GME Patient Safety Quality and Innovation Symposium

Issues Addressed/Background

Patients with suspected malignancy are routinely admitted inpatient for diagnostic evaluation for urgent but not emergent workups, utilizing limited inpatient resources. We wondered if some of these workups could be managed outpatient in a timely manner with the right infrastructure. Conventional oncology referral pathways follow a consultation-first sequence; ie patients are seen, then tested, then redirected, which delays diagnosis and consumes limited clinic capacity. The UCSD Suspicion of Cancer (SoC) clinic was designed around an inverted model: physician-led triage occurs right at referral, testing is coordinated before the first visit, and patients who can be safely redirected to disease-specific teams never need an SoC appointment. This report describes operational outcomes over the first four months following clinic launch in December 2025.

Description of the Project

The SoC clinic serves patients with findings suspicious for malignancy without a confirmed site-specific diagnosis. Referrals are restricted to ED providers, inpatient teams, and specialty oncology clinics. The referral order set was kept deliberately simple: two questions asking whether findings are suspicious for cancer and whether a known primary exists, to decrease friction with referrals. Core operational components included mandatory CT chest/abdomen/pelvis for all ED-placed referrals, a target of first patient contact within 1–2 business days, an expedited outpatient biopsy and imaging pathway, and a new patient access supervisor with expertise in scheduling, insurance verification, and records retrieval. Clinic capacity was set at approximately 2 SoC slots per week for now during the initial phase.

Lessons Learned

Between December 2025 and March 2026, 65 patients were referred to the SoC clinic. Of these, 30 (46%) were diverted to disease-specific oncology teams or primary care without an SoC visit, and 16 (25%) completed SoC appointments. The remainder involved insurance denials (n=5), patient refusals or no-shows (n=5), and cases pending or closed for other reasons. Cases were diverted from in-person SoC clinic (to subspecialty oncology clinics) following triaging actions, including the following: ordering additional imaging or other testing, placing IR biopsy referrals via expedited pathways, correcting misdirected referrals, and communicating this directly with patient families. This allowed for SoC staff to contact patients within a few days to begin the urgent outpatient workup and place referrals soon after, thereby decreasing time to workup compared to having to schedule clinic visits and have a formal visit to begin evaluation. 

Recommendations/Next Steps

The most meaningful structural improvement is establishing disease-team liaisons (designated oncologists on each disease team) who are comfortable accepting early referrals based on triage data alone, so patients can bypass the SoC visit when workup already points toward a specific diagnosis. Addressing patient follow-through will require a more active outreach protocol after initial contact, particularly for pre-visit orders. Future data collection should include time from referral to imaging completion, time to diagnosis, and longitudinal tracking of whether the 2-slot-per-week capacity remains appropriate as referral volume grows. Additionally, we would like to eventually open up the clinic referrals to be placed by PCPs and outpatient providers.

Background: Induction of fetal demise is an advanced procedural skill in Obstetrics and Gynecology (OBGYN) that expands patient access to later-gestation abortion care while mitigating risk of unintended live periviable births. Additionally, the literature shows that many patients prefer induction of fetal demise prior to termination of pregnancy when presented with the option. Despite this, ultrasound-guided injection for fetal asystole is an under-taught skill in abortion training programs, most OBGYN residencies, and many Complex Family Planning (CFP) fellowships. A simulation for this procedure could be a steppingstone for clinicians to learn this skill in a low-risk setting before incorporating it into clinical practice.

Description: This project aims to increase the average clinician comfort and confidence score when performing ultrasound-guided needle procedures such as induction of fetal asystole following standardized simulation training among the participating faculty clinicians. Clinician participants included attendings and fellows from the CFP and the Maternal-Fetal Medicine (MFM) divisions. Study team members used the Rubin Model to conduct standardized simulation of injection for fetal asystole (Figure 1). The Rubin Model is a high-fidelity system consisting of three nested ballons (one which represents the fetal heart, one which represents the fetal body, and one which represents the amniotic sac) specifically designed to teach ultrasound-guided intra-amniotic, intrafetal, and intracardiac injections. Other educational materials developed for this project include a division-wide protocol to facilitate introduction of this skill into clinical practice and a patient-facing Frequently Asked Questions document to address common questions and concerns that patients may have when being counseled on the risk/benefits/alternatives of undergoing injection for fetal asystole. These documents were reviewed with participants prior to procedural simulation along with relevant evidence on diVerent pharmacologic agent options and diVerent ultrasound techniques (Figure 2). Clinician comfort and confidence was assessed using pre-simulation and post-simulation 10-question 5-point Likert scale surveys. Questions covered areas including general confidence, technique and equipment, patient safety and communication, and overall preparedness.

