Enhancing Educational Quality and Continuity of Care in a Surgical Residency program using Industrial Engineering Methods

Heron E. Rodriguez MDJonathan P. Turner, MS

Paul Speicher, BA Mark S. Daskin, PhDDebra DaRosa, PhD

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Busy service dependent on residents

Strong fellowship

Low resident’s satisfactionDistance between VS and GS

Vascular Surgery : Not the “Model” Rotation for GS Residents

Endovascular revolutionLess # defined category cases

Duty hour reform

More time off but…

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Low resident’s satisfactionDistance between VS and GS

Divorce threat in the horizon!

Example: Industrial Engineering and Trucking

CustomerProducer

Trucking company

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Creating a trucking schedule

midnight

1 am 6 am 6 pm3 pmTruck

12 am

Truck 2Truck 3Truck 4

4 am5 am

Truck 5 7 am

10 am12 pm

4 pm7 pm

6 am noon 6 pmmidnig

ht

1 am 6 am

6 pm

3 pm2 am

4 am5 am

7 am10 am

12 pm

4 pm

7 pm

5

From 5 trucks to 4 trucks

0

1

2

3

4

5

6Utilization

Tru

ck

s i

n U

se

$0 in rebates$3 in rebates

midnight

1 am 6 am 6 pm3 pmTruck

12 am

Truck 2Truck 3Truck 4

4 am5 am

Truck 5 7 am

10 am12 pm

4 pm7 pm

6 am noon 6 pmmidnig

ht

0

1

2

3

4

5

6

Utilization

Tru

ck

s i

n U

se

7 am

10 am

6

midnight

1 am 6 am 6 pm3 pmTruck

12 am

Truck 2Truck 3Truck 4

4 am5 am

12 pm4 pm

7 pm

6 am noon 6 pmmidnig

ht

7 am

10 am

$3 in rebates$12 in rebates$21 in

rebates$24 in

rebates

1 am2 am

4 am 7 am6 am

5 am6 pm3 pm

4 pm10 am

0

1

2

3

4

5

6Utilization

Tru

ck

s i

n U

se

0

1

2

3

4

5

6Utilization

Tru

ck

s i

n U

se

From 4 trucks to 3 trucks

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Fleet utilization

Deliver the same number of loads with fewer trucks

0 2 4 6 8 10 12 14 16 18 20 220

3

6

9

12

15

18

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Utilization - Before

Hour of the Day

Tru

cks

on

th

e R

oad

0 2 4 6 8 10 12 14 16 18 20 220

3

6

9

12

15

18

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Utilization - After

Hour of the Day

Tru

cks

on

th

e R

oad

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Research Questions To what extent are residents spending time

engaged in educationally beneficial activities?

How many RRC-DC cases are residents logging on their VR?Are they evenly allocated?

What is the effect of rotation length on opportunity to achieve CoC?

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Question 1: To what extent are residents spending time engaged in educationally beneficial activities?

Methods – review of goals and objectives according to ACGME general competencies and using

ABS SCOREAPDVS

The location or learning activity that will facilitate its achievement was determined

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Question 1: To what extent are residents spending time engaged in educationally beneficial activities?

When treating a patient with limb ischemia the resident is able to identify the femoral, popliteal and tibial arteries on radiologic images.

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ClinicConferenceConsult

Question 1: To what extent are residents spending time engaged in educationally beneficial activities?

When treating a patient with limb ischemia the resident is able to identify the femoral, popliteal and tibial arteries on radiologic images.

When performing surgical thrombectomy, the resident is familiar with intraoperative angiography and thrombolysis

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ClinicConferenceConsult

ORConferenceReading

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Clinic - diagnosisClinic - follow-up

Pre-op carePost-op care

Meeting with atg physBriefing - educational

Watching surgeryParticipating in surgery

ConsultsConference

Teaching or supervisingUpdating the patient list

Briefing - non educationalPre-op scut

Post-op scutReadingSkills lab

Vascular labSign-out

Administrative dutiesLogging cases

Other?

0% 5% 10% 15% 20% 25% 30%

Likely lo-cation/ activity of learning

Most likely lo-cation/ activity of learning

Question 1: To what extent are residents spending time engaged in educationally beneficial activities?

Methods – paging cards and program objectives

Jane 19-Aug 8:19:41 AM

Swami 19-Aug 8:38:48 AM

Nick 19-Aug 9:13:30 AM

Swami 19-Aug 10:44:27 AM

Shyam 19-Aug 11:37:33 AM

Swami 19-Aug 12:52:01 PM

Swami 19-Aug 1:19:55 PM

Peter 19-Aug 2:23:12 PM

Jane 19-Aug 3:02:19 PM

Manuel 19-Aug 4:18:12 PM

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Pages sentRAC’s

received

Response

rate

PGY1-2 433 252 58%

PGY3-4 399 107 27%

Total 832 359 43%

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Clinic - diagnosisClinic - follow-up

Pre-op carePost-op care

Meeting with atg physBriefing - educational

Watching surgeryParticipating in surgery

ConsultsConference

Teaching or supervisingUpdating the patient list

Briefing - non educationalPre-op scut

Post-op scutReadingSkills lab

Vascular labSign-out

Administrative dutiesLogging cases

Other?

