Differences in medication reconciliation interventions between six hospitals: a mixed method study

Background Although medication reconciliation (MedRec) is mandated and effective in decreasing preventable medication errors during transition of care, hospitals implement MedRec differently. Objective Quantitatively compare the number and type of MedRec interventions between hospitals upon admission and discharge, followed by a qualitative analysis on potential reasons for these differences. Methods This explanatory retrospective mixed method study consisted of a quantitative and a qualitative part. Patients from six hospitals and various wards were included if MedRec was performed both on hospital admission and discharge. Information on pharmacy interventions to resolve unintended discrepancies and medication optimizations were collected. Based on these quantitative results, interviews and a focus group was performed to give insight in MedRec processes. Descriptive analysis was used for the quantitative-, content analysis for the qualitative part. Results On admission, patients with at least one discrepancy varied from 36-95% (mean per patient 2.2 (SD +/- 2.4) Upon discharge, these numbers ranged from 5-28% while optimizations reached 2% (admission) to 95% (discharge).The main themes explaining differences in numbers of interventions were patient-mix, healthcare professionals involved, location and moment of the interview plus embedding and extent of medication optimization. Conclusions Hospitals differed greatly in the number of interventions performed during MedRec. A combination of patient-mix, healthcare professionals involved, location and timing of the interview plus embedding and extent of medication optimization resulted in the highest yield of MedRec interventions on unintended medication discrepancies and optimizations. This study supports to give direction to optimize MedRec processes in hospitals.

Innovation in resident oncology education: Switching from an inpatient ward rotation to a hybrid model of inpatient consultations and outpatient clinics.

11006 Background: Interest in pursuing a career in oncology has decreased among internal medicine residents completing an inpatient oncology rotation. Over several years, our institutional data at Indiana University School of Medicine reflected lower resident satisfaction with the oncology inpatient ward rotation compared to other rotations. Methods: A hybrid model of inpatient consultations and outpatient clinics replaced the traditional inpatient oncology rotation at our institution. Over a six-month period preceding and following the change in format, residents completed anonymous rotation assessments and rated their experiences on a 5-point Likert scale (low 1 to high 5). Areas assessed included: patient load, educational value of patient mix, quality of didactics and teaching, quality of patient care delivery, adequacy of time for reading, and overall educational quality of the rotation. Results: The hybrid oncology rotation (8 respondents out of 10 residents approached) was rated as significantly superior to the traditional ward format (15 respondents out of 16 residents approached) in six out of eight areas. Improvements in the perceived quality of patient care delivery (p=0.139) and quality of didactics (p=0.058) were also observed without reaching statistical significance. The balance of inpatient and outpatient experiences with the hybrid rotation was highly rated (4.5 ± 0.5). Conclusions: The implementation of a hybrid oncology rotation was associated with perceived improvement in educational value, patient mix, and time for reflection and study without apparent compromise in the quality of patient care delivery. [Table: see text]

Introducing a clerkship curriculum based on entrustable professional activities: a pilot study

BackgroundGeneral clerkship quality criteria have not been studied after introducing a curriculum based on entrustable professional activities (EPAs). Therefore, we conducted a pilot study to explore educational outcomes of an EPA-based clerkship curriculum reform.MethodsWe collected multiple self-assessment and evaluation data on levels 1-3 of the New World Kirkpatrick model (KPM). For level 1 (reaction) we analyzed curriculum evaluations and verbal and written students’ feedback. For level 2 (learning) pre- and post-clerkship self-assessments of perceived need for supervision for each EPA and students’ written learning reflections based on patient mix exposure were analyzed. For level 3 (behavior) we evaluated workplace-based assessments.ResultsThe first student cohort in the new EPA-based clerkship completed 180 self-assessments (18 per student) of need for supervision and 63 documented workplace-based assessments (average of 6.3 per student in four weeks). On KPM level 1 we saw a high overall satisfaction with the clerkship (average of 4.9, range: 4.0-5.0 on a 5-point Likert scale). In written evaluations and feedback rounds students pointed out the importance of structured bedside teaching in the first clerkship week. On KPM level 2 the overall decrease of self-assessed need for supervision before and after the clerkship was two supervision levels (from direct to indirect supervision) and statistically significant (p < 0.05). For three EPAs students reached indirect supervision levels. Learning reflections and patient mix analysis indicated that students were exposed to a wide range of diagnostic categories (ICD-10: F0 – F6) and received actionable feedback for communication skills. On KPM level 3 clinical supervisors predominantly used EPAs 1 (History taking), 2 (Assessing mental status) and 8 (Documentation and presentation) for workplace-based assessments. We saw a decreasing need for supervision from the first to the last week in the clerkship according to the supervisors’ judgements.ConclusionStudents reacted positively to introducing an EPA-based clerkship curriculum. The EPA-oriented formative self-assessments and workplace-based assessments seemed to support achievement of competency-based learning goals. However, more in-depth understanding of the entrustment process in the clerkship context is necessary to fully leverage the potential of an EPA-based clerkship.

