acgme common duty hour requirements€¦ · acgme common duty hour requirements ii.a.4.j).(2):...

ACGME Common Duty Hour Requirements

II.A.4.j).(2): “The program director must monitor

resident duty hours, according to sponsoring institutional policies, with

a frequency sufficient to ensure compliance with ACGME

requirements.”

Duty Hours Dashboard AY 2012-2013

Components of a QI Project

The Nuts & Bolts

Objectives

•  Define QI •  Review models & tools •  Practical Exercise

What is Quality Improvement?

QI is a systematic, formal approach to the analysis of:

•  practice performance

•  efforts to improve performance

Basics of QI

•  Culture •  Determine & prioritize potential areas for

improvement •  Collect & analyze data •  Communicate results •  Commit to ongoing evaluation

Basics of QI

Culture

Areas of Improveme

nt

Collect & Analyze

Data Communicate Results

Commit to ongoing

evaluation

QI Models

•  IHI’s Model for Improvement – TQM + Rapid Cycle Improvement (PCI) =

PDSA

•  Lean Sigma – Lean + Six Sigma – Assess value of potential projects

QI Tools

•  Run Charts •  Process Maps •  Fishbone Diagrams

MODEL FOR IMPROVEMENT (PDSA)

Institute for Healthcare Improvement (IHI)

Plan Act

Do Study

What are we trying to accomplish?

How will we know if a change is an improvement?

What changes can we make that will result in an improvement?

What do you want to know?

Duty Hours Report August, 2012

•  24+4: 1 report -> stayed after for 1 hr of admin û •  Short Break: 3 reports < 8 hrs

–  PGY-2 -> 4.5 hrs / 5.5 hrs -> Continuity delivery ü / û

–  PGY-2 -> 4.5 hrs -> Continuity Delivery ü •  Short Break: 21 reports < 10 hrs but > 8 hrs

–  All on Inpatient Medicine –  Team Short 1 member

80 Hrs

16 Hrs

24+4 Hrs Call Short

Break Day Off

Night Float

0 0 1 0 24(3) 0 0

What are we trying

to accomplish?

How will we know if a change is an improvement?

What changes can we make

that will result in an improvement?

Model for Improvement

•  Setting Aims – Time-specific – Measureable – Specific population or

system

AIM: Reduce (eliminate?) short-break duty hour violations on the inpatient service within 30 days.

What are we trying

to accomplish?

How will we know if a change is an improvement?

What changes can we make

that will result in an improvement?

Model for Improvement

•  Establishing Measures – Quantitative

MEASURES: Short-break duty hour violations.

What are we trying

to accomplish?

How will we know if a change is an improvement?

What changes can we make

that will result in an improvement?

Model for Improvement

•  Selecting Changes

CHANGES: How do we know what changes to make?

Cue the tools…

Fishbone Diagrams

Process Maps

Run Charts

Run Charts

•  Graph that displays data in a time sequence.

•  Usually represents output or performance

DutyHoursReportAugust,2012

05101520

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31

InpatientCensus

0

1

2

3

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31

ShortBreakViolations

Flow (Process) Maps

Flow (Process) Maps Start / End

Action

Decision

Flow

Report Pre-round Morning Report Rounds

Admits (ER/Clinic) Procedure Inpt

Consult PM

Clinic

Tasking?

Procedure

Turnover

Go Home

Fishbone Diagrams (Cause & Effect)

Fishbone Diagrams (Cause & Effect)

Short Team Late day admits

New Interns High census

Duty Hr Violations

Inefficient

Late turnover time

One inpt team

Attrition

GMESB Awareness

Plan Act

Study Do

Plan Act

Do Study

Plan Act

Do Study Plan It

•  Education – Resident/attending lecture

•  Change turnover time – 1730 -> 1700 – NF 62.5 hrs -> 65 hrs (11 hrs out of hosp)

•  Avoid short-manned teams early in AY

Plan Act

Do Study Try It

•  Implemented for October 2012 •  Monitored monthly

Plan Act

Do Study Observe It

Inpatient: Oct – 0; Nov – 2; Dec – 1

Plan Act

Do Study Act on it

•  Any modifications to be made? •  Mirrored approach for post-

continuity delivery duty hour violations

What now?

•  Make small tweaks as needed – Continue PDSA cycle

•  Small scale -> large scale •  Spread change

Summary

•  Good QI/PI requires a culture of support

•  Structured approach

Website Recommendations •  AAFP Basics of Quality

Improvement •  IHI Science of Improvement •  Making Every Minute Count: Tools

to Improve Office Efficiency (FPM, April 2005)

Thank you!

What are we trying

to accomplish?

How will we know if a change is an improvement?

What changes can we make

that will result in an improvement?

Model for Improvement

•  Selecting Changes

What are we trying

to accomplish?

How will we know if a change is an improvement?

What changes can we make

that will result in an improvement?

Model for Improvement

Plan Act

Do Study

Plan Act

Do Study

Plan Act

Do Study