Resident's Showcase Process Improvement Projects and Case Reports at Naval Hospital Bremerton

BREMERTON, Wash. (NNS) -- The Naval Hospital Bremerton (NHB) Puget Sound Family Medicine Residency program held a Resident Academic Competition that showcased a variety of process improvement (PI) projects and case report initiatives, May 30.

"There are two forms of products: inpatient case reports and process improvement projects - two distinct and important scholarly reports being shared," said said Capt. Erik Schweitzer, Puget Sound Family Medicine Residency Graduate Medical Education (GME) program director. "This forum has a history of making the practice of medicine better. Practicing medicine is a team sport and sharing here helps take it to a higher level."

Presenting reports is a critical skill that combines collaboration, research, and learning. Through these collective efforts, the GME can make a lasting impact to in patient-centered health care.

The event was coordinated by Lt. Cmdr. Francesca Cimino, Puget Sound Family Medicine Residency Associate Program Director.

The Family Medicine Residency program trains residents to become family physicians in a community hospital setting such as NHB. In such an environment, the family medicine residents become primary physicians for their patients on all inpatient and outpatient services. The academic competition allowed them to share their acquired knowledge with their peers, advisors, and staff members.

One process improvement study was "Elective Rotation Curriculum Development," presented by Lt. David Zelinskas, team leader. Other team members were Lt. Jacques Bouchard, Lt. Ruth Smith, Lt. Adam Voelckers, with faculty advisor, Dr. Kristine Ewing.

"Making it better and more efficient is the goal," said Zelinskas.

There are inconsistencies between resident rotation experiences - within and amongst rotations - primarily because of a lack of awareness about and adherence to the current rotation curricula.

"We expect that this project will produce more consistent resident experiences, improve resident expectations, and improve understanding and knowledge of the specialty after the rotation, with the intent of improving family medicine training overall," said Zelinskas. "We aimed to accomplish the above by analysis of curriculum awareness via resident survey, evaluating pre and post intervention, developing an end-of-rotation verification process along with continued improvement to current curricula."

The PI project "Incorporating End of Life Documentation into the Electronic Medical Record (EMR)" was presented by Lt. Amelia Buttolph, teams leader, along with team members Lt. Andrew Peters, Lt. Amelia Wright, Lt. Adam Waterman, with faculty advisor, Cmdr. Dave Congdon.

Buttolph explained all patients should have discussions with their primary care physicians about desired care at the end of their lives as well as their current life stage.

"We understand this is a multi-year process, and we first needed to ensure easy access to POLST (Physician Orders for Life Sustaining Treatment) forms in clinic as well as have an available and reliable location to document in AHLTA (Armed Forces Health Longitudinal Technology Application, the EMR system used by medical providers)," said Buttolph. "After deciding that the clinical notes section was an established location for scanned advance directives, we presented this PI project to internal medicine and family medicine clinics, with random chart audit before and after implementation. Our goal for this project was to increase the number of patients with documented end-of-life discussion and desires by 20 to 30 percent over two months of project promotion. Planned follow up projects will address the clinic-based limitations of initiating this discussion, including provider/patient reluctance and time constraints, as well as further involvement in support staff to improve compliance."

Other PI projects included "Optimizing Asthma Management through Corpsmen Education," presented by Lt. Jon Wildi, team leader, with team members, Lt. Derek Austin, Lt. Billy Michael, Lt. Gordon Salgado, Lt. Katie Snyder, and under Lt. Cmdr. Noa Hammer, faculty advisor. They focused their goal on providing corpsmen education to enhance the management of asthma patients, specifically to increase compliance with national metrics in asthma care.

"The Four-Year Curriculum" PI project, prepared by Lt. John Roberts, team leader, along with team members, Lt. Casey McCann, Lt. Cmdr. Eric Peterson, under faculty advisor, Cmdr. Gray Dawson, explained how recent changes in Accreditation Council for Graduate Medical Education (ACGME) requirements in family medicine training could lead to extending the length of training to cover the breadth of information comprehensive medicine demands. The Navy is part of an ACGME pilot program to create a four-year curriculum. The goals were to develop a feasible four year family medicine residency curriculum for the Puget Sound Family Medicine residency, to address potential obstacles that may arise in transitioning from a three-year program to a four-year program, to develop specialized tracks to prepare a family medicine resident for possible fellowship, and to identify gaps in our knowledge and education and recommend possible rotations to fill those gaps.

The program also featured case studies such as "Vocal Cord Dysfunction: A career-saving diagnosis," by Lt. Cmdr. Eric Peterson; "Swimming Induced Pulmonary Edema - a case report," by Lt. Adam Voelckers; and "Herpes Zoster Ophthalmicus with Ipsilateral Parotitis: The Chicken or the Egg?" by Lt. David Zelinskas

"The experience and exposure is great for the residents," said John Crist, NHB Lean Six Sigma expert and competition panel judge. "Plus it gets a lot of the command involved the scholarly activities. The residents are required to do such projects and reports before they graduate, which helps form a foundation for them. They will continually do more when they come across unique cases throughout their career. And with the standard of care always changing and always improving over time, the residents are helping with that improvement by working on these projects and reports shown here."

The Puget Sound Family Medicine Residency (PSFMR) has a total of 18 residents, usually averaging approximately six per year group. The Family Medicine staff have received additional training in Faculty Development, with two having completed the two-year (U.S. Army) Madigan Fellowship. PSFMR staff and residents have been recognized by the Uniformed Services Academy of Family Physicians for their research efforts, and they have been published in such noted medical journals as American Family Physician, The Journal of the American Board of Family Medicine, The Journal of Family Medicine and Military Medicine.

The Residents also receive additional experience in the Intensive Care Unit and Neonatal ICU at Madigan Army Medical Center and on the Pediatric Wards and Emergency Room at Mary Bridge Children's Hospital, both in Tacoma, Wash. PSFMR also partners with the University of Washington Family Medicine Network which has been consistently rated the top training program in the country. In addition, PSFMR was rated as the top rotation site by UW medical students.

The PSFMR is one of five family medicine training programs in the Navy, and the family medicine is the only residency in the hospital with a resident-to-staff ratio of two to one. The program was fully accredited last year for five years by the Family Medicine Residency Review Committee of the Accreditation Council for Graduate Medical Education.


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For more news from Naval Hospital Bremerton, visit www.navy.mil/local/nhb/ .