Graduate Medical and Dental Education

2005 DIO Annual Report - Executive Summary

Designated Institutional Official
The University of Tennessee Graduate School of Medicine, Knoxville Tennessee

Rationale  

The Accreditation Council for Graduate Medical Education (ACGME) requires each sponsoring institution to appoint a Designated Institutional Official (DIO) who has the authority and responsibility for the oversight and administration of the Sponsoring Institution's ACGME accredited programs. This responsibility includes submission of an Annual Report to the Organized Medical Staff (OMS) and the governing bodies of major affiliated Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accredited hospitals in which the Sponsoring Institution's Graduate Medical Education (GME) programs are conducted. In turn, the latter is also a requirement for continued JCAHO accreditation. The current Annual Report is the second for the present DIO. When possible, changes in GME since his first report (2004) is described and longitudinal trends are also presented when historical data allows valid comparison.

Graduate Medical Education Mission Statement

To develop and implement the Graduate School of Medicine's primary mission of excellence in education that ensures graduating physicians and dentists who have attained technical excellence while learning to practice with the highest level of professional, ethical and compassionate behavior and who are prepared to engage in continual improvement of their own care-giving as well as to the continuing wellness of society.

INSTITUTIONAL COMMITMENT

Institutional commitment to GMDE includes resident salaries and benefits and partial support of teaching faculty. The Center for Medicare and Medicaid Services (CMS) reimburses hospitals for medical services rendered by supervised residents. These funds include indirect costs (IME) and direct costs (DME). The UTMH/UHS is contractually committed to transfer 100% of these funds to the GSM. In addition to CMS reimbursement, additional funding for GMDE includes State of Tennessee appropriations, TnCare GME funds, federal indirect funds, patient care revenue and other funds such as grants, gifts and donations. Funding streams for GMDE did not change significantly in 2005 except the addition of new patient care revenue from the Genetics Center . This resulted in a decrease in the overall percentage of total GMDE funding from IME/DME.

DIO/GME Leadership

On April 17, 2005, Dr. Eddie Moore was one of only 24 DIOs to graduate from the inaugural GME Leadership Course offered by the Group on Resident Affairs (GRA) of the Association of American Medical Colleges (AAMC).

Graduate Medical Education Programs

The University of Tennessee Graduate School of Medicine (UTGSM) offers graduate medical and dental education in partnership with The University of Tennessee Memorial Hospital (UTMH) and its parent organization University Health Systems Incorporated (UHS). To more accurately reflect its primary mission, the Office of Graduate Medical Education was recently re-titled Office of Graduate Medical and Dental Education (GMDE). Institutional (UHS and UTGSM) commitment to GMDE includes resident salaries and benefits and partial support of teaching faculty. The funding stream categories for GMDE did not differ from those for 2004. In 2005, the amount of funding from patient care revenue increased thereby decreasing the percent of GME total funding from IME/DME from 64% in 2004 to 57% in 2005. The actual total dollar amount from IME/DME did not decrease in 2005.

In 2005, GMDE provided a total of fifteen (15) ACGME accredited medical residencies and two (2) American Dental Association (ADA) accredited dental residency programs. Additionally, there were five (5) non-ACGME accredited medical training programs. One of these 5 residencies, Family Practice Emergency Medicine, is accredited by another agency. Also, the non-accredited Surgical Pathology program became available in 2005. Thus, there was a total number of 22 training programs for 2005 an increase of 1 program from 21 in 2004.

In current ACGME terminology, the rubric “resident” is used to describe all trainees, which include the historical term “fellow.” Using this terminology, ten of the 15 total ACGME accredited programs are “core residency programs,” and five are fellowship programs. The five unaccredited programs are all termed fellowship training programs.

New residents are added each year to our GMDE programs by various means including the National Residency Match Program (NRMP). In 2005, a total of 50 resident positions were offered via the NRMP to begin training in July 2006. This compares to 51 positions offered in 2004. Forty-two (42) of the 50 positions offered in 2005 were filled through the match process. The remaining eight (8) positions were filled following the match. Additionally, four (4) new general dentistry residents, and three (3) new oral and maxillofacial surgery residents will enter GMDE programs in July 2006.

