Spotlight on Night Float:

1. Spotlight on Night Float: Improving Orientation, Policies & Procedures of the UC Irvine Night Float Rotation William Graham, Julie Lyou, Zo Noor, Matt Glassy, Heather Hofmann, Katherine Yu Faculty Mentor: Cliff Fornwalt, MD

2. Background: What is Night Float? • - A nocturnal rotation where residents: • Admit new patients from the ED and outside hospital transfers • Evaluate and manage urgent overnight medicine consults • Oversee care for all admitted medicine patients • Function essentially unsupervised • Every resident in their 2nd and 3rd year does two night float rotations per year (4 total during residency). • Unique experience, unlike daytime ward rotation (cross-cover, team H, working with house supervisor/SPPO, etc) • In the past, material for night float has been in several places and much is passed on by word of mouth UC Irvine| September 9, 2014

3. FOCUS Statement • Find an opportunity for improvement: • UCI Ward night float rotation currently lacks a comprehensive orientation and information source for residents • Many residents have expressed concern that they do not know how to address night-float specific issues UC Irvine| September 9, 2014

4. FOCUS Statement • Organize Resources: • Personnel: • Residents, Chiefs, Dr. Swaroop, Norma Hardgrove, Susan Altmayer, Dr. Fornwalt • Polices: locate all polices relating to UCI night float rotation • Materials: locate and collect all other pertinent information UC Irvine| September 9, 2014

5. FOCUS Statement • Clarify current knowledge: • Current sources of information/policies: • Night float binder • Medicine Website • Medicine Sharepoint • Second-hand information from other residents • Baseline measurements obtained through: • Online survey – created by us • New Innovations survey – created by the resident program • New Innovations is used to survey the residents after each rotation • Gathers information about the resident experience so the program can implement changes where needed • Mandatory to complete by every resident UC Irvine| September 9, 2014

6. FOCUS Statement • Understand variation: • Night float is a broad topic • Procedures/policies for every possible scenario encountered may not exist • Current polices and procedures already in place may be outdated or no longer applicable • i.e. The policy on orthopedic admissions to internal medicine was written a decade ago UC Irvine| September 9, 2014

7. FOCUS Statement • Select changes to be made: • Meet with mentor and compile current orientation materials, the binder, policies, and procedures • Survey senior residents with online survey UC Irvine| September 9, 2014

8. Opportunity Statement • An opportunity exists to: • Provide a comprehensive resource orientation • This is important because residents are essentially working independently when on nightfloat • We need all information in one place for pt care/safety • We will know we are successful when our survey result scores improve UC Irvine| September 9, 2014

9. PDCA • Plan: describe plan in detail • Do: steps to implement plan • Check: what happened with outcome measures • Act: analyze outcomes and discuss revisions to enhance UC Irvine| September 9, 2014

10. Data Collection • Plan & Do: • Create a comprehensive night float manual • Survey the residents to obtain baseline information • Attend start of each night float rotation and go through orientation manual • Survey residents again after intervention (change orientation) UC Irvine| September 9, 2014

11. Data Collection – Plan & Do continued • Plan & Do: • Create a survey questionnaire for night float residents • Baseline survey prior to orientation process • Use same questionnaire after intervention (change orientation) • Compare survey results • Obtain New Innovations evaluation data • Obtain data prior to and after intervention • Compare survey results UC Irvine| September 9, 2014

12. DATA – New Innovations • New Innovations • Survey method already in place • Used to survey the residents after each rotation • Gathers information about the resident experience • Mandatory to complete by every resident • Available data goes back to 7/13 • Scale: • 1 = strongly disagree • 2 = somewhat disagree • 3 = neutral • 4 = somewhat agree • 5 = strongly agree UC Irvine| September 9, 2014

13. DATA – New Innovations • New Innovations retrospective data ratings • Responsibilities clearly defined (pre vs post) • 3.79 vs 4.26 • Learning objective clearly defined (pre vs post) • 3.81 vs 4.33 • Learning material and resources provided (pre vs post) • 3.22 vs 4.00 • Overall experience (pre vs post) • 3.95 vs 4.14 UC Irvine| September 9, 2014

14. Data – New Innovations UC Irvine| September 9, 2014

15. DATA – Online survey • Online survey • Survey Monkey emailed to all residents • Participants: • 30 residents completed pre-manual survey • 13 residents completed post-manual survey • All had completed a night float rotation or completed a weekend of night call at UCIMC • Scale: • 1 = strongly disagree • 2 = somewhat disagree • 3 = neutral • 4 = somewhat agree • 5 = strongly agree UC Irvine| September 9, 2014

16. DATA – Online Survey Questions • Online Survey retrospective data ratings • The logistics and policies specific to night float were adequately reviewed prior to my work on night float. (pre vs post) - 2.2 vs 2.69 • I know where to find the policies specific to night float, if questions arose in the middle of the night. (pre vs post) - 1.93 vs 2.85 • Overall, I felt I had adequate resources to effectively perform my duties while on call at night and/or on UCI night float. (pre vs post) - 2.97 vs 3.46 • While working at night, did you feel at any point you were providing substandard or unsafe care? (pre vs post) - 2.73 vs 1.31 • If yes, do you feel a lack of familiarity with resources or policies contributed to this? (pre vs post) - 2.47 vs 2.14 UC Irvine| September 9, 2014

17. DATA – Online Survey UC Irvine| September 9, 2014

18. DATA – Online Survey • The new Night Float Manual was helpful in completing my UCI night float duties. • Strongly agree 7.69% • Agree 30.77% • Neutral 53.85% • Disagree 7.59 % • Strongly disagree 0% UC Irvine| September 9, 2014

19. Data – Analysis • New Innovations Data • Responsibilities, learning objectives and learning material & resources provided scores all improved to > 4. • Survey Data • Resources adequately reviewed, policies locatable, and adequate resources available scores all improved. • Feelings of providing substandard care and this due to lack of uncertainty scores declined. UC Irvine| September 9, 2014

20. Where to Go From Here • Continued improvement • What Qs arose during night float that were not answered in manual • We would like to include a section in New Innovations for residents to address this Q • Need a method to provide long term sustainability for a night float orientation • Chiefs updating manual once per year • Application of findings to orientation of other rotations UC Irvine| September 9, 2014

21. Thank you! Drs. Cliff Fornwalt, BinduSwaroop & Lloyd Rucker Team 4: William Graham, Julie Lyou, Zo Noor, Matt Glassy, Heather Hofmann & Katherine Yu