Challenges and Opportunities for Graduate Medical Education: Steps to Keep Physician Training in North Carolina Exceptional.

Changes in health care present many challenges and opportunities to North Carolina's exceptional graduate medical education programs. Steps to keep these programs exceptional include boosting leadership training, championing well-being, expanding rural training, and more described here.

Impact of Faculty Training in Health Systems Science on Scholarly Presentation of Resident Physician and Fellow Quality Improvement Projects.

The objective was to evaluate whether faculty participation in a Health Systems Science training program was associated with increased presentation and publication of quality improvement (QI) projects involving resident physicians and fellows at 1 institution. The authors evaluated annual, department-level counts of QI projects with resident physician or fellow involvement, presented locally or published, according to residency or fellowship program director and faculty participation in Teachers of Quality Academy. Ten clinical departments had 82 presentations and 2 publications. Each additional faculty member's participation in Teachers of Quality Academy increased the annual count of published or presented QI projects by 9% (P < 0.001). At this institution, participation in a Health Systems Science training program among clinical faculty improved engagement of resident physicians and fellows in local presentation of QI projects.

Getting work done: a grounded theory study of resident physician value of nursing communication.

Poor communication between nurses and physicians results in patient injury and increased healthcare costs. While multiple attempts have been made to improve communication between the two professions, evidence confirms little progress has been made. Previous research focused on standardizing communication processes and protocols between nurses and physicians rather than examining the relational component of these human interactions. The purpose of this study was to explore physician valuing of nursing communication in the context of patient care. Interviews were conducted with 15 internal medicine resident physicians. A constructivist grounded theory approach was used to develop the substantive theory of Getting Work Done. Getting Work Done incorporated three major categories: discerning the team, shifting communication, and accessing nurse knowledge and abilities. Hierarchical behaviors and language, and nurse collusion in both, characterized nurse-physician communication and situated the nurse outside the decision-making team. Complex work environments further devalued nurse-physician communication. Interprofessional education and practice must advance the unique and essential role of all health care professionals such that mutual valuing replaces hierarchical actions with collaborative systems for determining the most effective approaches to patient care.

Making the Learning Continuum a Reality: The Critical Role of a Graduate Medical Education-Continuing Medical Education Partnership.

A true continuum of learning in physician education, envisioned as the seamless integration of undergraduate, graduate, and continuing medical education that results in lifelong learning, has yet to be realized. Rapid clinical change, evolving systems of health care, and a shift to competency-based training make the continuum and lifelong learning even more critical. Because they function independently, the efforts of Graduate Medical Education (GME) and Continuing Medical Education (CME) have fallen short of the integrated ideal. The complementary threads of accreditation requirements, expertise, resources, and scholarly activities provide an opportunity for GME and CME to operate in a more integrated and coordinated fashion. Our local GME-CME partnership model demonstrates that these complimentary threads can be tied together to effectively facilitate lifelong learning and promote an integrated learning continuum.

The Teachers of Quality Academy: Evaluation of the Effectiveness and Impact of a Health Systems Science Training Program.

This project aimed to evaluate the effectiveness of a faculty development program in health systems science (HSS)-the Teachers of Quality Academy (TQA). Participants in TQA and a comparison group were evaluated before, during, and 1 year after the program using self-perception questionnaires, tests of HSS knowledge, and tracking of academic productivity and career advancement. Among program completers (n = 27), the mean self-assessed ratings of knowledge and skills of HSS topics immediately after the program, as compared to baseline, increased significantly compared to controls (n = 30). Participants demonstrated progressive improvement of self-perceived skills and attitudes, and retention of HSS knowledge, from baseline to completion of the program. Participants also demonstrated substantially higher HSS scholarly productivity, leadership, and career advancement compared to the comparison group. The TQA effectively created a faculty cadre able to role model, teach, and create a curriculum in HSS competencies for medical students, resident physicians, and other health professionals.

Optimal Care for All: The Critical Need for Clinician Retention in Rural North Carolina.

Despite its increasing urbanization, North Carolina still has a large rural population that lacks optimal health care. While multiple programs have been successful in recruiting clinicians to rural communities, improving the retention of those clinicians will require the development and implementation of novel strategies along with the evaluation of their effectiveness.

The Teachers of Quality Academy: A Learning Community Approach to Preparing Faculty to Teach Health Systems Science.

PROBLEM: Although efforts to integrate health systems science (HSS) topics, such as patient safety, quality improvement (QI), interprofessionalism, and population health, into health professions curricula are increasing, the rate of change has been slow. APPROACH: The Teachers of Quality Academy (TQA), Brody School of Medicine at East Carolina University, was established in January 2014 with the dual goal of preparing faculty to lead frontline clinical transformation while becoming proficient in the pedagogy and curriculum design necessary to prepare students in HSS competencies. The TQA included the completion of the Institute for Healthcare Improvement Open School Basic Certificate in Quality and Safety; participation in six 2-day learning sessions on key HSS topics; completion of a QI project; and participation in three online graduate courses. OUTCOMES: Twenty-seven faculty from four health science programs completed the program. All completed their QI projects. Nineteen (70%) have been formally engaged in the design and delivery of the medical student curriculum in HSS. Early into their training, TQA participants began to apply new knowledge and skills in HSS to the development of educational initiatives beyond the medical student curriculum. NEXT STEPS: Important next steps for TQA participants and program planners include further incorporation as faculty advisors and contributors to the full implementation of the longitudinal HSS curriculum; expanded involvement with the Leaders in Innovative Care Scholars student leadership distinction track; continued in-depth evaluation of the impact of TQA participation on patient care, teaching, and role modeling; and the recruitment of the next cohort of TQA participants.

