1. Development of a House Staff-Leadership Collaborative
“Try it, You’ll Like It”
Development of a House Staff-Leadership Collaborative
Josh M. Heck, MD | Wade Iams, MD | Donald Brady, MD
Vanderbilt University School of Medicine
Nashville, TN 37232
In the summer of 2013, Vanderbilt began an initiative to meet the challenges of a rapidly changing health care system which not only addressed the operational efficiency of the hospital, but also focused on improving processes that would enable it to provide safer, patient-centered, high-value health care.
At the same time, the Accreditation Council for Graduate Medical Education (ACGME) began looking into how well residents and clinical fellows were integrated into institutional quality improvement and patient safety initiatives as part of its Clinical Learning Environment Review (CLER).
Background
Design
Hospital leadership meets with residents and fellows from (peri)-operative specialties on the first Monday of the month, followed by internal medicine, neurology, and radiology house staff on the second Monday, and pediatric house staff on the third Monday. Importantly, all departments are represented at one of the three meetings. 
The fourth Monday is reserved for the hospital leadership to meet and to recap the lessons learned from the prior meetings, plan next steps, and prepare action plans to present to the house staff at the following month’s meetings.
There are currently over 60 residents and fellows from a wide variety of specialties involved in the dialogue across the three meetings.
The residents are able to identify problems and propose potential solutions, thus deeply integrating house staff with C-Suite processes and quality improvement.
Week 1
Week 2
Week 3
Week 4
present plan to…
C-Suite + DIO
Meeting Cycle
(Peri)-Operative Specialties House Staff
Medicine / Neurology / Radiology House Staff
Pediatric House Staff
Recap lessons
Plan next steps
Prepare action plans
HLC Key Themes
Results
The broad representation of house staff allows hospital leadership to identify recurrent / hospital wide inefficiencies and safety issues.
From these meetings, subcommittees spin off and work on solutions to these issues.
Theme
General Feedback
Nursing Communication
Direct communication with nurses
Utilization of text messages as opposed to numeric pages
Nursing Documentation
Nursing documentation not clinically relevant
Documentation not standardized across departments
Documentation completed in other departmental systems is not easily available (MCE documentation is hand written)
Pager Communication
Accurate database for pager numbers
Standardization on how pages are sent
Support of paging on mobile devices
Messages garbled; not consistently received
Elimination of numeric pages
Rolling pagers inefficient, error prone, no feedback confirmation
Difficult to identify right person for a med consult (team pager)—spine is covered by 2 services, which service should be contacted?
Medication Reconciliation
User interface not easy to use
More collaboration with pharmacy staff
Issues with maintaining structure between inpatient/outpatient
Editing medications during discharge erases the dose
Inconsistency between medication list and what patient receives
Lab Results Display
Ability to sort/view by date/time results that are reported back from lab
Difficult to review lab data- too much data, not well structured or organized
Text/alert when specific labs are resulted
Equipment Utilization
Workstations in alcoves by patient rooms underutilized resulting in not enough mobile CWS machines available for rounding
Communication-Consults
More efficient way for consultants to communicate DC plan
Data Integration
More efficient way to aggregate of information for rounds; eliminating need for manual collection of information
Discharge Process
More streamlined process for preparing patient for DC
No standardized protocols/processes in place
Healthcare Team
Need to know intern, primary nurse, attending physician
Mobile Technology
More support of Vanderbilt systems on mobile devices
Patient Transfers
Challenging to get the right people into the MICU; bed tracking system not always accurate
Notification of patient transfer doesn’t always happen
Transfer orders are not always updated by the accepting team
Provider Documentation
Amendment to notes are not very visible and do not directly link to the area in the note where the note was changed (i.e. documentation error regarding site/laterality of procedure)
When note is changed by another person, notification is not sent to original creator
One example of a solution developed in response to these meetings was the creation of a standardized template for pages sent to house staff in order to reduce the need for callbacks and ability to prioritize activities.
It was quickly recognized that there was opportunity to incorporate the unique “front line” perspectives of the house staff in the hospital’s quality and efficiency initiative.
The DIO and resident-led House Staff Advisory Committee (HSAC) invited the “C-Suite” – the Chief Operating Officer, the Chief Medical Informatics Officer, and Chiefs of Staff – to discuss the house staff’s perspective on potential process improvement opportunities.
This initial meeting generated so many good ideas and discussions for the hospital leadership that the C-suite requested weekly meetings with house staff as an ongoing forum.
Origin
Benefits
Residents and fellows gain real experience in project management, patient safety, organizational methodologies and system design.
The hospital is able to improve the quality of care, employee satisfaction and eliminate waste. Time and money are saved in identifying inefficiencies.
The proposed changes benefit from increased support and enthusiasm because the end users have been involved in designing the solution.
The medical center leadership has gained an important perspective on the utility of house staff involvement in process improvement efforts.
Hospital leadership has now begun reaching out to the DIO and the HLC to involve residents and fellows in other, non-HLC generated process improvement efforts such as: standardization of nursing medication administration times, improving geographic localization of patients admitted to various services, and vetting rapid work flow redesign project priorities for the medical center.
HSAC
(House Staff Advisory Committee)
DIO
(ACGME Designated Institutional Official)
C-Suite
Chief Operating Officer, Chief Medical Informatics Officer, and Chiefs of Staff
House Staff – Leadership Collaborative