1. High Quality Residency Education and Patient Safety are Directly Related David T. Harrington, MD Program Director, General Surgical Residency Program Associate Professor of Surgery

2. Residency Work Hours Resident fatigue – clinical errors Residency work hours surrogate for patient safety Effects of work hour rules - mixed –Patient Safety Lack of definitive effect More cross-coverage and hand-offs –Residency Education Improved resident well-being, less “burn-out” Decreased operative experience (FA, TA, continuity) Increased choice of fellowships Decreased medical student teaching

3. KG Volpp et al, Mortality among hospitalized Medicare beneficiaries in the first 2 years….., JAMA 2007

4. Residency Work Hours Resident fatigue – clinical errors Residency work hours surrogate for patient safety Effects of work hour rules - mixed –Patient Safety Lack of definitive effect More cross-coverage and hand-offs –Residency Education Improved resident well-being, less “burn-out” Decreased operative experience (FA, TA, continuity) Increased choice of fellowships Decreased medical student teaching

5. Patient Safety and Surgical Quality Traditional M&M Process –Joint Commission –SCIP –Centers of Excellence Trauma - ASC/COT Bariatric - ASBS Cancer, Orthopedic, Cardiac Performance –NSQIP –UHC –CMS – MSDRG and P4P

6. NSQIP Observed to Expected (O/E) Ratio Represents the hospital’s outcomes compared to the other ACS NSQIP hospitals, adjusted for inter-hospital differences in patients’ characteristics, comorbidities, and preoperative laboratory values LOW OUTLIER: If the upper bound of the O/E confidence interval is <1.0, the hospital’s outcomes are statistically better than expected. Thus, the hospital’s outcomes are “Exemplary.” ACS NSQIP Hospital ID Number HIGH OUTLIER: If the lower bound of the O/E ratio is >1.0, the hospital’s outcomes are statistically worse than expected. Thus, the hospital’s outcomes “Need Improvement.” AS EXPECTED

7. Surgical Residency Training Outcomes Process –RRC accreditation Performance –ABSITE scores –Pass rates on QE & CE –Fellowship placement –Successful practice

9. Hypothesis Programs which deliver high quality care as measured by: participation in NSQIP verification as a trauma center high rates of compliance in SCIP would have a sound educational programs evidenced by: high pass rates on QE and CE

10. Methods & Materials NSQIP participation – NSQIP annual report Trauma Center verification – www.facs.org/trauma/verified www.facs.org/trauma/verified SCIP compliance for laparoscopic cholecystectomy: SCIP1, 2, 3, VTE1, VTE2 – www.hospitalcompare.hhs.gov www.hospitalcompare.hhs.gov QE and CE – https://home.absurgery.org/default.jsp?prog_passreport https://home.absurgery.org/default.jsp?prog_passreport

12. Results NSQIP –85 (34%) participated Trauma Center Verification –82 (32.8%) verified trauma centers –65 (26%) were Level 1 trauma centers SCIP –All hospitals had data available ABS Examinations – 1 st time passage rate –QE83.9 +/- 13.1 –CE84.5 +/- 11.1 –Combined80.0 +/- 16.2

13. NSQIP – YesNSQIP - Nop-value Qualifying Exam (average) 87.981.8< 0.001 Certifying Exam (average) 85.883.30.100 Combined (average)77.270.10.001 NSQIP Participation & QE/CE

14. Trauma Center Yes Trauma Center No p-value Qualifying Exam (average) 87.483.00.038 Certifying Exam (average) 88.683.90.006 Combined (average)78.871.30.003 Trauma Center Verification & QE/CE

15. Level 1 – YesLevel 1 - Nop-value Qualifying Exam (average) 88.483.10.012 Certifying Exam (average) 89.184.40.005 Combined (average)80.171.9< 0.001 Level 1 Verification & QE/CE

21. Hypothesis Programs which deliver high quality care as measured by: participation in NSQIP verification as a trauma center high rates of compliance in SCIP would have a sound educational programs evidenced by: high pass rates on QE and CE

22. Excellent Patient Safety = Excellent Education RRC site visit –Trauma center verification –Improving SCIP compliance –Improving NSQIP performance Teaching hospitals are quintessential quality model –New physicians –Ascending levels of responsibility 6 core competencies –System-based practice –Practice-based learning Multi-disciplinary –RRC, NSQIP, Trauma Verification, SCIP compliance

23. Shortcomings QE/CE pass rates ≠ quality of training Study has no relevance to medical training Participation in NSQIP ≠ higher quality of patient care

24. NSQIP: Changes in Morbidity 2005-2007

25. Conclusions Hospitals that participate in NSQIP have a higher quality of surgical resident education than hospitals that do not. Hospitals that obtain Trauma Center verification have a higher quality of surgical resident education than hospitals that do not. Hospitals that obtain Level 1 Trauma Center verification have a higher quality of surgical resident education than hospitals that do not.

26. High Quality Residency Education and Patient Safety are Directly Related David T. Harrington, MD Program Director, General Surgical Residency Program Associate Professor of Surgery