Transforming Medical Education is the Key to Meeting North Carolina's Physician Workforce Needs.

To meet the needs of the population of North Carolina, an epic transformation is under way in health care. This transformation requires that we find new ways to educate and train physicians and other health care professionals. In this commentary, we propose that the success of the Brody School of Medicine in preparing a primary care physician workforce can serve as a model for meeting the state's future physician workforce needs. Other considerations include increasing graduate medical education positions through state funding and providing incentives for medical students who stay in North Carolina.

Mobilization of the obese patient and prevention of injury.

OBJECTIVES AND BACKGROUND: Obese patients are difficult to transport between emergency departments, imaging facilities, operating rooms, intensive care units, acute care units, and rehabilitation facilities. Each move, along with turning, bathing, and access to bathrooms, poses risks of injury to patients and personnel. Similarly, inadequate mobilization raises the risk of pressure ulcers. The costs can be prohibitive. METHODS: On 6 pilot units, mobilization of patients was delegated to trained lift team technicians who covered the units in pairs, 24 hours per day, 7 days per week, to assist with moving and lifting of patients weighing 200 pounds or more, with a Braden Scale score of 18 or less and/or the presence of pressure ulcers. RESULTS: In fiscal year 2012, hospital-acquired pressure ulcers on pilot units decreased by 43% (from 61 to 35). Patient handling-related employee injuries on pilot units decreased by 38.5% (from 13 to 8). Employee satisfaction related to organizational commitment to employee safety and impact on job satisfaction was positively impacted by implementation of the lift team. With the reduction in employee injuries and the fall in the prevalence of pressure ulcers, the adoption of the lift team program decreased costs by $493,293.00. CONCLUSIONS: Implementation of lift teams on pilot nursing units decreased patient handling-related employee injuries, resulting in sharp improvements in quality patient care and reduced costs.

An economic toolkit for identifying the cost of emergency medical services (EMS) systems: detailed methodology of the EMS Cost Analysis Project (EMSCAP).

Calculating the cost of an emergency medical services (EMS) system using a standardized method is important for determining the value of EMS. This article describes the development of a methodology for calculating the cost of an EMS system to its community. This includes a tool for calculating the cost of EMS (the "cost workbook") and detailed directions for determining cost (the "cost guide"). The 12-step process that was developed is consistent with current theories of health economics, applicable to prehospital care, flexible enough to be used in varying sizes and types of EMS systems, and comprehensive enough to provide meaningful conclusions. It was developed by an expert panel (the EMS Cost Analysis Project [EMSCAP] investigator team) in an iterative process that included pilot testing the process in three diverse communities. The iterative process allowed ongoing modification of the toolkit during the development phase, based upon direct, practical, ongoing interaction with the EMS systems that were using the toolkit. The resulting methodology estimates EMS system costs within a user-defined community, allowing either the number of patients treated or the estimated number of lives saved by EMS to be assessed in light of the cost of those efforts. Much controversy exists about the cost of EMS and whether the resources spent for this purpose are justified. However, the existence of a validated toolkit that provides a standardized process will allow meaningful assessments and comparisons to be made and will supply objective information to inform EMS and community officials who are tasked with determining the utilization of scarce societal resources.

Effect of a postviolation driver improvement class on traffic convictions and crashes.

OBJECTIVE: To investigate the effect of a driver improvement class on postclass moving traffic violations and crashes among drivers charged with speeding. METHODS: A total of 5079 drivers who completed an 8-hour class were compared to a control group of 25,275 drivers from the same locale who had been convicted of speeding during the same time period but had not taken the class. Counts of convictions and crashes were available for all drivers for 2 years prior to the class and between 1 and 3 years after the class or key speeding conviction. Zero-inflated negative binomial models were used to measure the expected number of convictions among those who took the class compared with subjects who did not take it. RESULTS: Individuals with a moving violation conviction had 2.5 times the odds of having previous convictions for moving violations and almost 1.5 times the odds of having been involved in a crash. Drivers who took the class had convictions similar to the control group after the class (Incidence Rate Ratio [IRR]: 1.03, 95% confidence interval [CI]: 0.95-1.12) but were less likely to be involved in subsequent crashes (IRR: 0.83, 95% CI: 0.77-0.91). CONCLUSIONS: The results suggest that among drivers overall, exposure to driver improvement classes as a means to change drivers' behaviors is not significantly associated with fewer convictions for moving violations but may be effective in reducing crashes.

