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					     UCSF GME 2011:

Annual Report and Town Hall

     Robert B. Baron, MD MS
     Professor of Medicine, Associate Dean GME & CME
                             GME Faculty

     Robert B. Baron, MD,                          Mary McGrath, MD, MPH                         Susan Promes, MD
             MS                                            Professor of Surgery            Associate Professor, Emergency Medicine
                                                   Director, Resident and Fellow Affairs           Director, Curricular Affairs
        Professor of Medicine
  Associate Dean for GME and CME

       Arpana Vidyarthi, MD                                Claire Brett, MD                        Rene Salazar, MD
 Assistant Clinical Professor of Medicine             Professor of Clinical Anesthesia        Assistant Clinical Professor of Medicine
Director, Patient Safety and Quality Innovations     Chair, Internal Review Committee                  Director, Diversity
                                                             Vice Chair, GMEC
Office of GME Staff
                           UCSF GME

       25 accredited residency programs
           Average cycle length 4.44 years (out of 5)
       53 accredited fellowship programs
           Average cycle length 4.87 years (out of 5)
       40 non-standard programs
       1,365 residents and clinical fellows
       UCSF School of Medicine is Sponsoring Institution
       Designated Institutional Official (DIO) reports to the
                Short Cycle Programs

       Plastic Surgery: 3 years
       General Surgery: 3 years
       Thoracic Surgery: 2 years
       Pediatric Anesthesia: 2 years
       Nephrology: 3 years
       Infectious Disease: 3 years

       No particular pattern
           Less than 2 citations per program

       Institutional support
           Parking and transportation
       Faculty
       Education program
       Evaluation
       Duty Hours
Duty Hours – October 2010
GME Diversity 2004-2010
Underrepresented in Medicine in GME
          Recruitment of Underrepresented in
          Medicine: UCSF GME 2010 Match

           Applied       Interviewed    Ranked      Matched

            838 (9.3%)   179 (9.9%)    157 (9.6%)   30 (12.5%)

            127 (9.6%)   35 (9.4%)     24 (9.8%)    6 (6.3%)
Selected Training Outcomes: 2010 Resident
               Career Choices

  Higher training: 51%
  Academic position: 18%

  Practice: 20%

  Policy/consulting: 1%

  Other: 10 %
Selected Training Outcomes: 2010 Fellow
               Career Choices

  Higher training: 31%
  Academic position: 33%

  Practice: 26%

  Policy/consulting: 2.5%

  Other: 7.5 %
Selected Training Outcomes: 2010 Resident
  UCSF presentation: 28%

  Regional presentations: 9%

  National presentations: 17%

  International presentations: 4%

  Any presentation: 29 %

  First author publication: 22%

  Peer reviewed publication: 22%

  Any publication: 23%
Selected Training Outcomes: 2010 Fellow
  UCSF presentation: 57%

  Regional presentations: 10%

  National presentations: 27%

  International presentations: 11%

  Any presentation: 58%

  First author publication: 30%

  Peer reviewed publication: 29%

  Any publication: 39%
Selected Training Outcomes: 2010 Residents
   Courses and Structured Electives

     TICR: 2 (0.2%)
     DCR: 33 (3.8%)
     Pathways to Discovery: 109 (12.7%)
       6 programs
       Anesthesia, Dermatology, Family Medicine, Internal
        Medicine, OB-GYN, Pathology
Selected Training Outcomes: 2010 Fellows
   Courses and Structured Electives

    TICR: 33 (12.7%)
    DCR: 12 (4.6%)
    Pathways to Discovery: 1 (0.4%)
        Endocrinology
New Common Program Requirements

   Effective July 1, 2011; not just changes to duty hours
   Introduction: focus of graduate medical education on
    transitioning a medical student to an independent
    practitioner through graded and progressive
    responsibility in medical education.
   Professionalism, personal responsibility, and patient
    safety are discussed in detail
   Transitions of care must be minimized and structured.
   Residents and clinical fellows must work as members
    of effective interprofessional teams.
Patient Safety vs. Clinical Experience
Supervision vs. Autonomy
        Supervision vs. Autonomy


             Low                                                                                                             High

            Student ---------------------------- Intern -------------- Resident ------------ Fellow---------------------Attending
        Supervision vs. Autonomy


            Low                                                                                                                High

       Student ---------------------------- Intern -------------- Resident ------------ Fellow---------------------Attending
        Supervision vs. Autonomy



            Low                                                                                                           High

       Student ---------------------------- Intern -------------- Resident ------------ Fellow---------------------Attending
New Requirements: Fatigue
   Fatigue education, which has been required for
    trainees, will be required for all teaching faculty.

