High Quality Residency Education and Patient Safety are Directly Related
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High Quality Residency Education and Patient Safety are Directly Related David T. Harrington, MD Program Director, General Surgical Residency Program Associate Professor of Surgery
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High Quality Residency Education and Patient Safety are Directly Related. David T. Harrington, MD Program Director, General Surgical Residency Program Associate Professor of Surgery. Residency Work Hours. Resident fatigue – clinical errors Residency work hours surrogate for patient safety - PowerPoint PPT Presentation
Transcript of High Quality Residency Education and Patient Safety are Directly Related
High Quality Residency Education and Patient Safety are Directly Related
David T. Harrington, MDProgram Director, General Surgical Residency Program
Associate Professor of Surgery
Residency Work Hours
• Resident fatigue – clinical errors• Residency work hours surrogate for patient safety• Effects of work hour rules - mixed
– Patient Safety• Lack of definitive effect• More cross-coverage and hand-offs
– Residency Education• Improved resident well-being, less “burn-out”• Decreased operative experience (FA, TA, continuity)• Increased choice of fellowships• Decreased medical student teaching
Combined Surgical Group
3
3.2
3.4
3.6
3.8
4
4.2
4.4
4.6
4.8
5
-3 -2 -1 1 2
% M
orta
lity
V MajorMajorMinorV MinorNon-teach
KG Volpp et al, Mortality among hospitalized Medicare beneficiaries in the first 2 years….., JAMA 2007
Residency Work Hours
• Resident fatigue – clinical errors• Residency work hours surrogate for patient safety• Effects of work hour rules - mixed
– Patient Safety• Lack of definitive effect• More cross-coverage and hand-offs
– Residency Education• Improved resident well-being, less “burn-out”• Decreased operative experience (FA, TA, continuity)• Increased choice of fellowships• Decreased medical student teaching
Patient Safety and Surgical Quality
• Traditional M&M• Process
– Joint Commission– SCIP– Centers of Excellence
• Trauma - ASC/COT• Bariatric - ASBS• Cancer, Orthopedic, Cardiac
• Performance– NSQIP– UHC– CMS – MSDRG and P4P
NSQIP Observed to Expected (O/E) Ratio• Represents the hospital’s outcomes compared to the other ACS NSQIP hospitals, adjusted for inter-hospital differences in patients’ characteristics, comorbidities, and preoperative laboratory values
LOW OUTLIER: If the upper bound of the O/E confidence interval is <1.0, the hospital’s outcomes are statistically better than expected. Thus, the hospital’s outcomes are “Exemplary.”
ACS NSQIP Hospital ID Number
HIGH OUTLIER: If the lower bound of the O/E ratio is >1.0, the hospital’s outcomes are statistically worse than expected. Thus, the hospital’s outcomes “Need Improvement.”
AS EXPECTED
Surgical Residency TrainingOutcomes
• Process– RRC accreditation
• Performance– ABSITE scores– Pass rates on QE & CE– Fellowship placement– Successful practice
1st Time Pass Rate 2004 - 2009
0
10
20
30
40
50
60
70
80
90
100
0 20 40 60 80 100
CE
QE
Hypothesis
Programs which deliver high quality care as measured by:participation in NSQIP
verification as a trauma center
high rates of compliance in SCIP
would have a sound educational programs evidenced by:high pass rates on QE and CE
Methods & Materials
• NSQIP participation – NSQIP annual report• Trauma Center verification –
www.facs.org/trauma/verified
• SCIP compliance for laparoscopic cholecystectomy: SCIP1, 2, 3, VTE1, VTE2 – www.hospitalcompare.hhs.gov
• QE and CE – https://home.absurgery.org/default.jsp?prog_passreport
Results
• NSQIP– 85 (34%) participated
• Trauma Center Verification– 82 (32.8%) verified trauma centers– 65 (26%) were Level 1 trauma centers
• SCIP– All hospitals had data available
• ABS Examinations – 1st time passage rate– QE 83.9 +/- 13.1– CE 84.5 +/- 11.1– Combined 80.0 +/- 16.2
NSQIP – Yes NSQIP - No p-value
Qualifying Exam (average)
87.9 81.8 < 0.001
Certifying Exam (average)
85.8 83.3 0.100
Combined (average) 77.2 70.1 0.001
NSQIP Participation & QE/CE
Trauma CenterYes
Trauma CenterNo
p-value
Qualifying Exam (average)
87.4 83.0 0.038
Certifying Exam (average)
88.6 83.9 0.006
Combined (average) 78.8 71.3 0.003
Trauma Center Verification & QE/CE
Level 1 – Yes Level 1 - No p-value
Qualifying Exam (average)
88.4 83.1 0.012
Certifying Exam (average)
89.1 84.4 0.005
Combined (average) 80.1 71.9 < 0.001
Level 1 Verification & QE/CE
CE2007 vs SCIP1
0
10
20
30
40
50
60
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80
90
100
0 20 40 60 80 100
Certifying Exam
SCIP
1
p = 0.30
CE2007 vs SCIP2
0
10
20
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60
70
80
90
100
0 20 40 60 80 100
Certifying Exam
SCIP
1
p = 0.11
CE2007 vs SCIP3
0
10
20
30
40
50
60
70
80
90
100
0 20 40 60 80 100
Certifying Exam
SCIP
1
p = 0.01
CE2007 vs VTE 1
0
10
20
30
40
50
60
70
80
90
100
0 20 40 60 80 100
Certifying Exam
SCIP
1
p = 0.18
CE2007 vs VTE 2
0
10
20
30
40
50
60
70
80
90
100
0 20 40 60 80 100
Certifying Exam
SCIP
1
p = 0.092
Hypothesis
Programs which deliver high quality care as measured by:participation in NSQIP
verification as a trauma center
high rates of compliance in SCIP
would have a sound educational programs evidenced by:high pass rates on QE and CE
Excellent Patient Safety = Excellent Education
• RRC site visit– Trauma center verification– Improving SCIP compliance– Improving NSQIP performance
• Teaching hospitals are quintessential quality model– New physicians– Ascending levels of responsibility
• 6 core competencies– System-based practice– Practice-based learning
• Multi-disciplinary– RRC, NSQIP, Trauma Verification, SCIP compliance
Shortcomings
• QE/CE pass rates ≠ quality of training• Study has no relevance to medical training• Participation in NSQIP ≠ higher quality of
patient care
NSQIP: Changes in Morbidity 2005-2007
Conclusions
• Hospitals that participate in NSQIP have a higher quality of surgical resident education than hospitals that do not.
• Hospitals that obtain Trauma Center verification have a higher quality of surgical resident education than hospitals that do not.
• Hospitals that obtain Level 1 Trauma Center verification have a higher quality of surgical resident education than hospitals that do not.
High Quality Residency Education and Patient Safety are Directly Related
David T. Harrington, MDProgram Director, General Surgical Residency Program
Associate Professor of Surgery
