Quality Improvement Projects

I’m sure the QIP Paper is an utterly foreign idea to most of us who underwent training only in Malaysia. The 54-page description and example provided by MyCEP under¬†FRCEM Resources.¬†probably just makes it appear even more daunting. As far as I know, the Masters programme and other specialties do a thesis or dissertation, so it sounds like your bosses, colleagues and seniors are not going to be very helpful to advise on the subject.

But I assure you, the name is just fancy administrative jargon, and it is much easier to do than a dissertation. “How can I improve clinical practice in my department?” is the whole idea, which I’m sure you’ve pondered several times in your career in increasingly cynical tones.

Many are familiar with audits as that annoying data collection work that produces results which gets us screwed by the specialists, hospital directors, state department of health and/or Ministry of Health, then everything goes quiet for a while until another audit happens and we get screwed again. That screwing is essentially the QIP, and reporting that screwing in detail, including our performance after being screwed, is what we need to do for the QIP exam.

The steps to do a QIP are:

  1. Identify area of weakness in department
    • Hand hygiene
  2. Audit area of weakness
    • % of staff who adhere to 5 moments of handwashing over 1 week period
  3. Implement change to improve
    • supply more handrub on every bed or cubicle
  4. Re-audit
    • % of staff who adhere to 5 moments of handwashing over 1 week period
  5. Analyse data and write QIP report/progress report
    • Are more people practicing good hand hygiene now?

If you are happy or procrastinated too much, you can stop here and submit it for the exam. If you are dedicated (read OCD), then you can keep re-cycling change, reaudit, change, reaudit, change, reaudit until you are happy, as below:

  1. Can we make it even better?
    • During ward round/nursing handover, Registrar/Sister will remind everyone to adhere to hand hygiene
  2. Re-audit and re-analyse (write report/progress report)
  3. Can we make it EVEN better?
    • Posters in each zone reminding staff to handrub and encouraging patients to ask if handrub used
  4. Re-audit and re-analyse, etc.

Then your QIP report can have a fancy title like “Hand hygiene QIP using a 3-phase implementation model” and probably score more points for the exam. How simple is that?

Many departments already assign a portfolio to each MO, who are responsible for their assigned area. At my previous hospital, I was involved in 2 areas – infection control (hence the Hand Hygiene example), and trauma database. Every one of my colleagues had their respective portfolios too, and most could be easily audited and made into a QIP. In fact, most people probably have made some kind of report and never realised that was a QIP. Otherwise, I’m sure your department has booklets on certain conditions (eg STEMI, sepsis, cardiac arrest, etc.) that the HoD will always nag MOs, who will then nag HOs to fill in. Those basically save you the effort of data collection yourself, so you can focus on introducing change.

Looking back, my very first involvement with a QIP was as a HO when my Medical specialist did a STEMI audit and I was one of the data collection monkeys. The audit showed that the hospital had poor door-to-ECG time, and when I rotated into ED, I showed the results to the HoD who then modified the department entrance to include an ECG room for all chest pains. If I had known about QIPs then, I would have re-audited the data myself, slapped it together with the Medical audit, and authored a QIP report titled “Emergency Department Renovation as A Cross-Specialty Collaborative QIP” crediting both departments’ bosses, thus polishing many many boots while boosting my CV for specialty applications.

Now before you start looking for some report you wrote donkey years ago to stamp a QIP on it, please keep in mind that the QIP exam requires the project to have been conducted under your capacity as an ST3/4 and above (ie Registrar level). Which means you should do it after you’ve passed MRCEM OSCE or FRCEM Int SJP and completed your rotations.

If your department does not have a culture of assigning portfolios or some form of clinical data collection, and you need some suggestions, you can look at the RCEM Audits page for ideas, which are mostly really simple yet important things like:

  • Vital sign monitoring in the ED (a huge area for improvement at the cost of your friendship with nurses)
  • Pain management in ED (we are terrible at door-to-analgesia time, reassessment of pain after analgesia, and following analgesic ladder. Seriously, stop spamming IV fentanyl; use IV morphine instead!)
  • Fascia illiaca block for fractured NOF (easy to do with or without ultrasound and remarkable analgesia, just need bupivacaine in department)
  • Procedural sedation and analgesia (adequate monitoring, depth of sedation achieved, airway safety, etc.)

