Leadership in Quality Improvement Pathway

The Leadership in Quality Improvement Pathway was designed in line with the residency’s mission to prepare residents to become innovative leaders in health care. The pathway takes advantage of the internationally renowned Virginia Mason Production System (VMPS) to train residents in rigorous quality improvement methodology, leadership, and change management through one-on-one coaching and mentorship.

The Virginia Mason internal medicine residency curriculum consists of core inpatient rotations, ambulatory experiences including full-day continuity clinic and ambulatory blocks, customizable electives and high-yield conferences. The program has excellent adherence to ACGME duty hour limits, maximizing clinical time and supporting our mission to train excellent physicians, fulfilled individuals and innovative leaders. In addition to the internal medicine curriculum, the QI pathway includes additional training and classwork with the goal of creating residents as leaders and innovators of change highlighted by a culminating quality improvement project by the end of PGY-3.

Residents in the Leadership in QI Pathway will attend classes in quality improvement taught by in-house experts in the Virginia Mason Production System (VMPS). These classes compose the "VMPS for Leaders" curriculum, which is used to train leaders throughout the organization in VMPS methods. This course is now offered remotely. After the introductory course during first year, you will attend an intensive one-week in-person course “Leading at Virginia Mason” where you will work alongside fellow leaders in training and experts in the VMPS process within the Kaizen Promotion Office. Homework from each class will give residents a chance to apply their learning in a real clinical environment. This curriculum will give residents the foundation they need to complete a capstone quality improvement project.

In the first year, residents will start taking VMPS for Leaders classes during elective time and will also complete the Systems-Based Practice rotation. During this rotation, they will participate in a quality improvement event, attend a Patient Safety Alert (PSA) resolution meeting, participate in a “flow tour” and attend weekly "report out" sessions and "stand up" meetings to learn more about improvement work throughout the organization, and meet with various quality leaders in the organization.

During the end of the first year and beginning of the second year, residents are expected to start working on a Capstone Project. They will select a process and apply VMPS tools to gather data on the current state, identify waste, and develop team leadership and facilitation skills. After the initial data-gathering state, residents will lead a team first through a formal two-day event to generate and test ideas for improvement, and then through the post-event implementation process.

After finishing the Capstone Project, residents will gather post-event data to measure the effect of the changes they’ve implemented and present their results. Results may then be submitted as an abstract to be presented at a major conference or published in a quality improvement journal.

Throughout the three years, residents will receive extensive coaching and mentorship. Early in the first year, they will meet with leadership and advisory members of the QI track who are also former VMPS for Leaders graduates. They will be introduced to various potential mentors within the organization depending on their area of interest. In the beginning of their second year, residents will pick a sponsor for their Capstone Project after completion of the “Leading at Virginia Mason” course, who will help guide them through the process and assist in planning and implementation. In addition, residents will be assigned a coach from the Kaizen Promotion Office (KPO) who specializes in VMPS methods. Residents will report regularly on their project work progress to their KPO coach, who will work with them one-on-one to learn how to apply VMPS tools to their chosen project. Third year residents who have completed VMPS for Leaders will be expected to serve as mentors for first and second year residents, as well.

In addition to the experience of planning and leading a quality improvement project, residents will meet with key physician, and non-physician, leaders throughout Virginia Mason. They will have the opportunity to attend classes to further hone their skills alongside other leaders in the organization. In addition, residents in the pathway will play a key role in mentoring other residents and promoting overall residency involvement in quality improvement activities. 

The ideal applicant for the pathway would have a passion for quality improvement and be willing to take initiative and work independently. Residents interested in the Leadership in QI Pathway must first match into either the categorical or primary care tracks. After matching at Virginia Mason, residents will be given the opportunity to apply during their first year of training.

Improving Staffing Processes in a Resident Continuity Clinic
Carmen Allcock, Class of 2021
First presented at the 15th Annual Keith Lundberg Lectures, December 11th, 2020

Our residents have several continuity clinics based in different sites across our campuses as well with a partnership with King County Public Health in their primary care clinic in Bellevue Washington. At this continuity clinic, our residents noted that attending physicians had significant variability in terms of expectations for staffing patient visits and this impacted patient and resident wait times. Utilizing our quality improvement methodologies, a team of residents, nurses, medical assistants, and faculty launched a project to standardize the process of staffing patient visits to improve workflow and reduce these wait times. During a Rapid Improvement Workshop (RPIW), this team identified several opportunities to streamline the out of room work involved in a patient visit (including the time to staff a patient with an attending). Some of the key changes that were tested and then implemented residency wide were:

• The development of a standard script for resident presentations to attendings including having residents mention at the start of their presentation if they were on time for their clinic schedule and identifying specific questions that they wanted their attending to focus on. This allowed for attendings to better support resident clinic flow by focusing teaching to the time available and making it more useful in the moment.
• Standardization of presentation format and development of a tool to guide both attendings and residents on this format.
• Introducing the option for Senior residents to "fast track" specific patient visits where they could staff a patient before seeing the patient in question. This was done to improve wait times for patients, improve resident ability to maintain their schedule and increase resident autonomy.

