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Back to Bedside Project Highlights

CHILDREN’S HOSPITAL OF PHILADELPHIA

Project SPHERE: Shaping a Patient- and Housestaff-Engaged Rounding Environment

Team Leads: Bryn Carroll, MD; Melissa Argraves, MD; Sanjiv Mehta, MD
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Rounding is a staple of medical education, yet the experience can vary in terms of its benefit to residents. After receiving input from a 50-person group, the ACGME Back to Bedside team at Children’s Hospital of Philadelphia (CHOP) looked for ways to make their daily activities more meaningful and bring joy back to their daily tasks. The team’s target was rounding, and they took a quality improvement approach to making changes.

“Primarily rounds take place in the hallway outside the patient’s room. In our initiative, at the beginning of rounds the senior resident, sometimes in conjunction with interns, chooses a patient for a bedside exam,” said Melissa Argraves, MD. “We try to do at least one bedside exam on rounds each day with the whole team.”

The goal is to improve the educational experience for residents, and the team has used the Plan, Do, Study, Act (PDSA) quality improvement approach to address not only rounding, but also other areas of educating residents. To increase residents’ time at the bedside, the CHOP team wants residents to take a turn rounding with the attending so they can see some patients one on one and gain insight into how the attending handles both the exam and patient communication.

As the team followed the PDSA approach and analyzed early feedback, one adjustment was already made: having residents complete weekly surveys, instead of daily. With additional data, the team will be able to make improvements to the initiative and determine whether and when to expand to other units.

JOHNS HOPKINS ALL CHILDREN’S HOSPITAL

All about Us: Starting the Conversation on Patient and Provider Values

Team Lead: Nicole Nghiem, MD
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For busy, stressed residents and interns, being able to carve out time to spend with a patient seems like an impossibility. But at Johns Hopkins All Children’s Hospital, it’s not only possible but happening, thanks to Back to Bedside.

The project was designed to let members of the ward team take turns each week forwarding their phones to senior residents and not worrying about calls or putting in orders or writing notes. Being able to step away from clinical duties allows the team members to spend time playing with their patients and getting to know them on a deeper level.

One participant said of the opportunity to be that individual who steps away from clinical responsibilities, “This was one of the best days I’ve had.”

Incorporating this program into the hospital’s usual routine forced a bit of a culture shift. The project team needed to make everyone aware that it was a priority, and the ward team members had to help each other get through the day’s tasks so one person could step away. Discussions during pre-rounding have helped the team determine the day’s situation and whether they can get someone back to a patient’s bedside.

This effort to get physicians and patients to see—and understand—each other on a personal level has been in place for nearly a year. Additional plans are also being launched, including letting patients personalize and decorate their rooms with posters, and having the provider team hand out cards with their photos and roles.

“We have to be flexible, because taking good medical care of the children comes first,” said Nicole Nghiem, MD. “But having an opportunity for residents to get away and spend more time with their patients has been very rewarding for them.”

UNIVERSITY OF MICHIGAN

Meaningful Encounters at the Bedside: A Novel Resident Wellness Program

Team Leads: Jenna Devare, MD; Carl Truesdale, MD
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In the hospital, patients are often faced with a sea of white coats that can obscure the humans wearing them. And for residents, making meaningful personal connections with patients is tough. The ACGME Back to Bedside project at the University of Michigan Hospitals and Health Centers was designed to address these issues.

Developed by and for residents in the Otolaryngology Department, the program includes components at the bedside and away from it. At the bedside, each resident hands out a “trading card” with his or her name and photo on one side, and information about his or her role in treatment, personal history, education, and hobbies on the other. The cards help patients learn more about the residents caring for them, provide a window into the resident’s humanity, and start conversations through the exchange of personal information. Patients seem to like the cards and many collect them like baseball cards.

Away from the bedside, the wellness program includes a post-rotation get together where residents talk about their experiences—both positive and negative—outside of the immediacy of care. This provides an opportunity for a debriefing on patient care, as well as a time for closing and reflecting on residents’ experiences in a rotation.

The goal is to positively affect both residents and patients. The at-the-bedside cards and away-from-the-bedside discussions humanize residents and increase the joy and meaning in their work. At the same time, the program helps patients have a more positive experience in the hospital and improve their opinions of doctors and medical training.

“Burnout is so prevalent in our training and I am fairly confident that 100 percent of our residents experience it during our program,” said Jenna Devare, MD. “I’m hoping that we can bring humanity back to our patients and to ourselves, thereby increasing joy and meaning in our work.”