0% 5% 10% 15% 20% 25% 30% 35%

PGY3-4

PGY1-2

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Clinic

Patient care

Participating in surgery

Consults

Conference

Updating the patient list

Scut

Reading

0% 5% 10% 15% 20% 25% 30%

Resident Activities

Objectives

Question 1: To what extent are residents spending time engaged in educationally beneficial activities?

Patient list is now automatic

Increase time in clinic

Goal-oriented time in clinic

Entry and exit interviews (goal discussion)

Goal-oriented content of conferences

Skills development outside the OR

Guided self-study

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Question 2: How many RRC-DC cases are residents logging on their VR?Are they evenly allocated?

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Reviewed the charts of all patients undergoing surgery in a 2-month period

178 patients210 cases (29% inpatients 71% outpatients)129 were defined category66 were performed by residents

ACGME case log 2008-2009

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Ave cases logged Stdev of cases

PGY1 16.3 9.9

PGY2 36.3 10.7

PGY3 46.7 11.1

PGY4 25.8 6.4

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How do we assure even distribution of cases between fellows and residents?

Jul Aug Sep Oct Nov Dec0

2

4

6

8

10

12

FellowsResidents

Nu

mb

er

of

CE

As

How do we assure even distribution of cases between fellows and residents?

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How do we assure even distribution of cases between fellows and residents?

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ACGME case log informationProjected case pool“Menu” of priority, level-specific cases

Patients seen by residents in clinic or consults

Operative case assignments

Question 2: How many RRC-DC cases are residents logging on their VR?Are they evenly allocated?

25

Jul Aug Sep Oct Nov Dec0

2

4

6

8

10

12

Nu

mb

er

of

CE

As

Jul Aug Sep Oct Nov Dec

FellowsResidents

Question 3: What is the effect of rotation length on opportunity to achieve CoC?

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CoC time lags:

Outpatient clinic visits & surgery: 16.7 days

Inpatient consultation & surgery: 1.9 days

Surgery & outpatient follow up: 22 days

Question 3: What is the effect of rotation length on opportunity to achieve CoC?

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CoC time lags:

Outpatient clinic visits & surgery: 16.7 days

Inpatient consultation & surgery: 1.9 days

Surgery & outpatient follow up: 22 days

Patient seen by the same physician

Preop Post op

Attending87% 73%

Resident3% 2%

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max l lrp rp rf rf rcn rcn er er

r p r f l r c n e r

U V X Y

= 25% continuity of care

Question 3: What is the effect of rotation length on opportunity to achieve CoC?

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max l lrp rp rf rf rcn rcn er er

r p r f l r c n e r

U V X Y

= 25% continuity of care

Question 3: What is the effect of rotation length on opportunity to achieve CoC?

= 45% continuity of care

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30323537404244474952545659616466687173767880838588900%

10%

20%

30%

40%

50%

60%

70%

Length of rotation in days

Lik

eli

ho

od

th

at

all

ev

en

ts*

fall

in

th

e s

am

e r

ota

tio

n

Dx OR Post16.7 days 22.0 days

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max l lrp rp rf rf rcn rcn er er

r p r f l r c n e r

U V X Y

Alternative policies:“Concentrated“Borrowing”“Pursuit”

Other opportunities to improve CoC

Assigning cases

A ‘concentrated’ policy

R1

R2-5 Resident c

OR

OR

Follow upClinic /

consults OR Follow upClinic /

consults

Clinic / consults Follow up

Resident a Resident b

Time during which resident can go to previous clinic’s service is fixed (first half?)

Time commitment for borrowing is small Only contributes CoC on follow up visits

A ‘borrowing’ policy

Can go to clinical appts for previous service

Resident a on service 1 Resident a on service 2

Can go to clinical appts for service 1

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Conclusions Significant discrepancies exist between

the activities that residents spend time performing during their VR and the educational goals

The amount of time devoted to and the content of educational activities need to be modified

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Conclusions Surgical cases are unevenly distributed

among residents and fellows Scheduling systems that take into

account the specific case load of programs and the individual resident’s case log are needed

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Conclusions CoC is very difficult if not impossible to

achieve during a one month rotation. Industrial engineering offers excellent

tools to improve the educational quality and CoC in surgical residency

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Jonathan P. Turner, MSPaul Speicher, BA Mark S. Daskin, PhDDebra DaRosa, PhD

Augusta Weber Education Grant