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1.  Effect of a Physician-directed Educational Campaign on Performance of Proper Diabetic Foot Exams in an Outpatient Setting 
The established guidelines for a diabetes foot examination include assessing circulatory, skin, and neurological status to detect problems early and reduce the likelihood of amputation. Physician adherence to the guidelines for proper examination is less than optimal.
Our objective was to increase compliance with the performance of a proper foot examination through a predominantly physician-directed interventional campaign.
The study consisted of 3 parts: a retrospective chart review to estimate background compliance, an educational intervention, and prospective chart review at 3 and 6 months. A properly documented foot examination was defined as assessing at least 2 of the 3 necessary components. The educational intervention consisted of 2 lectures directed at resident physicians and a quality assurance announcement at a general internal medicine staff meeting. Clinic support staff were instructed to remove the shoes and socks of all diabetic patients when they were placed in exam rooms, and signs reminding diabetics were placed in each exam room.
There was a significant increase in the performance of proper foot examination over the course of the study (baseline 14.0%, 3 months 58.0%, 6 months 62.1%; P < .001). Documentation of any component of a proper foot examination also increased substantially (32.6%, 67.3%, 72.5%; P < .001). Additionally, performance of each component of a proper exam increased dramatically during the study: neurological (13.5%, 35.8%, 38.5%; P < .001), skin (23.0%, 64.2%, 69.2%; P < .001), and vascular (14.0%, 51.2%, 50.5%; P < .001).
Patients with diabetes are unlikely to have foot examinations in their primary medical care. A simple, low-cost educational intervention significantly improved the adherence to foot examination guidelines for patients with diabetes.
PMCID: PMC1494848  PMID: 12709092
diabetes; foot ulceration; foot exam; prevention; physical education
2.  Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety 
Long working hours and sleep deprivation have been a facet of physician training in the US since the advent of the modern residency system. However, the scientific evidence linking fatigue with deficits in human performance, accidents and errors in industries from aeronautics to medicine, nuclear power, and transportation has mounted over the last 40 years. This evidence has also spawned regulations to help ensure public safety across safety-sensitive industries, with the notable exception of medicine.
In late 2007, at the behest of the US Congress, the Institute of Medicine embarked on a year-long examination of the scientific evidence linking resident physician sleep deprivation with clinical performance deficits and medical errors. The Institute of Medicine’s report, entitled “Resident duty hours: Enhancing sleep, supervision and safety”, published in January 2009, recommended new limits on resident physician work hours and workload, increased supervision, a heightened focus on resident physician safety, training in structured handovers and quality improvement, more rigorous external oversight of work hours and other aspects of residency training, and the identification of expanded funding sources necessary to implement the recommended reforms successfully and protect the public and resident physicians themselves from preventable harm.
Given that resident physicians comprise almost a quarter of all physicians who work in hospitals, and that taxpayers, through Medicare and Medicaid, fund graduate medical education, the public has a deep investment in physician training. Patients expect to receive safe, high-quality care in the nation’s teaching hospitals. Because it is their safety that is at issue, their voices should be central in policy decisions affecting patient safety. It is likewise important to integrate the perspectives of resident physicians, policy makers, and other constituencies in designing new policies. However, since its release, discussion of the Institute of Medicine report has been largely confined to the medical education community, led by the Accreditation Council for Graduate Medical Education (ACGME).
To begin gathering these perspectives and developing a plan to implement safer work hours for resident physicians, a conference entitled “Enhancing sleep, supervision and safety: What will it take to implement the Institute of Medicine recommendations?” was held at Harvard Medical School on June 17–18, 2010. This White Paper is a product of a diverse group of 26 representative stakeholders bringing relevant new information and innovative practices to bear on a critical patient safety problem. Given that our conference included experts from across disciplines with diverse perspectives and interests, not every recommendation was endorsed by each invited conference participant. However, every recommendation made here was endorsed by the majority of the group, and many were endorsed unanimously. Conference members participated in the process, reviewed the final product, and provided input before publication. Participants provided their individual perspectives, which do not necessarily represent the formal views of any organization.
In September 2010 the ACGME issued new rules to go into effect on July 1, 2011. Unfortunately, they stop considerably short of the Institute of Medicine’s recommendations and those endorsed by this conference. In particular, the ACGME only applied the limitation of 16 hours to first-year resident physicans. Thus, it is clear that policymakers, hospital administrators, and residency program directors who wish to implement safer health care systems must go far beyond what the ACGME will require. We hope this White Paper will serve as a guide and provide encouragement for that effort.
Resident physician workload and supervision
By the end of training, a resident physician should be able to practice independently. Yet much of resident physicians’ time is dominated by tasks with little educational value. The caseload can be so great that inadequate reflective time is left for learning based on clinical experiences. In addition, supervision is often vaguely defined and discontinuous. Medical malpractice data indicate that resident physicians are frequently named in lawsuits, most often for lack of supervision. The recommendations are: The ACGME should adjust resident physicians workload requirements to optimize educational value. Resident physicians as well as faculty should be involved in work redesign that eliminates nonessential and noneducational activity from resident physician dutiesMechanisms should be developed for identifying in real time when a resident physician’s workload is excessive, and processes developed to activate additional providersTeamwork should be actively encouraged in delivery of patient care. Historically, much of medical training has focused on individual knowledge, skills, and responsibility. As health care delivery has become more complex, it will be essential to train resident and attending physicians in effective teamwork that emphasizes collective responsibility for patient care and recognizes the signs, both individual and systemic, of a schedule and working conditions that are too demanding to be safeHospitals should embrace the opportunities that resident physician training redesign offers. Hospitals should recognize and act on the potential benefits of work redesign, eg, increased efficiency, reduced costs, improved quality of care, and resident physician and attending job satisfactionAttending physicians should supervise all hospital admissions. Resident physicians should directly discuss all admissions with attending physicians. Attending physicians should be both cognizant of and have input into the care patients are to receive upon admission to the hospitalInhouse supervision should be required for all critical care services, including emergency rooms, intensive care units, and trauma services. Resident physicians should not be left unsupervised to care for critically ill patients. In settings in which the acuity is high, physicians who have completed residency should provide direct supervision for resident physicians. Supervising physicians should always be physically in the hospital for supervision of resident physicians who care for critically ill patientsThe ACGME should explicitly define “good” supervision by specialty and by year of training. Explicit requirements for intensity and level of training for supervision of specific clinical scenarios should be providedCenters for Medicare and Medicaid Services (CMS) should use graduate medical education funding to provide incentives to programs with proven, effective levels of supervision. Although this action would require federal legislation, reimbursement rules would help to ensure that hospitals pay attention to the importance of good supervision and require it from their training programs
Resident physician work hours
Although the IOM “Sleep, supervision and safety” report provides a comprehensive review and discussion of all aspects of graduate medical education training, the report’s focal point is its recommendations regarding the hours that resident physicians are currently required to work. A considerable body of scientific evidence, much of it cited by the Institute of Medicine report, describes deteriorating performance in fatigued humans, as well as specific studies on resident physician fatigue and preventable medical errors.
