The Housestaff Incentive Program (HIP) is an innovative partnership between UCSF Medical Center and the Department of Graduate Medical Education, whereby residents and fellows receive financial incentives tied to achievement of medical center quality goals. Beginning in the 2009-10 academic year, each department set one quality goal (in addition to 3 common goals across all training programs).
The Internal Medicine Residency Program focused our initial quality goal on improving inpatient resident teams' communication with primary care physicians, and developed a multifaceted quality improvement program (PDF)to target this goal. The project successfully improved documented rates of communication with PCP's from 55% of discharges to nearly 90% of discharges, with an associated improvement in PCP satisfaction with communication from the inpatient team. The results of this project were published in the American Journal of Medical Quality.
The residency program continued to build on the success of the PCP communication project by targeting communication with primary physicians at the time of hospital discharge. The quality goal for this academic year was to complete 75% of discharge summaries on the day of discharge. This goal was developed in conjunction with the Division of Hospital Medicine's effort to implement an electronic discharge summary (PDF), which was launched in the fall of 2010. This project was also successful, resulting in improvement in both timeliness and quality of discharge summaries. These results have been sustained since the conclusion of the formal QI project, and have been published in BMJ Quality and Safety.
In 2011, we initiated an effort to improve patient-centered care at times of care transitions by increasing the rate and quality of patients Advanced Care Planning (ACP) documentation. This project was designed and led by a group of 2nd and 3rd-year residents, and involved creation of an ACP template embedded in the electronic medical record, education of housestaff and attendings on high-quality ACP discussions and documentation, and regular team-specific performance feedback. This project resulted in an increase in ACP documentation at discharge from less than 20% of discharges to over 85% of discharges, with this improvement being sustained over the final 8 months of the academic year. This innovative project was featured in the New York Times health blog and was subsequently published in JAMA Internal Medicine.
In recognition of the patient safety concerns that can occur when admitted patients are boarded in the emergency room awaiting a bed, in 2012-13 the internal medicine residents implemented a QI project to reduce door-to-floor times for admitted patients. Thanks to a combination of educational interventions and system improvements, the project achieved a 10% reduction in overall door-to-floor time by reducing the time needed to complete admission orders. Through this project, patient flow through the emergency department was improved without any adverse patient care or educational consequences.
Our most recent program-wide project involved leveraging the capabilities of UCSF’s electronic medical record to attempt to improve patient satisfaction and communication among the multidisciplinary team at the time of hospital discharge. A group of 3rd year residents developed a program to improve the quality of the After-Visit Summary provided to patients at the time of discharge. This program targeted the completion of 3 essential elements of the AVS—the principal diagnosis, follow-up information, and patient instructions regarding medications, return precautions, and follow-up needs—with a goal of achieving a high-quality AVS for 75% of discharges. Through a combination of education, team-specific data feedback, and individual feedback, the goal was again accomplished, with 82% of patients discharged from UCSF receiving a high-quality AVS.
See the links below for additional information:
- UCSF Resident and Fellow QI Incentive Program
- Division of Hospital Medicine's Improving Discharge Process
- UCSF/Project BOOST Discharge Improvement Initiatives (PDF)
For additional information or questions please contact:
Sumant Ranji, MD
Associate Professor of Clinical Medicine
Associate Program Director for Residency Program