Evaluating intensive care unit admission and discharge policies using a discrete event simulation model

The efficient utilization and management of a scarce resource such as the intensive care unit (ICU) is critical to the smooth functioning of a hospital. This study investigates the impact of a set of operational policies on ICU behavior and performance. Specifically, the implemented policies are (a) wait time thresholds on how long patients can wait for an ICU bed, (b) the time windows during which patient discharges and transfers take place, and (c) different patient mix combinations. The average waiting time of patients for ICU beds and the admission ratio, the ratio of admitted patients to total ICU bed requests, are the performance measures under consideration. Using discrete event simulation, followed by analysis of variance and post hoc tests (Tukey multiple comparison), it is shown that increasing discharge windows has a statistically significant impact on the total number of admissions and average patient wait times. Moreover, average waiting time increased when wait time thresholds increased, especially when the number of emergency surgeries in the mix increased. In addition, larger proportions of elective surgery patients in the patient mix population can lead to significantly reduced ICU performance.

Professionals’ perspectives on factors affecting GP trainees’ patient mix: results from an interview and focus group study among professionals working in Dutch general practice

IntroductionSeeing and treating patients in daily practice forms the basis of general practitioner (GP) training. However, the types of patients seen by GP trainees do not always match trainees’ educational needs. Knowledge about factors that shape the mix of patient types is limited, especially with regard to the role of the professionals who work in the GP practice.AimWe investigated factors affecting the mix of patients seen by GP trainees from the perspective of professionals.Design and settingThis qualitative study involved GP trainees, GP supervisors, medical receptionists and nurse practitioners affiliated with a GP Specialty Training Institute in the Netherlands.MethodsTwelve focus groups and seven interviews with 73 participants were held. Data collection and analysis were iterative, using thematic analysis with a constant comparison methodology.ResultsThe characteristics of patients’ health problems and the bond between the doctor and patient are important determinants of GP trainees’ patient mix. Because trainees have not yet developed bonds with patients, they are less likely to see patients with complex health problems. However, trainees can deliberately influence their patient mix by paying purposeful attention to bonding with patients and by gaining professional trust through focused engagement with their colleagues.ConclusionTrainees’ patient mix is affected by various factors. Trainees and team members can take steps to ensure that this mix matches trainees’ educational needs, but their success depends on the interaction between trainees’ behaviour, the attitudes of team members and the context. The findings show how the mix of patients seen by trainees can be influenced to become more trainee centred and learning oriented.

IDENTIFIKASI PERUBAHAN BANGUNAN SEBAGAI PROSES EVIDENCE-BASED DESIGN DALAM PERANCANGAN RUMAH SAKIT

Dewasa ini evidence-based design dalam proses perancangan rumah sakit semakin dibutuhkan dalam pengambilan keputusan perancangan. Proses ini memberikan kesempatan bagi arsitek untuk dapat menemukan solusi baru dalam mengantisipasi berbagai permasalahan yang berkaitan dengan aspek-aspek arsitektur. Salah satu permasalahan yang ada pada kelompok bangunan bertipologi rumah sakit adalah adanya kebutuhan untuk mengakomodasi perubahan. Perubahan yang dimaksud dalam hal ini adalah perubahan akan konfigrasi arsitektur bangunan tersebut. Adanya perubahan menuntut rancangan arsitektur yang fleksibel dan adaptif. Perubahan memberikan kesempatan untuk semakin berkembang dan lebih baik namun juga memberikan peluang bagi permasalahan. Dalam ini permasalahan yang dihadapi adalah adanya kecenderungan perubahan tata ruang baik dikarenakan kapasitas maupun fungsinya. Penelitian terkait bertujuan mengidentifikasi bentuk perubahan sebagai langkah awal tahapan perancangan. Metode yang digunakan adalah studi literatur dan studi kasus pada rumah sakit umum di Surabaya guna menentukan kecenderungan bentuk perubahan yang secara umum terjadi. Berdasarkan hasil yang diperoleh terdapat 5 tipe perubahan yaitu Volume,service lines, Patient mix and standar of care, Size dan Medical Discovery serta tiga jenis perubahan yang dapat terjadi pada arsitektur rumah sakit yaitu improvisasi (Improvisation), perubahan bangunan (Building changes), Perluasan Bangunan (Building Extention). Adapun kecenderungan tipe dan bentuk perubahan pada kedua rumah sakit tersebut adalah Volume dan improvisation.