Utility of a Structured Self-Audit to Educate Internal Medicine Residents on Lessons Learned from Hospital Re-admissions

From the 2021 HVPAA National Conference

Fizza Hussain (Loyola University Medical Center), Leo Gozdecki, Stephanie Betcher, Abhinav Menon, Andrew Crone, Hina Dalal, Pavan Gupta, Cody Braun, Arouj Bajwa, Arushi Hukku, Faisal Husain, Nicolas Krepostman, Nathalie Antonios, Dan Kim, Holly Kramer, Meghan O’Halloran

Background

There is a paucity of data on educating internal medicine residents about hospital re-admissions. Furthermore, self-audits are underutilized as a method to engage young clinicians in quality and patient safety principles.

Objective

We designed an educational intervention using a structured self-audit to study resident perceptions on causal factors for unplanned, 30-day re-admissions and the educational value of the intervention.

Methods

Twelve categorical post-graduate year 2 (PGY2) internal medicine residents participating in a Quality Improvement & Patient Safety (QIPS) elective performed a self-audit of patient re-admissions discharged under their care during a Veteran Affairs (VA) inpatient general medicine rotation. Chief residents reviewed departmental admissions data and compiled a list of each resident’s unique patients with a 30-day, unplanned re-admission. Chief residents then randomly assigned up to 5 patients per resident for review.

On average, each PGY2 completed self-audits on 4.4 patients. A total of 53 re-admissions were reviewed with patient demographics and index admission/re-admission characteristics recorded. Residents then rated the likelihood of 23 causal factors in contributing to each re-admission. Residents also took pre and post perception surveys on how often they believed each of the 23 causal factors contribute to re-admissions at our VA hospital (Supplementary Tables).

Results

Pre-intervention survey responses revealed that 83.3% (10) often or always considered patient safety and quality of clinical care central to their educational experience. However, eleven residents stated they were rarely provided objective data about the quality of their inpatient care (Table 1). While 83.3% (10) of the residents did report reviewing electronic medical records after discharge at least sometimes, the majority, 58.4% (7), rarely or never performed systematic evaluation of causes for readmission (Table 1).

While there were no significant differences in pre and post perception surveys in which residents rated how often each of the 23 causal factors contributes to re-admissions (Supplementary Tables), residents still found the activity valuable. After the intervention, 83.3% of residents (10) responded that the activity “very much so” or “absolutely” facilitated a relevant review of patient safety or quality of clinical care (Table 2). Eleven residents (91.7%) answered they “probably will” or “definitely will” change how they manage future discharges (Table 2).

As part of a qualitative questionnaire in the self-audit, residents were asked how the review of their readmitted patient may facilitate change in future clinical practice. The three most frequently cited areas for improvement to prevent readmission included: 1) post-discharge follow up 2) patient and/or caregiver education at time of discharge and 3) communication with consultant teams (Figure 1).

Conclusion

Our internal medicine residents participating in a Quality Improvement & Patient Safety elective performed a self-audit educational intervention reviewing causal factors for readmission of patients discharged under their care during a general medicine rotation. Residents responded favorably to the intervention indicating that it was educationally valuable, relevant, and likely to alter their future practice.

Clinical Implications

A structured self-audit intervention to evaluate unplanned 30-day re-admissions teaches individuals practice based improvement and enhances houses-staff learning. Furthermore, the activity may improve future transitions in patient care.