   Fatigue mitigation processes must be adopted.
      i.e. strategic napping, back-up call schedules, etc.
     Adequate sleep facilities and safe transportation options
      for those who are too fatigued to drive home (i.e. taxi
      vouchers, nap rooms, etc.) must be provided.
New Requirements: Supervision
   Supervision is discussed in detail and definitions of
    direct and indirect supervision as well as oversight
    are provided.

   Identifiable faculty and trainees may supervise
     Emphasis on progressive responsibility based on specific
      national standards-based criteria.
     Interns (PGY1 residents) are required to have direct or
      indirect supervision at all times and day after “oversight” is
      no longer permitted.
New requirements: Duty Hours
   Duty hours must be limited to 80 hours per
    week over a four-week period, including
    all moonlighting (internal and external).

   All trainees must have one day off in
    seven over a four-week period; at-home
    call cannot be assigned on the free day.
New requirements: Duty Hours
   Maximum duty period length:
     PGY1: must not exceed 16 hours in duration
     PGY2 and above: may be scheduled a maximum of
      24 hours of continuous duty in the hospital plus four
      hours for transition (with naps encouraged)

   Minimum time off between scheduled duty periods:
     PGY1: should have 10 hours, must have eight
     PGY2 and above: should have 10 hours, must have
      eight, but this may be shortened in selected clinical
New requirements: Duty Hours
   Night float may occur no more than six consecutive

   In-house call may not occur more frequently than
    every third night when averaged over a four-week

   At-home call must not preclude rest and as with the
    previous requirements counts toward the maximum 80
    hour per week maximum, but not in the shift break.

   PGY1 residents may not moonlight.
ACGME Resident/Fellow Survey 2009-10
       Institutional Responses
Content Area                 Question              UCSF      National
               Teaching                             7.90%       7.50%
   Faculty     Supervsion                           2.60%       3.40%
               Conferences                          2.40%       3.30%
               Evaluate faculty                     1.50%       2.10%
  Evaluation   Evaluate program                     4.20%       3.10%
               Feedback for each rotation           7.60%       4.20%
               Goals and objectives                 3.30%       1.20%
               Fatigue and sleep deprivation        9.40%       6.00%
  Content      Research/scholarly activities        0.70%       1.80%
               Education vs. service obligations    17.70%      16.80%
               Excessive service obligations        36.10%      29.10%
ACGME Resident/Fellow Survey 2009-10
       Institutional Responses
Content Area                Question                   UCSF      National

               Raise problems/concerns w/out fear of
               intimidation/retaliation                 6.30%       6.90%
               Process to deal w/problems/concerns      19.60%      20.60%

               Reference materials                      14.80%      10.00%

               <80 hrs per week                         2.40%       2.30%

               >10 hour break                           3.30%       3.10%
 Duty Hours
               In-house call <24 + 6                    3.40%       3.30%

               Frequency at-home call                   3.40%       2.40%
ACGME Resident/Fellow Survey 2011

       Core specialty programs (regardless of size) and
        subspecialty programs (with 4 or more fellows) surveyed
        between January and June.

       13 new survey questions, including:
         Q14. Thinking about the faculty and staff in your program
          overall, how interested are they in your residency education?
         Q17. How satisfied are you that your program treats your
          evaluations of faculty members confidentially?
         Q20. How satisfied are you with the way your program uses
          the evaluations that residents/fellows provide to improve the
ACGME Resident/Fellow Survey 2011
     Q34. Which of the following best summarizes your opinion of
      your residency program?

