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High Quality Residency Education and Patient Safety are Directly Related
David T. Harrington, MDProgram Director, General Surgical Residency Program
Associate Professor of Surgery
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Residency Work Hours
• Resident fatigue – clinical errors• Residency work hours surrogate for patient safety• Effects of work hour rules - mixed
– Patient Safety• Lack of definitive effect• More cross-coverage and hand-offs
– Residency Education• Improved resident well-being, less “burn-out”• Decreased operative experience (FA, TA, continuity)• Increased choice of fellowships• Decreased medical student teaching
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Combined Surgical Group
3
3.2
3.4
3.6
3.8
4
4.2
4.4
4.6
4.8
5
-3 -2 -1 1 2
% M
orta
lity
V MajorMajorMinorV MinorNon-teach
KG Volpp et al, Mortality among hospitalized Medicare beneficiaries in the first 2 years….., JAMA 2007
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Residency Work Hours
• Resident fatigue – clinical errors• Residency work hours surrogate for patient safety• Effects of work hour rules - mixed
– Patient Safety• Lack of definitive effect• More cross-coverage and hand-offs
– Residency Education• Improved resident well-being, less “burn-out”• Decreased operative experience (FA, TA, continuity)• Increased choice of fellowships• Decreased medical student teaching
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Patient Safety and Surgical Quality
• Traditional M&M• Process
– Joint Commission– SCIP– Centers of Excellence
• Trauma - ASC/COT• Bariatric - ASBS• Cancer, Orthopedic, Cardiac
• Performance– NSQIP– UHC– CMS – MSDRG and P4P
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NSQIP Observed to Expected (O/E) Ratio• Represents the hospital’s outcomes compared to the other ACS NSQIP hospitals, adjusted for inter-hospital differences in patients’ characteristics, comorbidities, and preoperative laboratory values
LOW OUTLIER: If the upper bound of the O/E confidence interval is <1.0, the hospital’s outcomes are statistically better than expected. Thus, the hospital’s outcomes are “Exemplary.”
ACS NSQIP Hospital ID Number
HIGH OUTLIER: If the lower bound of the O/E ratio is >1.0, the hospital’s outcomes are statistically worse than expected. Thus, the hospital’s outcomes “Need Improvement.”
AS EXPECTED
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Surgical Residency TrainingOutcomes
• Process– RRC accreditation
• Performance– ABSITE scores– Pass rates on QE & CE– Fellowship placement– Successful practice
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1st Time Pass Rate 2004 - 2009
0
10
20
30
40
50
60
70
80
90
100
0 20 40 60 80 100
CE
QE
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Hypothesis
Programs which deliver high quality care as measured by:participation in NSQIP
verification as a trauma center
high rates of compliance in SCIP
would have a sound educational programs evidenced by:high pass rates on QE and CE
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Methods & Materials
• NSQIP participation – NSQIP annual report• Trauma Center verification –
www.facs.org/trauma/verified
• SCIP compliance for laparoscopic cholecystectomy: SCIP1, 2, 3, VTE1, VTE2 – www.hospitalcompare.hhs.gov
• QE and CE – https://home.absurgery.org/default.jsp?prog_passreport
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Results
• NSQIP– 85 (34%) participated
• Trauma Center Verification– 82 (32.8%) verified trauma centers– 65 (26%) were Level 1 trauma centers
• SCIP– All hospitals had data available
• ABS Examinations – 1st time passage rate– QE 83.9 +/- 13.1– CE 84.5 +/- 11.1– Combined 80.0 +/- 16.2
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NSQIP – Yes NSQIP - No p-value
Qualifying Exam (average)
87.9 81.8 < 0.001
Certifying Exam (average)
85.8 83.3 0.100
Combined (average) 77.2 70.1 0.001
NSQIP Participation & QE/CE
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Trauma CenterYes
Trauma CenterNo
p-value
Qualifying Exam (average)
87.4 83.0 0.038
Certifying Exam (average)
88.6 83.9 0.006
Combined (average) 78.8 71.3 0.003
Trauma Center Verification & QE/CE
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Level 1 – Yes Level 1 - No p-value
Qualifying Exam (average)
88.4 83.1 0.012
Certifying Exam (average)
89.1 84.4 0.005
Combined (average) 80.1 71.9 < 0.001
Level 1 Verification & QE/CE
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CE2007 vs SCIP1
0
10
20
30
40
50
60
70
80
90
100
0 20 40 60 80 100
Certifying Exam
SCIP
1
p = 0.30
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CE2007 vs SCIP2
0
10
20
30
40
50
60
70
80
90
100
0 20 40 60 80 100
Certifying Exam
SCIP
1
p = 0.11
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CE2007 vs SCIP3
0
10
20
30
40
50
60
70
80
90
100
0 20 40 60 80 100
Certifying Exam
SCIP
1
p = 0.01
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CE2007 vs VTE 1
0
10
20
30
40
50
60
70
80
90
100
0 20 40 60 80 100
Certifying Exam
SCIP
1
p = 0.18
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CE2007 vs VTE 2
0
10
20
30
40
50
60
70
80
90
100
0 20 40 60 80 100
Certifying Exam
SCIP
1
p = 0.092
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Hypothesis
Programs which deliver high quality care as measured by:participation in NSQIP
verification as a trauma center
high rates of compliance in SCIP
would have a sound educational programs evidenced by:high pass rates on QE and CE
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Excellent Patient Safety = Excellent Education
• RRC site visit– Trauma center verification– Improving SCIP compliance– Improving NSQIP performance
• Teaching hospitals are quintessential quality model– New physicians– Ascending levels of responsibility
• 6 core competencies– System-based practice– Practice-based learning
• Multi-disciplinary– RRC, NSQIP, Trauma Verification, SCIP compliance
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Shortcomings
• QE/CE pass rates ≠ quality of training• Study has no relevance to medical training• Participation in NSQIP ≠ higher quality of
patient care
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NSQIP: Changes in Morbidity 2005-2007
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Conclusions
• Hospitals that participate in NSQIP have a higher quality of surgical resident education than hospitals that do not.
• Hospitals that obtain Trauma Center verification have a higher quality of surgical resident education than hospitals that do not.
• Hospitals that obtain Level 1 Trauma Center verification have a higher quality of surgical resident education than hospitals that do not.
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High Quality Residency Education and Patient Safety are Directly Related
David T. Harrington, MDProgram Director, General Surgical Residency Program
Associate Professor of Surgery