, potentially using new methodologies such as the critical incident analysis technique, and thoughtful consideration of culture when implementing programmes in Singapore medical schools to improve the students' stress-and-coping responses.

The impact of duty hours on resident self reports of errors.

BACKGROUND: Resident duty hour limitations aim, in part, to reduce medical errors. Residents' perceptions of the impact of duty hours on errors are unknown. OBJECTIVE: To determine residents' self-reported contributing factors, frequency, and impact of hours worked on suboptimal care practices and medical errors. DESIGN: Cross-sectional survey. SUBJECTS: 164 Internal Medicine Residents at the University of California, San Francisco. MEASUREMENTS AND RESULTS: Residents were asked to report the frequency and contributing factors of suboptimal care practices and medical errors, and how duty hours impacted these practices and aspects of resident work-life. One hundred twenty-five residents (76%) responded. The most common suboptimal care practices were working while impaired by fatigue and forgetting to transmit information during sign-out. In multivariable models, residents who felt overwhelmed with work (p = 0.02) and who reported spending >50% of their time in nonphysician tasks (p = 0.002) were more likely to report suboptimal care practices. Residents reported work-stress (a composite of fatigue, excessive workload, distractions, stress, and inadequate time) as the most frequent contributing factor to medical errors. In multivariable models, only engaging in suboptimal practices was associated with self-report of higher risk for medical errors (p < 0.001); working more than 80 hours per week was not associated with suboptimal care or errors. CONCLUSION: Our findings suggest that administrative load and work stressors are more closely associated with resident reports of medical errors than the number of hours work. Efforts to reduce resident duty hours may also need to address the nature of residents' work to reduce errors.

Where to go if not the hospital? Reviewing geriatric bed utilization in an acute care hospital in Singapore.

AIM: Singapore is one of the fastest-aging countries in the world, and the demand for acute hospital care for older adults is expected to triple in the next 25 years. Hence, it is crucial to understand the opportunities in reducing potentially avoidable bed days (PABD), which are days spent in acute hospitals delivering only non-acute services. We aimed to access the prevalence, causes and consequences of PABD among geriatric patients. METHODS: We examined all hospitalizations from 1 August through 31 December 2013 in the geriatric wards of an acute hospital in Singapore. PABD were identified using a modified Appropriateness Evaluation Protocol. Non-acute services were classified as subacute care, rehabilitative care, long-term care or social care. Hospitalization patterns were determined based on the presence or absence of non-acute services, and multinomial logistic regression was used to determine predictors of different patterns. RESULTS: Of the 273 bed days used by 254 patients, 49% were potentially avoidable. The most common non-acute services provided were rehabilitative care (19%), subacute care (12%) and long-term care (8%). New acute issues arose after the admission conditions subsided in 2.4% of hospitalizations, 61% of which were nosocomial infections. Being socially at risk as assessed on admission predicted the development of new acute issues (sensitivity = 62%; specificity = 88%). CONCLUSIONS: In the present study, almost half of the bed days were potentially avoidable. New acute issues can arise after PABD, which are dangerous to these frail older adults. Proactive discharge planning and increasing access to intermediate and long-term care services are required to reduce PABD. Geriatr Gerontol Int 2017; 17: 1575-1583.

Impact of reduced duty hours on residents' educational satisfaction at the University of California, San Francisco.

