Title: QUALITY IMPROVEMENT EDUCATION
THROUGH SYSTEMS ERROR ANALYSIS: A SUCCESSFUL CURRICULAR IMPLEMENTATION
Loren Murphy, MD1, Robyn
J Blair, MD2 and Susan Guralnick, MD3.
- Resident, Department of Pediatrics, Stony Brook Long Island Children’s Hospital, Health Sciences Center T11-040, Stony Brook NY 11794-8111. loren.murphy@sbumed.org, (631) 444-2020
- Program Director, Department of Pediatrics, Stony Brook Long Island Children’s Hospital, Health Sciences Center T11-040, Stony Brook NY 11794-8111. robyn.blair@sbumed.org (631) 444-2020.
- Designated Institutional Official, Office of Academic Affairs, Winthrop University Hospital, 222 Station Plaza N., Suite 510, Mineola, NY, 11501, United States. sguralnick@winthrop.org. (516) 633-2521
Background: The Department of Pediatrics
recognized a need to enhance resident education in quality improvement and its
relation to the ACGME competency in Systems-Based Practice. Systems error
analysis is an essential component of high quality, safe patient care.
Objective: Our primary goal was to provide residents a structured format
for evaluating patient care while empowering residents to make quality
improvement recommendations for systems change within the hospital.
Design/Methods: After review of the literature, we designed a curriculum
that integrates the Healthcare Matrix into the training program as well as the
department of pediatrics. The curricular
implementation process was multiphase. The curriculum began with a workshop including
a short didactic session on systems error and the use of the Healthcare Matrix.
Residents came prepared to discuss a
real case in which there was a patient safety concern. Working in small groups, participants applied
the Healthcare Matrix to a selected case. Groups identified areas of systems error and
an action plan for systems change. Each
resident group generated a completed Healthcare Matrix that defined a quality
improvement project. Following the
resident didactic session, we instituted several phases including individual
education sessions for faculty and fellows, and the incorporation of the
Healthcare Matrix into monthly Quality Assurance (QA) meetings. There, residents analyze a QA case using the
Healthcare Matrix and present improvement ideas to faculty with a clear focus
on the system of care, rather than on individuals involved in the case. We concluded our educational intervention with
a reinforcement phase by inviting the co-creator of the Healthcare Matrix to
present both a grand rounds session and an interactive resident session.
Results: Post-session evaluation demonstrated a strong initial
educational impact. 86% of the residents
had no prior experience with this topic. 80% reported a better understanding of
systems-based practice, while 90% reported enhanced understanding of the
quality improvement process. Follow-up
surveys were performed at 3 and 6 months post workshop, to assess behavior
change and included questions regarding the application of the Matrix in
patient care settings.
Conclusions: The Healthcare Matrix was successfully integrated into a
residency program curriculum and department QA process. Resident understanding of systems-based
practice and resident-initiated systems changes have improved since the
implementation of our curriculum. We
anticipate the changes we have made will positively affect resident education,
the department, the hospital system, and most importantly patient care.
Disclosures: None of the authors have any financial disclosures.
