Presenter Status

Resident/Psychology Intern

Abstract Type

QI

Primary Mentor

Shobhit Jain, MD

Start Date

10-5-2021 12:45 PM

End Date

10-5-2021 1:00 PM

Presentation Type

Oral Presentation

Description

Problem Statement/Question: After meeting certain criteria, pediatric emergency medicine (PEM) fellows were previously permitted to independently manage and discharge patients. These encounters anecdotally fostered autonomy but missed educational opportunities. We have previously reported that fellow positive perception of education and autonomy was low (22% and 11%). Additionally, the absence of an attending’s attestation on these patient charts prevented the collection of a professional service fee, an average potential billed amount of $125.67 per unit of service or total of $620,307 in 2019.

Background/Project Intent (Aim Statement): After key stakeholder involvement, we recognized attending supervision for all fellow patients as an opportunity to improve fellow education and financial stewardship. Our goals were to 1. improve attending attestation on fellows’ cases from 91% to 98% by June 2020, and 2. Improve fellow-reported positive impact on education to >70% by January 2021.

Methods (include PDSA cycles): We performed this work at the CMH Adele Hall ED – 37 PEM attendings and 9 PEM fellows, 75,000 patient visits annually. For financial stewardship, we created an attestation template for the attendings and after 2 revisions and education, we implemented it in October 2019. For educational focus, we surveyed fellows and attendings to determine the interventions. The survey yielded multiple ideas, including #1-fellow checkout framework, #2-creating fellow-attending dyad per shift, and #3-video instruction on precepting. After collaboration with ED education leaders, we chose #1 and #2. We developed a framework to guide patient checkout between the fellow and attending. After 5 iterations, we implemented it in September 2020. We continue to survey the staff every quarter to gather feedback. Although outside of the project, the ED Lean work enabled closer fellow-attending collaboration through the new ED “pod” system starting in November 2020.

Results: Attending attestation increased to 100% and has remained sustained without additional interventions. On surveys after implementation, 56% of fellows cited using the framework frequently. 78% of fellows reported no improved/unchanged education, compared to an average of 45% in prior surveys. Survey results reveal a disparity between attending and fellow perception about improvement of education (30% v 11%).

Conclusions: Financial improvements were quick with simpler and sweeping process change. The educational improvements have been slow and need to be further investigated. The external change of the ED Pod system continues to be refined through PDSA cycles. The impact on education remains to be seen. We recognize that financial stewardship is warranted, and we must take steps to protect fellow autonomy. As next step, this project will pivot from quality improvement to an educational research project at CMH and beyond.

Comments

Abstract Only.

MeSH Keywords

teaching hospital, fellowship, professional autonomy

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May 10th, 12:45 PM May 10th, 1:00 PM

Educational Impact of Supervising Fellow Visits in the Emergency Department

Problem Statement/Question: After meeting certain criteria, pediatric emergency medicine (PEM) fellows were previously permitted to independently manage and discharge patients. These encounters anecdotally fostered autonomy but missed educational opportunities. We have previously reported that fellow positive perception of education and autonomy was low (22% and 11%). Additionally, the absence of an attending’s attestation on these patient charts prevented the collection of a professional service fee, an average potential billed amount of $125.67 per unit of service or total of $620,307 in 2019.

Background/Project Intent (Aim Statement): After key stakeholder involvement, we recognized attending supervision for all fellow patients as an opportunity to improve fellow education and financial stewardship. Our goals were to 1. improve attending attestation on fellows’ cases from 91% to 98% by June 2020, and 2. Improve fellow-reported positive impact on education to >70% by January 2021.

Methods (include PDSA cycles): We performed this work at the CMH Adele Hall ED – 37 PEM attendings and 9 PEM fellows, 75,000 patient visits annually. For financial stewardship, we created an attestation template for the attendings and after 2 revisions and education, we implemented it in October 2019. For educational focus, we surveyed fellows and attendings to determine the interventions. The survey yielded multiple ideas, including #1-fellow checkout framework, #2-creating fellow-attending dyad per shift, and #3-video instruction on precepting. After collaboration with ED education leaders, we chose #1 and #2. We developed a framework to guide patient checkout between the fellow and attending. After 5 iterations, we implemented it in September 2020. We continue to survey the staff every quarter to gather feedback. Although outside of the project, the ED Lean work enabled closer fellow-attending collaboration through the new ED “pod” system starting in November 2020.

Results: Attending attestation increased to 100% and has remained sustained without additional interventions. On surveys after implementation, 56% of fellows cited using the framework frequently. 78% of fellows reported no improved/unchanged education, compared to an average of 45% in prior surveys. Survey results reveal a disparity between attending and fellow perception about improvement of education (30% v 11%).

Conclusions: Financial improvements were quick with simpler and sweeping process change. The educational improvements have been slow and need to be further investigated. The external change of the ED Pod system continues to be refined through PDSA cycles. The impact on education remains to be seen. We recognize that financial stewardship is warranted, and we must take steps to protect fellow autonomy. As next step, this project will pivot from quality improvement to an educational research project at CMH and beyond.