Subsequent measurements of patient and resident wait times have shown significant improvement with implementation of these interventions.

Utilizing an “AM Lab Holiday” Order to Reduce Unnecessary Testing
James Barlow, Class of 2017
Oral Presentation Winner at Washington ACP 2016. Poster presentation at National ACP 2017

A project team of physicians, laboratory personnel, an information technology specialist, and two industrial engineering students designed an intervention to prevent unnecessarily morning lab draws: an “AM Lab Holiday” order. This electronic order appeared in an “AM lab” order set and allowed the primary provider to communicate to the nurse and other team members that morning labs did not need to be drawn. Following implementation of the new order, 1,513 “AM Lab Holiday” orders were placed by 83 different providers in the 7-month post-intervention period. Overall, lab draws per week decreased by 5.4 percent, and morning lab draws per week decreased by 7 percent, suggesting that the new order was an effective way of decreasing unnecessary lab draws.

Delivering Timely Lab Results to Patients: A Team-Based Approach
Lauren Powell, Chief Resident 2017-2018
Poster Presentation Winner at Washington ACP 2016. Poster presentation at National ACP 2017

At Eastgate Public Health Center, where many of our residents practice continuity clinic, residents faced challenges in managing their lab results in a timely manner. No back-up system for managing results existed, and patients experienced long wait times for their results to be acted on due to the lack of training and standards, off-site location, separate EMR system, and long absences from clinic during inpatient rotations. A project team of residents and attendings designed a three-pronged intervention to decrease lead times and standardize management of lab results, including a standard algorithm for results reporting, an inbox coverage system for residents out of clinic, and a checklist-based training system for new interns. Post-intervention, lead times to acting on lab results decreased by 63 percent, labs in processed decreased by 81 percent, and new interns were trained on 94 percent of essential clinic skills within two months of starting residency.

Lauren Powell, MD, MBA (Class of 2017) and James Barlow, MD (Class of 2017) present their scholarly work at National ACP, supported by Dr. Carrie Horwitch, core faculty and scholarly project advisor.

Restructuring hospitalist work schedules to improve care timeliness and efficiency
Monika Wells, Class of 2017
First Place Winner, Innovations Trainee Award. Society of Hospital Medicine Annual Conference 2016.
Published: BMJ Open Quality

In 2014, we recognized that the pace of admissions frequently exceeded our ability to assign a hospitalist. Long patient wait times occurred at admission, especially for patients arriving in the late afternoon when hospitalist day shifts were ending. Our purpose was to redesign hospitalist schedules, duties and method of distributing admissions to match demand. Using administrative data, we were able to estimate demand of admissions by time of day and identify mismatch between volume and capacity with the current staffing model. A team of hospitalists, residents, and administrators designed a new staffing model around demand, which increased admitting capacity and decreased patient wait times for admissions.

Identifying and helping people with unhealthy alcohol use in primary care
Amy Thomson, Chief Resident 2016-2017, Carly Magnusson, Chief Resident 2017-2018, Leighe Lincoln, Class of 2018, Michael Chu, Class of 2018
Oral Presentation Winner, Washington ACP Spring Meeting March 2017. Poster presentation, Alliance of Independent Academic Medical Centers Annual Meeting, April 2017

Our residency program is a member of the Alliance of Independent Academic Medical Centers (AIAMC), an organization that coordinates nationwide initiatives for member programs to conduct 18-month projects on a specific theme. For the 2016-17 AIAMC National Initiative V, our team chose to engage with the organizational goal of improving care of patients misusing alcohol. Prior to our intervention, screening for alcohol misuse was not standardized, using non-validated questions and documented inconsistently. Through multiple PDSA cycles we were able to implement standard screening at all primary care annual exams using a validated single question. Because clinicians indicated a lack of comfort in managing alcohol misuse, we also created tools for responding to a positive screen, including a patient education handout and an evidence-based note template guiding appropriate medications, vaccinations, and additional screening for those misusing alcohol. The process we developed at one initial site has become standard work at all primary care clinics across Virginia Mason.