Lessons learned or expected outcomes: Seven faculty clinicians participated in the standardized simulation of injection for fetal asystole and took the pre- and post-surveys. With success defined an average post-training score of 4.0 or higher across all ten questions OR an absolute increase of 1.0 points from the pre-training average score, this simulation had a 72% success rate. Average post-training scores increased by 36% (or 1.2 points out of 5) from average pre-training scores (Figure 3).

Recommendations/next steps: UCSD CFP faculty are now trained for and will begin to oVer injection for fetal asystole to appropriate patient candidates. This simulation will be conducted for CFP and MFM fellows on a yearly basis. Ultimately, the goal is to help clinicians expand their skillsets to include this procedure, thereby improving patient access to second-trimester abortion.

Background

The Emergency Department (ED) is often a place of high-stress or difficult cases, with very little time to process these events before returning to other duties in the department. “Hot debriefs”, or short discussions immediately following a difficult case, such as cardiac arrest, pediatric case, or high-stress situation have been shown to decrease burnout, reduce stress, and lead to key process improvements relevant to future codes. Many different styles of hot debriefs have been described, including the Take STOCK, BONE break, and TIM tool. Previous studies have compared hot vs cold debriefs, or examined standardized debrief implementation in the prehospital or ICU setting. In this project, we sought to implement the STOP 5 debrief tool immediately following cardiac arrests, pediatric codes, and other difficult cases in the ED, address physicians perceived lack of time to debrief, and improve confidence of those leading debriefs.

Methods

Nursing staff and residents were educated on the STOP 5 debrief during shift change and during educational conferences. Laminated posters were placed in the resuscitation rooms and in the “doc boxes”, areas of the ED most often occupied by attendings and residents. Standardized surveys were distributed to attendings and residents (PGY1-4) before implementation of the standardized tool and again 3 months later to gauge impressions and attitudes towards the STOP 5 debrief. Continuous variables were calculated with independent samples T-test, ordinal responses were calculated with Mann-Whitney U test, and binary responses were calculated with Fischer's exact test.

Results

A total of 50 participants completed pre-intervention surveys, and 26 participants completed post-intervention surveys. On a rating scale of 1-5, there was a significant increase in the number of physicians who felt comfortable initiating a debrief (3.28 vs 4.00, p-value = 0.036). On a rating scale of 1-5, there was no significant change in the level of confidence with regards to leading a successful debrief (3.2 vs 3.7, p-value = 0.169). The most commonly cited reasons for not having a debrief include lack of time (84%), lack of experience (30%), and “not my role” (15%), however, participants almost universally wanted more debriefs.

Conclusions

The implementation of a standardized hot debrief led to an improvement in how comfortable physicians felt initiating debriefs. There remains significant barriers to universal debriefs after appropriate cases, most notably physicians perceived lack of time and lack of confidence in leading these debriefs. Further work is needed to build a culture where hot debriefs are expected and encouraged , while further training is also needed to help ED staff feel more comfortable leading these debriefs.

Background

Access to emergency contraception (EC) is a key component of reproductive healthcare and time-sensitive pregnancy prevention. Two commonly used EC formulations include ulipristal acetate, a prescription medication that remains effective for up to 5 days after unprotected intercourse and across a wider body mass index (BMI) range, and levonorgestrel-based EC, an over-the-counter medication that is effective at pregnancy prevention for up to 3 days after unprotected intercourse. Clinical guidelines recommend ulipristal acetate as first-line EC, particularly for individuals with higher BMI or longer delay after unprotected intercourse. However, pharmacy stocking practices may limit timely access to ulipristal acetate, potentially creating disparities for patients with higher BMI and those facing structural barriers to care. This quality improvement project sought to evaluate the availability and dispensing timelines for stocking EC across San Diego pharmacies.

Description

Study team members conducted standardized telephone calls to retail pharmacies across San Diego using a structured script (Figure 1). Pharmacies were asked whether they stock ulipristal acetate for same-day prescription pickup, and the expected timeline for availability if it needed to be ordered. Availability of levonorgestrel EC and same-day access were also assessed. Responses were recorded and analyzed using descriptive statistics.

