A longitudinal, experiential quality improvement curriculum meeting ACGME competencies for geriatrics fellows: lessons learned.

Quality improvement (QI) initiatives are critical in the care of older adults who are more vulnerable to substandard care. QI education meets aspects of core Accreditation Council of Graduate Medical Education competencies and prepares learners for the rising focus on performance measurement in health care. The authors developed, implemented, and evaluated a QI curriculum for geriatrics fellows. The evidence-based curriculum included didactics and a fellow-led QI intervention based on audit and feedback through the Practice Improvement Module in Care of the Vulnerable Elderly. QI knowledge, attitudes, and behaviors were assessed before and after the improvement project. Fellows' knowledge of QI improved (p = .0156), but behavior did not change significantly across a short-term improvement project. A structured focus group with fellows revealed themes of accountability and the importance of interprofessional teamwork in QI. QI education for geriatrics fellows can be feasible, well received, and prepare future physician leaders for patient-centered care, performance measurement, and effecting systems change.

Geriatrics and palliative medicine leadership is needed now more than ever: What are the training gaps?

BACKGROUND: Geriatrics and palliative medicine specialists are uniquely trained to provide expert coordinated care for older adults and seriously ill and complex patients. Health system leadership geared towards this patient population is critically important as society ages. Currently, there is no standardized approach to teaching core leadership skills. To assess the leadership training needs of geriatrics and palliative medicine fellowship graduates, we conducted a needs assessment to identify (1) early career leadership trajectories and challenges and (2) knowledge and skills deemed essential for effective leadership. METHODS: Individuals identified as leaders in geriatrics and/or palliative medicine completed an electronic survey and a semi-structured qualitative interview. These leaders were divided into two categories: Icahn School of Medicine at Mount Sinai (ISMMS) trained leaders or non-ISMMS trained leaders. The semi-structured interviews were recorded, transcribed, and reviewed using thematic analysis. RESULTS: Within 1 year of fellowship graduation, 50% of ISMMS trained leaders had leadership positions; within 6 years, 100% had a leadership role. Based on qualitative interviews, both ISMMS trained leaders and non-ISMMS trained leaders perceived leadership training gaps in two domains: (1) knowledge and (2) skills. Knowledge and skill gap themes included communication and management, mentorship and negotiation, program development, knowledge, and apprenticeship. CONCLUSION: Geriatrics and palliative medicine physicians obtained leadership roles quickly after fellowship. Both ISMMS trained leaders and non-ISMMS trained leaders often felt unprepared, learned "on the job," and sought out additional leadership training. Early leadership training is needed to prepare fellowship graduates for the pressing demands of accelerated leadership.

House staff member awareness of older inpatients' risks for hazards of hospitalization.

BACKGROUND: Many hospitalized older adults develop iatrogenic complications unrelated to their presenting diagnoses that can result in longer hospitalizations, functional impairment, or unanticipated medical or surgical interventions. These complications are often referred to as "hazards of hospitalization" and include delirium, malnutrition, urinary incontinence, pressure ulcers, depression, falls, restraint use, infection, functional decline, adverse drug effects, and death. The aims of this study were to assess house staff member awareness of older patients' risk factors for developing hazards of hospitalization and to determine areas in which interventions may help improve recognition. METHODS: A cross-sectional study was performed, from December 1, 1999, through August 31, 2002, of internal medicine and medicine or pediatric house staff members and their patients from 4 medical units at Mount Sinai Medical Center. Each house staff member completed a 23-item survey on 3 of their recently admitted patients. These patients and, if appropriate, their surrogates were interviewed by the study investigator within 2 hours of the completion of the house staff survey. House staff member responses are compared with those obtained by the study investigator. The completed house staff surveys were compared with the reference standard, and areas of agreement and disagreement were noted. RESULTS: Eighty-six house staff teams, consisting of 1 intern and 1 resident (in either the second or third postgraduate year), and 105 patients were enrolled in the study. The house staff members were in frank disagreement or poor agreement with the reference standard in knowing the following: how well their patients were oriented to place or how long they had been hospitalized; patients' quality of sleep, presence of pain, history of falls, mood, quantity of food intake, and use of hearing aids, glasses, or an ambulation assistive device when at home; and the name of their patients' primary care physicians. CONCLUSIONS: This study showed that internal medicine house staff members are not aware of many of their patients' risk factors for developing the hazards of hospitalization. Some of these deficits are glaring, particularly the lack of awareness of patients' orientation to place and time (duration of hospitalization), presence of pain, and the identity of their primary care physician. It will likely take education and cultural change to improve this performance. Such improvement could be accomplished as part of 3 of the Accreditation Council for Graduate Medical Education competencies: interpersonal communication, patient care, and systems-based practice. Such a process might improve not only house staff member awareness but also patient outcomes, since interdisciplinary communication and interventions are key to preventing the hazards of hospitalization.

What is a geriatrician? American Geriatrics Society and Association of Directors of Geriatric Academic Programs end-of-training entrustable professional activities for geriatric medicine.

Entrustable professional activities (EPAs) describe the core work that constitutes a discipline's specific expertise and provide the framework for faculty to perform meaningful assessment of geriatric fellows. This article describes the collaborative process of developing the end-of-training American Geriatrics Society (AGS) and Association of Directors of Geriatric Academic Programs (ADGAP) EPAs for Geriatric Medicine (AGS/ADGAP EPAs). The geriatrics EPAs describes a geriatrician's fundamental expertise and how geriatricians differ from general internists and family practitioners who care for older adults.