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Department of Obstetrics and Gynecology
Residency Program
“A-FIT” Report
“A-FIT”: Areas For ImprovemenT
January 2016
Monthly A-FIT Report
• Monthly Updates
» Duty Hour “Time-out”
» Evaluations / Feedback:
• Rotational and myTIPreport
» Continuity Clinic Check-In
• Areas for Improvement (A-FIT) report
» Updates
• Milestone of the Month
• Faculty and Resident Development
» Topic of the Month
Duty Hour “Time Out”!!
AY 2015-16
Block Number
Duty Hour Standard / # Violations
80 hr work
week
1 day off in
7
1 and 2
1
2
3
1
24/28 hr rule
10 hrs between
shifts
In-House Call
1
1
1
2
1
4
3 and 4
1
2
5
2
1
1
4
11
3
2
6
1
5 and 6
5
7
1
8
1
1
1
7 and 8
1
4
3
Total possible number of violations:
In 4 week block:
3136
In 7 week block:
5487
Violation Rate:
In 4 week block:
In 7 week block:
0.12%
0.15%
Faculty/Fellow Wednesday
Conference Attendance
Average Conference Attendance
YTD:
Actual Body Number!
14
12
10
8
6
4
2
0
FP
REI
ONC
MFM
MIGS
Faculty
Conference Attendance YTD
Average:
Percentage
80.00%
60.00%
40.00%
20.00%
0.00%
FP
REI
ONC
MFM
Faculty
MIGS
URO
Fellows
WPH OTHER Total
URO
Fellows
WPH
OTHER
Total
Rotation Evaluations: Completed w/i 2 weeks
7-Week Rotations
120.00%
87.5% Completion
88% Completion for
for the last block
latest completed block
100.00%
ACGME
Requirement
80.00%
60.00%
40.00%
20.00%
0.00%
Overall
GYN
OB - 4th Years
Blocks 1/2
ONC
Block 3/4
REI
Block 5/6
URO
WAKE
Rotation Evaluations: Completed w/i 2 weeks
3 1/2 - 4 Weeks Rotations
120.00%
80% Completion for
latest completed block
100.00%
ACGME
Requirement
80.00%
60.00%
40.00%
20.00%
0.00%
Overall
ACC
FP (odd blocks)
Block 4
Block 5
GYN (even blocks)
Block 6
Block 7
OB - 1st Years
OB - 3rd Years
Resident Feedback
Use of "myTIPreport" Feedback Program
90
80
70
60
50
40
30
20
10
0
July
August
September
Milestones
October
November
Surgical Skills
December
January
Resident Feedback
myTIPreport Division Monthly Usage
35
30
25
20
15
10
5
0
FP
ONC
MFM
MWFY
November
MIGS
December
REI
January
URO
WPH
Wake
Continuity Clinic Follow-up
1. Educational Sessions
2. Milestone Worksheet Completion
Month
Total
Possible
Sessions
Completed
Sessions
Percentage
Completed
Milestone
Feedback
Completed
January
32
17
53%
17
December
--
--
--
9
November
--
--
--
*
October
36
22
61%
*
September
34
24
71%
*
August
34
19
56%
*
Areas for Improvement:
2015 ACGME Survey and Internal Survey
•
•
•
•
•
•
QI Training
Value of Conferences:
» Grand Rounds
» M and M
Satisfaction with feedback
Education not compromised by…
» Service
» Other trainees
Provided data about practice habits
Fatigue
» Instructed how to manage fatigue
» Provided a way to transition care when fatigued
Area #1: QI Training
Low = 1, High = 5
1
2
3
Not bad (34% neutral or low
2
4
10
responses)
but
room
for
(4.26%)
(8.51%)
(21.28%)
improvement…
Quality Improvement training and
value
involvement
4
5
18
(38.30%)
13
(27.66%)
Brimmage QI Project:
-First four modules of the QI training released
-Participation is open to faculty and fellows
-Class QI projects in development
-Operationalize
-Review results:
-Present results:
Jan – March,2016
April, 2016
May, 2016
Area #2: Value of Conferences
Area #2: Value of Conferences
Low = 1, High = 5
1
Grand Rounds
2
3
3
4
10
(15.15%)
bad(4.55%)
(25-30%(6.06%)
neutral or
low
Not
2
7 room for
12
value responses)
but
(2.99%) (10.45%)
(17.91%)
improvement…
Morbidity and Mortality
4
5
29
(43.94%)
20
(30.30%)
26
(38.81%)
20
(29.85%)
M&M Conference
Focus: ClinicalGrand
Reasoning
Areas
Rounds: Proposed:
Invited speakers ID’ing how talk content is
particularly relevant to Specialist Practice
M and M Programming Changes
Underway
Proposed
Improvement Plan:
--Programmatic focus on clinical reasoning
--4 cases per conference
--Active “management” of
questions/answer session:
----Discussants
----Presenting Chiefs
Rotation Huddle Items
Rotation
Service over education
Education
compromised
by other
trainees
Improve
satisfaction with
feedback
Ares for fatigue
teaching and
awareness
Transition
care when
fatigue is
identified
Benign
-organizing resident OR
schedule (not new
problem). Hard time
knowing when attendings
are available to operate
(esp for WPH). Lots of
emails back and forth to
settle on OR date consider having resident
block time –
-complicated
laparoscopies—
keep working on
ways to get
PGY2 involved,
what steps
he/she is going to
do -maybe have
a surgical
curriculum,
checklist (like the
medical students
have—8 cuffs
sewn, 5 ureters
dissected out, 3
ligation of uterine
at its origin, 3
skeletonizing IP,
etc)
-Mytipreport is
about as good as it
gets in terms of
ease and
simplicity, but we
still all find it hard
to make sure we
stay up on it.
