MEDU-4086 - Improving Clinical Outcomes for Patients with Diabetes in the Hospital: A Hands-on Experience in Quality Improvement Intervention

MEDU-4086 - Improving Clinical Outcomes for Patients with Diabetes in the Hospital: A Hands-on Experience in Quality Improvement Intervention

Elective Type: research
Improving Clinical Outcomes for Patients with Diabetes in the Hospital: A Hands-on Experience in Quality Improvement Intervention
Course Number
Prerequisites: Successful completion of Year 2 
      Additional Requirements:
A R form must be submitted 60 days in advance of all research electives. (MS3 or MS4). C-form is required
Responsible Faculty Director:
Maria L. Belalcazar, MD
Other Faculty:
Location to Report on First Day
Medical Research Bldg. 8.138
Periods Offered
1-7, 9-13
excluding holiday period 8
Maximum Enrollment

This elective rotation has the overall goal of allowing students to use diabetes as a model to expand clinical learning beyond the individual patient to the care of a large panel of patients within a health system as a way to advance efforts in quality and safety improvement. Students interested in academic productivity may consider signing up for a follow-up elective rotation that will allow them to finalize data gathering and analysis for presentation of findings at a local/regional forum prior to submission of residency applications.

1. To strengthen and apply knowledge of diabetes physiopathology and insulin pharmacology to the care of patients with diabetes presenting to the hospital with either an acute complication of their condition or with a chronic complication of diabetes and/or an associated co-morbidity. 2. To become familiar with guidelines and standards of care for inpatient diabetes management, identify implementation deficiencies in the hospital setting and understand how these errors/omissions are associated with unfavorable patient and health system outcomes. 3. To learn basic tools of quality of care assessment and participate in the proposal and/or implementation of an intervention to improve an unfavorable diabetes-related outcome related to prevailing hospital care.

Description of course activities
"Clinical": 1. Weeks 1-4: Patient rounds with course director 3 half days a week. Student will be in charge of doing 1-2 initial and 1-2 follow-up assessments per week on patients with diabetes admitted to the hospital. Student will present his/her patients during rounds for decision-making. Assessment will include focused history, physical exam, laboratory data; analysis of problem and plan of care. Course director will review patient with student and discuss findings, analysis and plan. Input from team will be incorporated into final recommendations given to consulting team. 2. Weeks 1-4: Student will be responsible of handing in a 1 page problem-focused analysis and plan for one of his/her patients presented during rounds each week. Problem-focused analysis and plan should include elements from the history, physical exam, laboratory supporting 2 of the main problems identified for the patient. A description of the rationale for the plan of care should be included. 3. Weeks 1-4: Weekly small group discussion of diabetes management using problem-focused analyses described above (2). "Quality and Safety in Patient Care": 1. Week 1: Identify a problem related to diabetes management in the hospital and create a fish bone cause and effect diagram depicting factors that contribute to it. 2. Week 2: Create a swim lane chart of processes of care for glucose management in the hospital that includes all members of the multidisciplinary team involved in the care of the patient with diabetes. 3. Weeks 3: Student will analyze the care provided to his/her assigned patients and identify any deficiencies in processes of care and decision--making. Frequency of deficiencies will be entered into a shared excel spreadsheet to provide data for a collective Pareto Chart that will be constructed and updated weekly. 4. Week 4: Students will create a Pareto Chart summarizing frequency of deficiencies in diabetes management during the first 3 weeks of the rotation for the group's patients and come up with solutions for two of the most frequently observed deficiencies. 5. Weeks 1-4: Weekly small group session to discuss results of quality assessment with tools described above. "Quality and Safety Research" Weeks 1-4: 1. Students will engage in a quality improvement/research project of their choosing related to diabetes management in the hospital. The project may: A. Address a deficiency observed in the hospital during rounds and found to be of significance and amenable to intervention or B. Apply quality tools learned with individual patients to a panel of hospital patients using available hospital databases and collaborate with an on-going quality/safety research project related to diabetes management in the hospital. For students opting to do the diabetes quality of care rotation, a new project is also an option. 2. Students will work with peers, residents and/or fellows in a quality project for presentation at a local/regional forum/venue. This may require some additional effort beyond the rotation to complete a product for presentation. 3. Weekly meeting with program director to discuss research project. "Knowledge and Skills" Weeks 1-4: 1. Standards of care in inpatient diabetes management. 2. Insulin therapy and use in patient care. 3. Quality tools including use and analysis of Cause and Effect Diagrams, Swim Lane Diagrams, Pareto Charts. 4. Application of clinical research principles to qualify/safety research.