- The best possible experience – if I had to select residency
   programs again, I’d pick this one
- A good experience – if I had to select residency programs
   again, I would probably choose this one.
- A neutral experience – if I had to select residency programs
   again, I might or might not choose this one.
- A negative experience – if I had to select residency program
   again, I would probably not choose this one.
- A very negative experience – if I had to select residency
   programs again, I would definitely not pick this one.
  What is meant by “non-physician
       service obligations”?
“Duties which in most institutions are performed by
technologists, aides, transporters, nurses, or other
categories of health care workers. Examples include
transport of patients from the wards or units for
procedures elsewhere in the hospital, routine blood
drawing for laboratory tests, routine monitoring of
patients when off the ward and awaiting or
undergoing procedures, etc.”
        ACGME Resident/Fellow Survey
              2011 Schedule
   Jan/Feb - Surgical Subspecialties (Dermatology,
    Neurology, OBGYN, Radiology)
   Feb/March - Neuro Surg, Nuc Med, Pathology,
    Pediatrics/Subspecialties, Psych, Rad Onc
   March/April - Anesthesiology, Family Med,
    Ophthalmology, Emergency Med
   April/May - Internal Med/Subspecialties, Surgery
        Medical Education and the
          New Public Interest
   1910: train future physicians to make care more
    scientific to reduce the burden of disease

   2011: train future physicians to continually improve
    the delivery of care to realize its fullest potential
    benefit to the health and well-being of the

                                    Berwick DM. Academic Medicine, 2010
    Selected Best Practices At UCSF
   Longitudinal clerkships (Parnassus, VA, SFGH, Fresno,
   Pathways to Discovery Program: Health Systems and
    Leadership Track
   Pediatric Leadership for the Underserved (PLUS)
   VA Quality Scholars, VA Quality Chief Resident
   VA Center of Excellence in Primary Care Education
   Monthly Chief Resident Dinner with CEO and Dean
   Resident and Fellow Quality and Safety Program
              SAFETY PROGRAM

Front line provider
Operational goals

                                                                                Educational goals:
                                                                                the trainee
                                 Residents and Fellows

                                                           Courtesy: Arpana Vidyarthi MD
              SAFETY PROGRAM

   Accountable                      GME           Accountable
   leadership                     Program         Leadership

                                                                 Educational goals:
                      Residents Council
Front line provider
Operational goals

                      CR development program
                      Patient Care Fund

                                                                 the trainee
                      RCA Engagement
                      Formal Curricula
                      Incentive Program

                      Residents and Fellows

                                               Courtesy: Arpana Vidyarthi MD
           Resident and Fellow
         Incentive Goals 09-10

Patient Satisfaction: For the period of June 2009 –
July 2010, on the patient satisfaction survey
likelihood of recommending question, maintain an
annual average mean score of 90 or a percentile
ranking of 71
Patient Satisfaction: 2009-10
 Patient Satisfaction 2010-2011

Patient Satisfaction: For the period of June 2010 –July 2011,
on the patient satisfaction survey likelihood of recommending
question, maintain an annual average mean score of 90.5.
                Clinical Housestaff
              Incentive Goals 09-10

     Patient Safety and Quality: By June 2010, residents
     will achieve an average combined compliance of
     85% with:
1)   Physician hand hygiene as measured by direct
2)   Influenza vaccination or completion of declination
3)   Completion of the mandatory infection control
  Clinical Housestaff
Incentive Goals 09-10
     Hand Hygiene: 2010-11

Patient Safety and Quality: For the period of July
2010 – June 2011, achieve 85% hand hygiene
compliance for at least six of twelve months.
      Resident and Fellow Incentive Goals:
              Resident Leadership
   Angela Walker MD:
     Pediatric-Dermatology Resident

     Co-chair, Resident and Fellow Council

   Devoted vacation week October 2011 to hand hygiene
     Met with fellow residents and chief residents

     Spoke at Grand Rounds

     Rounded with ward teams from multiple specialties

     Handed out cards, “Good Job, Hand-hygiene Card” good
      for raffle prize
     Set up and staffed table in patient entrance to inform
      patients about hand hygiene
     Hand Hygiene January 2011
     Hand Hygiene January 2011
        UHC Comparison Data

