Agenda for Change

1. Agenda for Change

2. PLANNING FOR THE FUTURE Healthcare is changing. Patients’ needs are changing. Government regulation is changing. Faced with a rapidly evolving landscape and overwhelming expectations, the CIR Policy and Education Initiative (PEI) is poised to prepare tomorrow’s physician leaders to play a critical role in this very necessary and exciting transformation.

3. PEI leadership and stakeholders are committed to contributing to the change we are seeking. We at PEI believe that, with intentional action, we will see: A transformation to a safer, high-quality, affordable, accessible, just and patient-centered healthcare system where insightful and humble doctors work together with patients, families, other health care providers and communities to drive change; and develop a new paradigm of service, professionalism and leadership. OUR MISSION:To educate physicians, other health care professionals and the general public about ways to increase access to health care, to improve the safety and quality of that care and to highlight the role that resident physicians play in our health care system.

4. The Challenge Since publication of the landmark 1999 Institute of Medicine report To Err is Human: Building a Safer Health System and its companion report, Crossing the Quality Chasm in 2001, much has been studied, but little improved. Estimates of preventable medical errors are still shockingly high and health care costs continue to rise; In 2010 the US Department of Health and Human Service's Office of the Inspector General estimated that up to 180,000 patients per year may die as a result of medical care, an extrapolation that would make harm due to medical care the third leading cause of death nationwide. Nearly half of these incidents were preventable, i.e. due to error .

5. The Challenge - 2 Millions of Americans are subjected to tests and procedures that are not supported by the scientific evidence and can even cause harm, while millions of uninsured Americans receive no care at all until they present in the emergency room with advanced disease; and An Institute of Medicine study in 2012 reported that about 30 percent of health spending in 2009 -- roughly $750 billion -- was wasted on unnecessary services, excessive administrative costs, fraud, and other problems. Moreover, inefficiencies cause needless suffering. By one estimate, roughly 75,000 deaths might have been averted in 2005 if every state had delivered care at the quality level of the best performing state.   Not surprisingly, patients commonly report high rates of dissatisfaction with their care and health care providers report high rates of dissatisfaction with their jobs.

6. Solutions We know the problems. Identifying and implementing solutions is a key activity and the pace with which we act must accelerate. Physicians need to be able to:

7. The transformation we seek is grounded in science but acknowledges the humanity and art of medicine, as well as the critical role that culture plays in achieving – or failing to achieve - our goals. PEI is embracing our role of helping to train today’s young physicians for both current and future challenges.

8. A Critical Goal Our aim is to develop the resident physician leadership necessary to achieve a safe, effective and just healthcare system.

9. Objective: Develop a Training Institute to implement the physician leadership transformation we seek. PEI is acutely aware that the innovative skills and processes necessary to make important change are relatively new and not widely known by the faculty that most resident physicians depend upon for their training and education. The Accreditation Council on Graduate Medical Education recognizes a "growing need to support faculty development, particularly in the areas of patient safety and health care quality. (JGME, September 2012) To breach that gap, PEI will establish a Training Institute. Through the Institute we will expose resident physicians to cutting edge educators in a series of learning events focused on three overarching areas: health justice, safetyand quality, and physician leadership. • Project 1: Organize Resident Physician Learning Events

10. Objective: Use research to identify the best ways to train resident physicians to be transformative leaders. To transform our current healthcare system to a safer, high-quality, affordable, accessible, just and patient-centered healthcare, we must understand where we are and measure our change in the clinical learning environment. PEI will play an important role in this transformation by supporting and conducting independent surveys and collaborative research. Additionally PEI will: Study and evaluate the rapidly growing Patient Safety and QI Fellowships in teaching hospitals across the country to identify best practices that move beyond a narrow focus on the acquisition of skills and broaden to include an emphasis on patient-centered care, transparency, disclosure and apology, teamwork and effective communication. Evaluate current resident physician community rotation electives across the country, with an eye towards identifying best practices and a curriculum that most effectively brings resident physicians and the patients and communities they serve closer together. • Project 1: Assess the Resident Physician Clinical Learning Environment for Change • Project 2: Determine the Critical Components for a Successful Resident Physician Patient Safety/Quality Improvement Fellowship • Project 3: Evaluate and Promote Resident Physician Community Rotations

11. Objective: Extend leadership development opportunities to resident physicians. Dramatic changes have taken place in health care in recent years, both in the delivery of care and in the organization of work, as more physicians move to salaried employment. More change is necessary, thereby increasing the need for compelling and compassionate physicians to step up and join their caregiver colleagues in the team-based environment that is best suited to provide safe, quality care. PEI will support resident physicians in the development of their leadership potential, by understanding the characteristics that make for transformative physician leaders and providing opportunities for that training and mentorship in today's health care workplace. As a core precept, PEI will promote the importance of a diverse physician workforce to best meet the needs of our diverse patients and communities. • Project 1: Sponsor Scholarships for Resident Physicians to Augment Their Training Outside the Hospital Walls • Project 2: Develop a Resident Physician Leadership Curriculum