Amy Thomson, MD, (Class of 2016) and Carly Magnusson, MD, (Class of 2017) presenting their work on alcohol screening at the AIAMC National Meeting in Amelia Island, Fla., in March 2017.

Below is a list of selected recent resident publications and presentations by Virginia Mason internal medicine residents.
Publications

• Zhang CR, Beiter MW, Gonzalez MM, Gebremeskel ET, Kashyap G, Hemeon K, Rosales J, Kennecke HF. Characteristics of end-of-life (EOL) chemotherapy (CTx) received by patients with advanced cancers and association with EOL emergency department (ED) and intensive care unit (ICU) care. J Clin Oncol. 2020 May;39(suppl):abstract e19222. doi:10.1200/JCO.2020.38.15_suppl.e19222
• Mayeda L. Glucose Time in Range and Peripheral Neuropathy in Type 2 Diabetes Mellitus and Chronic Kidney Disease. BMJ Open Diabetes Res Care. Jan 2020
• Slade SJ, Bauer EM, Stone VV, Dave AJ. Spinal IgG4-Related Hypertrophic Pachymeningitis with Spinal Cord Compression: Case Report and Literature Review. World Neurosurgery. 2019;130:65-70. doi:10.1016/j.wneu.2019.06.130.
• Slade SJ. Empathy Rounds: Residents Combating Impostor Syndrome. Journal of Graduate Medical Education. June 2020. In press.
• Schroeder, B. Histiocyte Predominate Myocarditis Resulting from the addition of Interferon Gamma to Cyclophosphamide-based Lymphodepletion for doptive Cellular Therapy. Journal for ImmunoTherapy of Cancer. 2020;8(1)e000247.
• Wells M, Coates E et al. Restructuring hospitalist work schedules to improve care timeliness and efficiency. BMJ Open Quality 2017 http://bmjopenquality.bmj.com/content/6/2/e000028
• Gulvin J, Rosales J. Using a QOPI-based template to monitor appropriate evaluation of constipation. J Clin Onc 34, 2016 (suppl 7S; abstr 94).
• Gulvin J, Aboulafia DM. Squamous Cell Cancer of Unknown Primary and Primary Breast Cancer in an HIV-Infected Woman: The Importance of Cancer Screening in People Living with HIV/AIDS. J Int Assoc Provid AIDS Care. 2016 May;15(3):194-200.
• Johnson C. Teaching improvement: quality improvement curriculum for residents. VM Bulletin 2015; 69(2)21-24.
• Schweitzer S. et al. Patient satisfaction with information delivery in the hospital: a quality improvement pilot study. VM Bulletin 2015; 69(2);25-29.
• Ericson S, Shah N, Liberman J, Aboulafia DM. Fatal bleeding due to acquired factor IX and X deficiency: a rare complication of primary amyloidosis; case report and review of the literature. Clin Lymphoma Myeloma Leuk. 2014;14(3):e81-6.
• Maldonado L, Brait M, Loyo M, Sullenberger L, Wang K, Peskoe SB, Rosenbaum E, Howard R, Toubaji A, Albadine R, Netto GJ, Hoque MO, Platz EA, Sidransky D, GSTP1® promoter methylation is associated with recurrence in early stage prostate cancer. The Journal of Urology. 2014:192(5):1542-8.
• Meier DT, Morcos M, Samarasekera T, Zraika S, Hull RL, Kahn SE. Islet amyloid formation is an important determinant for inducing islet inflammation in high-fat-fed human IAPP transgenic mice. Diabetologia. 2014: 57:1884-8.
• O’Neill, DF. PrEP Yourself: Making Better Sense of the Pre-Exposure Prophylaxis Debate. The Huffington Post: Gay Voices Section. Published online: 25 April 2014.
• Maxwell KL, Kowdley KV. Metals and the liver. Curr Opin Gastroenterol. 2012 May; 28(3):217-22.
• Snyder SM et al. Hyperbaric oxygen and reduction mammaplasty in the previously irradiated breast. Plast Reconstr Surg. 2010;125(6):255e-7e.
• Story B, Thirlby R, Schembre D. Diagnosis of ileal dysplasia in a patient with Crohn's disease by using retrograde enteroscopy with an overtube;a case report. Gastrointest Endosc. 2011;73:178-9.
• Ochenrider MG et al. Hepatosplenic T-cell lymphoma in a young man with Crohn's disease: Case report and literature review. Clini Lymphoma Myeloma Leuk 2010;10:1440-48.
• Dever JB et al. Outcomes of interventional ERCP in hereditary pancreatisis. J Clin Gastroenterol 2010;44:46-51.