The question before this conference was what work redesign and cultural changes are needed to reform work hours as recommended by the Institute of Medicine’s evidence-based report? Extensive scientific data demonstrate that shifts exceeding 12–16 hours without sleep are unsafe. Several principles should be followed in efforts to reduce consecutive hours below this level and achieve safer work schedules. The recommendations are: Limit resident physician work hours to 12–16 hour maximum shiftsA minimum of 10 hours off duty should be scheduled between shiftsResident physician input into work redesign should be actively solicitedSchedules should be designed that adhere to principles of sleep and circadian science; this includes careful consideration of the effects of multiple consecutive night shifts, and provision of adequate time off after night work, as specified in the IOM reportResident physicians should not be scheduled up to the maximum permissible limits; emergencies frequently occur that require resident physicians to stay longer than their scheduled shifts, and this should be anticipated in scheduling resident physicians’ work shiftsHospitals should anticipate the need for iterative improvement as new schedules are initiated; be prepared to learn from the initial phase-in, and change the plan as neededAs resident physician work hours are redesigned, attending physicians should also be considered; a potential consequence of resident physician work hour reduction and increased supervisory requirements may be an increase in work for attending physicians; this should be carefully monitored, and adjustments to attending physician work schedules made as needed to prevent unsafe work hours or working conditions for this group“Home call” should be brought under the overall limits of working hours; work load and hours should be monitored in each residency program to ensure that resident physicians and fellows on home call are getting sufficient sleepMedicare funding for graduate medical education in each hospital should be linked with adherence to the Institute of Medicine limits on resident physician work hours
Moonlighting by resident physicians
The Institute of Medicine report recommended including external as well as internal moonlighting in working hour limits. The recommendation is: All moonlighting work hours should be included in the ACGME working hour limits and actively monitored. Hospitals should formalize a moonlighting policy and establish systems for actively monitoring resident physician moonlighting
Safety of resident physicians
The “Sleep, supervision and safety” report also addresses fatigue-related harm done to resident physicians themselves. The report focuses on two main sources of physical injury to resident physicians impaired by fatigue, ie, needle-stick exposure to blood-borne pathogens and motor vehicle crashes. Providing safe transportation home for resident physicians is a logistical and financial challenge for hospitals. Educating physicians at all levels on the dangers of fatigue is clearly required to change driving behavior so that safe hospital-funded transport home is used effectively. Fatigue-related injury prevention (including not driving while drowsy) should be taught in medical school and during residency, and reinforced with attending physicians; hospitals and residency programs must be informed that resident physicians’ ability to judge their own level of impairment is impaired when they are sleep deprived; hence, leaving decisions about the capacity to drive to impaired resident physicians is not recommendedHospitals should provide transportation to all resident physicians who report feeling too tired to drive safely; in addition, although consecutive work should not exceed 16 hours, hospitals should provide transportation for all resident physicians who, because of unforeseen reasons or emergencies, work for longer than consecutive 24 hours; transportation under these circumstances should be automatically provided to house staff, and should not rely on self-identification or request
Training in effective handovers and quality improvement
Handover practice for resident physicians, attendings, and other health care providers has long been identified as a weak link in patient safety throughout health care settings. Policies to improve handovers of care must be tailored to fit the appropriate clinical scenario, recognizing that information overload can also be a problem. At the heart of improving handovers is the organizational effort to improve quality, an effort in which resident physicians have typically been insufficiently engaged. The recommendations are: Hospitals should train attending and resident physicians in effective handovers of careHospitals should create uniform processes for handovers that are tailored to meet each clinical setting; all handovers should be done verbally and face-to-face, but should also utilize written toolsWhen possible, hospitals should integrate hand-over tools into their electronic medical records (EMR) systems; these systems should be standardized to the extent possible across residency programs in a hospital, but may be tailored to the needs of specific programs and services; federal government should help subsidize adoption of electronic medical records by hospitals to improve signoutWhen feasible, handovers should be a team effort including nurses, patients, and familiesHospitals should include residents in their quality improvement and patient safety efforts; the ACGME should specify in their core competency requirements that resident physicians work on quality improvement projects; likewise, the Joint Commission should require that resident physicians be included in quality improvement and patient safety programs at teaching hospitals; hospital administrators and residency program directors should create opportunities for resident physicians to become involved in ongoing quality improvement projects and root cause analysis teams; feedback on successful quality improvement interventions should be shared with resident physicians and broadly disseminatedQuality improvement/patient safety concepts should be integral to the medical school curriculum; medical school deans should elevate the topics of patient safety, quality improvement, and teamwork; these concepts should be integrated throughout the medical school curriculum and reinforced throughout residency; mastery of these concepts by medical students should be tested on the United States Medical Licensing Examination (USMLE) stepsFederal government should support involvement of resident physicians in quality improvement efforts; initiatives to improve quality by including resident physicians in quality improvement projects should be financially supported by the Department of Health and Human Services
Monitoring and oversight of the ACGME
While the ACGME is a key stakeholder in residency training, external voices are essential to ensure that public interests are heard in the development and monitoring of standards. Consequently, the Institute of Medicine report recommended external oversight and monitoring through the Joint Commission and Centers for Medicare and Medicaid Services (CMS). The recommendations are: Make comprehensive fatigue management a Joint Commission National Patient Safety Goal; fatigue is a safety concern not only for resident physicians, but also for nurses, attending physicians, and other health care workers; the Joint Commission should seek to ensure that all health care workers, not just resident physicians, are working as safely as possibleFederal government, including the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality, should encourage development of comprehensive fatigue management programs which all health systems would eventually be required to implementMake ACGME compliance with working hours a “ condition of participation” for reimbursement of direct and indirect graduate medical education costs; financial incentives will greatly increase the adoption of and compliance with ACGME standards
Future financial support for implementation
The Institute of Medicine’s report estimates that $1.7 billion (in 2008 dollars) would be needed to implement its recommendations. Twenty-five percent of that amount ($376 million) will be required just to bring hospitals into compliance with the existing 2003 ACGME rules. Downstream savings to the health care system could potentially result from safer care, but these benefits typically do not accrue to hospitals and residency programs, who have been asked historically to bear the burden of residency reform costs. The recommendations are: The Institute of Medicine should convene a panel of stakeholders, including private and public funders of health care and graduate medical education, to lay down the concrete steps necessary to identify and allocate the resources needed to implement the recommendations contained in the IOM “Resident duty hours: Enhancing sleep, supervision and safety” report. Conference participants suggested several approaches to engage public and private support for this initiativeEfforts to find additional funding to implement the Institute of Medicine recommendations should focus more broadly on patient safety and health care delivery reform; policy efforts focused narrowly upon resident physician work hours are less likely to succeed than broad patient safety initiatives that include residency redesign as a key componentHospitals should view the Institute of Medicine recommendations as an opportunity to begin resident physician work redesign projects as the core of a business model that embraces safety and ultimately saves resourcesBoth the Secretary of Health and Human Services and the Director of the Centers for Medicare and Medicaid Services should take the Institute of Medicine recommendations into consideration when promulgating rules for innovation grantsThe National Health Care Workforce Commission should consider the Institute of Medicine recommendations when analyzing the nation’s physician workforce needs
Recommendations for future research
Conference participants concurred that convening the stakeholders and agreeing on a research agenda was key. Some observed that some sectors within the medical education community have been reluctant to act on the data. Several logical funders for future research were identified. But above all agencies, Centers for Medicare and Medicaid Services is the only stakeholder that funds graduate medical education upstream and will reap savings downstream if preventable medical errors are reduced as a result of reform of resident physician work hours.
