• Poor information exchange during inpatient consultations between primary teams and consulting teams can result in delayed diagnoses, inadequate follow up, or duplication of services

• Subspecialty trainees do not receive formal instruction in how to provide an effective consultation. As a result, consultation notes are variable in quality and often do not meet the needs of the referring provider or the patient

• Early “champion” engagement and buy-in were key to fellow participation

• Focus group discussions and individual conversations with fellows confirm that our peer evaluation provides valuable feedback, while encouraging self-directed learning in a core ACGME training competency

• Additional changes are needed to reach program goals:

Cultural: Including more in-person discussions (e.g. academic detailing), rather than relying exclusively on emails to discuss quality metrics

Structural: Revising the electronic consultation note template to highlight communication and standards

The Problem

Project Goals and Objectives

Project Plan

Phase I: 2010-2011

Conducted focus groups and reviewed literature to develop the QCAT

Implemented a peer evaluation program and disseminated quarterly results to fellows and fellowship directors

Phase II: 2011-2012

Recruited divisional QCAT champions to increase fellows’ participation and share responsibility for presenting results and areas for improvements to their peers

Asked fellows to evaluate fewer notes at more regular intervals (i.e. monthly), thereby providing more frequent feedback to fellows and fellowship directors

Lessons Learned Next Steps

A Peer Evaluation Program to Improve the Quality of Fellow-Written Inpatient Consultation Notes Delphine S. Tuot, MDCM, MAS1; Naama Neeman, MSc2; Krishan Soni, MD, MBA2; Andrew Auerbach, MD, MPH2; Niraj L. Sehgal, MD, MPH2

1UCSF Division of Nephrology; 2 UCSF Division of Hospital Medicine

University of California, San Francisco (UCSF) Department of Medicine

Goal: improve quality of initial inpatient, fellow-written consult notes

Phase I: 2010-2011 – Objectives:

Create a standardized Quality of Consultation Assessment Tool (QCAT) to systematically assess and evaluate initial consult notes

Implement a peer evaluation program that allows fellows to evaluate notes, provide feedback, and reflect on the quality of their own consult notes

Phase II: 2011-2012 – Objectives:

Achieve >80% fellow participation & attain a minimum score of 80% in the "Communication" and "Education" QCAT domains

• We will continue implementation of this program with the following modifications:

Partner with fellowship administrators to increase fellow participation in the peer evaluation program

Create greater face-to-face sessions with fellows about note quality, communication/education elements, and role of documentation

Take advantage of the electronic medical record change at UCSF to customize consultation templates and emphasize "high quality" fields, including those pertaining to “Education” and “Communication”

Results / Progress to Date

Special thanks to: Leanna Zaporozhets, Zac Martin, RedCAP, the UCSF KL2 program, and all of the 2011-2012 QCAT divisional champions

Figure 1: Process map of the QCAT peer evaluation program Figure 2: Fellow participation and QCAT quality domain scores

27%

52%

29%

60% 63%

45%

21%

54% 54%

49%

20%

57%

0%

10%

20%

30%

40%

50%

60%

70%

Fellow Participation Education Score Communication Score Overall QCAT Score (mean of all 5 domains)

Baseline (2010-11) Oct-Dec 2011 Jan-Mar 2012

Source: https://www.mededportal.org/icollaborative/resource/368