-wish they didn’t
have vacation as
chief during this
rotation (lots piles up
while he/she is out
and it’s a little
overwhelming to
take care of upon
return—>source of
fatigue)
-not really
applicable
Wednesdays afternoons:
it’s challenging to put
the pieces together of
what happened during
resident didactics.
Fellows and attendings
need to be diligent about
updating GYN team with
post- didactic sign-out.
-keep the PGY2 as the
primary conduit to sign
out to UNC-CH team and
hospitalists at HBH
Attendings need to
respond to
mytipreport
requests from
residents
Rotation Huddle Items
Rotation
Service
over
education
Education compromised by
other trainees
Improve satisfaction with
feedback
Ares for
fatigue
teaching and
awareness
Transition
care when
fatigue is
identified
REI
No issues
No problems in clinic setting. In
the OR, having multiple levels
of trainees including Fellow,
4th year and 2nd year can
detract from the experience
and opportunities of individual
trainees.
If specific roles are
assigned in the OR (as
above) then it would be
easy to provide feedback
on that specific task or
portion of the case
No issues
No issues
Solution: Depending on the
case, consider sending the 4th
year to cover a different Gyn
service OR if there is need for
coverage and have the fellow
and 2nd year in the REI OR
Related to the above
suggestion, defining which
cases or parts of cases are
appropriate for certain levels of
training would help with this.
Setting expectations prior to
the case starting would make it
clear what your role should be
at the specific level of training.
Consider having a mid
rotation checkpoint to
receive feedback
Consider having "resident
patients" (maybe as a part
of fellows clinic or a half
day of clinic precepted by
an attending) so that we
could get full history,
suggest work up and
formulate a plan for a few
patients and then have
specific feedback on
clinical knowledge - This
may be difficult logistically
but if possible would be
great for putting what we
learn into practice.
Rotation Huddle Items
Rotation
OB
Service over education
1. Cleaning up patients after delivery, particularly cesarean delivery, but also SVDs.
-Currently residents feel they are “expected” to clean patient up after delivery when they have other more
pressing clinical responsibilities.
Action item: Dr. Strauss scheduled to speak at upcoming nursing meeting on Monday, November 23rd. Dr.
Strauss also to meet with scrub techs. Will propose the below guideline to be shared with both nursing/scrub
techs and resident groups:
“OB providers should help RN and/or scrub tech clean patient after delivery, unless urgently needed
elsewhere; in which case will explain to RN/scrub tech they are unable to help clean the patient because of
other immediate responsibilities.”
Metric: Frequency residents clean patient when other immediate responsibilities are present.
2. New anesthesia rotation on L&D. This year, two anesthesia residents have elected to do an OB
rotation. Current guidelines exist regarding the role of this anesthesia resident, however they do not offer
specific guidelines regarding the type of patients the anesthesia resident can follow, thus leading to
some stress placed on the OB chief when they need to supervise that anesthesia resident if/when caring
for any “high risk” patients.
Action item: Dr. Strauss to meet with current OB chief (Dr. Jarvis) and review anesthesia resident guidelines
Follow up: Drs. Strauss and Jarvis met on 10-15-15 and updated the guidelines as follows: “Anesthesia
resident on OB would share/split running the board with OB intern but only care for “low risk” patients, as
determined by an upper year resident.”