PMCID: PMC3630963  PMID: 23616719
resident; hospital; working hours; safety
3.  Assessing Intern Core Competencies With an Objective Structured Clinical Examination 
Residents are evaluated using Accreditation Council for Graduate Medical Education (ACGME) core competencies. An Objective Structured Clinical Examination (OSCE) is a potential evaluation tool to measure these competencies and provide outcome data.
Create an OSCE to evaluate and demonstrate improvement in intern core competencies of patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice before and after internship.
From 2006 to 2008, 106 interns from 10 medical specialties were evaluated with a preinternship and postinternship OSCE at Madigan Army Medical Center. The OSCE included eight 12-minute stations that collectively evaluated the 6 ACGME core competencies using human patient simulators, standardized patients, and clinical scenarios. Interns were scored using objective and subjective criteria, with a maximum score of 100 for each competency. Stations included death notification, abdominal pain, transfusion consent, suture skills, wellness history, chest pain, altered mental status, and computer literature search. These stations were chosen by specialty program directors, created with input from board-certified specialists, and were peer reviewed.
All OSCE testing on the 106 interns (ages 25 to 44 [average, 28.6]; 70 [66%] men; 65 [58%] allopathic medical school graduates) resulted in statistically significant improvement in all ACGME core competencies: patient care (71.9% to 80.0%, P < .001), medical knowledge (59.6% to 78.6%, P < .001), practice-based learning and improvement (45.2% to 63.0%, P < .001), interpersonal and communication skills (77.5% to 83.1%, P < .001), professionalism (74.8% to 85.1%, P < .001), and systems-based practice (56.6% to 76.5%, P < .001).
An OSCE during internship can evaluate incoming baseline ACGME core competencies and test for interval improvement. The OSCE is a valuable assessment tool to provide outcome measures on resident competency performance and evaluate program effectiveness.
PMCID: PMC2931201  PMID: 21975704
4.  Use of a Structured Template to Facilitate Practice-Based Learning and Improvement Projects 
The Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to meet and demonstrate outcomes across 6 competencies. Measuring residents' competency in practice-based learning and improvement (PBLI) is particularly challenging.
We developed an educational tool to meet ACGME requirements for PBLI. The PBLI template helped programs document quality improvement (QI) projects and supported increased scholarly activity surrounding PBLI learning.
We reviewed program requirements for 43 residency and fellowship programs and identified specific PBLI requirements for QI activities. We also examined ACGME Program Information Form responses on PBLI core competency questions surrounding QI projects for program sites visited in 2008–2009. Data were integrated by a multidisciplinary committee to develop a peer-protected PBLI template guiding programs through process, documentation, and evaluation of QI projects. All steps were reviewed and approved through our GME Committee structure.
An electronic template, companion checklist, and evaluation form were developed using identified project characteristics to guide programs through the PBLI process and facilitate documentation and evaluation of the process. During a 24 month period, 27 programs have completed PBLI projects, and 15 have reviewed the template with their education committees, but have not initiated projects using the template.
The development of the tool generated program leaders' support because the tool enhanced the ability to meet program-specific objectives. The peer-protected status of this document for confidentiality and from discovery has been beneficial for program usage. The document aggregates data on PBLI and QI initiatives, offers opportunities to increase scholarship in QI, and meets the ACGME goal of linking measures to outcomes important to meeting accreditation requirements at the program and institutional level.
PMCID: PMC3399615  PMID: 23730444
5.  Educational Experiences Residents Perceive As Most Helpful for the Acquisition of the ACGME Competencies 
The Accreditation Council for Graduate Medical Education (ACGME) requires physicians in training to be educated in 6 competencies considered important for independent medical practice. There is little information about the experiences that residents feel contribute most to the acquisition of the competencies.
To understand how residents perceive their learning of the ACGME competencies and to determine which educational activities were most helpful in acquiring these competencies.
A web-based survey created by the graduate medical education office for institutional program monitoring and evaluation was sent to all residents in ACGME-accredited programs at the David Geffen School of Medicine, University of California-Los Angeles, from 2007 to 2010. Residents responded to questions about the adequacy of their learning for each of the 6 competencies and which learning activities were most helpful in competency acquisition.
We analyzed 1378 responses collected from postgraduate year-1 (PGY-1) to PGY-3 residents in 12 different residency programs, surveyed between 2007 and 2010. The overall response rate varied by year (66%–82%). Most residents (80%–97%) stated that their learning of the 6 ACGME competencies was “adequate.” Patient care activities and observation of attending physicians and peers were listed as the 2 most helpful learning activities for acquiring the 6 competencies.
Our findings reinforce the importance of learning from role models during patient care activities and the heterogeneity of learning activities needed for acquiring all 6 competencies.
PMCID: PMC3399609  PMID: 23730438
6.  Treat to Goal: Impact of Clinical Pharmacist Referral Service Primarily in Diabetes Management 
Hospital Pharmacy  2013;48(8):656-661.
To describe the impact of pharmacist services in a collaborative practice providing care to primarily Medicaid and indigent patients. The practice includes primary care physicians, nurses, a care navigator, and pharmacists. Pharmacy services are provided by pharmacists, including PGY-1 pharmacy residents and pharmacy students.
A retrospective chart review was conducted to perform a pre-post analysis on all patients referred to pharmacists within an adult medicine clinic. Patients were included if they were more than 18 years old; were referred for type 1 or 2 diabetes mellitus, hypertension, hyperlipidemia, or medication reconciliation; and were seen from August 2010 to March 2011. All charts were reviewed to assess pharmacist impact on adherence to standards of care including hemoglobin A1c; lipids; blood pressure; vaccination status; usage of aspirin, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins; and other criteria. Subgroup analysis was performed on diabetic patients who were not at goal at the time of referral to the pharmacy clinic.
Ninety-three charts were reviewed. In the overall group, rates of influenza and pneumococcal vaccination improved significantly, as did annual foot and eye exams in diabetics. Pharmacists significantly decreased A1c from 9.12% at baseline to 8.13% (P < .001), systolic blood pressure (SBP) from 142.6 to 133.5 mm Hg (P < .001), and low-density lipoprotein (LDL) from 143.6 to 103.2 mg/dL (P < .001) in diabetic patients who were not at goal at baseline.