Risk adjustment measures and outcome measures for prehospital trauma research: recommendations from the emergency medical services outcomes project (EMSOP).

OBJECTIVES: The objectives were to conduct a comprehensive, systematic review of the literature for risk adjustment measures (RAMs) and outcome measures (OMs) for prehospital trauma research and to use a structured expert panel process to recommend measures for use in future emergency medical services (EMS) trauma outcomes research. METHODS: A systematic literature search and review was performed identifying the published studies evaluating RAMs and OMs for prehospital injury research. An explicit structured review of all articles pertaining to each measure was conducted using the previously established methodology developed by the Canadian Physiotherapy Association ("Physical Rehabilitation Outcome Measures"). RESULTS: Among the 4,885 articles reviewed, 96 RAMs and/or OMs were identified from the existing literature (January 1958 to February 2010). Only one measure, the Glasgow Coma Scale (GCS), currently meets Level 1 quality of evidence status and a Category 1 (strong) recommendation for use in EMS trauma research. Twelve RAMs or OMs received Category 2 status (promising, but not sufficient current evidence to strongly recommend), including the motor component of GCS, simplified motor score (SMS), the simplified verbal score (SVS), the revised trauma score (RTS), the prehospital index (PHI), EMS provider judgment, the revised trauma index (RTI), the rapid acute physiology score (RAPS), the rapid emergency medicine score (REMS), the field trauma triage (FTT), the pediatric triage rule, and the out-of-hospital decision rule for pediatrics. CONCLUSIONS: Using a previously published process, a structured literature review, and consensus expert panel opinion, only the GCS can currently be firmly recommended as a specific RAM or OM for prehospital trauma research (along with core measures that have already been established and published). This effort highlights the paucity of reliable, validated RAMs and OMs currently available for outcomes research in the prehospital setting and hopefully will encourage additional, methodologically sound evaluations of the promising, Category 2 RAMs and OMs, as well as the development of new measures.

Injury and death on the farm: improving prevention through improved surveillance.

Work-related injury data suggest that agricultural workers in North Carolina are experiencing high rates of injury and death compared with workers in other occupations. However, current occupational injury data sources are insufficient to calculate accurate injury and mortality rates. We propose recommendations to improve existing farm injury surveillance, to guide prevention.

Is fatality-free travel on North Carolina's streets and highways feasible? It's time to think the unthinkable.

The persistent downward trajectory in the traffic fatality rate during the past 90 years suggests that fatality-free travel on North Carolina's streets and highways may one day be a reality. Multiple interventions, including raising the driving age to 17 years and banning cell phone use, will help North Carolina achieve this vision.

Awareness of the bicycle helmet law in North Carolina.

BACKGROUND: One in 3 bicyclists killed in North Carolina is under the age of 16. Since enactment of a mandatory bicycle helmet law for children in 2001, there has been no observed increase in helmet use in North Carolina. The goal of this study was to assess perceptions of helmet effectiveness and the level ofawareness of the North Carolina bicycle helmet law. METHODS: A written survey was distributed to parents, physicians, teachers, and emergency medical services (EMS) personnel throughout Pitt County, North Carolina, to ask their knowledge of the bicycle helmet law, the frequency of their helmet use, their perceptions of the effectiveness of helmets, their opinions of who should be providing education about bicycle helmets, and their knowledge ofpr oper bicycle helmet use. RESULTS: The survey response rate was 72% (n=43). Seventy-five percent of teachers and EMS personnel, 69% ofparents, and 580% of physicians were aware of the North Carolina helmet law. Nineteen percent of parents responded that their children wore helmets "always", 1% answered "often", and 18% answered "never". The effectiveness of helmets in preventing head injuries was underestimated by many respondents with 49% estimating 50%-75% effectiveness. LIMITATIONS: This survey was distributed only in Pitt County and does not reflect helmet awareness for the state as a whole. CONCLUSIONS: The majority ofparents, teachers, physicians, and EMS personnel in Pitt County, North Carolina, are aware of the mandatory bicycle helmet law for children. Enforcement of and education about the bicycle helmet law should be increased .

A comprehensive framework for determining the cost of an emergency medical services system.

To determine the cost of an emergency medical services (EMS) system, researchers, policymakers, and EMS providers need a framework with which to identify the components of the system that must be included in any cost calculations. Such a framework will allow for cost comparisons across studies, communities, and interventions. The objective of this article is to present an EMS cost framework. This framework was developed by a consensus panel after analysis of existing peer-reviewed and non-peer-reviewed resources, as well as independent expert input. The components of the framework include administrative overhead, bystander response, communications, equipment, human resources, information systems, medical oversight, physical plant, training, and vehicles. There is no hierarchical rank to these components; they are all necessary. Within each component, there are subcomponents that must be considered. This framework can be used to standardize the calculation of EMS system costs to a community. Standardizing the calculation of EMS cost will allow for comparisons of costs between studies, communities, and interventions.