Successful Resident Engagement in Quality Improvement: The Detroit Medical Center Story

摘要

Background?In 2014, the Detroit Medical Center launched a new program to engage residents and fellows in a strategy to deliver optimal care within 1 year, focusing on quality at an earlier stage of their careers and preparing them for working posttraining.;Methods?Residents from clinically relevant residency and fellowships programs were selected to be Resident Quality Directors. The project involved development of an interactive electronic health record (EHR) checklist to visually depict real time gaps in 40 process measures, while focusing on 14 areas related to stroke and venous thromboembolism (VTE) prophylaxis. We also implemented an incentive approach, using a pay-for-performance (P4P) model.;Results?The project included 800 residents led by 14 resident quality directors. We were able to achieve 100% resident participation. Prior compliance with VTE quality measures 6 months was 88.5%, with performance increasing to 94.2% (P < .006) at 6 months and 100% at 12 months (P < .005) after the intervention. The VTE prophylaxis score improved from the 89.7% to 92.9% range at inception to 100% by 12 months. A similar steady improvement of stroke process measures was observed, with a 100% compliance within 12 months. The institution made 4 incentive payments to trainees (ranging from $300 to $4,000 per year). The remaining 26 process measures remained at goal with above 95% compliance.;Conclusions?This quality improvement initiative was associated with system-wide quality performance on VTE prevention and stroke care process measures, which was facilitated by a interactive EHR-based checklist and linkage to P4P incentive payments.;What was known and gap Academic medical centers seek to improve their performance on common quality metrics.;What is new An innovative resident engagement program and electronic health record (EHR)–based quality tool were associated with improved performance on venous thromboembolism prevention and stroke care process measures.;Limitations Single institution study; multiple intervention components make attribution of effectiveness complex.;Bottom line The EHR-based tool is available to other facilities utilizing the same vendor and allows the intervention to be adapted by other academic medical centers.;Introduction In 1999, the groundbreaking report from the Institute of Medicine, To Err is Human, led to widespread awareness of gaps in patient safety.1 Recently, the Accreditation Council for Graduate Medical Education unveiled the Clinical Learning Environment Review process, which is considered a pathway to institutional excellence and aspires to promote resident and fellow engagement in quality improvement activities.2 In 2014, the Detroit Medical Center (DMC) noted a significant opportunity to improve our performance on venous thromboembolism (VTE) prevention and stroke care. These were chosen as intervention targets, as they were new quality metrics that our system started reporting on publicly in 2014. We decided to focus on these conditions as VTE is the most common cause of hospital deaths,3 and VTE thromboprophylaxis is considered “the No. 1 patient safety practice” for hospitalized patients according to the Agency for Healthcare Research & Quality (AHRQ).4 In addition, stroke mortality and morbidity—a major cause of disability—remain high in the United States.3 The goal of this study was to determine if a hospital-wide, electronic health record (EHR)–based program using financial incentives and led by residents could improve adherence to guidelines for hospital VTE and stroke prophylaxis, and also be acceptable and feasible. Although many hospital-based quality improvement projects have been developed, none have involved a system-wide approach led by residents and fellows from multiple training programs, included several quality measures simultaneously, and embedded measures in the EHR.;Methods A total of 800 residents and fellows from DMC clinically relevant programs (anesthesiology,