This report describes VMMC's work to integrate graduate medical education and quality improvement as part of the Alliance of Independent Academic Medical Centers National Initiative, Improving Patient Care Through Graduate Medical Education.

Brian Owens, MD, Director, Graduate Medical Education (GME), Executive Sponsor Lead

Lynne Chafetz, Senior Vice President, General Counsel, Executive Sponsor

Alvin Calderon, MD, Program Director, Internal Medicine, Physician Champion, Internal Medicine

Joe Panerio-Langer, MD, Internal Medicine Resident, Resident Champion, Internal Medicine

Robert Gould, MD, Internal Medicine Resident, Resident Lead, Internal Medicine

Rosemary Tempel, RN, Quality and Patient Safety Project Manager 

Richard Thirlby, MD, Program Director, General Surgery, Physician Champion, General Surgery

Richard Koehler, MD, General and Thoracic Surgeon, Physician Champion, General Surgery

Beejay Feliciano, MD, General Surgery Resident, Resident Lead, General Surgery

Sarah Levasseur, MD, General Surgery Resident, Resident Lead, General Surgery

Clancy Clark, MD, General Surgery Resident, Resident Lead,  General Surgery

Keith Dipboye, MD, GIM, CIS Development Champion

To increase patient safety, content reliability, and peer satisfaction with resident-to-resident handoff communication at Virginia Mason Medical Center (VMMC) by 33 percent (goal: 100 percent) within the 18-month time period of the Alliance of Independent Academic Medical Center National Initiative, Improving Patient Care Through GME.

• Compliance with SBAR format (as a bundle, “all or none” metric)
• Complete resident-to-resident handoff includes:

1. Patient Demographics (Situation)
2. Problems / Diagnosis (Background)
3. Plan of Care (Assessment), and
4. Specific On-Call To Do Tasks (Recommendation).

• Satisfaction rating by receiving resident pos orientation training

• Engaged Janet Nagamine, RN, MD, a nationally recognized expert on patient safety and communication (of Kaiser Permanente Northern California, and former VMMC resident) to observe and teach residents and other care team members about effective communication strategies, communication failures in health care, and methods to incorporate safe handoffs in work flow
• Developed project team, supported by project manager, key administrative leadership, and resident champions
• Collated current examples of handoff communication; tested and evaluated to create a single, standard template with key criteria for Medicine and Surgical Handoffs
• Applied key learnings and expectations into a one-on-one/small group didactic training session
• Surveyed residents about handoffs to validate concerns and obtain feedback
• Integrated handoff communication into new intern orientation
• Appraised handoff effectiveness and satisfaction
• Purchased information technology programming time to design and construct handoff application within the electronic medical record.

The percent of complete resident handoffs rose from 76 percent in the fall of 2007 to 96 percent during the fall of 2008. Recipients of handoffs reported a 93.5 percent satisfaction rate with the quality of handoffs they received. We believe our improvements stem from the creation of a standard handoff template and directed, early (orientation) resident training.

Lessons Learned:

• Identify early adopters: Internal medicine program residents initiated efforts for many months; surgery residents followed
• Distinguish passionate residents (process owners): Integral leadership, involvement in every process improvement cycle, training, communication, and change management effort
• Recognize need for project management support/facilitation: Push project/team forward, clarify the goals, and provide outside perspective
• Support by organizational initiative: Provided funding and resources to accomplish difficult goals; effective sponsorship  
• Allow differentiation of tools (handoff template): Surgical residents workflow required additional elements of handoff content; recognizing practice differences and local adaptation enhanced adoption
• Embed concepts and learnings into training and future electronic applications: Improvement efforts are a continuous process
• Incorporate workplace transition into team rounds: Working together to address individual patient problems and building anticipatory handoff/task needs (goal planning and follow-up)
• Integrate quality/patient safety as required element of Graduate Medical Education: Goal to involve every core program resident into a quality/patient safety improvement project over the course of their training at Virginia Mason Medical Center; necessary education for physicians of future and health care culture

Challenges:

• Providing actionable feedback and submission of data: Additional steps required to obtain data from residents; paper tool collation for data abstraction and elicit satisfaction marks
• Designing educational experiences within clinical experiences: When is the best time and place to teach; how to provide just-in-time education; focused remediation; incremental learning curve; Hawthorne effects
• Time commitment: Injecting non-patient care related improvement work into workday

Next Steps:

• Inspect data (follow trends, perform root cause analysis for non-compliance, and obtain more feedback)
• Refine didactic presentation to include future electronic application (continuous improvement)
• Simulate and test electronic handoff application

Brian Owens, MD
Director Graduate Medical Education (GME)
Executive Sponsor Lead
Virginia Mason Medical Center
Brian.owens@vmmc.org