Multidisciplinary Performance Improvement (MDPI)

Description:

This conference focuses on adverse clinical events or “close calls” which occur on the teaching service. Cases can be brought forward by any party involved in patient care including administration, nursing, residents, pharmacists, chief residents, and attending physicians. The presenting resident (working closely with an attending preceptor or chief resident) will present the case, review pertinent literature, analyze causes and consequences of the event, and work with the care team to create system changes to prevent future incidents.

As supported by the quality improvement literature change occurs most successfully with multidisciplinary input and team ownership. Therefore a critical feature of this conference is the presence and participation of the entire care team. All parties involved in the case will be notified prior to the conference (by the Chief Medical Resident) so that they may come prepared to offer input and solutions. This conference is part of the BMC Department of Medicine Peer Review process, all information presented is treated as confidential and protected and the Department Chair periodically reminds attendees of this.

Participants:

Nurse ManagementClinical Nurse Leadership

PharmacyMedical Residents

Dept. of Medicine Chair &PDChief Operating Officer

Chief Medical Officer Quality Officer (or designated representative)

*ED Medical and Nursing Leadership* Pathology / Clinical Lab

* ICU Medical and Nursing Leadership* Surgical Medical Leadership

(* delineates that these parties are present as case requires)

Participants are eligible for (1) AMA PRA category one Credit™ which counts toward (1) hour category one risk management for the Board of Registration in Medicine of the Commonwealth of Massachusetts.

Core Competencies:

This experience will integrate several of the core clinical competencies including: patient care, medical knowledge, practice-based learning and improvement, professionalism, interpersonal and communication skills, and systems based practice.

Goals and Objectives:

  • Analyze causes of adverse events
  • Analyze consequence of adverse events
  • Gain expertise in reviewing patient safety literature
  • Gain comfort in presenting to a group of educated listeners
  • Learn to work effectively with a multidisciplinary group
  • Learn to use multimedia / computers / PowerPoint
  • Learn to create and implement system change to prevent adverse events

Format:

  • Case chosen by any member of care team and assigned to appropriate Senior by Chief Medical Resident.
  • Conference occurs three times monthly during hours of 11a-12p on designated Tuesdays.
  • Presenting Resident selects a faculty member to precept (includes Chief Resident)
  • Resident should work with preceptor to define teaching goals
  • Resident should work with preceptor to define organization of talk
  • Resident analyzes case for causes of adverse event(s)
  • Resident reviews appropriate literature
  • Resident works with appropriate faculty and hospital personnel to propose, create and implement systems to prevent future events.
  • Resident discussesappropriate details of case (using timeline format), teaching points, and leads discussion of system changes in an interactive manner with multidisciplinary team during the 1 hour conference.
  • Chief Medical Resident maintains a spread sheet (see heading examples below) that contains salient features of case and includes action plan and follow up.

Case ID / Brief Case Report / Relevant Issue / Intervention / Person Responsible / Update/Status / Additional Comments

Evaluation:

  • Resident will meet with preceptor, chief residents and/or program directors following talk and receive formal feedback on presenting skills, organization, content, relevance of material, and any other appropriate areas.