Finally, for 2006, 113 residents were retained and promoted to upper residency levels. Therefore, as of July 01, 2006, a total of 183 residents and fellows will be enrolled in all GMDE programs (Tables 2-3, page 2). The historical significance of the total number of residents confirms the continuing growth of GMDE programs as shown in the following table.

There is limited national data on optimal faculty/resident ratios to maximize resident learning. RRC guidelines generally require a number of “key faculty” but do not specifically address total faculty. Compensation to faculty can be by contract with individuals or by contract with a group within which there are multiple teachers. Using present GSM data (Table 5, page 3), the number of regular (permanent) faculty in 2002 was 172 versus 181 in July 2005, or a 5% increase. However, there has been no change in the number of residents in 2002 (184) compared to 183 in July 2006. Further, the 181 regular faculty is low as it does not include multiple faculty within a group. Optimal resident/faculty ratios (or cost/resident of GMDE) can not be estimated at present. The DIO and Data Manager are constructing a new database that will allow multiple queries related to the economies of GMDE.

GMDE ORGANIZATIONAL COMMUNICATION AND ADMINISTRATION

The University of Tennessee Graduate School of Medicine (GSM) is fully accredited by the ACGME for institutional operation of medical and surgical GME programs. Additionally, the GSM is accredited by the American Dental Association (ADA) for operation of GME programs in general dentistry and oral and maxillofacial surgery (OMFS). As previously noted, the UTMH is the primary Joint Commission on Accreditation of Healthcare Organizations (JACHO) educational facility. Six additional area hospitals are affiliated to meet training needs in various programs. All of these hospitals have JACHO accreditation.

The institutional DIO, Office of GMDE, and the institutional Graduate Medical and Dental Education Committee (GMDEC) are charged with the responsibility for administration, supervision and oversight of all ACGME accredited programs (Appendix A). The DIO and the Office of Graduate Medical Education work together to accomplish this mission. The GSM-UTMH affiliation also operates dental and OMFS residencies. To more accurately reflect the primary mission of the GSM, the rubric for this office was changed to the Office of Graduate Medical and Dental Education (GMDE) and the Graduate Medical Education Committee to GMDEC effective May 1, 2006.

The organizational chart and lines of communication for GMDE is shown in Appendix B. The organizational chart shows the oversight role for the Director of GMDE for all graduate education programs. The Director of GMDE reports to the Associate Dean for GME who is also the Institutional Designated Official (DIO). The reporting lines for the DIO are shown in compliance with ACGME guidelines.

Anonymous Reporting Mechanism

To ensure organization wide communication without fear of retribution, an Anonymous Electronic Reporting System for organization wide communication has been in place since 2003. This mechanism can be accessed by any UTMH/UHS or UTGSM employee and is particularly related to observations of putative instances of resident sleep deprivation, excess fatigue or disruptive behavior. Significantly, the anonymous reporting system can also be accessed by the public and specifically is available to resident families as well as UTMH customers. The guaranteed anonymous report comes directly to the DIO for reaction. Similar to 2004, in 2005 there was no report received via this system. However, it is apparent that Patient Safety Network (PSN) has served this purpose; attempts are in progress to determine if the two reporting systems are mutually exclusive.

Graduate Medical and Dental Education Metrics

Purpose

The identification of GMDE quality and performance measures (metrics) contributes to both ACGME accreditation for UTGSM as well as to JCAHO accreditation for UTMH. Further, GMDE quality and performance measures provide an important impetus for institutional support for GMDE through enhanced understanding of the impact of GMDE in clinical service delivery and provide a partial economic estimate of the value of GMDE on our organization and the State of Tennessee . In 2005, we implemented preliminary monitoring of GMDE quality and performance measures to establish the value of GMDE to our organization. We have identified the following seven (7) quality metrics:

1. Resident Supervision

All GMDE residents receive three levels of supervision in rendering patient care services. These levels of resident supervision, i.e., general, direct, or personal , are provided by appropriately credentialed hospital clinicians. The Resident Supervision Policy (RSP) was approved by the U TMH Executive Committee in 2002 and is distributed to the OMS by posting on the GSM intranet (a/k/a Insite). Resident's responsibilities are limited only to those procedures and patient care activities authorized by the UTMH credentialed supervising clinician. Specifically, the RSP states: “under no circumstances will a resident examine a patient or perform an invasive procedure for any purpose other than for the benefit of the patient or to achieve a diagnosis. This policy extends to and includes patients who are near death or have expired.”