Lessons learned or expected outcomes

A total of 129 of 132 (97.7%) San Diego retail pharmacies were able to be contacted. Levonorgestrel EC was immediately available at 82 pharmacies (63.6%), compared to ulipristal acetate at 39 pharmacies (30.2%).

Thirty-three pharmacies (25.6%) stocked both ulipristal acetate and levonorgestrel EC, while 49 pharmacies (38.0%) stocked levonorgestrel EC but not ulipristal acetate. Additionally, 41 pharmacies (31.8%) stocked neither product at the time of contact (Figure 2).

Among pharmacies that stocked ulipristal acetate EC, the average number of tablets currently stocked was 1.8 (± 1.5 SD) with a minimum of 1 and a maximum of 9 tablets available. For the 85 pharmacies where ulipristal acetate was not currently stocked, and information was available, 2 pharmacies (2.4%) reported access to ulipristal acetate the same day, 50 pharmacies (85.5%) reported availability within 24 hours, and 20 pharmacies (23.5%) reported availability within 48 hours through distributor ordering or transfer from nearby locations.

Recommendations/Next Steps

Levonorgestrel EC is widely accessible across San Diego pharmacies, whereas ulipristal acetate availability remains limited and often dependent on ordering delays. Over 63% of pharmacies stocked levonorgestrel EC while only 30% stocked ulipristal acetate, highlighting a substantial access gap between EC formulations. Even when pharmacies can obtain ulipristal acetate within 24–48 hours, delays reduce the effectiveness of this time-sensitive medication. Limited on-site inventory further constrains immediate dispensing capacity and may disproportionately affect patients with higher BMI.

Ongoing quality improvement efforts include provider education, development of a clinician-facing EC pharmacy directory, and repeat pharmacy assessments to determine whether increased prescribing demand improves pharmacy stocking and timely access to ulipristal acetate.

Background: Advance care planning is essential to providing medical care that is aligned with patients’ goals and values. However, conversations regarding goals of care and life-sustaining interventions are often initiated late in the course of illness, such as during hospitalization for critical illness or after loss of decision-making capacity. For high-risk patients in particular, proactive initiation of these discussions in the primary care setting is important to ensure patients’ preferences are known and respected throughout their medical care.

As part of a nationwide quality improvement initiative at the VA, the Life Sustaining Treatment (LST) note was implemented to document patients’ preferences regarding resuscitation and other life-sustaining interventions. LST documentation is especially important for high-risk patients who are at an increased risk for hospitalization and mortality—defined as having a Care Assessment Needs (CAN) score of ≥ 95. The rate of LST note completion for high-risk patients at the San Diego VA is 27%, compared to the national VA average of 49%. To address this need, we conducted a quality improvement initiative to increase advance care planning discussions and LST documentation for high-risk patients in the VA primary care setting.

Methods: Patients with a CAN score of ≥ 96 and no prior LST documentation were identified across eight VA primary care resident clinic panels. Dedicated appointments for up to 30 minutes (in-person, video, or phone) were scheduled for each patient. Family members were encouraged to join if the patient preferred. Educational materials with detailed information regarding advance care planning and life-sustaining treatments were mailed to each patient for review 1-2 weeks prior to the appointment. One medical provider conducted all appointments. Patients' health care goals and life-sustaining treatment preferences were discussed, and an LST note was completed along with an advance directive (if not previously completed) and POLST form (if applicable). Resuscitation status orders were updated in the VA Computerized Patient Record System (CPRS).

Results: Of the 10 patients identified as high-risk, 8 patients agreed to participate in this intervention. 5 patients (63%) had not previously discussed advance care planning with a medical provider. 2 patients (25%) had not previously completed an advance directive. 4 of 5 patients (80%) with a do-not-resuscitate status did not have a previously completed POLST form. During the 4-week intervention period, there was a 100% rate of LST note, advance directive, and POLST form completion.

Conclusions: We have demonstrated an effective approach to integrating advance care planning and LST documentation for high-risk patients in the primary care setting. An important next step involves developing a team-based workflow to routinely access the CAN score database, identify patients with high CAN scores, and notify providers. In addition, surveying patients about their experience participating in this intervention can help assess the impact and benefit of these discussions and identify areas for improvement. Future efforts will also focus on increasing provider education and engagement in this initiative across other VA primary care clinics.

