Quality assessment and improvement of post graduate family medicine training in the USA.

BACKGROUND: In 2013, the World Organisation of Family Doctors published training standards for post-graduate medical education (GME) in Family Medicine/General Practice (FP/GP). GME quality has not been well-defined, other than meeting accreditation standards. In 2009, the Association of Family Medicine Residency Directors (AFMRD) developed a tool that would aid in raising the quality of family medicine residency training in the USA. OBJECTIVE: We describe the development of this quality improvement tool, which we called the residency performance index (RPI), and its first three years of use by US family medicine residency (FMR) programmes. The RPI uses metrics specific to family medicine training in the USA to help programmes identify strengths and areas for improvement in their educational activities. Our review of three years of experience with the RPI revealed difficulties with collecting data, and lack of information on graduates' scope of practice. It also showed the potential usefulness of the tool as a programme improvement mechanism. CONCLUSIONS: The RPI is a nationwide, standardised, programme quality improvement tool for family medicine residency programmes in the USA, which was successfully launched as part of AFMRD's strategic plan. Although some initial challenges need to be addressed, it has the promise to aid family medicine residencies in their internal improvement efforts. This model could be adapted in other post-graduate training settings in FM/GP around the world.

Health is primary: Family medicine for America's health.

PURPOSE: More than a decade ago the American Academy of Family Physicians, American Academy of Family Physicians Foundation, American Board of Family Medicine, Association of Departments of Family Medicine, Association of Family Practice Residency Directors, North American Primary Care Research Group, and Society of Teachers of Family Medicine came together in the Future of Family Medicine (FFM) to launch a series of strategic efforts to "renew the specialty to meet the needs of people and society," some of which bore important fruit. Family Medicine for America's Health was launched in 2013 to revisit the role of family medicine in view of these changes and to position family medicine with new strategic and communication plans to create better health, better health care, and lower cost for patients and communities (the Triple Aim). METHODS: Family Medicine for America's Health was preceded and guided by the development of a family physician role definition. A consulting group facilitated systematic strategic plan development over 9 months that included key informant interviews, formal stakeholder surveys, future scenario testing, a retreat for family medicine organizations and stakeholder representatives to review strategy options, further strategy refinement, and finally a formal strategic plan with draft tactics and design for an implementation plan. A second communications consulting group surveyed diverse stakeholders in coordination with strategic planning to develop a communication plan. The American College of Osteopathic Family Physicians joined the effort, and students, residents, and young physicians were included. RESULTS: The core strategies identified include working to ensure broad access to sustained, primary care relationships; accountability for increasing primary care value in terms of cost and quality; a commitment to helping reduce health care disparities; moving to comprehensive payment and away from fee-for-service; transformation of training; technology to support effective care; improving research underpinning primary care; and actively engaging patients, policy makers, and payers to develop an understanding of the value of primary care. The communications plan, called Health is Primary, will complement these strategies. Eight family medicine organizations have pledged nearly $20 million and committed representatives to a multiyear implementation team that will coordinate these plans in a much more systematic way than occurred with FFM. CONCLUSIONS: Family Medicine for America's Health is a new commitment by 8 family medicine organizations to strategically align work to improve practice models, payment, technology, workforce and education, and research to support the Triple Aim. It is also a humble invitation to patients and to clinical and policy partners to collaborate in making family medicine even more effective.

Six Years' Experience Using Specialty National Residency Index: An Early Dashboard to Document Change Over Time.

BACKGROUND AND OBJECTIVES: A decade ago, the Association of Family Medicine Residency Directors developed the Residency Performance Index (RPI) as a novel dashboard of metrics to support residency programs' quality improvement efforts. Although the RPI has since been discontinued, we sought to identify lessons learned from an analysis of 6 years of data collected while the RPI was in use to inform future quality and accreditation efforts implemented at the national level. METHODS: The RPI collected data from 2012-2017 for nearly 250 distinct family medicine residency programs, identifying strengths and areas for improvement. Eighty-two programs provided data for 3 or more years of measures allowing analysis of improvement trends. RESULTS: For participating programs, aggregate data over 6 years indicated the majority had stable leadership and accreditation. Total family medicine center (FMC) visits by graduates and resident visit demographics were robust. Graduate scope of practice was consistent with nationally publicized trends. Programs hit most aspirational targets more than 40% of the time. However, analysis for those programs with 3 or more years of data revealed that the tool did not result in significant changes for most metrics. Linear regression analysis showed improvements in total patient visits, visits under 10 years of age, and certain procedural competencies for those programs with 3 or more years of data. CONCLUSIONS: The RPI was the first and only nationally utilized family medicine graduate medical education quality improvement tool. Individual programs did not show substantial change in quantifiable metrics over time despite limited evidence of select programmatic improvements. Nationally, aggregated data provided insight into scope of practice and other areas of interest in residency training. Further efforts in provision of residency improvement tools are important to support programs given the increasing complexity and high stakes of family medicine residency education.

The Residency Performance Index: An Effort at Residency Quality Assessment and Improvement in Family Medicine.

BACKGROUND: Residency programs are increasingly being asked to defend their quality, and that of the residents they produce. Yet "residency quality" is a construct that has not been well defined, with no accepted standards other than meeting accreditation standards. In 2009, the Association of Family Medicine Residency Directors developed a strategic plan that included the goal of raising the quality of family medicine training. OBJECTIVE: We describe the development of this quality improvement tool, which we called the residency performance index (RPI), and its first year of use by family medicine residency programs. We describe the use of the tool as a "dashboard" to facilitate program self-improvement. INTERVENTION: Using program metrics specific to family medicine training, and benchmark criteria for these metrics, the RPI was launched in 2012 to help programs identify strengths and areas for improvement in their educational activities and resident clinical experiences that could be tracked and reviewed as part of the annual program evaluation. RESULTS: Approximately 100 program directors began using the tool and 70 finished the process, and were provided aggregate data. Initial review of this experience revealed difficulties with collecting data, and lack of information on graduates' scope of practice. It also showed the potential usefulness of the tool as a program improvement mechanism. CONCLUSIONS: The RPI is a new quality improvement tool for family medicine residency programs. Although some initial challenges need to be addressed, it has the promise to aid family medicine residency in its internal improvement efforts.

Neonatal herpes simplex virus infections.

Neonatal herpes simplex virus infections can result in serious morbidity and mortality. Many of the infections result from asymptomatic cervical shedding of virus after a primary episode of genital HSV in the third trimester. Antibodies to HSV-2 have been detected in approximately 20 percent of pregnant women, but only 5 percent report a history of symptomatic infection. All primary episodes of HSV and secondary episodes near term or at the time of delivery should be treated with antiviral therapy. If active HSV infection is present at the time of delivery, cesarean section should be performed. Symptomatic and asymptomatic primary genital HSV infections are associated with preterm labor and low-birth-weight infants. The diagnosis of neonatal HSV can be difficult, but it should be suspected in any newborn with irritability, lethargy, fever or poor feeding at one week of age. Diagnosis is made by culturing the blood, cerebrospinal fluid, urine and fluid from eyes, nose and mucous membranes. All newborns suspected to have or who are diagnosed with HSV infection should be treated with parenteral acyclovir.