To ensure organization-wide knowledge of trainee-level specific approved skills and qualifications to perform designated procedures, all GMDE programs assembled a database for each resident that lists skills and procedures for each resident; the policy requires individual approved resident procedures to be updated on a regular basis as individual resident acquisition of skills increases. The basic Resident Procedure Database was submitted to and approved by the UTMH Executive Committee. The Resident Procedures Database is not accessible to the public. However, the individual resident procedure list has not been updated on a regular basis and there have been a few recent instances where the nurse manager for a procedure was unable to determine the resident's approval to perform the procedure. A GMDE goal for 2006 is to implement, in collaboration with the Department of Nursing, a corrective action policy for quarterly updating of approved resident procedures to ensure residents perform only the procedures credentialed by their program directors.

2. Patient Care and Patient Safety

During 2005, residents participated in the care of all patients receiving inpatient healthcare services at UTMH. Similar to 2004, there are no known reports of patient refusal of resident participation in their care.

In 2004, patient safety was incorporated into teaching ACGME mandated general competencies with specific reference to general competencies of Interpersonal Skills and Communication, Professionalism and Systems-Based Practice. To ensure optimal learning experiences of the competencies, GMDE recognized a joint effort by both GMDE and major service components of UTMH was required. Therefore, the following joint teaching and learning activities were continued in 2005:

•  Joint general orientation for all new residents prior to assumption of patient care activities

•  A unique Foundational Curriculum for First Year Residents.

•  Press-Ganey Patient Satisfaction Surveys

•  Patient Safety and ACGME General Competencies (Outcome Project)

•  Interdisciplinary Patient Care Rounds

The Critical Event Review is to evaluate systems processes that may or may not have contributed to the event. The Event Review is not a peer-review process. In 2005, critical event reviews decreased by 76%. Each type of critical event (sentinel, near miss, and state reportable) averaged an 80% decrease from 2004. Regrettably, this decrease is a result of a change in reporting methods rather than a true decrease in organizational deficiencies. Even though there was a decrease in the number of critical event reviews using a different reporting method, the total number of residents that participated in reviews increased from 15 in 2004 to 19 in 2005. In all Event Reviews involving residents, there was no instance of human error. The most often observed process problem involved communication deficiencies.

To ensure that recommendations derived from critical reviews become teaching tools for all residents, the DIO and the UTMH Patient Safety Coordinator developed the electronic “ GMDE Patient Safety Bulletin” that is distributed to all residents and attending clinicians in GMDE programs. As a result of Critical Event Reviews, two (2) GMDE Safety Bulletins were issued in 2005 compared to three (3) in 2004. Copies of the two 2005 GMDE Patient Safety Bulletins are shown in Appendix K.

Press Ganey Patient Satisfaction Surveys

Two queries on this survey specifically relate to healthcare provided by residents. One question addresses courtesy and attentiveness of the residents and reads: “Ask the patient how well he/she was treated by the resident and if they felt the resident gave their undivided attention to them while in the room.” The second query relates to the overall rating of the performance by the resident and reads: “Ask the patient how they felt the care was overall . In 2005, Ninety-three percent (93%) reported the level being good (32%) to very good (61%) compared to 92% in 2004. Ninety-two (92%) percent indicated that the performance was good (32%) or very good (60%) compared to 90% in 2004. Thus, our customer satisfaction with resident delivered healthcare remains very good/good with a slight increase in 2005. An internal benchmark for this metric will be established beginning in 2006 using the three consecutive year results for 2004-2006.

Patient Safety and ACGME General Competencies (Outcome Project)

This metric will be measured as a component of Part III of the ACGME Outcome Project. Phase 3, integration of outcome assessment measurements with changes in program-specific curriculum did not go into effect until July 01, 2006. The initial results will be reported in the 2006 Annual Report.

Interdisciplinary Patient Care Rounds

Resident participation in these rounds is voluntary and activity is presently not monitored.