Metric: OB chief feedback in March 2016, when next anesthesia resident scheduled to rotate on L&D
Rotation Huddle Items
Rotation
Education compromised by other trainees
OB
3. Missed opportunities to participate in more advanced OB procedures (ie, rescue cerclage,
forceps, breech extraction) because of MFM fellow participation
Action item: Dr. Strauss to meet with MFM fellows and discuss at next fellows meeting on Monday,
November 30th. In addition, the following statement has been added to the fellows “Rotation
Guidelines”:
“MFM fellow has first right of refusal over chief resident in performing more advanced procedures (ie,
rescue cerclage, forceps, breech extraction), however, the fellow is expected to inform the chief resident
of the procedure and allow the resident the opportunity to assist/participate/observe the procedure.”
Metric: OB chief resident feedback regarding opportunities to participate in more advanced OB
procedures.
Rotation Huddle Items
Rotation
Improve satisfaction with feedback
Ares for fatigue teaching and
awareness
OB
Encourage both faculty and residents to
take advantage of the smart phone App
available for MyTIPReport.
Chief resident or OB Attending
could ask OB team members
each day at lunchtime if any
concerns over fatigue. In addition,
the Antepartum Attending could
ask team members during
antepartum rounds if any
concerns over fatigue.
Transition care when
fatigue is identified
When fatigue identified,
OB chief could determine
which resident available to
cover the resident
experiencing fatigue, so
that individual could go
home at lunchtime.
Rotation Huddle Items
Rotation
Service over education
Education compromised by other trainees
WakeMe
d
Rachel/Sharon:
Seeing all consults who are stable but need 48 hour
quants in clinic
Assisting private attendings on cesareans at night
Covering triage when midlevels are out
Covering an entire clinic schedule when midlevels are
out.
Esper:
I believe since we have a large volume of patients
service can supercede education. I think that we try to
balance it out during the week by having providers in
triage and also in clinic. In addition, we have a provider
that helps with rounding in the AM (Mac Pannill),
Perhaps when we split antepartum rounding with the
MFMs then walk rounds can occur so there is one-onone teaching.
Not an issue
Rachel
No fellows - gives us more exposure to patients
and cases.
Enough deliveries that EM and FM interns don't
compromise number
Esper:
We do have off service residents however now that
an intern takes vacation on the rotation, it
decreases the number of bodies on the floor. This
does not play a role in surgical exposure, which is
important but can reflect the number of deliveries
and repair. I believe our volume is great that
everyone should feel proficient with low risk
deliveries and repairs by the end of the rotation.
Sharon
I don’t think our training is compromised by the
presence of other trainees (EM/FM residents).
There’s plenty of volume for everyone.
Rotation Huddle Items
Rotation
Improve satisfaction with feedback
Ares for fatigue teaching and awareness
WakeMe
d
Not an issue
Rachel
Not sure that we need to do anything else here
Esper
We do not address this however, we do have a buddy car pool in
place. In addition, residents are encouraged to sleep at the
hospital if overly fatigued. We have a night float system for the
interns. We can try to institute that for the upper level residents
however in years past, the residents did not like the idea of night
float.
Sharon:
Rachel:
Already doing a good job of giving inperson mid-rotation and post-rotation
feedback.
Attendings are doing a good job of
MyTip reports after cases
Esper:
We are all trying to participate in
MyTip report. In addition, we make
time for one on one feedback midrotation and at the termination of the
rotation.
Sharon:
Attendings are all very good at
completing MyTips after cases, and
everyone meets with Dr. Esper in
person at least twice to receive inperson feedback during the rotation.
The carpool is great, but it usually tends to work in the upperlevels favor because they don’t have to drive home after being
on a 24+ hr call. However, upper-levels often elect to stay postcall to write notes and/or do procedures, and the intern has to stay
late in the morning to drive the upper-level home. I know of interns
who have left as late as 12-1 pm (even though signout is at 8:15
AM) when they have to come back in at 8 pm for a night call.
When this happens repeatedly, it contributes to fatigue and should
be discouraged, either by having the oncoming team round on
antes/gyns instead of the off-going resident, or by having upperlevels drive themselves if they intend on staying post-call to
operate.
Rotation Huddle Items
Rotation
Transition care when fatigue is identified
WakeMed
Rachel:
Could we ever consider doing a night float for upper levels?
Could we ever consider having 2 day interns/ 2 night interns rather than 3/1?
Could we ever have the oncoming team round on the antes/gyns, so that the off-going resident doesn't
have to stay post-rounds to finish notes?
Sharon:
The EM/FM residents have a lot of restrictions on their work schedules secondary to didactics and
clinic hours, leaving the OB residents to cover many more night shifts and calls. If we sacrifice our
didactic time on Wednesdays and our clinic hours in order to fully commit ourselves to our patients at
Wake, I think the EM and FM residents should be held to the same standard.