Type of students who would benefit from the course
3rd year medical students with an interest in medical specialties, clinical research and/or public health; students looking for opportunities beyond learning that will allow them to actually make contributions to improved patient care; students wanting to engage in clinical research and who are interested in advancing their academic career. "Enhancement of Clinical & Quality/Safety Skills: 1. Students will have direct patient contact & responsibilities. 2. Students will participate in the care & decision-making of their assigned patients during the rotation. 3. Students will become knowledgeable on the complexity of diabetes management & learn to identify deficiencies in care. 4. Students will strengthen skills needed to effectively communicate with patients & other members of the health care team. 5. Students will recognize the importance of quality & safety in patient care & become familiar with the use of tools to identify & intervene on deficiencies in processes of care, including medical decision-making. "Critical Thinking/Reasoning Skills" 1. Application of concepts learned on the physiopathology & treatment of diabetes to the care of patients with diabetes presenting to the hospital with either an acute complication of their condition or with a chronic complication of diabetes and/or an associated co-morbidity. 2. Identification of the gap between standards of care in inpatient diabetes management & the actual care patients receive in the hospital setting. 3. Understanding the complexity of disease (diabetes) management within a health system. 4. Critical evaluation of deficiencies in health care delivery thought to contribute to unfavorable diabetes outcomes. 5. Us of quality tools to design feasible interventions to observed deficiencies in patient care. "Integrate concepts from longitudinal Themes" I know there is interest to develop a core curriculum around chronic disease management & that diabetes is on of them. I would like to participate in those initiatives & promote the integration of elements on quality & safety to the clinical rotations.

Weekly Schedule
  Clinical Activities (estimated schedule)
  Day of Week AM PM
  Monday 8:00 5:00
  Tuesday 8:00 5:00
  Wednesday 8:00 5:00
  Thursday 8:00 5:00
  Friday 8:00 5:00
   Average number of patients seen per week: 1-2 initial and 1-2 follow-up  
   Call Schedule:   none  

Research Activities (estimated schedule)
Activity Hours per Week
Faculty Contact-Time 20
Self-Directed Study 10
Data-Collection/Analysis 10

Method of Student Evaluation
1.  Clinical Observation
  A. Where are students observed on this elective?
    Inpatient Service   Ambulatory   Surgery   Standardized patients
Patients simulators   Other
  B. Frequency - How often are students observed clinically?
  C. Format - What method(s) are used to document the student's clinical performance?
    Daily oral feedback   End of period oral feedback   Written feedback

2.  Oral Presentation
  A. Audience - To whom does the student present?
    peers, residents, fellows, & faculty
  B. Frequency / Duration of Presentation(s)?
  C. Format - What guidelines are set for the student's presentation?
    syllabus, students will present their patients cases, small group sessions to discuss results of quality assessments
  D. Assessment - Who assesses the student's presentation performance?
    Self-assessment   Peer assessment   Faculty assessment
  E. Method of content selection
    Current cases  Student-selected topic   Assigned topic