PURPOSE: To assess the impact of the Accreditation Council for Graduate Medical Education duty-hour limitations on residents' educational satisfaction. METHOD: In 2003, the authors surveyed 164 internal medicine residents at three clinical training sites affiliated with the University of California, San Francisco, after system changes were introduced to reduce duty hours. On a questionnaire that used various rating scales, residents reported the value of educational activities, frequency of administrative tasks interfering with education, and educational satisfaction after duty hours were reduced. The authors compared univariate statistics and developed multivariable models to discern the relationship between hours worked and educational outcomes. RESULTS: In all, 125 residents (76%) responded. Residents rated the educational activities, morning report, and teaching others most highly. Answering pages and tasks related to scheduling were the most frequent barriers to educational activities. Residents reported that time spent in administrative activities did not change after duty-hour restrictions, and 68% said that decreased duty hours had no impact or a negative impact on education. In multivariable models, postgraduate year (PGY)-1 residents (p = .004), residents who reported feeling overwhelmed at work (p < .0001), and residents who reported working more than 80 hours per week (p < .05) had lower work satisfaction. However, only PGY-1 residents (p < .05) and those who felt overwhelmed with work (p = .01) were less satisfied with their education. CONCLUSIONS: In this residency program, duty-hour reduction did not improve educational satisfaction. Educational satisfaction may be more a function of workload than hours worked; therefore, systematic changes to residents' work-life may be necessary to improve educational satisfaction.

Achieving Hand Hygiene Success With a Partnership Between Graduate Medical Education, Hospital Leadership, and Physicians.

Engaging physicians in hand hygiene programs is a challenge faced by many academic medical centers. Partnerships between education and academic leaders present opportunities for effective collaboration and improvement. The authors developed a robust hand hygiene quality improvement program, with attention to rapid-cycle improvements, including all levels of staff and health care providers. The program included a defined governance structure, clear data collection process, educational interventions, rapid-cycle improvements, and financial incentive for staff and physicians (including residents and fellows). Outcomes were measured on patients in all clinical areas. Run charts were used to document compliance in aggregate and by subgroups throughout the project duration. Institutional targets were achieved and then exceeded, with sustained hand hygiene compliance >90%. Physician compliance lagged behind aggregate compliance but ultimately was sustained at a level exceeding the target. Successfully achieving the institutional goal required collaboration among all stakeholders. Physician-specific data and physician champions were essential to drive improvement.

Factors associated with medical student clinical reasoning and evidence based medicine practice.

OBJECTIVES: To identify the factors associated with medical students' clinical reasoning (CR) use and evidence-based medicine (EBM) use in the clinical setting. METHODS: Our cross-sectional study surveyed 44 final-year medical students at an emerging academic medical center in Singapore. We queried the students' EBM and CR value and experiences in the classroom and clinical settings. We compared this to their perceptions of supervisors' value and experiences using t-tests. We developed measures of teaching culture and practice culture by combining relevant questions into summary scores. Multivariate linear regression models were applied to identify factors associated with the students' CR and EBM clinical use. RESULTS: Eighty-nine percent of students responded (n=39). Students reported valuing CR (p=0.03) and EBM (p=0.001) more than their supervisors, but practiced these skills similarly (p=0.83; p=0.82). Clinical practice culture and classroom CR experience were independently associated with students' CR clinical use (p=0.05; p=0.04), and classroom EBM experience was independently associated with students' EBM clinical use (p=0.03). Clinical teaching culture was not associated with students' CR and EBM clinical use. CONCLUSIONS: Our study found that medical students' classroom experience and the clinical practice culture influenced their CR and EBM use. The clinical teaching culture did not. These findings suggest that in order to increase student CR and EBM use, in addition to providing classroom experience, medical educators may need to change the hospital culture by encouraging supervisors to use these skills in their clinical practice.

Changing resident test ordering behavior: a multilevel intervention to decrease laboratory utilization at an academic medical center.

Hospital laboratory test volume is increasing, and overutilization contributes to errors and costs. Efforts to reduce laboratory utilization have targeted aspects of ordering behavior, but few have utilized a multilevel collaborative approach. The study team partnered with residents to reduce unnecessary laboratory tests and associated costs through multilevel interventions across the academic medical center. The study team selected laboratory tests for intervention based on cost, volume, and ordering frequency (complete blood count [CBC] and CBC with differential, common electrolytes, blood enzymes, and liver function tests). Interventions were designed collaboratively with residents and targeted components of ordering behavior, including system changes, teaching, social marketing, academic detailing, financial incentives, and audit/feedback. Laboratory ordering was reduced by 8% cumulatively over 3 years, saving $2 019 000. By involving residents at every stage of the intervention and targeting multiple levels simultaneously, laboratory utilization was reduced and cost savings were sustained over 3 years.

