Quality Improvement

(May 2, 2011) Faculty and staff at the Anschutz Medical Campus have begun teaching nursing and medical students how to improve patient care by working together to solve problems that often cause higher medical costs and more re-hospitalizations.

The shift came when educators “realized that students didn’t have the tools they needed to improve systems,” says Wendy Madigosky, MD, Foundations of Doctoring Curriculum Director.

Students are now being taught a rapid cycle improvement technique – “You can measure it, look at the data and tell in a week if it’s working,” Madigosky says.

Small groups of medical and nursing students are piloting quality improvement curriculum in two Anschutz Medical Campus hospitals; studying systems, interviewing patients and coming up with ways to encourage patients to be more engaged in their health care. Nursing and medical students work together on these projects in hopes that they will continue the practice once they begin their professional careers.

Some interprofessional education projects include:

University of Colorado Hospital:

    Prevention of patient falls     
    Improvement of Intensive Care  to unit transitions
    Increasing inpatient bed availability
    Prevention of decubitus ulcers
    Improvement in discharge processes
    Increasing patient-centered communication through whiteboards

The Children’s Hospital:

    Improving patient identifiers to prevent mix-ups

Inserting an interdisciplinary approach to the clinical setting is a challenge, says Mark Earnest, MD, director of Interprofessional Development at the University of Colorado Anschutz Medical Campus, because students report to supervisors in their own field, e.g., nurses to nursing supervisors, medical students to residents.

“It’s really not easy or natural,” he says.  Expanding quality improvement curriculum is part of the Interprofessional Clinical Rotations Program portion of grants from the Josiah Macy Jr. and Colorado Health foundations.

Students said they liked both the interprofessional aspect of the experience, as well as the quality improvement lessons:

Jessica Warmack, medicine
Project: Fall prevention

“I thought it was an eye opening experience. For example, I never knew why some patients had red socks on. It’s because they’re a high fall risk. That gap was important. It was part of the nurse’s standardized assessment that doctors might not know.”

Warmack said she appreciated the methods her group was taught to find solutions to problems and has been asked to use them since in another internship.

“I know where to start now,” she said. “When they first started to describe the project to me I thought it almost sounded too big.  Now we’ve been given some tools, and it seems more manageable.”

Cristol Keenan, nursing
Project: White Board

“It was a great to work that closely with each other and get insight as to what we’re both feeling as we begin in our new fields.”

She said both medical and nursing students revealed during the project that they were hesitant to approach each other in clinical settings. “It was probably the most important thing overall. There’s a lot of culture that has gone on for a long time between doctors and nurses, but it’s changed a lot to more of a team work dynamic.

“Working as a team definitely helped me personally. It’s good to know as a nurse that when I need to do things that I am afraid of doing, I won’t worry about approaching a doctor or voicing my opinion. They actually can appreciate our perspective because we may pick up on things they don’t because we see the patients more often. It helped give me more confidence in communication.”

Eleanor Diamse, nursing
Project: White Board

“We were able to learn the cycle of evaluating and implementing improvement projects. We looked at the work done before, asked questions about it like, ‘What information is missing and how can we obtain that?’

“What I liked about this particular project is that it was based on continuing the work done by other students. Previous groups asked what information they wanted to see on the white board.  They generally wanted the phone number of the cafeteria, what was the name of the person who gives the pain medication, what the phone number to their room was.

“With our group, we decided to give the patient a context and ask them, ‘What do you want to know to feel more empowered? What would help you do that?’

“The first day they’d say, ‘I don’t know.’ But we decided to give them a day to think about it. The response the second day was more meaningful. They wanted to know when they got their pain meds next, what their treatment schedule is, and an explanation of their disease.

“I really liked it. I’d say it’s the highlight of my senior year.”

Ryan Bender, medicine
Project: Fall prevention

“Having worked before med school in a production environment, I realized that the idea of designing a hospital work environment is like designing any other place. People who do certain types of jobs or who are in management might not have the understanding of how to do the job. Without that insight, you wouldn’t produce a very good result. There are just going to be things you would never think of.”

His group spent some time looking at the efficiency of bed alarms, which sound if a patient falls.

“I learned that those things create a lot of fatigue for nurses if they go off all the time. The doctors might not know how tiring it is to run after the alarms all the time, and sometimes we set them off while we’re caring for a patient. The nurses’ input was important. The results were better when we had multidisciplinary teams.”

Jessica Sidelko, nursing
Project: Discharge process

“It was great to go get into the mindset that things can be improved.

“I’ve been able to use it since I started working. I helped a student who was in her rotation and we came up with a process that helped her put together a booklet of how to run different (lab) tests. She’d noticed she didn’t always know where to look for things so we put it all into one reference guide.

“I have the confidence now to look up evidence based articles and look at how we treat patients and make sure that we’re all on the same page.”