Pharmacists were effective in improving surrogate outcomes for patients with diabetes and in assisting physicians to address all standards of care.
PMCID: PMC3847985  PMID: 24421536
diabetes mellitus; hyperlipidemias; pharmacists; pharmaceutical services; standard of care; vaccination
7.  Clinical instructors' perception of a faculty development programme promoting postgraduate year-1 (PGY1) residents' ACGME six core competencies: a 2-year study 
BMJ Open  2011;1(2):e000200.
The six core competencies designated by Accreditation Council for Graduate Medical Education (ACGME) are essential for establishing a patient centre holistic medical system. The authors developed a faculty programme to promote the postgraduate year 1 (PGY1) resident, ACGME six core competencies. The study aims to assess the clinical instructors' perception, attitudes and subjective impression towards the various sessions of the ‘faculty development programme for teaching ACGME competencies.’
During 2009 and 2010, 134 clinical instructors participated in the programme to establish their ability to teach and assess PGY1 residents about ACGME competencies.
The participants in the faculty development programme reported that the skills most often used while teaching were learnt during circuit and itinerant bedside, physical examination teaching, mini-clinical evaluation exercise (mini-CEX) evaluation demonstration, training workshop and videotapes of ‘how to teach ACGME competencies.’ Participants reported that circuit bedside teaching and mini-CEX evaluation demonstrations helped them in the interpersonal and communication skills domain, and that the itinerant teaching demonstrations helped them in the professionalism domain, while physical examination teaching and mini-CEX evaluation demonstrations helped them in the patients' care domain. Both the training workshop and videotape session increase familiarity with teaching and assessing skills. Participants who applied the skills learnt from the faculty development programme the most in their teaching and assessment came from internal medicine departments, were young attending physician and had experience as PGY1 clinical instructors.
According to the clinical instructors' response, our faculty development programme effectively increased their familiarity with various teaching and assessment skills needed to teach PGY1 residents and ACGME competencies, and these clinical instructors also then subsequently apply these skills.
Article summary
Article focus
In order to train PGY1 residents, we need to help clinical instructors to become familiar with the teaching and assessment skills that form the Accreditation Council for Graduate Medical Education six core-competencies.
Our study used a self-reported questionnaires based analysis to evaluate the clinical instructors' perception to our faculty development programme.
Key messages
Participants reported that their most commonly used skills were learnt from itinerant and circuit bedside teaching, and mini-clinical evaluation exercise evaluation demonstration in our programme.
Participants also reported that the 40 h basic training course improved their abilities to train and assess PGY1 residents in patient care, interpersonal and communication skills, and medical knowledge domains whereas postcourse training workshop and videotape session enhanced their ability in system-based practice, practice-based learning and improvement, and professionalism domains.
A serial follow-up questionnaire suggested that the degree of participant application of skills learnt from our programme increased progressively after finishing the 40 h basic training course, the postcourse training workshop and videotape session.
Strengths and limitations of this study
According to the clinical instructors' responses, our programme effectively increased their familiarity with teaching and assessment skills needed when teaching PGY1 residents' Accreditation Council for Graduate Medical Education competencies and that these skills were subsequently applies.
This study was limited by the fact that questionnaire used to track and assess the effectiveness of the training programme may have had information and recall bias. In addition, this study had a relatively small sample size and did not contain a control group. However, no controlled educational trials on this subject have been published as yet.
PMCID: PMC3225591  PMID: 22116089
8.  Insights about the process and impact of implementing nursing guidelines on delivery of care in hospitals and community settings 
Little is known about the impact of implementing nursing-oriented best practice guidelines on the delivery of patient care in either hospital or community settings.
A naturalistic study with a prospective, before and after design documented the implementation of six newly developed nursing best practice guidelines (asthma, breastfeeding, delirium-dementia-depression (DDD), foot complications in diabetes, smoking cessation and venous leg ulcers). Eleven health care organisations were selected for a one-year project. At each site, clinical resource nurses (CRNs) worked with managers and a multidisciplinary steering committee to conduct an environmental scan and develop an action plan of activities (i.e. education sessions, policy review). Process and patient outcomes were assessed by chart audit (n = 681 pre-implementation, 592 post-implementation). Outcomes were also assessed for four of six topics by in-hospital/home interviews (n = 261 pre-implementation, 232 post-implementation) and follow-up telephone interviews (n = 152 pre, 121 post). Interviews were conducted with 83/95 (87%) CRN's, nurses and administrators to describe recommendations selected, strategies used and participants' perceived facilitators and barriers to guideline implementation.
While statistically significant improvements in 5% to 83% of indicators were observed in each organization, more than 80% of indicators for breastfeeding, DDD and smoking cessation did not change. Statistically significant improvements were found in > 50% of indicators for asthma (52%), diabetes foot care (83%) and venous leg ulcers (60%). Organizations with > 50% improvements reported two unique implementation strategies which included hands-on skill practice sessions for nurses and the development of new patient education materials. Key facilitators for all organizations included education sessions as well as support from champions and managers while key barriers were lack of time, workload pressure and staff resistance.
Implementation of nursing best practice guidelines can result in improved practice and patient outcomes across diverse settings yet many indicators remained unchanged. Mobilization of the nursing workforce to actively implement guidelines and to monitor the delivery of their care is important so that patients may learn about and receive recommended healthcare.
PMCID: PMC2279128  PMID: 18241349
9.  Duty Hour Recommendations and Implications for Meeting the ACGME Core Competencies: Views of Residency Directors 
Mayo Clinic Proceedings  2011;86(3):185-191.
OBJECTIVE: To describe the views of residency program directors regarding the effect of the 2010 duty hour recommendations on the 6 core competencies of graduate medical education.
METHODS: US residency program directors in internal medicine, pediatrics, and general surgery were e-mailed a survey from July 8 through July 20, 2010, after the 2010 Accreditation Council for Graduate Medical Education (ACGME) duty hour recommendations were published. Directors were asked to rate the implications of the new recommendations for the 6 ACGME core competencies as well as for continuity of inpatient care and resident fatigue.
RESULTS: Of 719 eligible program directors, 464 (65%) responded. Most program directors believe that the new ACGME recommendations will decrease residents' continuity with hospitalized patients (404/464 [87%]) and will not change (303/464 [65%]) or will increase (26/464 [6%]) resident fatigue. Additionally, most program directors (249-363/464 [53%-78%]) believe that the new duty hour restrictions will decrease residents' ability to develop competency in 5 of the 6 core areas. Surgery directors were more likely than internal medicine directors to believe that the ACGME recommendations will decrease residents' competency in patient care (odds ratio [OR], 3.9; 95% confidence interval [CI], 2.5-6.3), medical knowledge (OR, 1.9; 95% CI, 1.2-3.2), practice-based learning and improvement (OR, 2.7; 95% CI, 1.7-4.4), interpersonal and communication skills (OR, 1.9; 95% CI, 1.2-3.0), and professionalism (OR, 2.5; 95% CI, 1.5-4.0).