UNIVERSITY OF WASHINGTON

Standardizing Evening Bedside Huddles to Promote Patient-Centered Care and Interdisciplinary Teamwork

Team Leads: Kathryn Stadeli, MD; Jay Zhu, MD
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The I-Pass hand-off tool is already used for provider-to-provider patient hand-offs at the University of Washington Medical Center. But in an effort to improve communication and teamwork among general surgery night float residents and nurses on acute care surgical floors, the Back to Bedside team there designed an evening bedside huddle initiative.

The night float surgery resident now goes to the nursing stations on floors where most of the acute care surgery patients are located, meets with the charge nurse and any bedside nurses that are available, and discusses the patients labelled as either unstable or needing more observation or acute intervention. The discussion includes both the patient’s current status and their plan. Then the resident/nurse team visits the beside of patients who need an evaluation.

“By improving interdisciplinary teamwork with these regular evening huddles, the goal is to improve both the work environment and patient care,” explained Kathryn Stadeli, MD.

Previously, surgical float residents and nurses were frustrated with poor communication during the evening shift, with both sides feeling like they didn’t have the same information or weren’t on the same page. But by creating this standardized time for provider-nurse communication, the working environment and patient care could be improved.

What started as a two-month pilot on one floor to see how the huddles worked expanded in early winter to two additional surgical floors and is now on track to expand to the final acute care surgical floor. The program has also launched at the area’s county trauma hospital.

Surveys before and after the evening huddles began have shown that both nurses and residents feel communication and teamwork have improved. Some residents noted an improved relationship with evening shift nurses, as well as a decrease in the number of pages they receive, which helps improve their workflow overnight. The annual ACGME Resident Survey questions measuring impact on resident burnout will be analyzed after the sample is large enough.

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UNIVERSITY OF PITTSBURGH MEDICAL CENTER

Addressing Code Status Discussions and Interventions for Vascular Surgeons

Team Leads: Jason Wagner, MD; Alicia Topoll, MD
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The patient codes. Now what? Knowing what interventions the patient needs is the easy part. Knowing what interventions the patient actually wants should be just as easy.

Vascular surgery residents at University of Pittsburgh Medical Center (UPMC) launched an ACGME Back to Bedside  project to make sure they have those answers.

They are being trained to have code status and end-of-life discussions the first time they sees a patient. “The goal is to make these conversations as routine as finding out what a patient’s allergies are,” said Jason Wagner, MD. “The training is not just ‘how to have the discussion’ but also demystifying and destigmatizing it.”

Training begins with surveys to find out residents’ thoughts on code status discussions and concerns about having them, followed by defining the problems and issues with code status and levels of interventions. Residents talk about various scenarios they might encounter with patients when explaining interventions and code status, as well as how to defuse tough family situations.

Residents role play patient/physician conversations in small groups with a facilitator to simulate the interaction and gain experience in helping patients come to terms with these issues. Residents also practice explaining what could happen in terms of interventions and helping patients arrive at decisions about what they want.

Additional training includes documenting the discussion in the electronic health record so the patient’s preferences can be available to everyone in case there is a code.

Code status documentation rate is reviewed every month, with the eventual goal of having 100 percent documentation. To date, code status conversations with patients are increasing as the entire Vascular Surgery Department at UPMC has been trained, as have everyone in the Cardiology and Cardiac Surgery Departments. Now everyone who practices in the school’s Cardiovascular Institute goes through training during initial orientation. And many residents and advanced practice providers have begun documenting code status discussions in clinic, not just when the patient arrives in the hospital.

OREGON HEALTH AND SCIENCES UNIVERSITY

Returning the Patient to Medical Conferences: Can We Improve Physician Burnout?

Team Leads: Heather Hoops, MD; Katherine Kelley, MD
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“Protected time” during medical conferences is so valuable for residents, boosting learning opportunities without the distractions of pages and clinical duties. At Oregon Health and Sciences University (OHSU), general surgery residents have a new element added to their medical conferences: hearing patients share their experiences.

The goals are to build a stronger relationship between patients and residents as part of the ACGME Back to Bedside  initiative, and to help residents feel more comfortable counseling and consenting patients. The first patient-centered conferences have focused on anatomy-altering surgeries, such as ostomies, so residents can gain a greater understanding of the whole process from the patient’s point of view.

Following a shortened didactic portion of the conference, an invited patient shares his or her perspective about everything from what information they received prior to surgery, whether it was helpful, and what the consent process was like. Patients also give residents insight into what life is like after surgery.

“It’s pretty informal. We set it up so patients can tell their story and then we ask specific questions,” said Heather Hoops, MD. “Having the message delivered from patients and families that have gone through it has been pretty powerful. It really sticks with you.”

Faculty members and even residents have helped in recruiting patients or suggesting someone who might be able to contribute to the conference. Another resource is patients who have already agreed to serve as peer-to-peer counselors.

