Why Residencies Are Worth Building (Part 2 of 2)

In my previous post, I discussed the many benefits a graduate medical education (GME) program can bring to hospitals, plus some tips on starting one. Today, I'd like to tell the story of Kaweah Delta Health Care District in Visalia, Calif., which recently made its GME vision a reality.


For decades, Kaweah Delta Medical Center was a community hospital — and a very good one. Located in California's medically underserved Central Valley, it has used innovative delivery models to achieve better population outcomes. Due to its large catchment area, the Kaweah Delta patient population represent highly diverse pathology, from neuroscience, cardiac, trauma, and transplant recipients. Vituity staffs the district's ED, which receives about 93,000 visits annually.
Early in the 21st century, Kaweah Delta's leaders approached Vituity about working together to build a residency program. Vituity already managed a successful AOA accredited EM residency at Arrowhead Regional Medical Center, in Colton, Calif. External residents also rotated through many Vituity EDs. However, this was the partnership's first experience with building an ACGME-accredited residency program from the ground up.

Firm Foundation

Kaweah Delta's GME vision involved several years of infrastructure building. Capital investments included ED improvements (such as new ultrasound machines), a simulation lab, a medical library, classrooms, faculty office space, call rooms and a resident lounge.
One of biggest tasks Kaweah Delta needed to tackle was to recruit highly qualified program leaders and core faculty. To accomplish this on the EM side, they turned to Vituity.
Over the next several years, Vituity lined up a core/clinical faculty of 30 (+) board-certified emergency physicians, 10 of whom are core faculty. (We expect four more to join within the next six to 12 months). This total number includes a residency program director, associate program director, research, simulation, and ultrasound directors. All common core faculty (serve all residency programs) within the institution are Vituity emergency physicians. Vituity clinical faculty also serve with distinction within the district such as the medical director for performance improvement, medical director of the transfer center, trauma liaison, EMS liaison, designated institutional official (DIO) and stroke medical director, just to name a few.
They also fostered of academic involvement. The new faculty conducted research, authored textbook chapters, developed ultrasound and simulation learning programs and sat on multiple regional, national and international EM committees. They have also been intimately involved in the progress of academic medicine within Vituity.
Curriculum was another major accreditation requirement. Residency program director Linda Herman, designated institutional officer Lori Winston, MD and myself as academic chair continue to work with Vituity's, KDMC’s, and ACGME RRC leadership to develop an innovative, evidence-based, progressive and forward looking curriculum, that exceeds ACGME's minimum requirements. In addition to the usual competencies and procedures, students learn Vituity's systemic approach to improving quality, business performance and the patient experience.
All of this hard work paid off. In November 2011, Kaweah Delta signed an affiliation agreement with the University of California, Irvine School of Medicine, Western University of Health Sciences, and American University of Antigua which all provide faculty appointments. In 2012, after years of hard work, ACGME granted the district full institutional accreditation.
The family medicine and transitional year residencies each have received 10 years of continuous accreditation, and the EM residency program expects to receive continuous accreditation in April 2016. In addition, the EM residency was granted an increase in resident complement to 10 residents starting in July 2016, which will increase the program's numbers to 30 residents in total. We have also committed to beginning post EM residency fellowships in simulation and education, ultrasound, global emergency medicine, administration and neurologic emergencies within the next year or so, with several others to follow. This is in addition to our PA/NP Emergency Medicine Fellowship that will plan to matriculate two candidates in November of 2016.

Opportunities to Integrate

Kaweah Delta welcomed its inaugural class of residents on July 1, 2013. Rotations include the district's ED, inpatients units, clinics and urgent care centers as well as the PICU and pediatric ED at Children's Hospital Central California. Some residents also rotate at the University of California – Irvine and elective rotations around the world.
Originally, Vituity was charged with managing only the EM residency. However, based on our successes, the Kaweah Delta leadership asked us to oversee its district-wide residency curriculum by appointing a Vituity-A partner as the DIO. We also now provide oversight, management and faculty/clinical services for family medicine and transitional year residencies.  
In September 2015, Vituity began managing the district's Family Medicine Center, a community health clinic that serves as an important resident training ground. Within a few months, we fully staffed the facility with board-certified faculty. In the same timeframe, visits to the center increased from less than 400 per month to an average of 800 to 900.

A Win for Everyone

GME at Kaweah Delta has had many benefits for stakeholders:
For Patients. Kaweah Delta residencies have improved care quality and access within Visalia and surrounding communities. Traditionally, this area has been medically underserved. Today, we're able to integrate our EM, UCC, transitional year and family medicine programs to provide a full continuum of care. Notably, unassigned patients can now receive post-acute follow-up in the Family Medicine Center. Not only does this help keep patients in the Kaweah Delta system, it furthers the district's mission of caring for the public.
We're very curious about how patients view Kaweah Delta's transformation. Overall, my impression is that they welcome the change. They see teaching happening at the bedside and hear us discuss and apply the latest evidence-based medical knowledge. They seem reassured by all the energy that goes into caring for them.
However, few studies have examined patient perceptions of academic medicine. To learn more, we're currently surveying Kaweah Delta patients to assess their feelings about our new approach to care.
For Kaweah Delta. The GME programs have helped Kaweah Delta meet the challenges of increasing patient volumes and acuity. Residents provide valuable manpower to the district's EDs and outpatient clinics, increasing the number of patients we can see. In addition, the presence of expanded services supported by the training of residents and the presence of academic initiatives has helped support many advancements of care within the district. Examples including a robust ultrasound program, a new helipad, 24-7 coverage in neurosurgery and gastroenterology plus American College of Surgeons accreditation for trauma care.
For Vituity. GME has paid off handsomely for our partnership. The EM, FM, and TY residencies give us an opportunity to immerse residents in our culture and train them in our care delivery systems. So far, one of our EM residency graduates and two of our family medicine residency graduates have chosen to join the Partnership. We look forward to building on these numbers with each graduating class. In the future, we hope to provide job opportunities within other specialties as well as GME expands throughout the district and partnership.
The programs we use to educate members of our team have also paid off for our Partners. For example, one of our EM faculty developed an advanced practice review program. Every quarter or so, myself and Steve Warrington, MD, director of simulation and fellowship program director in simulation and education, choose a topic and he conducts an exhaustive literature review, then presents these findings in an open format to all members of the Kaweah Delta team. Soon this information will be available within all of Vituity as part of our CME program.
The review program has really driven academic rigor at Kaweah Delta to new levels. It gets everyone in our department talking about the same issues and keeps us up-to-date on the latest advances. We have also helped develop in Vituity-A an advanced simulation course, a central valley difficult airway course, and academic interest meeting that will all have their inaugural meetings this calendar year.

A Wide Open Future

ACGME at Kaweah Delta continues to be a work in progress. We plan to increase resident class sizes until 2018 when our cap closes.
In the future, we hope to work with Kaweah Delta to create a seamless continuum of care and learning experiences. At present, most institutions compartmentalize undergraduate, graduate and continuing medical education. However, some experts have suggested that like clinical care, learning should be integrated across settings. Eventually, we hope to merge those three traditional programs into a single Office of Lifelong Learning that fosters a mindset of ongoing professional development and reflection.
In parting, I'd just like to say how much I've enjoyed the opportunity to be part of Kaweah Delta's journey. I think investing in GME is an excellent strategy for Vituity America, Kaweah Delta and any other hospital or physician practice. We now have the ability to touch the careers of dozens of young physicians each year and show them how we believe medicine should be practiced. And if they agree, we might just gain new colleagues in the process.