1. Building CLER Infrastructure: Integrating Reporting and Improvement Science into Daily Work Atishi Aggarwal, M.D., Lisa Maxwell, M.D., Neil Jasani, M.D., Robert Dressler, M.D., Loretta Consiglio-Ward, M.S.N., Carol Kerrigan Moore, M.S.
Christiana Care Health System, Newark-Wilmington, Delaware
Introduction
Physicians in training are exceptionally positioned to create a positive safety culture which results in the delivery of safer patient care. Willingness to report safety events and participate in forums to prevent adverse events is often shaped by the beliefs, experiences, and infrastructure of the organizations in which they train.
As part of the ACGME Next Accreditation System, the CLER (Clinical Learning Environment) program puts great emphasis on the need for an organizational structure that integrates GME within the system’s quality infrastructure and can truly demonstrate resident engagement in system efforts.1 Christiana Care, a major teaching healthcare system, provides the clinical learning environment for more than 270 residents/ fellows within 18 residency programs. Our vision is that all residents will demonstrate that patient safety is a part of their profession. We aimed to increase resident engagement and participation in patient safety through the creation of a Resident Quality & Safety Council that consists of faculty –resident dyads from all our residency programs.
Methods
Reporting data, a safety attitude assessment 2,3, and feedback from an ACGME CLER visit formed the basis for our effort and focus on Patient Safety. We found that while many residents observe safety events, few personally report them ( <1% of all events reported by electronic form). And, if events are reported, they are communicated through various paths, making it difficult to capture trends and patterns.
An interdisciplinary, inter-professional Steer Committee led by Academic Affairs with representatives from the Department of Medicine, Office of Quality and Safety, Risk Management, and others established a pyramid framework (Figure 1) to organize the various quality and safety initiatives involving residents that have been implemented throughout the system to provide a high quality clinical learning environment. The initiatives involve most of the residency programs across the system.
Level 1 = Foundation
These elements are considered required, but not sufficient, to achieve the goal. They involve a combination of basic resident training, faculty development and institutional support.
Level 2 = Program Leadership and Representation
This represents the creation of a forum with representatives from all programs that act as a conduit between the system and individual residency programs allowing flow of information, education and ideas as well as priority alignment with the system.
Level 3 = Structured Resident Activities
These consist of initiatives at both system and program levels that promote active participation by residents in activities that incorporate quality and safety principles.
Level 4 = Culture Change
This represents the ultimate desired state of observed behavior and attitudes that serve as marker of culture change.
To increase resident engagement and participation in patient safety, we created a Resident Quality & Safety (Q&S) Council that consists of faculty-resident dyads for all our residency programs. Chairs and Programs Directors nominated the participating faculty–resident dyads. The Council serves as a vehicle for enhancing communication between hospital committees and clinical departments, and provides a forum for teaching safety concepts, discussing/disseminating specific system efforts, developing new initiatives, collaboration across departments, participation in safety activities, data review, and providing feedback and solution generation for system level concerns.  The council meets monthly for 1.5 hours with assignment of between session activities. Each session typically includes didactics, discussion of events/event reporting, report outs of dyad driven Q&S activities/ findings, and advice or consultation on system level initiatives. The Council reports activities to the system’s GMEC and Safety Committees.
Key measures of effectiveness included (Figures 2-4):
Reporting climate data (# resident submitted events reported sorted by department)
Resident participation in committees/councils,
Change in self-reported attitudes about patient safety.
Results
Safety Issue: Needlesticks
Figure-2. Resident reporting climate.
Figure-3. Resident participation in committees/councils.
Figure-4. Resident participation in committees/councils.
In February 2015, the RQSC tackled a significant safety concern experienced by residents in our work environment. Needlestick & Sharp Injuries are our #1 recordable injury (35% of 154 in FY14, with an increase projected this year). The data told us who was affected, during what procedures, and frequency, but we needed to learn “why?”. RQSC analyzed causes of the problem, using cause & effect diagram. Results were shared with our safety director, providing a collaborative two-way interface to disseminate safety activities and ideas across departments.
Discussion
Framework
Faculty- resident dyad participation not only enabled effective dissemination of quality and safety initiatives within and between programs but also strengthened mentoring relationships.
Providing protected time for participation in council meetings and organizational committee meetings was critical.
Curricula were integrated to address the skills gap for implementation and reinforcement of fundamental patient safety concepts.
Access to data reports and the availability of (electronic) toolkits for RCA, 5 WHYs, Cause & Effect Diagrams supported valuable council output.
Enthusiasm to seek the Resident Quality & Safety Council’s advice was unexpected, including specific requests from CEO/COO to help problem solve excessive capacity issues.
Figure-1. Pyramid of initiatives.
Conclusions
References
1 Nasca TJ, Philibert I, Brigham T, et al. The next GME accreditation system--rationale and benefits. New England Journal of Medicine 2012 Mar. 366(11):
2 O’Leary, KJ et al. Hospital Quality and Patient Safety Competencies: Development, Description, and Recommendations for Use. Journal of Hospital Medicine. 2011:0(0):1-7.
3 Boike, JR et al. Patient Safety Event Reporting Expectation: Does it Influence Residents’ Attitudes and Reporting Behaviors? Journal of Patient Safety. 2013:9(2):
During our study period, we were able to demonstrate more than a 2-fold increase in the total number of resident submitted SFLR reports. Safety attitudes remained relatively the same. It is unclear at this time whether quality and safety forums experienced during training shapes future participation and reporting as medical physician leaders. We believe that the culture within our residency programs, amongst our faculty, and within our institution needs to be aligned in order to create the highly reliable environment our patients and community deserves.
Contact Information
Lisa Maxwell, MD - ; Neil Jasani, MD - ;
Robert Dressler, MD - ; Carol K. Moore, MS -
Loretta Consiglio-Ward, MSN - Atishi Aggarwal, MD -