The World 2 Challenge is an innovative quality improvement competition designed by our Reynolds Next Steps team, based on the concept of a healthcare hackathon.  We partnered with institutional leadership in our health system, graduate medical education leadership, nursing, physical therapy, pharmacy, and other interprofessional representatives to design a platform which promotes friendly competition led by specialty faculty, fellows, and residents aimed at improving quality of care for older adults. In the process, interprofessional teams learn key principles of geriatrics and how to apply them at a broader level across the institution. Our first competition in April 2016 focused on improving communication at transitions of care for older patients.  At a retreat, 9 QI project "pitches" were delivered to a broad interprofessional audience, 5 were chosen by a voting process and developed their ideas further through interprofessional team collaboration. Ultimately, 2 project ideas were selected to go forward, and the ultimate winner of the QI competition was selected at the 2017 competition.  The two finalists presented updates to judges who compared the projects and selected a winner with the most successful implementation and the broadest impact for the care of older patients institution-wide.

The second year of the World 2 Challenge was entitled Compassion & Dignity through Advance Care Planning and focused on increasing the prevalence of ACP documents among patients and staff of our health system.   Twenty-nine proposals were received from resident-faculty dyads.  Of these 10 were selected to pitch their project at the in-person retreat. Consulting teams of five to seven subject matter experts were assembled from the following domains: Family & Community Engagement Project Design & Implementation, Project Impact, Advance Care Planning.  Two projects were selected as finalists and were provided funding and project management support to move forward to implementation.  Teams presented findings and a winning team was selected after twelve months of implementation.

The project has several unique aspects that promote its success. The most important are the interprofessional focus, teamwork, contextual learning, and alignment with institutional priorities to make actual change in the way that patients are cared for at our institution.    This has been an energizing effort, and similar programs have continued in our institution based on this model, including a modification to fit the Internal Medicine Residency Program’s curriculum in quality improvement.  We provide a timeline that illustrates the key inputs and steps to promote such a QI competition to enhance geriatric education and care.  We also provide the event agenda, pitch template, judging template, list of pitch topics, and follow-up in-house publicity from our institution to give our geriatrics colleagues at other institutions sample materials which could be adapted to their specific needs.

One important goal of the Wake Forest Geriatrics Principles for Specialists program is to train faculty, chief residents and fellows in the use of quality improvement techniques to enhance care for older adult patients that they serve.  As a product of this effort, chief residents and their faculty mentors in General Internal Medicine developed functional assessment and delirium risk assessment tools that have been incorporated into the history and physical template of the electronic medical record (EMR) to identify pre-hospital functional and cognitive limitations that affect admitted patients age 65 or older.  At present these tools are found in the note template of the following services: four general medicine teaching services, two cardiology services, the renal service, the hematology oncology service, the leukemia service, the Acute Care for the Elderly service, the cardiac critical care service, and the medical intensive care service. 

The functional assessment, implemented in July 2014, includes four questions to help determine a patient’s baseline functional status, including ability to complete activities of daily living and independent activities of daily living, ambulation status, and pre-hospital residence.  Analysis involving chart reviews pre-and post- functional assessment tool implementation showed increased documentation of functional history data in the EMR. 

The delirium risk assessment, implemented in July 2015, includes four items to help identify a patient’s cognitive status, including age greater than 80, a reverse spelling task, orientation to location, and illness severity.  Analysis of delirium incidence of hospitalized patients pre- and post- delirium risk tool implementation is planned for fall 2015.  Our hypothesis is that delirium incidence will rise as awareness and watchfulness by providers increases with use of the tool. 

While the results of implementing these physical and cognitive assessment tools are preliminary or still in process, anecdotal feedback received from case managers and other stakeholders in the discharge planning process indicate that they find such information incorporated in the H&P by admitting physicians to be valuable.  Further study is needed to determine whether such documentation expedites discharge planning, improves use of therapy services, or improves readmission rates or morbidity outcomes.  Next steps planned beyond testing of the delirium assessment tool include implementing a delirium prevention order set to standardize measures taken to decrease delirium among inpatients, followed by further evaluation of changes in delirium incidence, and eventual implementation of a delirium management order set.  The success of these measures within Internal Medicine could encourage roll-out of these tools institution-wide.

An additional benefit of this effort has been the educational value of supporting the training of residents in informatics so that they can contribute to developing solutions for improving patient safety and quality of care.