title: Resident-initiated interventions to improve inpatient heart-failure management.
abstract: BACKGROUND
  Third-year internal medicine residents participating in a quality improvement rotation identified gaps between the Joint Commission's ORYX quality guidelines and clinical practices for the inpatient management of heart failure (HF) at the William S. Middleton Memorial Veterans Hospital. Residents focused on the performance metrics associated with tobacco-cessation counselling documentation, ejection fraction assessment and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker prescriptions.
  
  
  METHODS
  After analysing data collected by the External Peer Review Program, residents reviewed the institution's admissions and discharge processes with the aim of improving quality and compliance. In redesigning these processes, residents created an admissions template and a discharge face sheet, and compared specific ORYX measure compliance rates before and after institution-wide implementation.
  
  
  RESULTS
  Following implementation of the tobacco-cessation admissions template, 100% of HF patients who used tobacco received documented cessation counselling, compared with 59% prior to intervention (p<0.01, n=32). Following implementation of the mandatory discharge face sheet, 97% of HF patients (compared with 92% preintervention, p>0.05) received comprehensive discharge instruction; LV function assessment went from 98% to 100% (p>0.05); and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker prescription for left ventricular systolic dysfunction at discharge (or documentation of a contra-indication) went from 82% to 100% (p<0.01, n=48).
  
  
  CONCLUSIONS
  By implementing a standardised admissions template and a mandatory discharge face sheet, the hospital improved its processes of documentation and increased adherence to quality-performance measures. By strengthening residents' learning and commitment to quality improvement, the hospital created a foundation for future changes in the systems that affect patient care.
authors.affiliation: William S Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA.
authors.forename: James
authors.initials: J
authors.lastname: Oujiri
authors.forename: Abdul
authors.initials: A
authors.lastname: Hakeem
authors.forename: Quinn
authors.initials: Q
authors.lastname: Pack
authors.forename: Robert
authors.initials: R
authors.lastname: Holland
authors.forename: David
authors.initials: D
authors.lastname: Meyers
authors.forename: Christopher
authors.initials: C
authors.lastname: Hildebrand
authors.forename: Alan
authors.initials: A
authors.lastname: Bridges
authors.forename: Mary A
authors.initials: MA
authors.lastname: Roach
authors.forename: Bennett
authors.initials: B
authors.lastname: Vogelman
mesh_terms: D003376:Counseling; D019468:Disease Management; D006333:Heart Failure / Q000628:therapy*; D006801:Humans; D007297:Inpatients; D007396:Internship and Residency; D007591:Joint Commission on Accreditation of Healthcare Organizations; D008485:Medical Audit; D019982:Organizational Case Studies; D010819:Physician's Role; D011785:Quality Assurance, Health Care; D016540:Smoking Cessation; D014481:United States; D014922:Wisconsin