Anjala Tess

Bio: Anjala Tess is an academic researcher from Beth Israel Deaconess Medical Center. The author has contributed to research in topics: Patient safety & Curriculum. The author has an hindex of 13, co-authored 30 publications receiving 553 citations. Previous affiliations of Anjala Tess include Harvard University.

Medical evaluation of patients undergoing electroconvulsive therapy.

Abstract: In evaluating patients before electroconvulsive therapy (ECT), especially those with conditions such as hypertension, coronary artery disease, and congestive heart failure, the medical consultant should undertake risk stratification, assess management of coexisting conditions, and use strategies to reduce the risk of such post-ECT complications as prolonged blood-pressure elevation, myocardial ischemia, and headache.

Creating a Quality Improvement Elective for Medical House Officers

Abstract: The Accreditation Council on Graduate Medical Education (ACGME) requires that house officers demonstrate competencies in “practice-based learning and improvement” and in “the ability to effectively call on system resources to provide care that is of optimum value.” Anticipating this requirement, faculty at a Boston teaching hospital developed a 3-week elective for medical house officers in quality improvement (QI).

Combining clinical microsystems and an experiential quality improvement curriculum to improve residency education in internal medicine.

Abstract: Beth Israel Deaconess Medical Center's internal medicine residency program was admitted to the new Education Innovation Project accreditation pathway of the Accreditation Council of Graduate Medical Education to begin in July 2006. The authors restructured the inpatient medical service to create clinical microsystems in which residents practice throughout residency. Program leadership then mandated an active curriculum in quality improvement based in those microsystems. To provide the experience to every graduating resident, a core faculty in patient safety was trained in the basics of quality improvement. The authors hypothesized that such changes would increase the number of residents participating in quality improvement projects, improve house officer engagement in quality improvement work, enhance the culture of safety the residents perceive in their training environment, improve work flow on the general medicine ward rotations, and improve the overall educational experience for the residents on ward rotations.The authors describe the first 18 months of the intervention (July 2006 to January 2008). The authors assessed attitudes and the educational experience with surveys and evaluation forms. After the intervention, the authors documented residents' participation in projects that overlapped with hospital priorities. More residents reported roles in designing and implementing quality improvement changes. Residents also noted greater satisfaction with the quality of care they deliver. Fewer residents agreed or strongly agreed that the new admitting system interfered with communication. Ongoing residency program assessment showed an improved perception of workload, and educational ratings of rotations improved. The changes required few resources and can be transported to other settings.

The Revolving Door of Resident Continuity Practice: Identifying Gaps in Transitions of Care

Abstract: It is well documented that transitions of care pose a risk to patient safety. Every year, graduating residents transfer their patient panels to incoming interns, yet in our practice we consistently find that approximately 50% of patients do not return for follow-up care within a year of their resident leaving. To examine the implications of this lapse of care with respect to chronic disease management, follow-up of abnormal test results, and adherence with routine health care maintenance. Retrospective chart review We studied a subset of patients cared for by 46 senior internal medicine residents who graduated in the spring of 2008. 300 patients had been identified as high priority requiring follow-up within a year. We examined the records of the 130 of these patients who did not return for care. We tabulated unaddressed abnormal test results, missed health care screening opportunities and unmonitored chronic medical conditions. We also attempted to call these patients to identify barriers to follow-up. These patients had a total of 185 chronic medical conditions. They missed a total of 106 screening opportunities including mammogram (24), Pap smear (60) and colon cancer screening (22). Thirty-two abnormal pathology, imaging and laboratory test results were not followed-up as the graduating senior intended. Among a small sample of patients who were reached by phone, barriers to follow-up included a lack of knowledge about the need to see a physician, distance between home and our office, difficulties with insurance, and transportation. This study demonstrates the high-risk nature of patient handoffs in the ambulatory setting when residents graduate. We discuss changes that might improve the panel transfer process.

