From Probation to Accreditation: Successful Change Management

Abstract

Background: In 2015 our residency program located within a regional medical campus was placed on probation. Five of the 13 citations were related to the residents’ clinic experience. The resident clinic was encased within a medical culture of chronic opiate prescription management that did not provide a sufficient or balanced ambulatory education for internal medicine residents. Objective: This paper describes our experience of moving from a residency program within a regional medical campus on probation to full accreditation status over a 19-month time period. Methods: We used a project management approach with a strong coordinating council designed to empower leaders to effect change in the residency program, and in particular, the residency clinic. Results: We were able to create and enact a plan that extricated the residency’s ambulatory clinic from managing a panel of ~700 patients requiring chronic monthly opiate prescriptions. The patients were referred to community pain management providers for these prescriptions. We established a policy of providing no chronic opiate prescriptions in the residency clinic. Residency ACGME surveys from 2015 through 2017 demonstrated improved resident satisfaction. CG-CAHPS scores demonstrated a temporary decrease in patient satisfaction scores returning to previous baseline after a year. Conclusion: We employed a project management approach to 1) get our program off probation, and 2) change the focus of our residency’s ambulatory practice and re-establish its educational mission.

Keywords

• accreditation
• regional medical campus