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Bridging the gap between patient safety and

specialty residents’ training:


compliance with the standards for Medical Professional Education (MPE) of
the Joint Commission International (JCI)

Edith ter Braak*, Saskia Imhof, Reinier Hoff, Joost Frenkel, Jan Willem Lammers
Patient safety and clinical training:
an issue for decades

Ann Intern Med. 2006;145:592-598.

1984: Death of Libby Zion


N Engl J Med 1988; 318: 771-775

A Case That Shook Medicine


By Barron H. Lerner
Special to The Washington Post
Tuesday, November 28, 2006
BACKGROUND, general

Patient safety & quality of care: top priorities UMC Utrecht

Approach:
accreditation by Joint Commission International (JCI);
standards include Professional Medical Education (MPE)

Aim MPE standards:


safety and quality of care delivered by medical trainees
MPE of JCI: UMC Utrecht goals

• Governance, leadership: institutional and organizational


• Provision of adequate clinical supervision
Documentation of supervision provided (EHR)
• Adequate training and teaching competence of clinical staff
• Trainees complying with standards of quality and safety

“Tell me…, show me”


Implementation: WHAT?

• Documented authorization of the resident to provide clinical


services, under the condition of the required level of supervision
(competency based)

• Documentation of supervision provided in the EHR

• Compliance with staff development participation requirements

• Educational file for each resident (≠ portfolio)

• Educating residents in Quality and Safety,


e.g. International Patient Safety Goals (IPSG)
Definition of supervision levels
(adapted from ACGME)

Supervision level Description

0 Not applicable Service/action not permitted or not applicable

Supervisor is physically present with the resident and the


1 Direct supervision
patient or equipment

Supervisor is physically within the UMCU and


2 Indirect supervision
immediately available to provide (1)

Supervisor can be reached by telephone and is available


3 Limited supervision
for (1)

Oversight: supervisor is available for review with


4 Evaluation afterwards
feedback after care is delivered
Documentation of authorization form
(internal medicine)
case management
per context

(reserved) clinical
procedures

supervising others

Sheet 7
Approach to implementation: HOW?

“change management”

• Clearly explaining backgrounds and goals

• Designing policies: practical approach and building on previous


work and national programs. Board approval.

• Involving both residents and program directors as teams

• Facilitating programs (n=38) with generic tools and formats, but…..


Fostering “ownership”: requesting program specific tasks

• Feedback of progress (shared)


Feeding back progress per program:
% of forms with documented supervision levels received

Slides shown during meeting of program directors and residents,


3 weeks before JCI audit
Lessons learned

Strengths and Opportunities


• Stakeholders’ motivation for “educational change” fostered by
goals related to patient care (pull)
• Many people love to have a shared ambition (pull)
• Time constraints may be advantageous (push)
• Rules and regulations, e.g. JCI standards may be helpful for
change (push)

Weaknesses and Threads


• (Technical) preconditions (setup EHR, electronic filing)
• Sustaining results after the accreditation
Take home message

The tension between Patient safety & Quality of care and


clinical training is apparent and sometimes results in
“hazardous intersections”

However, striving for accreditation with applicable


standards may foster both quality of care and quality of
training and education.

e.terbraak@umcutrecht.nl
BACKGROUND, MPE standards

MPE.1 Those responsible for governance and leadership of the organization approve and
monitor the participation of the organization in providing medical education.

MPE.2 The organization’s professional staff, patient population, technology, and facility are
consistent with the goals and objectives of the education program.

MPE.3 Clinical teaching staff members are identified and each staff member’s role and
relationship to the academic institution is defined.

MPE.4 The organization understands and provides the required frequency and intensity of
medical supervision for each type and level of medical student and resident trainee.

MPE.5 Medical education provided in the organization is coordinated and managed through
a defined operational mechanism and leadership structure

MPE.6 Trainees comply with all organization policies and procedures, and all care is
provided within the quality and patient safety parameters of the organization.
MPE.7 Medical trainees who provide care or services within the organization—outside of the parameters of their academic program—are granted
permission to provide those services through the organization’s established credentialing, privileging, job specification, or other relevant program.
Institutional Governance of residency in UMCU

Board UMCU providing


UMCUtrecht Residency Training

External
accreditation
audit
every 5 yrs Central
“MVO”
Council for
Center of
Residency Training
Educ & Training
“COC”

Program director A Program director B Program directors Program director X


Program I Program II ……….. Program N = 38
Adapted from ACGME
common program requirements
July 1st 2011
Supervising
others
Competent to perform
independently 

4. Oversight, review of
selected cases
responsibility

Able to perform 
Residents, fellows

3. Limited supervision (not physically


in hospital), immediately
available via phone

Mostly able to perform 

2. Indirect supervision (on or near ward),


immediately available for direct supervision

Shows how 

interns
1. Direct (hands on) supervision

Knows how 

Observational participation

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