Interventions to improve the appropriate use of polypharmacy for older people

Abstract: Background Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, hence interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients, is growing. Objectives This review sought to determine which interventions, alone or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication-related problems in older people. Search methods In November 2013, for this first update, a range of literature databases including MEDLINE and EMBASE were searched, and handsearching of reference lists was performed. Search terms included 'polypharmacy', 'medication appropriateness' and 'inappropriate prescribing'. Selection criteria A range of study designs were eligible. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people 65 years of age and older in which a validated measure of appropriateness was used (e.g. Beers criteria, Medication Appropriateness Index (MAI)). Data collection and analysis Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. Study-specific estimates were pooled, and a random-effects model was used to yield summary estimates of effect and 95% confidence intervals (CIs). The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to assess the overall quality of evidence for each pooled outcome. Main results Two studies were added to this review to bring the total number of included studies to 12. One intervention consisted of computerised decision support; 11 complex, multi-faceted pharmaceutical approaches to interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals, such as prescribers and pharmacists. Appropriateness of prescribing was measured using validated tools, including the MAI score post intervention (eight studies), Beers criteria (four studies), STOPP criteria (two studies) and START criteria (one study). Interventions included in this review resulted in a reduction in inappropriate medication usage. Based on the GRADE approach, the overall quality of evidence for all pooled outcomes ranged from very low to low. A greater reduction in MAI scores between baseline and follow-up was seen in the intervention group when compared with the control group (four studies; mean difference -6.78, 95% CI -12.34 to -1.22). Postintervention pooled data showed a lower summated MAI score (five studies; mean difference -3.88, 95% CI -5.40 to -2.35) and fewer Beers drugs per participant (two studies; mean difference -0.1, 95% CI -0.28 to 0.09) in the intervention group compared with the control group. Evidence of the effects of interventions on hospital admissions (five studies) and of medication-related problems (six studies) was conflicting. Authors' conclusions It is unclear whether interventions to improve appropriate polypharmacy, such as pharmaceutical care, resulted in clinically significant improvement; however, they appear beneficial in terms of reducing inappropriate prescribing.

Teaching quality improvement and patient safety to trainees: a systematic review.

Abstract: PurposeTo systematically review published quality improvement (QI) and patient safety (PS) curricula for medical students and/or residents to (1) determine educational content and teaching methods, (2) assess learning outcomes achieved, and (3) identify factors promoting or hindering curricu

Measurement of the general competencies of the accreditation council for graduate medical education: a systematic review.

Abstract: Purpose To evaluate published evidence that the Accreditation Council for Graduate Medical Education’s six general competencies can each be measured in a valid and reliable way. Method

Effectiveness of teaching quality improvement to clinicians: a systematic review.

Abstract: ContextAccreditation requirements mandate teaching quality improvement (QI) concepts to medical trainees, yet little is known about the effectiveness of teaching QI.ObjectivesTo perform a systematic review of the effectiveness of published QI curricula for clinicians and to determine whether teaching methods influence the effectiveness of such curricula.Data SourcesThe electronic literature databases of MEDLINE, EMBASE, CINAHL, and ERIC were searched for English-language articles published between January 1, 1980, and April 30, 2007. Experts in the field of QI were queried about relevant studies.Study SelectionTwo independent reviewers selected studies for inclusion if the curriculum taught QI principles to clinicians and the evaluation used a comparative study design.Data ExtractionInformation about the features of each curriculum, its use of 9 principles of adult learning, and the type of educational and clinical outcomes were extracted. The relationship between the outcomes and the number of educational principles used was assessed.ResultsOf 39 studies that met eligibility criteria, 31 described team-based projects; 37 combined didactic instruction with experiential learning. The median number of adult learning principles used was 7 (range, 2-8). Evaluations included 22 controlled trials (8 randomized and 14 nonrandomized) and 17 pre/post or time series studies. Fourteen studies described educational outcomes (attitudes, knowledge, or skills or behaviors) and 28 studies described clinical process or patient outcomes. Nine of the 10 studies that evaluated knowledge reported only positive effects but only 2 of these described a validated assessment tool. The 6 assessments of attitudes found mixed results. Four of the 6 studies on skill or behavior outcomes reported only positive effects. Eight of the 28 studies of clinical outcomes reported only beneficial effects. Controlled studies were more likely than other studies to report mixed or null effects. Only 4 studies evaluated both educational and clinical outcomes, providing limited evidence that educational outcomes influence the clinical effectiveness of the interventions.ConclusionsMost published QI curricula apply sound adult learning principles and demonstrate improvement in learners' knowledge or confidence to perform QI. Additional studies are needed to determine whether educational methods have meaningful clinical benefits.