A Potent Partnership: Empowering Residents to Lead a Failure‐Modes‐and‐Effects Analysis for an Academic Medical Center

1University of California —
San Francisco, San Francisco, CA
2University of California —
San Francisco, San Francisco, CA
3University of California —
San Francisco, San Francisco, CA
4University of California —
San Francisco, San Francisco, CA
5University of California —
San Francisco, San Francisco, CA

Meeting: Hospital Medicine 2010, April 8-11, Washington, D.C.

Abstract number: 174

Background:

The Joint Commission requires hospitals to conduct failure‐modes‐and‐effects analyses [FMEAs] to evaluate error‐prone care processes. The Accreditation Council for Graduate Medical Education (ACGME) similarly expects resident competency in quality improvement and patient safety but providing residents with relevant education is challenging. Empowering meaningful resident participation in hospital safety initiatives creates a partnership that aligns hospital and training program goals.

Purpose:

We engaged a group of internal medicine residents to conduct a formal FMEA focused on the safe delivery of therapeutic anticoagulants. In doing so, we aimed to enhance palienl safety competency among residents while advancing medical center priorities.

Description:

Twelve internal medicine residents with an interest in health policy and systems leadership participated in a 16‐hour curriculum on the core principles of quality improvement, patient safety, teamwork, and project leadership. The curriculum prepared residents for subsequent immersion in a real‐world health syslem and conduction of a FMEA around the safe delivery of anlicoagulants to inpatients — a process targeted by medical center leadership. Residents worked within a multidisciplinary team interviewing more lhan 10 providers in 5 disciplines and developed a 47‐step FMEA for Ihe provision of inpatient heparin and transition to discharge on anticoagulants. Their analysis identified 20 steps that were vulnerable tc failure and classified Ihese into 3 principle themes to focus quality improvement initiatives. As a part of their experience, residents presented the analysis to 2 high‐level medical center committees: the patient safety and medication safety committees. In response, the medical center adopted the resident findings as a formal Joint Commission FMEA report and resourced a centralized anticoagulation working group. The working group subsequently restructured the process for inpatient heparin ordering, delivery, and patienl education and redesigned an outpatient anticoagulation clinic. A post hoc facilitated focus group confirmed very high resident satisfaction with the project. Qualitative analysis of the focus group manuscript identified enhanced competency in the following domains; (1) knowledge of quality and safety concepts, (2) self‐directed learning about patient safely, (3) creation of a process map and FMEA, (4) interdisciplinary team building, and (5) strategies for securing buy‐in from key executive stakeholders.

Conclusions:

Resident engagement in quality improvement education can provide tangible products that reinforce the safety improvement and educational priorities of academic medical centers and residency programs alike. Participation in these efforts is perceived as valuable to residents and enhances resident competency in patient safety and leading systems change.

Author Disclosure:

P Kneeland, none; R. Pierce, none; A. Vidyarthi, none; D. Dohan, none; S. Ranji, none

To cite this abstract:

Kneeland P, Pierce R, Ranji S, Dohan D, Vidyarthi A. A Potent Partnership: Empowering Residents to Lead a Failure‐Modes‐and‐Effects Analysis for an Academic Medical Center. Abstract published at Hospital Medicine 2010, April 8-11, Washington, D.C. Abstract 174. Journal of Hospital Medicine. 2010; 5 (suppl 1). https://www.shmabstracts.com/abstract/a-potent-partnership-empowering-residents-to-lead-a-failuremodesandeffects-analysis-for-an-academic-medical-center/. Accessed July 24, 2019.

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