Rotation Huddle Items
Rotation
Service over education
Education
compromis
ed by other
trainees
Improve
satisfaction with
feedback
Ares for
fatigue
teaching and
awareness
Transition care
when fatigue is
identified
Onc
3 possible areas of
improvement could be:
(1)coordination with our nurse
clinicians to keep a better list of
patients who are to be admitted
for chemotherapy
(2)much time spent working on
prior authorization for discharge
medications
(3)much time spent
coordinating appointments for
patients with their outside
cardiologists, PCPs etc. The
AIs are very helpful with #2 and
#3, but we don’t always have
AIs on our service. Our nurse
clinicians may be able to help
with #2.
Not a prob
w/ Fellows.
Increase the use of
my tip report,
especially in areas
outside of surgical
feedback (this would
be particularly nice
for the interns who
are not typically in
the OR). I thought
that I could come up
with a list of the
topics in my tip
report that would be
applicable during this
rotation to send out
to the fellows and
attendings – this
may encourage
increase use.
Signout
happening
later than
5:30pm:
-work to signout at
prescribed
time to
ensure duty
hour
compliance
and address
fatigue
Some of the
stress/fatigue
from being the
intern on gyn onc
is related to
continuity clinic –
prepping clinic
Monday night
and doing notes
on Tuesday
night, after a long
day on the floor.
We thought that
on Tuesdays
(usually a lighter
day in the OR),
maybe the intern
could get a extra
hour before
coming back to
the floor to work
on notes.
We do think
that 3 AIs on
service can
be difficult,
Could work
to keep this
to 2 AIs at a
time, if
possible.
Rotation Huddle Items
Rotation
Service over education
Education
compromised
by other
trainees
Improve
satisfaction with
feedback
Ares for fatigue
teaching and
awareness
Transition care
when fatigue is
identified
Urogyn
N/A
N/A
N/A
N/A
N/A
Area #5: Provided data about practice
habits
Provided data about practice habits
Proposed
Improvement Plan:
“Yes”
(UNC ‘14’15)
“Yes”
(UNC ‘14-’15)
“Yes”
(National)
50%
50%
68%
-Rotation Directors to discuss
-May have a LOT to do with “labeling” work
regarding Practice Based Learning and
Improvement
Area #6: Mitigating effects of fatigue and
excessive stress
“Yes”
(UNC ‘14-’15)
“Yes”
(UNC ‘14’15)
“Yes”
(National)
Instructed on how to manage fatigue
79%
82%
92%
Provided a way to transition care when
fatigued
64%
61%
80%
“Resiliency corner”: Feature of new monthly Residency
Program Update (The next issue will be arriving in your
inbox this week, keep an eye out!)
Proposed
Improvement Plan:
Reinstitute twice yearly programming with
Dr. Meltzer-Brody
“Departmental engagement” work in AY 15-16
Professional Development
Opportunities…
• Get to know our Milestones!
• Professional Development Topic-of-the-Month
Professional Development
Opportunities…
• Get to know our Milestones!
» Care of Patients in the Intrapartum Period
• Professional Development Topic-of-the-Month
» Identifying and addressing fatigue and
impairment
Milestone of the Month
Care of Patients in the Intrapartum Period:
•
Demonstrates basic knowledge of routine/uncomplicated intrapartum obstetrical care
including, conduct of normal labor
•
Provides intrapartum obstetrical care for women with uncomplicated pregnancies
(e.g., identification of fetal lie, interpretation of fetal heart rate monitoring, and
tocodynamometry)
•
Differentiates between normal and abnormal labor
•
Recognizes intrapartum complications (e.g., chorioamnionitis, shoulder dystocia)
•
Manages abnormal labor
•
Manages intrapartum complications (e.g., cord prolapse, placental abruption)
•
Provides care for women with complex intrapartum complications and conditions
•
Identifies indications for consultation, referral, and/or transfer of care for patients with
intrapartum complications
•
Effectively supervises and educates lower-level residents in intrapartum care
•
Collaborates and provides consultation to other members of the health care team in
intrapartum care
•
Applies innovative approaches to complex and atypical intrapartum conditions and
implements treatment plans based on emerging evidence
Identifying and addressing fatigue and
impairment
If you have were not able to attend the January 27th Grand Rounds with Dr.
Meltzer-Brody, here is the link to her presentation:
http://www.med.unc.edu/obgyn/events/grand-rounds21?utm_source=meetings&utm_medium=email&utm_campaign=4
Department of Obstetrics and
Gynecology
Residency Program
“a-FIT” Report
“a-FIT”: areas For ImprovemenT
Thank you for all you do!