Background Third-year internal medicine residents participating in a quality improvement rotation identified gaps between the Joint Commission's ORYX quality guidelines and clinical practices for the inpatient management of heart failure (HF) at the William S. Middleton Memorial Veterans Hospital. Residents focused on the performance metrics associated with tobacco-cessation counselling documentation, ejection fraction assessment and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker prescriptions.
Methods After analysing data collected by the External Peer Review Program, residents reviewed the institution's admissions and discharge processes with the aim of improving quality and compliance. In redesigning these processes, residents created an admissions template and a discharge face sheet, and compared specific ORYX measure compliance rates before and after institution-wide implementation.
Results Following implementation of the tobacco-cessation admissions template, 100% of HF patients who used tobacco received documented cessation counselling, compared with 59% prior to intervention (p<0.01, n=32). Following implementation of the mandatory discharge face sheet, 97% of HF patients (compared with 92% preintervention, p>0.05) received comprehensive discharge instruction; LV function assessment went from 98% to 100% (p>0.05); and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker prescription for left ventricular systolic dysfunction at discharge (or documentation of a contra-indication) went from 82% to 100% (p<0.01, n=48).
Discussion By implementing a standardised admissions template and a mandatory discharge face sheet, the hospital improved its processes of documentation and increased adherence to quality-performance measures. By strengthening residents' learning and commitment to quality improvement, the hospital created a foundation for future changes in the systems that affect patient care.
- Heart failure
- myocardial infarction
- patient safety
- clinical guidelines
- control charts
- graduate medical education
- healthcare quality improvement
- quality of care
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This is a reprint of a paper that first appeared in BMJ Quality & Safety, February 2011, Volume 20, pages 181–186.
Funding Completion of this paper was made possible by a grant from the Medical Education and Research Committee (MERC) of the University of Wisconsin-Madison School of Medicine and Public Health as well as by the support of the Education Innovation Project of the Residency Review Committee for Internal Medicine, of which we are a participating residency. These QI projects received widespread support from the William S Middleton Memorial Veterans Administration Hospital, especially the director, D Thompson, and personnel in the Information Technology, Pharmacy, Nursing, and Organisation Improvement departments. Results of these projects were shared at the Association of Program Directors in Internal Medicine (APDIM) meeting in April, 2009. We also wish to acknowledge the support of the University of Wisconsin Institute for Clinical and Translational Research, funded through an NIH Clinical and Translational Science Award (CTSA), grant no 1 UL1RR025011.
Competing interests None.
Ethics approval Ethics approval was provided by the University of Wisconsin Health Sciences Institutional Review Board—categorised as exempt.
Provenance and peer review Not commissioned; externally peer reviewed.
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