OHSU has a two-year curriculum of these patient-centered didactic resident conferences planned, with four each in the spring and fall. Pre- and post-conference surveys will provide data about residents’ comfort level when counseling patients, but to date the team leaders have reported interest and active engagement by residents in questioning patients.

Conferences after the first year will branch out beyond general surgery patients and may expand to other departments or divisions.

UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT SAN ANTONIO

Bedside Therapy

Team Leads: Morgan Hardy, MD
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At the San Antonio Military Medical Center, a teaching affiliate of the University of Texas Health Science Center School of Medicine at San Antonio, many patients are younger and healthier, with fewer cognitive issues and less dementia than civilian patients in other facilities. Their in-patient stays may also last longer than in civilian hospitals. That provides an opportunity to expose psychiatry residents to conducting psychotherapy sessions earlier in their education.

“A lot of these young patients in the military are dealing with stage-of-life issues and existential crises,” said Morgan Hardy, MD. “That means we can begin training our interns and residents how to help patients using cognitive behavioral therapy and other therapeutic techniques to improve their sense of self, their relationships, and their sense of the world.”

With a broader social focus on preventing suicides in the military, this ACGME Back to Bedside  program is very timely and helpful to both residents and patients. The therapy itself is not novel, but incorporating opportunities for it into the work day is. There is more of an emphasis on therapy so residents have longer interactions with patients and spend more time getting to know them. So over time residents are better able to gauge improvements. The goal is not only to help patients, but also create a more positive learning environment for residents.

The program started with a survey to assess residents’ outlook on and satisfaction with their work. Initially, lecture time on therapy increased, but that was reduced when feedback indicated the extra time was adding to stress. Now more time has been built into the work day for therapy with patients. Following lectures on psychotherapy, residents each pick one patient for weekly therapy sessions.

While initial results for reducing resident stress and burnout appear positive, final data will reveal actual results at the end of a year. Patients are also reporting an appreciation for increased time with doctors and the help they provide. For a lot of patients, therapy to improve their ability to cope can be more valuable than an anti-depressant.

CONNECTICUT CHILDREN’S MEDICAL CENTER

Building Meaning in Work for Residents through Enhanced Communication

Team Leads: Erin Goode, MD; Owen Kahn, MD
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Documentation and communication are key to effective patient care. Finding ways to improve both has been the goal of the team at Connecticut Children’s Medical Center.

“We want to have more time to spend with our patients and their families, as well as more time for learning,” said Erin Goode, MD.

In this ACGME Back to Bedside  project, one focus has been on improving hand-offs. The documentation side of hand-offs has changed to be more efficient, making pre-rounding time shorter so residents spend less time at the computer and more time at the bedside. Now all the data the residents used to document in multiple places will be entered in a single step.

Accomplishing this meant the co-leader of the team, Owen Kahn, MD, and one of the attendings traveled to Epic Systems headquarters in Wisconsin to learn how to build the system the team envisioned. Having progress notes and the hand-off both in Epic’s electronic health record has reduced the documentation burden—a change that has been rolled out for residents across the hospital, not just in pediatrics.

The team also worked with management to get rid of pagers and transition to a phone app. Without pagers, residents are now on the same communication system as nurses and the rest of the hospital, streamlining what had been an inefficient and time-consuming arrangement.

These efficiencies in documentation and communication have been developed to free up time for residents to spend with patients and return meaning to their work. Some of the program funding has been allocated for activities and projects that residents can do with patients as they gain more time at the bedside. Residents don’t usually have time to play a game or work on an art project with their pediatric patients, but the hope is they now will.

As these improvements are implemented, surveys will track how much time residents are spending with patients and the impact on their well-being.

UNIVERSITY OF NORTH CAROLINA MEDICINE

The Face Time Fraction: A Patient-Focused Shift in Emphasizing Empathic Communication and Multidisciplinary Rounding

Team Leads: Kathryn Haroldson, MD; Heath Patel, MD
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What a difference a few feet can make. University of North Carolina (UNC) Medicine’s new patient-centered multidisciplinary rounding has moved rounding to the bedside, and patients no longer wonder what the group talking outside their door is discussing. With the launch of the ACGME Back to Bedside  initiative, patients are now part of the team, along with the physician, medical students, pharmacist, and nurse.

The new strategy arose out of a desire to increase meaningful face time with patients, as well as to improve physician and patient well-being. With input from the institution’s Patient Advisory Council, the Back to Bedside  team knew that patients didn’t like having people standing outside their doors talking and then entering the room to discuss what the team planned to do. “Patients didn’t feel like they were involved and felt that things were being done to them, rather than the plan being developed with  them,” explained Kathryn Haroldson, MD.

