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Heron E. Rodriguez MD Jonathan P. Turner, MS Paul Speicher , BA Mark S. Daskin , PhD

Heron E. Rodriguez MD Jonathan P. Turner, MS Paul Speicher , BA Mark S. Daskin , PhD Debra DaRosa , PhD. Enhancing Educational Quality and Continuity of Care in a Surgical Residency program using Industrial Engineering Methods. Vascular Surgery :

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Heron E. Rodriguez MD Jonathan P. Turner, MS Paul Speicher , BA Mark S. Daskin , PhD

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  1. Heron E. Rodriguez MD Jonathan P. Turner, MS Paul Speicher, BA Mark S. Daskin, PhD Debra DaRosa, PhD Enhancing Educational Quality and Continuity of Care in a Surgical Residency program using Industrial Engineering Methods

  2. Vascular Surgery : Not the “Model” Rotation for GS Residents Busy service dependent on residents Strong fellowship Endovascular revolution Less # defined category cases Duty hour reform More time off but… Low resident’s satisfaction Distance between VS and GS

  3. Divorce threat in the horizon! Low resident’s satisfaction Distance between VS and GS

  4. Example: Industrial Engineering and Trucking Producer Customer Trucking company

  5. Creating a trucking schedule 1 am 6 am 3 pm 2 am 7 am 4 pm 4 am 10 am 6 pm 5 am 12 pm 7 pm Truck 1 1 am 6 am 3 pm 6 pm Truck 2 2 am 10 am 4 pm Truck 3 4 am 12 pm 7 pm Truck 4 5 am Truck 5 7 am midnight 6 am noon 6 pm midnight

  6. From5 trucks to 4 trucks Truck 1 1 am 6 am 3 pm 6 pm Truck 2 2 am 7 am 10 am 4 pm Truck 3 4 am 12 pm 7 pm Truck 4 5 am 10 am Truck 5 7 am midnight 6 am noon 6 pm midnight $3 in rebates $0 in rebates

  7. From4 trucks to 3 trucks Truck 1 1 am 1 am 5 am 6 am 10 am 3 pm 4 pm 6 pm Truck 2 2 am 2 am 6 am 7 am 3 pm 4 pm 6 pm Truck 3 4 am 4 am 7 am 12 pm 7 pm Truck 4 5 am 10 am midnight 6 am noon 6 pm midnight $21 in rebates $12 in rebates $3 in rebates $24 in rebates

  8. Fleet utilization Deliver the same number of loads with fewer trucks

  9. Research Questions • To what extent are residents spending time engaged in educationally beneficial activities? • How many RRC-DC cases are residents logging on their VR?Are they evenly allocated? • What is the effect of rotation length on opportunity to achieve CoC?

  10. Question 1: To what extent are residents spending time engaged in educationally beneficial activities? Methods – review of goals and objectives according to ACGME general competencies and using ABS SCORE APDVS The location or learning activity that will facilitate its achievement was determined

  11. Question 1: To what extent are residents spending time engaged in educationally beneficial activities? When treating a patient with limb ischemia the resident is able to identify the femoral, popliteal and tibial arteries on radiologic images. Clinic Conference Consult

  12. Question 1: To what extent are residents spending time engaged in educationally beneficial activities? When treating a patient with limb ischemia the resident is able to identify the femoral, popliteal and tibial arteries on radiologic images. When performing surgical thrombectomy, the resident is familiar with intraoperative angiography and thrombolysis Clinic Conference Consult OR Conference Reading

  13. Question 1: To what extent are residents spending time engaged in educationally beneficial activities? Methods – paging cards and program objectives

  14. Question 1: To what extent are residents spending time engaged in educationally beneficial activities? Patient list is now automatic Increase time in clinic Goal-oriented time in clinic Entry and exit interviews (goal discussion) Goal-oriented content of conferences Skills development outside the OR Guided self-study

  15. Question 2: How many RRC-DC cases are residents logging on their VR?Are they evenly allocated? Reviewed the charts of all patients undergoing surgery in a 2-month period 178 patients 210 cases (29% inpatients 71% outpatients) 129 were defined category 66 were performed by residents

  16. ACGME case log 2008-2009

  17. How do we assure even distribution of cases between fellows and residents?

  18. How do we assure even distribution of cases between fellows and residents?

  19. How do we assure even distribution of cases between fellows and residents? ACGME case log information Projected case pool “Menu” of priority, level-specific cases Patients seen by residents in clinic or consults Operative case assignments

  20. Question 2: How many RRC-DC cases are residents logging on their VR?Are they evenly allocated?

  21. Question 3: What is the effect of rotation length on opportunity to achieve CoC? • CoC time lags: Outpatient clinic visits & surgery: 16.7 days Inpatient consultation & surgery: 1.9 days Surgery & outpatient follow up: 22 days

  22. Question 3: What is the effect of rotation length on opportunity to achieve CoC? • CoC time lags: Outpatient clinic visits & surgery: 16.7 days Inpatient consultation & surgery: 1.9 days Surgery & outpatient follow up: 22 days

  23. Question 3: What is the effect of rotation length on opportunity to achieve CoC? = 25% continuity of care

  24. Question 3: What is the effect of rotation length on opportunity to achieve CoC? = 25% continuity of care = 45% continuity of care

  25. 16.7 days 22.0 days Post Dx OR

  26. Other opportunities to improve CoC Assigning cases Alternative policies: “Concentrated “Borrowing” “Pursuit”

  27. A ‘concentrated’ policy Clinic / consults Clinic / consults OR Follow up OR Follow up R1 Resident a Resident b R2-5 Resident c Clinic / consults OR Follow up

  28. A ‘borrowing’ policy • Time during which resident can go to previous clinic’s service is fixed (first half?) • Time commitment for borrowing is small • Only contributes CoC on follow up visits Can go to clinical appts for previous service Can go to clinical appts for service 1 Resident a on service 1 Resident a on service 2

  29. Conclusions • Significant discrepancies exist between the activities that residents spend time performing during their VR and the educational goals • The amount of time devoted to and the content of educational activities need to be modified

  30. Conclusions • Surgical cases are unevenly distributed among residents and fellows • Scheduling systems that take into account the specific case load of programs and the individual resident’s case log are needed

  31. Conclusions • CoC is very difficult if not impossible to achieve during a one month rotation. • Industrial engineering offers excellent tools to improve the educational quality and CoC in surgical residency

  32. Jonathan P. Turner, MS • Paul Speicher, BA • Mark S. Daskin, PhD • Debra DaRosa, PhD • Augusta Weber • Education Grant

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