Srinivasan Ranjini, Sambatakos Peter, Lane Mariellen, Krishnan Usha, Weller Rachel, Flyer Jonathan N, Robinson Keith, Glickstein Julie
Morgan Stanley Children's Hospital of New York, Columbia University Medical Center, New York, N.Y.
University of Vermont Children's Hospital, The Robert Larner, M.D. College of Medicine at The University of Vermont, Burlington, Vt.
Pediatr Qual Saf. 2020 May 20;5(3):e306. doi: 10.1097/pq9.0000000000000306. eCollection 2020 May-Jun.
Patient-to-physician continuity is the result of coordinated and consistent care. Optimizing continuity can be a challenge in medical training without impacting work hours. We sought to use quality improvement science during graduate medical training to increase outpatient continuity.
The primary goal was to improve outpatient continuity in our pediatric cardiology fellowship, without increasing trainee clinic hours, from a baseline of 38% to ≥70% within 18 months.
Our fellowship conducted a quality improvement project across 3 years to improve continuity-of-care in our outpatient clinic using the Institute for Healthcare Improvement model for improvement. We conducted Plan-Do-Study-Act cycles and completed a key driver diagram using a multidisciplinary team. We defined continuity as a patient being evaluated by their primary fellow or a different fellow that was provided a handoff. The outcome measure was the continuity rate over 2-week periods.
Continuity improved from 38% to ≥80%. The improvement resulted from a series of interventions, including creating a handoff system among fellows, identifying follow-up patients in advance, and communicating this information to the clinic team. Although we anticipated a decrease when new fellows were incorporated, continuity continued to be ≥70%. This system retained continuity above 90% one year after completion of the project.
Our fellowship created a system change to improve primary patient-to-fellow continuity care rates. We achieved sustainable continuity by working with a multidisciplinary team without altering staffing, infrastructure, or fellow work hours. This project engaged trainees to address the practical application of quality improvement methodology to solve a common clinical problem.
患者与医生之间的连续性是协调一致的护理的结果。在不影响工作时长的情况下，优化连续性在医学培训中可能是一项挑战。我们试图在毕业后医学培训期间运用质量改进科学来提高门诊连续性。
主要目标是在不增加受训人员门诊时长的情况下，将我们儿科心脏病学 fellowship 项目中的门诊连续性从基线的 38%提高到 18 个月内的≥70%。
我们的 fellowship 项目在 3 年时间里开展了一个质量改进项目，使用医疗保健改进研究所的改进模型来改善我们门诊诊所的护理连续性。我们进行了计划-实施-研究-改进循环，并使用多学科团队完成了关键驱动因素图。我们将连续性定义为患者由其主要 fellowship 成员或接受了交接的其他 fellowship 成员进行评估。结果指标是两周期间的连续性率。
连续性从 38%提高到了≥80%。这一改善源于一系列干预措施，包括在 fellowship 成员之间建立交接系统、提前识别随访患者并将此信息传达给诊所团队。尽管我们预计新的 fellowship 成员加入时连续性会下降，但连续性仍保持在≥70%。该系统在项目完成一年后仍将连续性保持在 90%以上。
我们的 fellowship 项目进行了系统变革，以提高患者与 fellowship 成员之间的主要连续性护理率。我们通过与多学科团队合作，在不改变人员配备、基础设施或 fellowship 成员工作时长的情况下实现了可持续的连续性。该项目让受训人员参与进来，以解决质量改进方法的实际应用问题，从而解决一个常见的临床问题。