3.  Written Assignment (H&P's, notes, papers, abstracts, etc.)
  A. Frequency of written assignment(s)?
  B. Format - What guidelines are set for the student's written work?
    1-2 initial and 1-2 follow-up assessments per week of their patient cases. They will present at grand rounds for decision-making.
  C. Length of written assignment(s)?
    Abstract   Annotated bibliography   1 - 2 page paper   3+ page paper
  D. Are recent references required?   No    If yes, how are they selected?
  E. Method of content selection - e.g. student-selected, relate to cases, etc.?
    related cases
  F. Audience - Who assesses the student’s written performance?
    Peer Assessment     Faculty Assessment     Other

4.  Examination
    Oral   Written multiple choice   Written essay / short answer   OSCE

5.  Extra Course Activities
  What expectations do you have for the student to demonstrate participation in the elective (e.g. small group activities, seminars, thoughtful questions, providing resources, journal club, resident lecture attendance)?
    They will have to present their inpatients cases at grand rounds, they will have small groups go over their assessments of their patients & Weekly they will be responsible for a 1 page problem-focused analysis and plan for their patients. They will have a Pareto Chart, Swim Lane Diagram, & Cause & Effect Diagrams to help.

6.  Additional Costs
  Please list any additional costs and/or purchases (books, materials, movies to watch, etc.) that are required for this course. Include an estimated total cost. If there are no additional costs, please enter "None".

7.  Other Modes of Evaluation
  Please explain below.
    I will provide them with a syllabus that will include learning objectives, rotation schedule and reference material. I will give them weekly feedback and an overall written evaluation at the end of the 4 week activity.

8.  If this course is an Acting Internship, please complete the following:
  A. Objectives for the AI should relate directly to the Entrustable Professional Activities (EPAs). Each AI should describe how the four key Year-4 EPAs that our school has identified as being Year-4 skills are assessed. The Year-4 objectives are:
1. Entering and discussing orders/prescriptions.
2. Give or receive patient handover to transition care responsibility.
3. Recognizing a patient requiring urgent or emergent care and initiating management.
4. Obtaining informed consent for tests and procedures.
Specify how the student will be given formative feedback on their clinical skills.

Year-4 students should demonstrate mastery of EPAs they developed in the clerkship year, including recommending and interpreting common diagnostic and screening tests, and performing general procedures of a physician. They should be able to demonstrate masterfully and independently skills they mastered in Years 2-3, including efficiently performing comprehensive admission-notes and succinct daily progress notes and perform accurate, concise, and hypothesis-driven clinical presentations, form clinical questions and retrieve evidence to advance patient care. They should be able to demonstrate basic understanding of and beginning mastery of collaborate as a member of the interprofessional team and identify system failures and contribute to a culture of safety improvement.

List advanced clinical skills that a student will be assured an opportunity to practice.

How specifically will this AI build on developing skills from the clerkship year to prepare students for internship?

What opportunities will typically be available to all students who take this AI (procedures, required presentations, etc.)? What opportunities may be available based on patient load/presentation or student initiative (ie. Writing a case report)?

An AI should have expectation of a minimum of 32 hours per week of clinical responsibilities. Duty hours should be capped at ACGME limits for an intern, thus up to 24 hours followed by 4 hours of activities related to patient safety, education, and handoff. Students cannot work more than 80 hours per week averaged over 4 weeks. They can only have 1 day off in a 7-day work week with 8 hours off between shifts.

Clinical responsibilities will vary depending on specialty, but how is the student functioning with work commensurate to a PGY1 with an appropriate level of training?

How is the student demonstrating drawing clinical conclusions and/or developing a management plan and documentation as an intern would do?

How and by whom will midpoint feedback be provided to the student? How will you remediate deficiencies identified at midpoint?

Acting Internship students often seek letters of recommendation following their experience. How many different Faculty will work directly with the student and have knowledge of the student’s abilities to detail in a written evaluation? Describe the degree of supervision and interaction with faculty vs. residents or other providers and how feedback will be obtained if more direct work is with residents or other providers.