Poster Presentations

• Zhang CR, Flores JP. To bleed or not to bleed: VTE treatment in a patient with hereditary hemorrhagic telangiectasia and factor V Leiden [Abstract]. Poster presentation at the American College of Physicians Washington Chapter Fall Scientific Meeting; 2019 Nov 1; Seattle, WA.
• Mayeda, L. "Glycemia assessed by continuous glucose monitoring and peripheral neuropathy among participants with type 2 diabetes and CKD." Presented at American College of Physicians Washington Chapter’s Spring Scientific Meeting; Seattle, WA, USA May 2019.
• Slade, SJ. "Empathy Rounds: Nurturing Resident Community through Vulnerability." Presented at the Gold Humanism Honor Society Symposium – Orlando, FL Oct 2019.
• Arjomand, A. "Bubble Trouble: Arterial Gas Embolism due to Transcutaneous Lung Biopsy Under Positive Pressure Ventilation." American Thoracic Society Conference Poster Presentation - Dallas Texas May 2019.
• Yount, E. "Bends Shock – A Severe Case of Decompression Sickness in a Puget Sound Diver." American Thoracic Society Conference Poster Presentation - Dallas Texas May 2019.
• Rieck, C.A. “Gastric bypass induced hyperammonemic encephalitis; a rare case of adult onset functional urea cycle disorder” presented at: American College of Physicians Washington Chapter’s Scientific Meeting; Seattle, WA, USA November 2019.
• Thomson A, Chu M, Geyer L, Lincoln L, Magnusson C. Identifying and helping people with unhealthy alcohol use in primary care. Poster presentation. Alliance of Independent Medical Centers Annual Meeting, April 2017. Amelia Island, FL.
• Powell L, Batik O, Pittenger K. Delivering Timely Lab Results to Patients: A Team-Based Approach. Poster presentation. Washington State ACP Annual Meeting. Nov 2016. Seattle, WA. Poster presentation winner.
• Bukiri H, Benzar R. Not Your Average [anti]-Jo: Recognizing antisynthetase syndrome as a cause of inflammatory myopathy. Poster presentation. Washington State ACP Annual Meeting. Nov 2016
• Sargent J. Atrial myopathy cases biventricular heart failure in a 55 year old man. Poster presentation. Washington State ACP Annual Meeting. Nov 2016
• Wells, Monika. Adrenal crisis presenting as acute severe hypoglycemia. Poster presentation. Washington State ACP Annual Meeting. Nov 2016.
• Beck K. Acute pancreatitis secondary to metastasis. Poster presentation. Washington State ACP Annual Meeting. Nov 2016
• Barlow JL, Gerbino AJ, Holm JR. Severe immersion pulmonary edema in a diver requiring endotracheal intubation. Poster presentation. Undersea Hyperbaric Medical Society Annual Scientific Meeting. June 2016. Las Vegas, NV.
• Barlow JL, Mehta AM, Fagley RE. Clinical course and treatment of systemic capillary leak. Poster presentation. American Thoracic Society International Conference. May 2016. San Francisco, CA.
• Booras D. Utility of emergency department CT Scans in patients with ulcerative colitis. Poster presentation. Digestive Disease Week; San Diego, CA and at United European Gastroenterology week. 2016. Vienna, AUT.
• Parsons T. Delayed paracentesis and spontaneous bacterial peritonitis – no increase in mortality. Poster presentation. Society of Hospital Medicine (SHM) Annual Meeting. March 2016. San Diego, CA.
• Wells M, Coates E, Calderon A, Blackmore C, Williams B. Designing hospitalist shifts around admission demand reduces patient wait times, cost, and resident duty hour violations. Poster presentation. Society of Hospital Medicine Annual Conference. Mar 2016. San Diego, CA. 1st place winner of Innovations Trainee Award.
• Kane Z. Hoffman’s syndrome: a polymyositis like illness. Poster presentation. Washington State ACP Annual Meeting. Nov 2015. Seattle, WA.
• Parsons T. The automated 2Ts Score: A decision support system for the diagnosis of heparin-induced thrombocytopenia. Poster presentation. Washington State ACP Annual Meeting. Nov 2015. Seattle, WA. Poster presentation winner.
• Thomson A. Gastrointestinal amyloidosis in an IV drug user. Poster presentation. Washington State ACP Annual Meeting. Nov 2015. Seattle, WA.
• Triska I. E. coli bacteremia in the setting of Strongyloides stercoralis hyperinfection syndrome. Poster presentation. Washington State ACP Annual Meeting. Nov 2015. Seattle, WA.
• Blayney M. Management of pancreaticopleural fistula: the Virginia Mason experience. Poster presentation. Washington State ACP Annual Meeting. Nov 2014. Seattle, WA.
• Fang A. A Rarely Confirmed Diagnosis with a Classic Presentation: Primary Systemic Amyloidosis (AL) with Tissue-Proven Cardiac Involvement. Poster presentation. Society of General Internal Medicine. February 2013. Portland, OR and ACP Annual Meeting April 2013. San Francisco, CA.
• Ghosh, T. The 40 year old IUD: actinomyces mimicing a gyncecologic malignancy. Poster presentation. Washington State ACP Annual Meeting. Nov 2013. Seattle, WA.
• Jensen A. Amyloid cardiomyopathy causing heart failure. Poster presentation. Washington State ACP Annual Meeting. Nov 2013. Seattle, WA.
• Shih W H. Calcific uremic arteriolopathy (calciphylaxis) in a woman with end stage renal disease after initiating peritoneal dialysis. Poster presentation. Society of General Internal Medicine. February 2013. Portland, OR.
• Ward, DJ and DF O'Neill. Nucleoside-Sparing Antiretroviral Regimens in Clinical Practice. Poster presentation. Interscience Conference on Antimicrobial Agents and Chemotherapy. September 2013. Denver, CO.
• Parker J. Nitrofurantoin induced respiratory failure. Poster presentation. Washington State ACP Annual Meeting Nov 2012. Seattle, WA.
• Maxwell K. Abdominal mass in a young patient with juvenile rheumatoid arthritis. Poster presentation Washington State ACP conference Nov 2011. Seattle WA.