CONCLUSION: Residency program directors' reactions to ACGME duty hour recommendations demonstrate a marked degree of concern about educating a competent generation of future physicians in the face of increasing duty hour standards and regulation.
The reactions of residency program directors to the ACGME duty hour recommendations demonstrate a marked degree of concern about educating a competent generation of future physicians in the face of increasing duty hour standards and regulation.
PMCID: PMC3046937  PMID: 21307391
10.  Accreditation council for graduate medical education (ACGME) annual anesthesiology residency and fellowship program review: a "report card" model for continuous improvement 
BMC Medical Education  2010;10:13.
The Accreditation Council for Graduate Medical Education (ACGME) requires an annual evaluation of all ACGME-accredited residency and fellowship programs to assess program quality. The results of this evaluation must be used to improve the program. This manuscript describes a metric to be used in conducting ACGME-mandated annual program review of ACGME-accredited anesthesiology residencies and fellowships.
A variety of metrics to assess anesthesiology residency and fellowship programs are identified by the authors through literature review and considered for use in constructing a program "report card."
Metrics used to assess program quality include success in achieving American Board of Anesthesiology (ABA) certification, performance on the annual ABA/American Society of Anesthesiology In-Training Examination, performance on mock oral ABA certification examinations, trainee scholarly activities (publications and presentations), accreditation site visit and internal review results, ACGME and alumni survey results, National Resident Matching Program (NRMP) results, exit interview feedback, diversity data and extensive program/rotation/faculty/curriculum evaluations by trainees and faculty. The results are used to construct a "report card" that provides a high-level review of program performance and can be used in a continuous quality improvement process.
An annual program review is required to assess all ACGME-accredited residency and fellowship programs to monitor and improve program quality. We describe an annual review process based on metrics that can be used to focus attention on areas for improvement and track program performance year-to-year. A "report card" format is described as a high-level tool to track educational outcomes.
PMCID: PMC2830223  PMID: 20141641
11.  Incorporating Evidence-based Medicine into Resident Education: A CORD Survey of Faculty and Resident Expectations 
The Accreditation Council for Graduate Medical Education (ACGME) invokes evidence-based medicine (EBM) principles through the practice-based learning core competency. The authors hypothesized that among a representative sample of emergency medicine (EM) residency programs, a wide variability in EBM resident training priorities, faculty expertise expectations, and curricula exists.
The primary objective was to obtain descriptive data regarding EBM practices and expectations from EM physician educators. Our secondary objective was to assess differences in EBM educational priorities among journal club directors compared with non–journal club directors.
A 19-question survey was developed by a group of recognized EBM curriculum innovators and then disseminated to Council of Emergency Medicine Residency Directors (CORD) conference participants, assessing their opinions regarding essential EBM skill sets and EBM curricular expectations for residents and faculty at their home institutions. The survey instrument also identified the degree of interest respondents had in receiving a free monthly EBM journal club curriculum.
A total of 157 individuals registered for the conference, and 98 completed the survey. Seventy-seven (77% of respondents) were either residency program directors or assistant / associate program directors. The majority of participants were from university-based programs and in practice at least 5 years. Respondents reported the ability to identify flawed research (45%), apply research findings to patient care (43%), and comprehend research methodology (33%) as the most important resident skill sets. The majority of respondents reported no formal journal club or EBM curricula (75%) and do not utilize structured critical appraisal instruments (71%) when reviewing the literature. While journal club directors believed that resident learners’ most important EBM skill is to identify secondary peer-reviewed resources, non–journal club directors identified residents’ ability to distinguish significantly flawed research as the key skill to develop. Interest in receiving a free monthly EBM journal club curriculum was widely accepted (89%).
Attaining EBM proficiency is an expected outcome of graduate medical education (GME) training, although the specific domains of anticipated expertise differ between faculty and residents. Few respondents currently use a formalized curriculum to guide the development of EBM skill sets. There appears to be a high level of interest in obtaining EBM journal club educational content in a structured format. Measuring the effects of providing journal club curriculum content in conjunction with other EBM interventions may warrant further investigation.
PMCID: PMC3219923  PMID: 21199085
evidence-based medicine; knowledge translation; faculty development
12.  Evaluating Practice-Based Learning and Improvement: Efforts to Improve Acceptance of Portfolios 
The Accreditation Council for Graduate Medical Education (ACGME) recommends resident portfolios as 1 method for assessing competence in practice-based learning and improvement. In July 2005, when anesthesiology residents in our department were required to start a portfolio, the residents and their faculty advisors did not readily accept this new requirement. Intensive education efforts addressing the goals and importance of portfolios were undertaken. We hypothesized that these educational efforts improved acceptance of the portfolio and retrospectively audited the portfolio evaluation forms completed by faculty advisors.
Intensive education about the goals and importance of portfolios began in January 2006, including presentations at departmental conferences and one-on-one education sessions. Faculty advisors were instructed to evaluate each resident's portfolio and complete a review form. We retrospectively collected data to determine the percentage of review forms completed by faculty. The portfolio reviews also assessed the percentage of 10 required portfolio components residents had completed.
Portfolio review forms were completed by faculty advisors for 13% (5/38) of residents during the first advisor-advisee meeting in December 2005. Initiation of intensive education efforts significantly improved compliance, with review forms completed for 68% (26/38) of residents in May 2006 (P < .0001) and 95% (36/38) in December 2006 (P < .0001). Residents also significantly improved the completeness of portfolios between May and December of 2006.
Portfolios are considered a best methods technique by the ACGME for evaluation of practice-based learning and improvment. We have found that intensive education about the goals and importance of portfolios can enhance acceptance of this evaluation tool, resulting in improved compliance in completion and evaluation of portfolios.
PMCID: PMC3010953  PMID: 22132291
13.  Effect of a Multidisciplinary-Assisted Resident Diabetes Clinic on Resident Knowledge and Patient Outcomes 
Despite the rising prevalence of diabetes, there is a paucity of diabetes curricula in residency training. The multidisciplinary diabetes team approach is underused in residency education.
To assess the feasibility of an innovative multidisciplinary resident diabetes clinic (MRDC) in enhancing (1) resident diabetes knowledge via a Diabetes Awareness Questionnaire, and (2) subsequent process and patient outcomes in patients with diabetes via a Diabetes Practice Behavior Checklist.
From October 2008 to February 2010, 14 internal medicine residents managed patients with uncontrolled diabetes in a weekly half-day MRDC for 1 month (total 4–5 half-day sessions/resident), with a collaborative team of internists, diabetes educators, an endocrinologist, and a pharmacist. The curriculum included didactic sessions, required readings, and patient-specific case discussions. A 20-question Diabetes Awareness Questionnaire was administered to each resident prerotation and postrotation. Records of 47 patients with diabetes in the residents' own continuity clinics (not the MRDC) were audited 6 months before and after the MRDC for Diabetes Practice Behavior Checklist measures (glycated hemoglobin, blood pressure, low-density lipoprotein cholesterol, retinal referral, foot exam, microalbumin screen). Pre-MRDC and post-MRDC data were compared via paired t test.
