UCSF GME 2011: Annual Report and Town Hall Discussion

1. UCSF GME 2011:Annual Report and Town Hall Discussion Robert B. Baron, MD MS Professor of Medicine, Associate Dean GME & CME

2. Mary McGrath, MD, MPH Professor of Surgery Director, Resident and Fellow Affairs Robert B. Baron, MD, MS Professor of Medicine Associate Dean for GME and CME Claire Brett, MD Professor of Clinical Anesthesia Chair, Internal Review Committee Vice Chair, GMEC Rene Salazar, MD Assistant Clinical Professor of Medicine Director, Diversity Arpana Vidyarthi, MD Assistant Clinical Professor of Medicine Director, Patient Safety and Quality Innovations GME Faculty Susan Promes, MD Associate Professor, Emergency Medicine Director, Curricular Affairs

3. Office of GME Staff

4. 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 Dean

5. 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

6. Citations • No particular pattern • Less than 2 citations per program • Institutional support • Parking and transportation • Faculty • Education program • Evaluation • Duty Hours

7. Duty Hours – October 2010

8. GME Diversity 2004-2010

9. Underrepresented in Medicine in GME

10. Recruitment of Underrepresented in Medicine: UCSF GME 2010 Match AppliedInterviewedRankedMatched Residencies 838 (9.3%) 179 (9.9%) 157 (9.6%) 30 (12.5%) Fellowships 127 (9.6%) 35 (9.4%) 24 (9.8%) 6 (6.3%)

11. Selected Training Outcomes: 2010 Resident Career Choices • Higher training: 51% • Academic position: 18% • Practice: 20% • Policy/consulting: 1% • Other: 10 %

12. Selected Training Outcomes: 2010 Fellow Career Choices • Higher training: 31% • Academic position: 33% • Practice: 26% • Policy/consulting: 2.5% • Other: 7.5 %

13. Selected Training Outcomes: 2010 Resident Scholarship PRESENTATIONS • UCSF presentation: 28% • Regional presentations: 9% • National presentations: 17% • International presentations: 4% • Any presentation: 29 % PUBLICATIONS • First author publication: 22% • Peer reviewed publication: 22% • Any publication: 23%

14. Selected Training Outcomes: 2010 Fellow Scholarship PRESENTATIONS • UCSF presentation: 57% • Regional presentations: 10% • National presentations: 27% • International presentations: 11% • Any presentation: 58% PUBLICATIONS • First author publication: 30% • Peer reviewed publication: 29% • Any publication: 39%

15. 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

16. Selected Training Outcomes: 2010 Fellows Courses and Structured Electives • TICR: 33 (12.7%) • DCR: 12 (4.6%) • Pathways to Discovery: 1 (0.4%) • Endocrinology

17. 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.

18. Patient Safety vs. Clinical Experience

19. Supervision vs. Autonomy

20. High Low Low High Supervision vs. Autonomy 20 Student ---------------------------- Intern -------------- Resident ------------ Fellow---------------------Attending

21. High Low Low High Supervision vs. Autonomy 21 Student ---------------------------- Intern -------------- Resident ------------ Fellow---------------------Attending

22. Supervision vs. Autonomy 22 High Low Low High Student ---------------------------- Intern -------------- Resident ------------ Fellow---------------------Attending

23. 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.

24. 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 trainees • 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.

25. 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.

26. 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 circumstances.

27. New requirements: Duty Hours • Night float may occur no more than six consecutive nights. • In-house call may not occur more frequently than every third night when averaged over a four-week period. • 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.

28. ACGME Resident/Fellow Survey 2009-10 Institutional Responses

29. ACGME Resident/Fellow Survey 2009-10 Institutional Responses

30. 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 program?

31. 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.

32. 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.”

33. 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

34. 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 population Berwick DM. Academic Medicine, 2010

35. Selected Best Practices At UCSF Longitudinal clerkships (Parnassus, VA, SFGH, Fresno, Kaiser) 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

36. BUILDING A RESIDENT AND FELLOW QUALITY AND SAFETY PROGRAM Hospital GME Program Operational goals Front line provider Educational goals: the trainee Residents and Fellows Courtesy: Arpana Vidyarthi MD

37. BUILDING A RESIDENT AND FELLOW QUALITY AND SAFETY PROGRAM Hospital GME Program Accountable leadership Accountable Leadership Residents Council CR development program Patient Care Fund RCA Engagement Formal Curricula Incentive Program Educational goals: the trainee Operational goals Front line provider Residents and Fellows Courtesy: Arpana Vidyarthi MD

38. Resident and FellowIncentive 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

39. Patient Satisfaction: 2009-10

40. 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.

41. Clinical Housestaff Incentive Goals 09-10 Patient Safety and Quality: By June 2010, residents will achieve an average combined compliance of 85% with: Physician hand hygiene as measured by direct observation Influenza vaccination or completion of declination form Completion of the mandatory infection control module

42. Clinical Housestaff Incentive Goals 09-10

43. 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.

44. 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

45. Hand Hygiene January 2011 45

46. Hand Hygiene January 2011 46

47. UHC Comparison Data UCSF Ranks #1 in Tests Used per Patient Discharged

48. Laboratory Testing: 2009-10

49. 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.

50. Ordering Electrolytes: 2010-2011