Initially residents were concerned about making presentations at the patient’s bedside. But the program team created videos to address different scenarios, including differences of opinion or mistakes, involving the patient in the discussion, and handing out Face Sheets with team members’ photos, names, roles, anticipated rounding schedule, and an explanation of what patients can expect during rounds. The videos also demonstrate a key component of this rounding strategy: having the primary communicator sit at eye level for improved patient engagement.

Multidisciplinary bedside rounding was first tested in one medicine service, and has now expanded to all services at UNC. Patients have provided positive feedback, particularly on the Face Sheets and feeling like they are part of their own care team. Residents have found that this new rounding strategy is actually more efficient. It takes less time, which allows them more time to spend with patients or on other duties, or even to get home sooner. They also have a greater understanding of their patients as people.

UNIVERSITY OF BUFFALO JACOBS SCHOOL OF MEDICINE AND BIOMEDICAL SCIENCES

Redefining Meaning in Residency

Team Leads: AnneMarie Laurri, MD; Eric Moss, MD; Regina Makdissi, MD
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The Redefining Meaning in Residency project hopes to improve resident satisfaction and burnout through consolidation of education and encouragement of resident responsibility to practice medicine and educate patients. The project will provide afternoon meetings with patients and caregivers to communicate plans and barriers, and educate patients about their disease. The idea for the project grew out of the resident team’s ongoing efforts to improve resident satisfaction and feelings of value. During electronic health record (EHR) downtimes, the residents realized it was very satisfying to talk to patients, nurses, and their colleagues.

The idea is that establishing a meaningful relationship with the patient is critical for medical residents to develop as physicians,” explained Regina Makdissi, MD, associate director of the University of Buffalo Jacobs School of Medicine internal medicine residency program.

By using close-the-loop rounds, the team hopes to educate patients about their health and improve their quality of life. The group also envisions the project expanding to include a series of patient education videos and other easy-to-digest resources to facilitate discussions between provider and patient. Ultimately, the team hopes to create an all-encompassing online resource to help educate patients.

HOFSTRA NORTHWELL SCHOOL OF MEDICINE AT COHEN CHILDREN'S MEDICAL CENTER

Resident Trading Card Program

Team Leads: Joshua Belfer, MD; Kinjal Desai, MD
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The team members at Cohen Children’s Medical Center were inspired to create their project during the winter months of their first year of residency when they started to experience burnout.

We wanted to do something engaging and exciting that would help us become re-energized at work,” said project co-leader Joshua Belfer, MD, something that reminded us of the reason we went into medicine: our patients.”

The team has created the Resident Trading Card Program, which features cards, similar to baseball cards, with fun pictures of each resident, as well as fun facts, such as favorite ice cream flavor, where the resident is from, and hobbies. The inpatient teams can use these cards to introduce themselves to their patients, who are given the opportunity to create their own trading cards to teach their physicians about who they are and what they like.

The team hopes that by encouraging residents to learn more about their patients outside of their medical conditions, while in turn allowing patients to learn more about them, they’ll reignite their sense of meaning in work.

BAYLOR COLLEGE OF MEDICINE

Humanism Rounds: Fighting Physician Burnout through Strengthened Human Connection

Team Leads: Brett Styskel, MD; Reina Styskel, MD
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When residents leave patients’ rooms laughing and smiling, re-energized and recharged, that’s an indication of joy and meaning returning to residents’ lives. An ACGME Back to Bedside project behind those good feelings is taking place at Baylor College of Medicine.

The goal of this project is to strengthen the human connections between residents and their patients through three activities. The first is creating stronger resident/patient understanding when residents see their patients as human beings. That effort is initiated when residents take a “human history” to discover who that patient is as a person, including where the patient lives, his or her occupation, the other family members, what they like to do for entertainment, and more.

Another part of the effort to increase connections and decrease resident burnout is setting aside designated, protected, pager-free time within ward blocks for each resident to visit one or two patients per week and spend 10-20 minutes at the bedside getting to know that patient. They can talk about anything they want, and the goal is to promote the human-to-human connection and get to know the patient’s story and experiences.

The residents also gather at conferences to share their stories about connecting with patients on a more human level. The team plans to compile some of the stories on video to show at grand rounds.

The team at Baylor is encouraging all residents at Michael E. DeBakey VA Medical Center, MD Anderson, and Ben Taub Hospital to participate in the project, and currently the residents in general medicine are involved, but there are plans to expand the effort to subspecialties and possibly beyond residents.

“The residents who have done it really enjoy it,” said Brett Styskel, MD. “And a lot of the teams say the patients afterward seem much happier and more comfortable and less lonely.”

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