3. Resident Health and Satisfaction

Resident Duty Hours Policy :

The major objective of the Duty Hours Policy is to limit resident duty hours to minimize resident sleep deprivation and excess fatigue which have the potential to result in patient care errors. The resident duty hours policy limits maximum duty hours per week averaged over 4 continuous weeks (80 hrs/week), minimal hours of rest between duty hours, and there must be at least one day in seven free from all duty assignments. The UTGSM institutional Resident Duty Hours Policy was approved by the Graduate Medical and Dental Education Committee (GMDEC), implemented in 2002, and has subsequent revisions each year. It should be noted that, although the ADA has not imposed duty hours restrictions on its training programs, however, in the interest of patient safety, UTGSM requires the general dentistry and the oral and maxillofacial surgery programs to also adhere to this policy. As of September 2005, all ACGME programs came into compliance with this policy with regards to 80 hours/week duty hours. There were no violation of the on-call limitations, the required rest between duty assignments and the 1/7 days duty free requirement. General dentistry has remained in compliance since inception of the program. However, OMFS was in non-compliance all of 2005. The DIO has requested the OMFS program to submit a corrective action plan. There is no current evidence that this non-compliance has impaired patient care or resident well being.

Resident Assistance Program:

The Resident Assistance Program (RAP) director received 22 new referrals during 2005. This shows a steady increase in referrals from 2003 (14) and 2004 (15). In 2005, the referrals were from seven programs as compared to six programs in 2003 and 2004. From 2003 to 2005 the majority of the referrals were from surgery and internal medicine. Thirty- two percent were self-referrals compared to thirteen percent in 2004 and forty-three percent in 2003. The reasons for referrals in 2005 compared to previous years are shown in Table 7 on page 9. Interestingly, from 2003 to 2005, there has been an 8% increase in males whereas a 20% decrease in females participating in the RAP.

Resident Salaries and Benefits:

Resident salaries and benefits for 2005 were increased by 3% compared to 2004. As in previous years, resident salaries and benefits are aligned with those operative for GMDE programs at the University of Tennessee Health Science Center, Memphis . There were no previous 2004 benefits eliminated in 2005.

Housestaff On-Call Quarters:

Joint UTMH-UHS/GSM extensive renovation and refurbishing of the house staff sleeping quarters begun in the fall of 2004 was completed in 2005.

Resident Satisfaction Survey

In October 2005, the DIO/GMDE developed and implemented a new Resident Satisfaction Survey to proactively determine real and potential issues that could negatively impact resident satisfaction and performance. The survey was anonymous and 100% of the residents completed the survey. The analysis of this survey is in progress; however, a very superficial perusal of all reports indicated at least 2 residents who stated they would not choose UT for residency if they had another chance to select an institution. The statistical validity of the survey has not been verified at present.

4. ACGME Outcome Project and Resident Evaluations

All GMDE programs have activated Phase I and Phase II of the ACGME mandated Outcome Project, a long-term initiative that changes the paradigm of cognitive learning to one that includes applied behavioral outcomes that ensures patient centered care. Although not currently specifically stated, the intent of the Outcome Project is to improve patient safety through the paradigm shift in GMDE. Six General Competencies apply to all residents: (1) Patient Care; (2) Medical Knowledge; (3) Practice –Based Learning and Improvement; (4) Interpersonal and Communication Skills; (5) Professionalism and (6) Systems-Based Practice. Presently, the ADA does not require its programs to adhere to these general competencies. However, to ensure patient safety, the UTGSM requires the dental and oral and maxillofacial surgery programs to also participate in these general competencies.

All GMDE programs have completed Phase I that required documentation of venues utilized to teach these general competencies. Similarly, all GMDE programs have completed Phase II documenting the evaluation and assessment instruments employed for general competencies outcomes.

A formative evaluation instrument documenting resident progress toward acquisition of the general competencies is required for each resident. All UTMH patient care providers and staff have the opportunity to participate in resident assessment most often via the 360-degree evaluation instrument. The 360-degree evaluation consists of measurement tools completed by multiple staff in individual patient care settings. At UTMH, the evaluators generally are nurses and allied health personnel and, in some instances, patients and families. However, UTMH customers most often participate in resident evaluations when Patient Survey instruments are utilized such as the Press-Ganey Patient Satisfaction Survey discussed above.