The MRDC residents exhibited a modest increase in mean (SD) scores on the Diabetes Awareness Questionnaire (before, 8.2 [2.8]; after, 10.9 [2.8]; P  =  .02) and a modest mean (SD) performance increase in overall process outcomes from the Diabetes Practice Behavior Checklist (before, 74% [18%]; after, 84% [18%]; P  =  .004). No improvements occurred in patient outcomes.
Multidisciplinary diabetes teaching may be useful in fostering certain resident knowledge and performance measures but may not alter clinical outcomes. Further large-scale, longitudinal studies are needed to understand the effect of our curriculum on residents' diabetes knowledge and future practice behavior.
PMCID: PMC3613301  PMID: 24404243
14.  Residency Programs' Evaluations of the Competencies: Data Provided to the ACGME About Types of Assessments Used by Programs 
In 1999, the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project began to focus on resident performance in the 6 competencies of patient care, medical knowledge, professionalism, practice-based learning and improvement, interpersonal communication skills, and professionalism. Beginning in 2007, the ACGME began collecting information on how programs assess these competencies. This report provides information on the nature and extent of those assessments.
Using data collected by the ACGME for site visits, we use descriptive statistics and percentages to describe the number and type of methods and assessors accredited programs (n  =  4417) report using to assess the competencies. Observed differences among specialties, methodologies, and assessors are tested with analysis of variance procedures.
Almost all (>97%) of programs report assessing all of the competencies and using multiple methods and multiple assessors. Similar assessment methods and evaluator types were consistently used across the 6 competencies. However, there were some differences in the use of patient and family as assessors: Primary care and ambulatory specialties used these to a greater extent than other specialties.
Residency programs are emphasizing the competencies in their evaluation of residents. Understanding the scope of evaluation methodologies that programs use in resident assessment is important for both the profession and the public, so that together we may monitor continuing improvement in US graduate medical education.
PMCID: PMC3010956  PMID: 22132294
15.  Impact of 2011 Resident Duty Hour Requirements on Neurology Residency Programs and Departments 
The Neurohospitalist  2014;4(3):119-126.
In 2011, the Accreditation Council on Graduate Medical Education (ACGME) redefined resident duty hour requirements by reducing in-hospital duty hour requirements for residents in an effort to improve patient care, resident well-being, and resident education. We sought to determine the cost of adoption based on changes made by neurology residency programs and departments due to these requirements.
We surveyed department chairs or residency program directors at 123 ACGME-accredited US adult neurology training programs on programmatic changes and resident expansion, hiring practices, and development of new computer-based resources in direct response to the 2011 ACGME duty hour requirements. Using data from publicly available resources, we estimated respondents’ financial cost of adoption.
In all, 63 responded (51% response rate); 76% were program directors. The most common changes implemented by programs were adding night float systems (n = 31; 49%) and increasing faculty responsibility (n = 26; 41%). In direct response to the requirements, 21 programs applied to ACGME for 40 additional residents, 29 of which were fully covered by institutional funds. In direct response to the requirements, nearly half of the departments (n = 26) hired individuals for a total of 80 hires (or 64 full-time equivalents), most commonly mid-level practitioners. The total estimated cost to responding departments was US $12.7 million or US $201,000 per department annually. When projecting expenses of planned changes for the following year, costs increased to US $360,000 per department, with 5-year costs exceeding US $1 million.
The most recent restriction on resident duty hours comes at substantial cost to neurology departments and residency programs.
PMCID: PMC4056414  PMID: 24982715
education; training; academic; quality; safety; costs
16.  Impact of state mandatory insurance coverage on the use of diabetes preventive care 
46 U.S. states and the District of Columbia have passed laws and regulations mandating that health insurance plans cover diabetes treatment and preventive care. Previous research on state mandates suggested that these policies had little impact, since many health plans already covered the benefits. Here, we analyze the contents of and model the effect of state mandates. We examined how state mandates impacted the likelihood of using three types of diabetes preventive care: annual eye exams, annual foot exams, and performing daily self-monitoring of blood glucose (SMBG).
We collected information on diabetes benefits specified in state mandates and time the mandates were enacted. To assess impact, we used data that the Behavioral Risk Factor Surveillance System gathered between 1996 and 2000. 4,797 individuals with self-reported diabetes and covered by private insurance were included; 3,195 of these resided in the 16 states that passed state mandates between 1997 and 1999; 1,602 resided in the 8 states or the District of Columbia without state mandates by 2000. Multivariate logistic regression models (with state fixed effect, controlling for patient demographic characteristics and socio-economic status, state characteristics, and time trend) were used to model the association between passing state mandates and the usage of the forms of diabetes preventive care, both individually and collectively.
All 16 states that passed mandates between 1997 and 1999 required coverage of diabetic monitors and strips, while 15 states required coverage of diabetes self management education. Only 1 state required coverage of periodic eye and foot exams. State mandates were positively associated with a 6.3 (P = 0.04) and a 5.8 (P = 0.03) percentage point increase in the probability of privately insured diabetic patient's performing SMBG and simultaneous receiving all three preventive care, respectively; state mandates were not significantly associated with receiving annual diabetic eye (0.05 percentage points decrease, P = 0.92) or foot exams (2.3 percentage points increase, P = 0.45).
Effects of state mandates varied by preventive care type, with state mandates being associated with a small increase in SMBG. We found no evidence that state mandates were effective in increasing receipt of annual eye or foot exams. The small or non-significant effects might be attributed to small numbers of insured people not having the benefits prior to the mandates' passage. If state mandates' purpose is to provide improved benefits to many persons, policy makers should consider determining the number of people who might benefit prior to passing the mandate.
PMCID: PMC2881060  PMID: 20492699
17.  Characteristics of Insured Patients with Persistent Gaps in Diabetes Care Services: The Translating Research into Action for Diabetes (TRIAD) Study 
Medical care  2010;48(1):31-37.
Although prevention of complications in diabetes requires careful control over many years, little is known about which patients persistently fail to get recommended care.
To determine the frequency and correlates of persistent long-term gaps in diabetes care.
Patient surveys and reviews of medical records were used to assess preventive care services for diabetes among 8392 patients who were continuously enrolled in 10 US managed care plans from 1999 to 2002. Demographic and socioeconomic characteristics, access to care, social support, and mental and physical health were determined by interview. Five preventive care services of diabetes care (testing of hemoglobin A1c, cholesterol, and albuminuria, dilated eye exams, and foot exams) were assessed by survey and chart abstraction for a 3-year period (1999–2002). We defined a “persistent lapse” as a participant’s missing a preventive care service for the entire 3 years.