UCSF Ranks #1 in Tests Used per Patient Discharged
Laboratory Testing: 2009-10
  Laboratory Testing: 2010-11

Lab Utilization: By June 2011 residents will decrease by 5% the
aggregated utilization of common laboratory tests (defined as tests/
inpatient day). Common tests will include, CBC, CBC with differential
electrolytes (Na, K, CI, CO2, HCO3, Mg, Ca, Phos), BUN, Cr, AST, ALT, total
bilirubin, alkaline phosphatase, and albumin.
Ordering Electrolytes: 2010-2011

   Anesthesia: Administer antibiotics within one hour of
     Goal: 96% of patients
     Results: 96.3% (Achieved)

   Dermatology
     Goal: Decrease wait time in clinic by 25% (below 18
     Results: 13.3 minutes (Achieved)

   Emergency Medicine
     Goal: Contact 50% of PCPs at Discharge
     8% (Not achieved)

   Internal Medicine:
     Goal: Contact 80% of PCPs
     Results: 87.6% (Achieved)

   Neurology
     Goal: Document Swallow exam 90% stroke patient)
     Results: 91.2% (Achieved)

   Neurological Surgery
     Goal: Increase on time start in OR for 95% of cases
     97.5% (Achieved)

   Ob-Gyn
     Goal: Adequate inpatient diabetes orders and
      outpatient follow-up of 90% of diabetes patients
     Results: 97% (Achieved)

   Pediatrics
     Goal: Complete asthma care plan on 90% asthma
     Results: 93.7% (Achieved)

   Radiology
     Goal: Report critical results in 95% of eligible cases
     97.3% (Achieved)

        Anatomic Pathology (Achieving)
           Goal: Decrease incorrectly submitted specimens

        Anesthesia (Achieving)
           Goal: ICU transfer note

        Dermatology (Achieving)
           Goal: Appropriate Medication monitoring

        Emergency Medicine (Close)
           Goal: Smoking cessation in Emergency Department

        Internal Medicine (Achieving)
           Goal: Same day electronic discharge summary

        Internal Medicine Subspecialty Fellowships (NA)
           Goal: Improve consultation notes

        Neurology (Close)
          Goal: Increase primary care provider communication

        Ob-Gyn (Not achieving yet)
          Goal: Decrease wait from presentation to induction

        Otolaryngology (Achieving)
          Goal: Patient satisfaction on “time spent with patients.”

        Pediatrics (Close)
          Goal: Immunization status documented

        Radiation Oncology (Achieving)
          Goal: Use of correct ICD-9 codes

        Urology (Achieving)
          Goal: Reduce use of CBC by 15%

        Applications for 2011-2012 Program-Specific Incentive
         Program now being accepted
            Application Deadline: Tuesday, March 15, 2011
            Application:

        Incentive goals should be:
            Related to quality, safety, operations/efficiency or patient satisfaction
            Aligned with the department and medical center quality improvement
            Feasible to measure; and
            Educationally relevant

        Contact Arpana Vidyarthi, Paul Day, or Kara Bischoff

   Enhanced educational outcomes (systems-based practice,
    practice-based learning and improvement)
   Improved clinical outcomes and quality measures
   Cost avoidance and savings
      Costs to meet core measure compliance

      Increased efficiency (e.g. OR starts)

   Revenue Generation
      Potential for increase market share (e.g. patient satisfaction)

   Enhanced reputation (e.g UHC ranking, other publically
    reported quality measures)
   Alignment of missions within institution
                                 APeX UPDATE

        About 60 days from the first Go Live!
        Upcoming Go Live Schedule:
            April 6 & 13 – Primary Care
            June 22 & July 13 – Peds Primary Care, OB/GYN, Peds, Adult Med Specialties,
            October 1 – Inpatient Go Live at Parnassus (ED) and Mt. Zion (cPOE)
            November 2011 – February 2012 – Cancer Center, Neurology, Urology
            March 2012 – cPOE at Parnassus
            February – April 2012 – Surgery all remaining clinics

        Looking for SuperUsers! Be a resource tool for your clinic and
         receive compensation.
Keeping an “E” in GME

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