The individual resident evaluation, with corrective action proposals, if applicable, is submitted to the DIO/GMDE at six-month intervals. Further, an annual summative evaluation is to be submitted to DIO/GMDE that attests to level-specific acquisition of general competencies and a specific proposal for academic remediation, termination, promotion or graduation as appropriate. All final resident dispositions are approved by the GMDEC.

Assessment of Resident Proficiencies in the General Competencies

Resident acquisition of proficiency in the general competencies is measured, at least in part, by the following variables: 1) Academic Probation; 2) Non-promotion with requirements to repeat the year; 3) Non-renewal of contract and, 4) Voluntary withdrawal by the resident. The latter category may reflect a change in career goals. In 2005, there were 4 programs that had residents that were placed in some form of academic remediation. The period of remediation ranged from 1 to 6 months. Additionally, there was 1 program where a resident did not have a contract renewed and 2 programs had residents who voluntarily chose to leave.

5. Resident Knowledge and Distinction

During 2005, 27 residents participated in supervised clinical research. In 10 instances, the resident served as co-investigator and the remaining 17 served as participants. The number of residents participating in supervised research increased 8% in 2005 compared to 2004.

Residents' knowledge and distinction was further evident in presentations at national meeting and publications. In 2005, 7 GMDE programs had 31 residents with 26 national presentations and 15 publications as either author or as a co-author. The number of national presentations and publications by residents decreased 2% from 2004.

6. GMDE Program Technical Excellence

Quality measures for programs include metrics such as USMLE and COMLEX scores for new residents, in-training examination sequential results, and board certification rate on first attempt. The database for these metrics is under construction.

7. GMDE Meaningful Presence

In 2005, 63 (85%) of 74 medical and dental residents completed GMDE Residency programs. Thirty-two (43%) of the 74 residents remained in Tennessee in varying capacities while 42 (57%) completed their training, transferred to another program or left Tennessee. Of the 32 residents continuing in Tennessee , 10 entered into private practice while 15 continued at UTGSM/UTMH as faculty, hospitalists, fellows, or completed transitional PGY-1 years and entered into new GMDE programs.

Analysis of 2005 DIO/GMDE Goals

Six (6) goals were listed for 2005. These were:

Goal 1 was accomplished and in February 2006, Institutional Accreditation was renewed for 4 years. Goal 2 was accomplished and our GMDE Resident Satisfaction Survey administered in October was commended as a “Best Practice” by the Institutional Review Committee of ACGME. Goal 3 is a work in progress by GSM and UTMH, in particular the Patient Safety Committee and the Department of Performance Improvement. Goal 4 was accomplished through interaction with the UTMH Patient Safety Committee and The UTMH Office of Performance Improvement. Goal 5 was not accomplished as the integrated curriculum Committee activities were suspended in lieu of attention to preparation for the institutional review. Goal 6 was not accomplished, in the main, as a consequence of suspension of activities of the Integrated Curriculum Committee in preference to preparation for the Institutional Accreditation Site Visit.

DIO/GMDE GOALS FOR 2006

•  Initiate process to organize, edit and compress current resident database to improve efficiency of GMDE attestation of residency achievement of proficiencies in the ACGME competencies.

•  Develop a new database to query economies of GMDE.

•  Conduct second Resident Satisfaction Survey and begin preliminary statistical analysis using the 2005 comparative data.

•  Pursuant to retirement of the GMDE Director and Administrative Director, restructure the organization of this office to ensure the primacy of the administrative and oversight mission of the Office of GMDE.

•  Parri passu with goal #4, initiate a corresponding primary research and academic mission related, in part, to the application of principles of quality and performance improvement to GMDE.

•  Reactivate the GSM-UTMH Integrated Curriculum Committee

•  Apply for membership in the Group on Resident Affairs (GRA) of the Association of American Medical Colleges (AAMC).

•  Submit an abstract related to current analysis of the relationship of GSM individual program NRMP Rank Preference to matched resident USMLE or COMLEX scores.

Respectfully submitted July 10, 2006

Eddie S. Moore, M.D.
Designated Institutional Official (DIO)
Associate Dean for Graduate Medical Education

Cortni K Haralson, MPH
Data Manager, GSM

In collaboration with:
Jo Ann Cornelius, RN, MSN, Administrative Director, GMDE
Alfred D. Beasley, M.D., Director, GMDE