Issues Addressed / Background 

Informed consent is a foundational component of ethical, patient-centered care, particularly in procedural specialties such as interventional radiology (IR). At its core, consent is not merely a legal requirement, but a critical opportunity to build trust, foster meaningful patient-clinician partnerships, and support shared decision-making. High-quality consent conversations enable patients to ask questions, express their values and concerns, and make informed, personalized decisions about their care. 

Despite this, most clinicians receive limited, if any, formal training in how to conduct these conversations effectively. In high-throughput procedural environments, consent is often compressed into a time-constrained, transactional process, limiting opportunities for dialogue, understanding, and alignment with patient goals. In IR, where patients may first meet their proceduralist immediately prior to an intervention, these challenges are amplified. This highlights a critical need for structured training that supports relational, communicative, and ethically grounded consent practices. 

Description of the Innovation 

iCONSENT is an ethics- and humanities-based curriculum designed to improve the quality of informed consent conversations across the procedural care team. Developed by the Interventional Initiative, a 501(c)(3) not-for-profit organization, the curriculum reframes consent as a collaborative process centered on patient understanding, values, and trust. 

The iCONSENT curriculum includes six modules and integrates: 

- Evidence-informed communication frameworks to support clear, patient-centered discussions 

- Practical tools for assessing understanding, addressing uncertainty, and guiding shared decision-making 

- Varied and interactive learning methods, including didactics, role-playing, case-based discussions, and animated videos 

- Humanities-based reflective components (e.g., narrative, visual art, and poetry) to explore the emotional and ethical dimensions of patient care 

The curriculum is designed for integration into real-world training and continued education and is accessible both as a self-directed online curriculum and as a live, facilitated training program. An in-person pilot launch of iCONSENT was held at UC San Diego in August 2025 with participation from diagnostic and interventional radiology trainees, medical students, and faculty. 

Lessons Learned / Expected Outcomes 

Early implementation demonstrates strong engagement across learner groups and highlights a previously unmet need for structured training in consent communication. Preliminary evaluation demonstrates improvements in learner-reported confidence and communication approaches, particularly in facilitating more open, patient-centered conversations. 

Anticipated outcomes include: 

- Improved quality and consistency of consent conversations 

- Enhanced patient understanding, trust, and engagement in decision-making 

- Stronger alignment between clinical recommendations and patient goals 

- Increased clinician confidence in navigating complex or emotionally charged discussions 

By emphasizing the relational and ethical dimensions of care, iCONSENT may also help mitigate moral distress and contribute to more meaningful clinical interactions, though this remains an area of ongoing study. 

Recommendations / Next Steps 

iCONSENT represents a scalable approach to strengthening informed consent as a core clinical skill grounded in trust, communication, and partnership. 

Next steps include ongoing assessment of the durability of training effects on clinician communication and shared decision-making skills, as well as evaluation of its impact on clinician well-being, including burnout and moral injury. Expansion efforts are underway to implement iCONSENT across additional institutions and procedural specialties, both nationally and internationally. 

Future directions include formal evaluation of the curriculum’s impact on patient experience, comprehension, and decision-making. 

Background: Resident-run minor surgery clinics have been shown to increase operative autonomy experience for trainees, while delivering high-quality patient care. However, at least 3 mislabeled lab specimens were reported from the resident-run San Diego VAMC minor surgery clinic from May 2025-November 2025, with 47 mislabeling events total across our institution. A root cause analysis (RCA) investigating institution-wide specimen mislabeling identified a lack of standardized clinic processes as a source of mislabeling errors. We aimed to standardize the minor surgery clinic process by implementing pre- and post-operative checklists, including a double verification of accurate specimen labeling, with a goal of residents recording 75% compliance over 4 months. 