In all, 70% of patients had no persistent lapses, 22% had 1, 6% had 2, and 2% had ≥ 3. Persistent lapses occurred most often for lipid testing (11.6%), microalbuminuria testing (9.7%), and eye exams (9.0%), but less frequently for foot exams (6.9%) and A1c tests (4.2%). In multivariate analyses, the odds of a persistent lapse in care was 42% higher for young (age 18–44) than middle aged persons and 26% higher among lean than very obese persons. In addition, the odds of a persistent lapse was 26% higher for those of low income, 29% higher among employed persons, 18% higher for smokers, 27% higher in those with fewer than 5 years of diabetes than those with > 15 years, and 42% higher for persons with zero or 1 comorbid conditions (compared to ≥ 3). In addition, non-Hispanic blacks were particularly likely to miss lipid tests (15.3%) and those not taking medications were especially likely to miss foot exams (7.1%), A1c tests (10.6%), and proteinuria tests (10.8%). Sex, education, marital status, family demands, transportation, trust in physicians, and mental health were not associated with lapses in care.
Even in an insured cohort, 3 in 10 participants had 1 or more persistent lapses in diabetes care. Patients with lower income, younger age, having fewer co-morbidities, taking fewer medications and poor health behaviors are particularly vulnerable to persistent lapses in care and a group who warrant targeted interventions to improve preventive diabetes care.
PMCID: PMC4269465  PMID: 20009778
18.  Development, Testing, and Implementation of the ACGME Clinical Learning Environment Review (CLER) Program 
Since the release of the Institute of Medicine's report on resident hours and patient safety, there have been calls for enhanced institutional oversight of duty hour limits and of efforts to enhance the quality and safety of care in teaching hospitals. The ACGME has established the Clinical Learning Environment Review (CLER) program as a key component of the Next Accreditation System with the aim to promote safety and quality of care by focusing on 6 areas important to the safety and quality of care in teaching hospitals and the care residents will provide in a lifetime of practice after completion of training. The 6 areas encompass engagement of residents in patient safety, quality improvement and care transitions, promoting appropriate resident supervision, duty hour oversight and fatigue management, and enhancing professionalism.
Over the coming 18 months the ACGME will develop, test, and fully implement this new program by conducting visits to the nearly 400 clinical sites of sponsoring institutions with two or more specialty or subspecialty programs. These site visits will provide an understanding of how the learning environment for the 116 000 current residents and fellows addresses the 6 areas important to safety and quality of care, and will generate baseline data on the status of these activities in accredited institutions. We expect that over time the CLER program will serve as a new source of formative feedback for teaching institutions, and generate national data that will guide performance improvement for United States graduate medical education.
PMCID: PMC3444205  PMID: 23997895
19.  Impact of implementing an EMR on physical exam documentation by ambulance personnel 
Applied Clinical Informatics  2012;3(3):301-308.
Georgetown University has a student run Emergency Medical Services (EMS) organization with over 100 emergency medical technicians (EMTs). We set out to determine whether implementing an electronic patient care report (ePCR) system was associated with improved physical exam documentation.
This study evaluated documentation of the physical exam on prehospital patient care reports (PCRs). An ePCR system was implemented. ePCR documentation was compared to that of the previously used paper PCRs. This study looked retrospectively at 154 PCRs. 77 were hand written PCRs from before the electronic system. The PCRs involved chief complaints that were primarily respiratory, neurologic, or both. 77 ePCRs of matching chief complaint categories were used for comparison. Each chart was reviewed for completion of certain physical exam findings. The mean percentage of documented components from the ePCRs was compared to that of the hand written PCRs. The null hypothesis was that the absolute increase in the mean was not more than 20 percent. The two exclusion criteria were PCRs completed by study investigators after the design of the project and partially or completely missing PCRs.
The absolute increase in mean physical exam component documentation was 36% (95% CI = 29–43%). A weighted kappa of 0.894 showed very good agreement between chart reviewers.
This study rejected the null hypothesis that the ePCR system was associated with a mean increase of no more than 20%. It observed increase in physical exam documentation. Limitations of this study included the inability to determine whether documentation of physical exam findings reflected performance of the physical exam, and what components of the ePCR system bundle were responsible for the increase in physical exam component documentation.
PMCID: PMC3613032  PMID: 23646077
Documentation; quality improvement; emergency medical technicians; universities; emergency medical services; electronic health records
20.  Improved Clinical Outcomes Combining House Staff Self-Assessment with an Audit-Based Quality Improvement Program 
Journal of General Internal Medicine  2010;25(10):1078-1082.
There is a focus on integrating quality improvement with medical education and advancement of the American College of Graduate Medical Education (ACGME) core competencies.
To determine if audits of patients with unexpected admission to the medical intensive care unit using a self-assessment tool and a focused Morbidity and Mortality (M&M) conference improves patient care.
Charts from patients transferred from the general medical floor (GMF) to the medical intensive care unit (ICU) were reviewed by a multidisciplinary team. Physician and nursing self-assessment tools and a targeted monthly M&M conference were part of the educational component.
Physicians and nurses participated in root cause analysis.
Records of all patients transferred from a general medical floor (GMF) to the ICU were audited. One hundred ninety-four cases were reviewed over a 10-month period.
New policies regarding vital signs and house staff escalation of care were initiated. The percentage of calls for patients who met medical emergency response team/critical care consult criteria increased from 53% to 73%, nurse notification of a change in a patient’s condition increased from 65% to 100%, nursing documentation of the change in the patients condition and follow-up actions increased from 65% percent to a high of 90%, the number of cardiac arrests on a GMF decreased from 3.1/1,000 discharges to 0.6/1,000 discharges (p = 0.002), and deaths on the Medicine Service decreased from 34/1,000 discharges to 24/1,000 discharges (p = 0.024).
We describe an audit-based program that involves nurses, house staff, a self-assessment tool and a focused M&M conference. The program resulted in significant policy changes, more rapid assessment of unstable patients and improved hospital outcomes.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-010-1427-5) contains supplementary material, which is available to authorized users.
PMCID: PMC2955460  PMID: 20556534
house staff; Self-assessment; Audit-based quality improvement program
21.  Measuring Resident Physicians' Performance of Preventive Care 
The Accreditation Council for Graduate Medical Education has suggested various methods for evaluation of practice-based learning and improvement competency, but data on implementation of these methods are limited.
To compare medical record review and patient surveys on evaluating physician performance in preventive services in an outpatient resident clinic.
Within an ongoing quality improvement project, we collected baseline performance data on preventive services provided for patients at the University of Alabama at Birmingham (UAB) Internal Medicine Residents' ambulatory clinic.
Seventy internal medicine and medicine-pediatrics residents from the UAB Internal Medicine Residency program.
Resident- and clinic-level comparisons of aggregated patient survey and chart documentation rates of (1) screening for smoking status, (2) advising smokers to quit, (3) cholesterol screening, (4) mammography screening, and (5) pneumonia vaccination.
