SUBJECT: Orthopedic Surgery Patient and Resident Safety and Quality Improvement

All physicians share responsibility for promoting patient safety and enhancing the quality of patient care. Graduate medical education must prepare residents to provide the highest level of clinical care with continuous focus on the safety, individual needs, of each patient. It is the right of each patient to be cared for by residents who are appropriately supervised; possess the requisite knowledge, skills, and abilities; understand the limits of their knowledge and experience; and seek assistance as required to provide optimal patient care. Residents must demonstrate the ability to analyze the care they provide, understand their roles within health care teams, and play an active role in system improvement processes. Graduating residents will apply these skills to critique their future unsupervised practice and effect quality improvement measures.

Policy:

A culture of safety requires the continuous identification of possible issues that may occur within the clinical areas and the willingness of the institutional leadership, the program director, and program staff to deal with safety and quality of care rendered to patients. Residency education must occur in the context of a learning and working environment that emphasizes professionalism through faculty modeling of:

• Excellence in the safety and quality of care rendered to patients

• Effacement of self-interest that supports physician development

• Compassion for the humanity of their patients

• Residents must actively participate in formal educational to promote safety goals, tools, and techniques. To meet these goals, residents will be provided with education regarding:

  • The formal processes to report, investigate, and follow-up adverse events related to patient safety

  • The disclosure of adverse events with an opportunity to disclose a real or simulated patient safety activity

  • Their professional responsibilities to report patient safety events, including near misses, at clinical sites

  • Personal involvement in at least one safety activity during their residency, such as, attendance at a Hospital safety Committee meeting and preparation of a paper related to its activities, a presentation on the use of patient safety reports, or participation in real or simulated interprofessional safety activities

• Although each attending physician is ultimately responsible for the care of their patient, each institution and program must develop and monitor a chain of responsibility for patient care to document that each resident must have an identifiable and appropriately credentialed attending physician or independent practitioner accountable for patient care ad that a structure to promote interprofessional team-based care must be available to members of the health care team and to each patient when providing direct patient care

• Education on Patient Safety

  • Programs must provide formal educational activities that promote patient safety-related goals, tools, and techniques

• Patient Safety Events

  • Reporting, investigation, and follow-up of adverse events, near misses, and unsafe conditions are pivotal mechanisms for improving patient safety, and are essential for the success of any patient safety program

  • Feedback and experiential learning are essential to developing true competence in the ability to identify causes and institute sustainable systems-based changes to ameliorate patient safety vulnerabilities

• Residents, fellows, faculty members, and other clinical staff members must:

  • Know their responsibilities in reporting patient safety events at the clinical site

  • Know how to report patient safety events, including near misses, at the clinical site

  • Be provided with summary information of their institution’s patient safety reports

• Residents must participate as team members in real and/or simulated interprofessional clinical patient safety activities, such as root cause analyses or other activities that include analysis, as well as formulation and implementation of actions

• Resident Education and Experience in Disclosure of Adverse Events

  • Patient-centered care requires patients, and when appropriate families, to be apprised of clinical situations that affect them, including adverse events. This is an important skill for faculty physicians to model, and for residents to develop and apply

  • All residents must receive training in how to disclose adverse events to patients and families

  • Residents should have the opportunity to participate in the disclosure of patient safety events, real or simulated

• Quality Improvement

• Education in Quality Improvement

  • A cohesive model of health care includes quality-related goals, tools, and techniques that are necessary in order for health care professionals to achieve quality improvement goals

  • Residents must receive training and experience in quality improvement processes, including an understanding of health care disparities

• Quality Metrics

  • Access to data is essential to prioritizing activities for care improvement and evaluating success of improvement efforts.

  • Residents and faculty members must receive data on quality metrics and benchmarks related to their patient populations.

  • Engagement in Quality Improvement Activities

  • Experiential learning is essential to developing the ability to identify and institute sustainable systems-based changes to improve patient care

  • Residents must have the opportunity to participate in interprofessional quality improvement activities

  • This should include activities aimed at reducing health care disparities (Detail)

• Supervision and Accountability

• Although the attending physician is ultimately responsible for the care of and accountability for their efforts in the provision of care. Effective programs, in partnership with their Sponsoring Institutions, define, widely communicate, and monitor a structured chain of responsibility and accountability as it relates to the supervision of all patient care

• Supervision in the setting of graduate medical education provides safe and effective care to patients; ensures each resident’s development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine; and establishes a foundation for continued professional growth

  • Each patient must have an identifiable and appropriately-credentialed and privileged attending physician (or licensed independent practitioner as specified by the applicable Review Committee) who is responsible and accountable for the patient’s care

  • This information must be available to residents, faculty members, other members of the health care team, and patients

  • Residents and faculty members must inform each patient of their respective roles in that patient’s care when providing direct patient care

  • Supervision may be exercised through a variety of methods. For many aspects of patient care, the supervising physician may be a more advanced resident or fellow. Other portions of care provided by the resident can be adequately supervised by the immediate availability of the supervising faculty member, fellow, or senior resident physician, either on site or by means of telephonic and/or electronic modalities. Some activities require the physical presence of the supervising faculty member. In some circumstances, supervision may include post-hoc review of resident-delivered care with feedback

  • The program must demonstrate that the appropriate level of supervision in place for all residents is based on each resident’s level of training and ability, as well as patient complexity and acuity. Supervision may be exercised through a variety of methods, as appropriate to the situation

• Levels of Supervision

  • To promote oversight of resident supervision while providing for graded authority and responsibility, the program must use the following classification of supervision: classification of supervision:

  • Direct Supervision – the supervising physician is physically present with the resident and patient.

  • Indirect Supervision:

    • with Direct Supervision immediately available – the supervising physician is physically within the hospital or other site of patient care, and is immediately available to provide Direct Supervision

    • with Direct Supervision available – the supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide Direct Supervision

  • Oversight – the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered

  • The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each resident must be assigned by the program director and faculty members

  • The program director must evaluate each resident’s abilities based on specific criteria, guided by the Milestones

  • Faculty members functioning as supervising physicians must delegate portions of care to residents based on the needs of the patient and the skills of each resident

  • Senior residents or fellows should serve in a supervisory role to junior residents in recognition of their progress toward independence, based on the needs of each patient and the skills of the individual resident or fellow

  • Programs must set guidelines for circumstances and events in which residents must communicate with the supervising faculty member(s)

  • Each resident must know the limits of their scope of authority, and the circumstances under which the resident is permitted to act with conditional independence

    • Initially, PGY-1 residents must be supervised either directly, or indirectly with direct supervision immediately available

  • Faculty supervision assignments must be of sufficient duration to assess the knowledge and skills of each resident and to delegate to the resident the appropriate level of patient care authority and responsibility

  • Professionalism

  • Programs, in partnership with their Sponsoring Institutions, must educate residents and faculty members concerning the professional responsibilities of physicians, including their obligation to be appropriately rested and fit to provide the care required by their patients

  • The Learning Objectives of the Program must:

    • Be accomplished through an appropriate blend of supervised patient care responsibilities, clinical teaching, and didactic educational events

    • Be accomplished without excessive reliance on residents to fulfill non-physician obligations; and, Ensure manageable patient care responsibilities