Methods: A Gemba walk was performed of the General Surgery Minor Procedures Clinic at the San Diego VAMC, where small soft tissue mass excisions (e.g. lipomas) are performed by residents on veterans. A single clinic nurse is present for each appointment. There is minimal attending supervision to maximize resident autonomy. Using Lean theory (Figure 1), we identified muri, or overburden, as the potential source of error, as residents must develop their own processes in clinic to remember all key elements of pre- and post-operative veteran care, including submission of an anatomic pathology consult order that exactly matches the labeled specimen cup. The RCA identified checklists and double verification of accurate specimen labeling matching pathology consult orders as a strong measure to reduce errors and improve reliability. Pre- and post-operative checklists, modeled after the pre-operative huddle and post-operative debrief performed in the operating rooms, were piloted in clinic in November 2025. Procedure note templates for residents were created for residents to self-indicate whether the checklists and double verification were performed or not, with chart reviews performed weekly starting January 2026 to monitor recording of compliance. Risk management updated the team with any new JPSR for mislabeled specimens from the General Surgery Minor Procedures Clinic. Residents also completed Redhatch Consulting, Ltd., System Usability Scale (SUS) surveys that were modified to evaluate the checklists' ease-of-use. 

Results: Since implementation of checklists from January 2026-April 2026, there were 86 minor procedures performed in which specimens were collected. Performance of checklists and double verification of specimen labeling were recorded in 81% of procedures (70/86). There were 2 mislabeled lab specimens: 1 date was mislabeled and 1 cup letter was mislabeled. SUS surveys of 5 residents reported an average usability score of 99 out of 100, suggesting the checklists were easy to learn and use, with minimal disruption to clinic flow. These quantitative results were reflected in associated interviews with residents at the end of service (see Table for residents' responses). 

Discussion: Pre- and post-operative checklists were easy to use and reduced specimen mislabeling with over 75% recorded compliance by residents by standardizing clinic processes for overburdened residents, especially interns. We aim to have more surgical specialty clinics adopt similar checklists. Further careful adaptation will be needed to implement these changes in institution-wide, such as in the emergency department. 

Title: Plotting Progress: Improving Recognition and Education for Patients with Elevated

BMI admitted to the Pediatric Hospital Medicine Service

Authors: Toney, C, Kupelian, C, Chong, A, Pierce, H.

Background/Objective:

Nationally, children with body mass index (BMI) ≥ 95th% have tripled over the last three decades. Children with elevated BMI may be at risk for chronic health problems, adverse psychosocial effects, and increased healthcare utilization (~$14 billion/year). Prior studies have shown suboptimal recognition of elevated BMI. In a retrospective multicenter study, only 13.2% of hospitalized children who had clinical obesity (19.5%) received an appropriate obesity diagnosis. To increase the percentage of non-tube fed patients on the pediatric hospital medicine service (PHM) with BMI >85% to have the diagnosis added to problem list, receive standardized discharge education, and evidence-based follow-up plan communicated to the primary care physician (PCP) from 0% to 80% by 5/31/2026.

Description of Project/Design/Methods:

Stakeholders from PHM, primary care and specialty groups completed an Ishikawa Diagram (Figure 1) to identify barriers in education for patients with elevated BMI and Key Driver Diagram (Figure 2) outlining project drivers. Measures include percentage of patients with 1) elevated BMI added to problem list, 2) written discharge education with resources, and 3) communication of follow-up plan to PCP. Balancing measures include increased Nutrition referral burden. Interventions include: 1) Our Practice Advisory (OPA) in the EHR to improve identification of elevated BMI; 2) DC education packet using patient-inclusive language; 3) DC Summary template providing PCP guidance using AAP Obesity Clinical Practice Guidelines (CPG).

Baseline Data/Preliminary Results:

Baseline data assessed utilization of current Our Practice Advisory (OPA) prior to interventions (Figure 3b). Our baseline is 0% for all outcome measures. Reviewing baseline data from November 2024 to September 2025, the prior OPA had baseline 70% for adding “obesity” or “overweight” to the problem list (Figure 3a). Eligible patients ranged from 34-58 per month. Nutrition consults were placed 14% at baseline for “overweight/obesity”. The revised OPA (Figure 3b) ensures diagnoses on the hospital problem list align with updated obesity classifications outlined in CPG. We collaborated with specialists frommultiple disciplines to create a standardized DC education packet. The EHR DC summary template incorporates recommendations from the CPG relayed to the PCP.

Expected Outcomes/Next Steps:

Data collection is underway and reviewed monthly. In the coming months, we aim to show improvement in identifying patients admitted to the PHM service with elevated BMI, provide standardized weight-inclusive education to patients and families, and communicate evidence-based recommendations for follow-up to the PCP. We anticipate demonstrating improvements in all three methods individually and collectively (“all-or- nothing" metric).