Comprehensive Aortic Center, Cardiovascular Thoracic Institute, Keck Medical Center of University of Southern California, Los Angeles, California.
Comprehensive Aortic Center, Cardiovascular Thoracic Institute, Keck Medical Center of University of Southern California, Los Angeles, California.
J Surg Educ. 2019 May-Jun;76(3):771-778. doi: 10.1016/j.jsurg.2018.09.016. Epub 2018 Dec 12.
System-based practice with an emphasis on quality improvement (QI) is a recent initiative for the American College of Surgeons and a core-competency for surgical trainees. Few surgical training programs have a curriculum for hospital-based QI.
Our vascular surgery service implemented several QI initiatives focused on decreasing length of stay (LOS) by targeting resident education and engagement. Residents were educated on terminology and processes impacting hospital and CMS QI metrics such as Medicare geometric mean LOS (CMS GMLOS) and diagnostic-related groups (DRG) with complication or comorbidity (CC/MCC) coding. LOS initiatives focused on identifying, tracking and removing avoidable perioperative delays, and improving accuracy of clinical documentation. Residents were given specific roles in QI initiatives and the impact on LOS was quantified. Patients' CMS GMLOS were compared to actual LOS during daily rounds, with confirmation that resident progress notes contained thorough and accurate documentation of diagnoses, comorbidities, and complications. Ten minutes during weekly preoperative conferences were dedicated to ongoing QI, with LOS metrics for the inpatient census presented by trainees and reviewed by attendings. Feedback was given addressing barriers to avoidable delays and impact on LOS. Data for July 2016-June 2017 (FY17) was compared to preimplementation baseline data (FY16) for vascular discharges overall. Accurate documentation of acuity was evaluated with in-depth review of notes and overall case mix index.
Within the first year of implementation, overall vascular admissions demonstrated a 21% reduction in LOS, closing the gap between observed LOS and expected CMS GMLOS, from 2.1days to 0.5days on average. Documentation improved, with a shift in 24% of DRGs to accurately reflect CC/MCC. Overall case mix index increased by 10%, from 3.07 to 3.37.
A culture of continuous quality improvement can be created with the establishment of a QI infrastructure that educates and involves trainees as stakeholders. Assigning discrete roles to increase resident accountability supports both formal and informal resident education that can substantially impact hospital benchmarking metrics.
强调质量改进（QI）的以系统为基础的实践是美国外科医师学院的一项新举措，也是外科住院医师的核心能力。很少有外科培训计划有基于医院的 QI 课程。
我们的血管外科服务实施了几项 QI 计划，重点是通过教育和参与住院医师来减少住院时间（LOS）。教育住院医师有关影响医院和 CMS QI 指标的术语和流程，例如 Medicare 几何平均值 LOS（CMS GMLOS）和诊断相关组（DRG）伴有并发症或合并症（CC/MCC）编码。 LOS 计划侧重于确定、跟踪和消除可避免的围手术期延迟，并提高临床文档的准确性。住院医师在 QI 计划中担任具体角色，并量化了对 LOS 的影响。在日常查房期间，将患者的 CMS GMLOS 与实际 LOS 进行比较，并确认住院医师的进展记录包含了诊断、合并症和并发症的全面准确记录。每周术前会议中专门用 10 分钟进行持续的 QI，由住院医师介绍住院患者的 LOS 指标，并由主治医生进行审查。提供反馈，解决可避免延迟的障碍和对 LOS 的影响。比较 2016 年 7 月至 2017 年 6 月（FY17）的数据与血管出院的预先实施基线数据（FY16）。通过深入审查记录和总体病例组合指数来评估对严重性的准确记录。
在实施的第一年，血管总入院人数的 LOS 减少了 21%，将观察到的 LOS 与预期的 CMS GMLOS 之间的差距从 2.1 天缩小到 0.5 天。文档得到了改善，24%的 DRG 准确反映了 CC/MCC。总体病例组合指数增加了 10%，从 3.07 增加到 3.37。
通过建立一个教育和让住院医师作为利益相关者参与的 QI 基础设施，可以创造一种持续质量改进的文化。为增加住院医师的责任感而分配具体角色可以支持正式和非正式的住院医师教育，这可以对医院基准测试指标产生重大影响。