12. Objective: Spread the word that resident physicians are transforming health care. Thoughtful, successful, communication of PEI’s work is essential if we are to succeed in contributing to the transformation in health care we seek. We will employ effective, multi-channeled communication strategies to engage members of our organization, allies, thought leaders and healthcare consumers. We know that messages need to be delivered multiple times in multiple ways to have the most impact. • Project 1: Expand Our Capacity to Spread PEI’s Message of Transformative Health Care Leadership and Engage Others •  Project 2: Capture and Share the Stories of Transformed Resident Physician Leaders • Project 3: Establish A PEI Advisory Council to Connect New Voices to the Discussion

13. Our aim is to develop the resident physician leadership skills necessary to achieve a safe, effective and just healthcare system. Why? Failures in Care Lewis Blackman was a healthy 15-year-old who developed severe upper abdominal pain while on a NSAID and narcotic pain regimen following elective surgery. The resident physicians and nurses charged with his care failed to act upon increasing signs of instability. Lewis died four days post-op. His autopsy showed a giant duodenal ulcer and 2.8 liters of blood and gastric secretions in the peritoneal cavity • Unfamiliarity with pediatric dosing • Unfamiliarity with medication contraindications • Failure to consider the possibility of medication reaction • Unwillingness to challenge incorrect orders • Unwillingness to change the plan • Failure to recognize the signs of sepsis and shock • Prolonged inaction in the face of alarming symptoms • Undue deference to hierarchy • Unwillingness to intervene with someone else’s patient • Delay in calling code Because there are many more like Lewis. What Needs to Change • Tunnel vision • Bluffing • Task-oriented behavior • Overwork • Inadequate training • Inadequate backup • Complacency

14. Our aim is to develop the resident physician leadership skills necessary to achieve a safe, effective and just healthcare system. Why? Because patient-centered care requires effective and compassionate communication. Safe, quality patient care is dependent upon the relationship between health care providers and their patients. Good communication is essential, yet residents typically receive little training. The PEI-sponsored Art of Medicine: A Physician-Patient Communication Conference held in New York City in November 2011 attracted over 200 resident physicians, medical students and faculty. Two 35-minute videos were produced from presentations by Drs. Auguste Fortin (Yale Medical School) and SheiraSchlair (Montefiore Medical Center) on patient-centered interviewing and Dr. Jonathan Fader (Albert Einstein College of Medicine) on motivational interviewing. Both have been widely disseminated. “After the Physician-Patient Communication Conference, I listen more and ask less; surprisingly this has allowed me to obtain more useful information and organize the visit in a more effective way for both the patient and myself.” Dr. Gloria Ortiz Internal Medicine Resident, Bronx-Lebanon Hospital Center

15. Our aim is to develop the resident physician leadership skills necessary to achieve a safe, effective and just healthcare system. Why? Because creating a culture of safety requires physician self-awareness and respect and commitment to a team-based approach to health care delivery. In late 2007, at the behest of Congress, the Institute of Medicine embarked on a yearlong examination of the scientific evidence linking resident physician sleep deprivation with clinical performance deficits and medical errors. The IOM’s report, published in 2009, recommended far-reaching changes in medical education to improve patient safety and protect the safety and well-being of resident physicians. In 2010, PEI organized a two day roundtable of 26 representative stakeholders at Harvard Medical School and produced this white paper, which was published in the journal Nature and Science of Sleep. “The biggest obstacle to change is culture. The profession needs to reconsider what it means t o be a professional in the age of teamwork, e.g. the ‘lone provider’ versus team responsibility for the patient. When does knowing one’s own limits take precedence over endurance in the interest of patient care?” Implementing the 2009 Institute of Medicine Recommendations on Resident Physician Work Hours, Supervision and Safety: Report from a Conference at Harvard Medical School

16. Our aim is to develop the resident physician leadership skills necessary to achieve a safe, effective and just healthcare system. Why? Because one opportunity can change a life trajectory. The Telluride Patient Safety Roundtable & Summer Camp is an annual four-day deep dive into changing the culture and safety of medicine. PEI sponsored five resident physician participants in 2012, including Dr. Nate Margolis from Bellevue Hospital Medical Center. “One thing that struck me,” said Dr. Margolis, “ was a faculty person’s advice: ‘On the first day of residency you should learn where you locker is, where your beeper is and where to report patient safety errors.’ It was something I had never thought of before, and I don’t think residents normally do.” After Telluride, Dr. Margolis worked with the resident patient safety council to develop a ‘buddy badge’ to instruct residents on how to make an adverse event report.

17. Our aim is to develop the resident physician leadership skills necessary to achieve a safe, effective and just healthcare system. Why? Because one opportunity can change a life trajectory. Thanks to PEI financial scholarships, 20 resident physicians traveled to Haiti in 2012 to provide medical relief through the University of Miami’s Project Medishare. Twenty more PEI scholarships will be available in 2013. “My deployment experience in Haiti was amazing,” wrote back one volunteer. “Although it was just for one week, I learned a lot about the people and the unfortunate state of conditions in Haiti. It was a very difficult and grueling week, but a very positive experience. I would not trade the experience for anything else.”

18. "Physicians in training are going to make a difference -- they've got to make a difference -- in how we care for our patients and communities, treat our colleagues on the health care team, and understand our own strengths and limitations.But that training doesn't fall from the sky. It's got to be enthusiastically nurtured in many different ways.“ Dr. Simon Ahtaridis, MD, MPHBoard President CIR Policy and Education Initiative

19. CIR Policy and Education Initiative 520 8th Avenue, Suite 1200New York, NY 10018 (212) 356-8100 info@cirpei.org www.cirpei.org