Oral Presentations

• Geck, Kaitlin. Scurvy and Other Complications of Treatment for Sel-Reported Mast Cell Activation Disorder. Oral Presentation at the Society of Hospital Medicine Pacific Northwest Chapter Annual Abstract Competition, and Competition Winner.
• Zhang CR, Beiter MW, Gonzalez MM, Gebremeskel ET, Kashyap G, Hemeon K, Rosales J, Kennecke HF. Change in rate of weight loss at end-of-life in patients with cancer [Abstract]. Oral presentation at the American College of Physicians Washington Chapter Spring Scientific Meeting; 2020 May 8; Seattle, WA.
• Thomson A, Magnusson C. Identifying and helping people with unhealthy alcohol use in primary care. Oral Presentation. Washington ACP Spring Meeting March 2017. Oral presentation winner
• Liskey D. Kaposi sarcoma presenting as a large bowel obstruction. Oral presentation. Washington State ACP Annual Meeting. Nov 2016. Seattle, WA and National ACP April 2017, San Diego, CA.
• Magnusson C. An unforgettable business trip: a case of anterograde amnesia. Oral presentation. Washington State ACP Annual Meeting. Nov 2016. Seattle, WA.
• Barlow J. Reducing unnecessary lab draws with an AM lab holiday order. Oral presentation. Washington State ACP Spring meeting. 2016. Seattle, WA. Oral presentation winner
• Cunningham E. Chronic care management during residency implementing a diabetes metric tracking system. Oral presentation. Grand Rounds presentation. April 2016. Virginia Mason Medical Center. Seattle, WA.
• Popko L. Case of thrombophlebitis of the internal jugular vein misdiagnosed as meningitis. Oral presentation. Grand Rounds presentation. April 2016. Virginia Mason Medical Center. Seattle, WA.
• Sullenberger L, Shenoy A. Silent disparity-health literacy enhancing provider awareness. Oral presentation. Grand Rounds presentation. May 2015. Virginia Mason Medical Center. Seattle, WA.
• Parsons, F. New Technologies: Apps for Patients. Oral presentation. Washington State ACP Annual Meeting. November 2014. Seattle, WA.
• Morcos, M et al. Dietary sucrose does not exacerbate the effect of dietary fat to promote islet amyloid deposition and beta-cell loss in human islet amyloid polypeptide transgenic mice. Oral Presentation. ENDO 2013 annual meeting. San Francisco, CA
• Parker J, TB or Not TB: Testing clinician knowledge regarding PPD and IGRA’s with an educational intervention. Oral Presentation. Washington State ACP Annual Meeting. Nov 2012. Seattle, WA. Oral presentation winner
• D'Souza A. Caroli disease presenting as epididimytis. Oral presentation. Washington State ACP conference Nov 2011. Seattle WA
• Lee T. Case of anti-NMDA receptor encephalitis in a young woman with worsening cognitive function and psyhcomotor retardation. Oral presentation. Washington State ACP conference. Nov 2011. Seattle, WA.