Engaging residents and fellows to improve institution-wide quality: the first six years of a novel financial incentive program.

PURPOSE: Teaching hospitals strive to engage physicians in quality improvement (QI), and graduate medical education (GME) programs must promote trainee competence in systems-based practice (SBP). The authors developed a QI incentive program that engages residents and fellows, providing them with financial incentives to improve quality while simultaneously gaining SBP experience. In this study, they describe and evaluate success in meeting goals set during the program's first six years. METHOD: During fiscal years (FYs) 2007-2012, QI project goals for all or specific training programs were set collaboratively with residents and fellows at the University of California, San Francisco (UCSF). Data were collected from administrative databases, via chart abstraction, or through independently designed techniques. RESULTS: Approximately 5,275 residents and fellows were eligible and participated in the program. A total of 55 projects were completed. Among the 18 all-program projects, goals were achieved for 11 (61%) in three domains: patient satisfaction, quality/safety, and operation/utilization. Among the 37 program-specific projects, goals were achieved for 28 (76%) in four categories: patient-level interventions, enhanced communication, workflow improvements, and effective documentation. Residents and fellows earned an average of $800 in bonuses/FY for achieving these goals. CONCLUSIONS: Thousands of residents and fellows across disciplines participated in real-life, real-time QI during the program's first six years. Participation provided an experience that may promote SBP competence and resulted in improved quality of care across the UCSF Medical Center. Similar programs may assist teaching hospitals and GME programs in meeting current and future QI and training mandates.

Bringing continuing medical education to the bedside: the University of California, San Francisco Hospitalist Mini-College.

INTRODUCTION: As a relatively new generalist specialty, hospitalists must acquire new competencies that may not have been taught during their training years. Continuing medical education (CME) has traditionally been a mechanism to meet training needs but often fails to apply adult learning principles and fulfill current demands. METHODS: We developed an innovative 3-day course called the University of California, San Francisco Hospitalist Mini-College (UHMC) that brings adult learners to the bedside for small-group learning focused on content areas relevant to today's hospitalists. The program was built on a structure of 4 clinical domains and 2 clinical skills labs. Sessions about patient safety and immersion into traditional academic learning vehicles, such as morning report and a morbidity and mortality conference, were also included. Participants completed a precourse survey and a postcourse evaluation. RESULTS: Over 5 years, 152 participants enrolled and completed the program; 91% completed the pre-UHMC survey and 89% completed the postcourse evaluation. Overall, participants rated the quality of the UHMC course highly (4.65; 1-5 scale). Ninety-eight percent of UHMC participants (n = 57) in 2011 to 2012 reported a "high" or "definite" likelihood to change practice, higher than the 78% reported by the 11,447 participants in other UCSF CME courses during the same time period. DISCUSSION: The UHMC successfully brought participants to an academic health center for a participatory, hands-on, and small-group learning experience that was highly rated. A shift of CME from a hotel conference room to the bedside is feasible, valued by participants, and offers a new paradigm for how to maintain and improve hospitalist competencies.

The effect of a resident-led quality improvement project on improving communication between hospital-based and outpatient physicians.

This article reports on a resident-led quality improvement program to improve communication between inpatient internal medicine residents and their patients' primary care physicians (PCPs). The program included education on care transitions, standardization of documentation, audit and feedback of documented PCP communication rates with public reporting of performance, rapid-cycle data analysis and improvement projects, and a financial incentive. At baseline, PCP communication was documented in 55% of patients; after implementation of the intervention, communication was documented in 89.3% (2477 of 2772) of discharges during the program period. The program was associated with a significant increase in referring PCP satisfaction with communication at hospital admission (baseline, 27.7% "satisfied" or "very satisfied"; postintervention, 58.2%; P < .01) but not at discharge (baseline, 14.9%; postintervention, 21.8%; P = .41). Residents cited the importance of PCP communication for patient care and audit and feedback of their performance as the principal drivers of their engagement in the project.