DEEPA A. VASUDEVAN, MD, MPH MICHELLE R. KLAWANS, MPH THOMAS F. NORTHRUP, PHD ANGELA L. STOTTS, PHD Tools for Implementing Resident and Medical Student Quality Improvement Projects

How Do Physicians Learn Research? Residents have very little time (and sometimes little interest) to engage in scholarly activity Funding for scholarly activity during residency is hard to come by However, gaining an appreciation for scholarly activity is vital to a career in medicine

Community Medicine Month During second year of residency Components and grading  Quality Improvement Project – 40%  Article Review and Presentation – 20%  Home Visits – 20%  Occupational Medicine clinic and didactics – 10%  Other Administrative Duties – 10%

Quality Improvement (QI) Projects Initiatives that focus on a clinical outcome Aim: Improve healthcare delivery and/our outcomes Do not collect PHI  Do not require IRB approval Can be conducted on a small scale Can be completed quickly Complement research

QI Projects During Community Month Beginning in 2013, all second year residents completed a month-long QI project Projects are completed during community month  Adequate time to collect data As of November 2015, 30 residents have completed a QI project  6 have presented posters at STFM conferences  Dr. Dino Nguyen and Dr. Jessica Williams are presenting at this conference  1 has presented at TAFP conference  1 has presented at NAPCRG conference  1 is publishing a brief report

Past Project Examples Use of a diabetes care card to increase the rate of recommended diabetic screenings  Distribution of care card with chart reviews at 3 time points Importance of dental health during pregnancy  Cross-sectional physician survey Screening for abdominal aortic aneurysm  Chart review on all men >75 years old with a lifetime history of smoking seen at the clinic over the past year

Project Timeline TaskDeadline Read through this guide and complete the quiz on the QI Project - R2MN R2MN One month prior to beginning of community month Meet with Dr. Vasudevan to identify project ideas One month prior to the beginning of community month Meet with Dr. Northrup and Michelle Klawans to discuss your question and design data collection and/or intervention One week prior to the beginning of community month Select final topic and identify project aims and questions; finalize and submit protocol Day 3 of community month Initiate data collection and/or other project components Beginning of week 2 of community month Data collection complete*Beginning of week 4 of community month Review data with Dr. Northrup & Michelle Klawans End of week 4 Draft of PowerPoint presentation sent to Drs. Vasudevan and Northrup and Michelle Klawans NO LATER than 1 week before presentation to be given (see schedule of presentations) Conference/Project abstract**Must be sent to Dr. Vasudevan, Dr. Northrup, and Michelle within 2 weeks of the presentation.

Step One: Deciding on a Question Meet with physician coordinator for community medicine – discuss and collaborate with other interested faculty physician to discuss topic of interest  Narrow down a topic We encourage residents to choose a topic that they are interested in Meet with research team to define a feasible question Bring faculty members with the same interest on board

Types of Projects Chart Review Physician Survey Patient Survey Brief intervention with clinic staff Generally Cross-sectional

Step Two: Protocol Development Introduction/Background Project Question Aims/Goals of the project Hypotheses (if any) Methods Generally brief (2 pages)

Step Three: Develop Measure Brief is best – limit to 1 page Multiple choice questions are recommended  Limit write-in answers Demographic questions are ok – just no identifying information Paper vs. electronic  We have had great success using electronic methods to survey physicians

Example Measures Project on complementary and alternative medicine (CAM) (physician survey):

Example Measures Project on depression screening (chart review):

Step Four: Collect Data We recommend 2 weeks for data collection Electronic data capture when surveying physicians Paper data forms when surveying patients Paper or Excel for chart reviews

Step Five: Data Entry All data entry is done in a customized Excel spreadsheet  RA creates the spreadsheet for each resident Numerical data entry is used  0=no, 1=yes

Step Five: Data Entry Example Codebook: Example Data Entry:

Step Six: Analyze data RA completes data analysis  However, most residents could complete frequentist data analysis using Excel Due to the cross-sectional nature and small sample sizes, data analysis is quite simple Generally, frequencies are reported  Chi-square tests are used is sample size is large enough Resident meets with RA to ensure that they understand and can interpret the results

Steps Seven, Eight, and Nine: Dissemination Residents are required to create and present a brief PowerPoint on their QI project Presentations occur at the didactic session in the month following QI project completion Other residents and faculty members attend and ask questions Residents are also required to draft a conference abstract in order to improve their scientific writing skills

Step Ten: Submit to Conference Optional! Department chair will fund resident conference and travel

Example Projects Use of a diabetes care card to increase the rate of recommended screenings for diabetic patients DCC distributed to all patients, chart reviews at baseline, 6-months, and 1-year Findings: DCC did not significantly increase routine diabetic screenings in the clinic Clinical Implication: DCC may not be a viable low- cost way to increase routine diabetic screenings

Example Projects Importance of dental health during pregnancy Physician survey on dental health practices with pregnant women Patient survey with pregnant patients Findings:  Only 28% of physicians perform oral exams on pregnant women  Only 52% of women saw a dentist during pregnancy Clinical Implications: family physicians should routinely perform oral exams on pregnant women

Example Projects Screening for abdominal aortic aneurysm (AAA) Chart review of male patients age >75 with lifetime smoking history Results: Only 5% of at risk patients had an abdominal ultrasound ordered in the past year Clinical Implications: family physicians are not currently adequately screening patients at risk for AAA

Example Projects Waist circumference measurement nurse intervention Baseline chart review of WC measurements Brief training intervention with nursing staff Repeat chart review at one- and three-months Findings: The intervention significantly increased WC measurement compliance Clinical Implications: Training nurses to measure WC is a low-cost way to increase compliance

Challenges Time Management Finding faculty interested in being mentors Data mining Resident Schedules

Conclusions Residency is an ideal time to introduce scholarly activity It is feasible to complete high quality QI projects in a short amount of time and with no funding Having a set of QI guidelines and deadlines is critical for success