Six hundred and fifty-nine patient surveys and 761 charts were abstracted. At the clinic level, rates for screening of smoking status, recommending mammogram, and for cholesterol screening were similar (difference <5%) between the 2 methods. Higher rates for pneumonia vaccination (76% vs 67%) and advice to quit smoking (66% vs 52%) were seen on medical record review versus patient surveys. However, within-resident (N=70) comparison of 2 methods of estimating screening rates contained significant variability. The cost of medical record review was substantially higher ($107 vs $17/physician).
Medical record review and patient surveys provided similar rates for selected preventive health measures at the clinic level, with the exception of pneumonia vaccination and advising to quit smoking. A large variation among individual resident providers was noted.
PMCID: PMC1828097  PMID: 16499544
education; medical; preventive health services; patient survey; medical record review; cost evaluation
22.  Effectiveness of foot care education among people with type 2 diabetes in rural Puducherry, India 
The burden of diabetes and its foot complications is increasing in India. Prevention of these complications through foot care education should be explored. The objective of our study was to assess the risk factors of poor diabetic foot care and to find the effectiveness of health education in improving foot care practice among diabetes patients.
Materials and Methods:
A structured pre-tested questionnaire was administered to the outpatients of a rural health center with type 2 diabetes. Awareness regarding diabetes, care of diabetes and foot care practice ware assessed and scored. Individual and group health education focusing on foot care was performed. Foot care practice was reassessed after 2 weeks of education.
Only 54% were aware that diabetes could lead to reduced foot sensation and foot ulcers. Nearly 53% and 41% of the patients had good diabetes awareness and good diabetes care respectively. Only 22% of the patients had their feet examined by a health worker or doctor. The patients with poor, satisfactory and good practice scores were 44.7%, 35.9% and 19.4% respectively. Low education status, old age and low awareness regarding diabetes were the risk factors for poor practice of foot care. Average score for practice of foot care improved from 5.90 ± 1.82 to 8.0 ± 1.30 after 2 weeks of health education. Practice related to toe space examination, foot inspection and foot wear inspection improved maximally.
Foot care education for diabetics in a primary care setting improves their foot care practice and is likely to be effective in reducing the burden of diabetic foot ulcer.
PMCID: PMC3968714  PMID: 24701439
Diabetes; diabetic foot ulcer; foot care; health education; India
23.  Impact of the implementation of the AAN epilepsy quality measures on the medical records in a university hospital 
BMC Neurology  2013;13:112.
The American Academy of Neurology (AAN) suggested eight quality measures to be observed at every patient visit. The aim of this work is to compare the percentage of documentation of each measure before and after the implementation of a new worksheet in a third-level center.
Quasi-experimental study including medical records filled by medical school seniors and junior residents supervised by an epileptologist. The authors surveyed 80 consecutive charts of people with epilepsy who were seen in the outpatient clinic before and after the intervention. McNemar change test was used to compare the percentages of documentation of each quality measure–i.e., seizure type and frequency, etiology, EEG, MRI/CT head scans, AED side effects, surgical therapy referral, safety counseling, preconception counseling–and physical exam. Each quality measure was considered to be fulfilled only if it was assessed and properly recorded.
Mean age was 35(±13) years, 55% women, mean epilepsy onset at age 18(±15), 82% presented with partial-onset seizures. The reporting rate improved for all quality measures (previous vs new), reaching statistical significance for: seizure type 80vs94% (p < 0.05), AED side effects 8vs24%, etiology 66vs88% (p < 0.01), safety counseling 5vs64%, preconception counseling 4vs20%, and physical exam 63vs94% (p < 0.001).
A quality-oriented epilepsy worksheet led to a better practice standardization and documentation of AAN standards for diagnostic and counseling purposes. Further evaluations should be undertaken to assess the impact on medical education and patient care.
PMCID: PMC3765766  PMID: 23984949
Academic medical center; Quality of health care; Adult epilepsy; Health education; AAN epilepsy quality measures; General practitioners
24.  Internal Reviews Benefit Programs of the Review Team Members and the Program Under Review 
The Accreditation Council for Graduate Medical Education (ACGME) mandates that sponsoring institutions conduct internal reviews. In 1998, the ACGME Institutional Review Committee gave Duke University Hospital a citation for an inadequate internal review (IR) process. Since then, we have instituted several iterative changes. We describe the evolution of Duke University Hospital's current internal review process.
We implemented a new review team composition, template report, use of the program information form, and centralization of documentation to improve our internal review process. In 2007, a more formal evaluation of the outcome and impact of these changes was instituted. This included a yearly survey of all participants and review team members, a review of programs, and a tracking process for the decisions of our Graduate Medical Education Committee (GMEC) on the status of reviewed programs.
Participants from both the program under review and the review team evaluated the process favorably. Review teams reported they learned from the best practices of the program being reviewed. Program directors from the reviewed programs reported the process improved their documentation. Both groups reported the process better prepared them for their next ACGME Review Committee site visit. The GMEC has recommended “probationary sponsorship” for fewer programs since the IR process changes have been implemented. The IR process was recognized as a best practice in Duke University Hospital's 2004 ACGME institutional review.
We believe our IR process, review-team composition, template report, program information form, and centralized documentation now fully meets accreditation standards. Participants are reasonably satisfied and report value from the process. More programs are judged to be within substantial compliance by the GMEC.
PMCID: PMC3010948  PMID: 22132286
25.  An evaluation of the core physical exam in patients with minor peripheral chief complaints 
Emergency Medicine Journal : EMJ  2007;24(12):820-822.
We sought to determine (1) how often and why emergency medicine resident physicians perform core physical exams in patients with minor peripheral chief complaints (MCCs); and (2) the clinical impact this practice.
This prospective observational study was conducted at an urban emergency department with a 4 year emergency medicine residency. Charts of all emergency department patients presenting with MCCs in June–September 2003 were reviewed by blinded assistants for documentation of (1) core physical exams; (2) abnormal core physical exam findings; and (3) additional work up, treatment or follow up related to abnormal core physical exam findings. In May–June 2004 all emergency medicine residents were asked how often they perform core physical exams on emergency department patients with MCCs and their motivating factors for this practice.
297 patients met MCC inclusion/exclusion criteria. Among the 591 total cardiac, lung and abdominal exams performed, 8 (1.4%, 95% confidence interval (CI) 0.7% to 2.7%) were abnormal and only 1 (0.1%, 95% CI 0% to 0.1%) finding led to further testing (ECG); none prompted change in treatment or follow up. All 46 eligible emergency medicine residents were evaluated; 72% (33) performed core physical exams in half or more patients with MCCs. Their primary reasons were to screen the underserved emergency department population, the belief that such exams are standard of care, and establishment of physician–patient rapport.
Because they want to screen an underserved population, establish rapport, and meet what they believe is a standard of care, most emergency medicine residents performed core exams on patients with MCCs. Abnormal core physical exam findings are unusual and rarely lead to further testing or change in management.
PMCID: PMC2658350  PMID: 18029511

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