If you have any friends working in the UK, audits are mandatory at HO level and QIPs at MO level, so they will likely have lots of suggestions, experience and advice to give.

Lastly, I have not attempted the QIP Paper, nor even really looked into their grading method, so please don’t expect much details from me about it yet. I am otherwise happy to discuss more about QIPs themselves. Projects I have attempted myself are:

  • “Introducing an ED curriculum guide for HOs” (never took off because I left the hospital before it could be implemented although I did prepare the curriculum. Let’s face it, the HO logbook is the thickest among all specialties yet has too little detail, and their brutal shifts may not give them enough time to cram even Sarawak Handbook.)
  • “Reducing unnecessary blood testing” (my own audit found a few unnecessary blood tests being done regularly ie coag for nonbleeding patients, uric acid, etc.)

The FRCEM Parallel Pathway in Malaysia.

The schematics for the FRCEM pathway has been unveiled. It is a 5 year pathway in total, designed similarly to the UK DRE-EM pathway.

There are 2 phases:

‘Core’ phase:

  • Minimum 12 months in ED, 4 months in Medicine, 4 months in Paeds, 2 months in Anaesth and 2 months in ICU. (Math says that totals up to 24 months)
  • Pass FRCEM Primary, Intermediate Cert, and MRCEM OSCE.

‘Advanced’ phase:

  • 36 months in EM, including an option to train in the UK for 12 months.
  • Pass FRCEM Finals

You may arrange for your rotations via your head of department and hospital director. Upon successful completion of the required rotations, exams and logbook, hooray, you can be recognised as an emergency physician!

Rotations Starting Soon!

This is a bit late to be called news, but Dr Sabariah, head of Emergency Medicine Services in Malaysia, recently emailed all ED MOs who have registered with PGMSS to update their exam status, as she is in the process of arranging rotations for the Parallel Pathway.

Especially those of you who have completed all parts of MRCEM, do collect and fill up the PGMSS forms as it is now mandatory for your rotations to be recognised as part of training. Otherwise, you will not be able to register with NSR.

Do also consider joining the FRCEM/MRCEM Malaysia Support Group on Facebook, as there are loads of information, study resources and support available there now.

MRCEM Taken After Today No Longer Valid for FRCEM Final

Congratulations to the batch who passed their MRCEM OSCEs held in June 2018! You are the last batch who are eligible for FRCEM Final without sitting for SJP.

Beyond this, the FRCEM Intermediate Certificate (SAQ + SJP) becomes the standard criteria for all to be eligible for Final examinations.

There will continue to be a MRCEM OSCE for those interested in obtaining the title, but it is no longer a compulsory exam.

What does this mean for us? Well, PGMSS insists that we need to have MRCEM to register with them for eligibility into the FRCEM structured training programme, unless you somehow already have an active GMC Registration (then you only need Int Cert). This is possible if you were previously a UK medical student who converted your student registration to doctor. I am not sure if you can reactivate it now if you didn’t back then, so better ask the GMC and let me know so I can include it here.

Anyway, I think the OSCE will still be hosted regularly, at least in India, as it is necessary for GMC Registration. With the MTI programme still in place, Indian and Pakistani trainees still need to register with the GMC in order to do their attachment in UK, and for now, only MRCEM is recognised for that. It is unlikely that FRCEM Int Cert will be recognised for registration, as the GMC mandates a clinical skills exam component. Otherwise people will flock to do FRCEM instead of PLAB just to get into UK.

Oh yes, one last note on FRCEM Final eligibility, you must have minimum 7 years experience (including HO) to apply. I apologise if I mislead anyone into thinking you can become an EP within 6 years after medical school if you take this route.

MRCEM Award Ceremony in UK

While there hasn’t been an official invitation or notice, the RCEM has strongly indicated here that the annual award ceremony for new FRCEM/MRCEM diploma recipients will be held on 6 December 2018 in Central London.

So save your leaves and book your tickets for a UK trip! It’s Christmas season and Europe will certainly look beautiful that time of year!

Edit (25/7/2018): They have just confirmed the ceremony date and venue here. Those eligible can expect an invitation anytime soon!

FRCEM vs Masters in ED

I once said that the FRCEM/MRCEM is more similar to MRCS than MRCP, because it is mainly used to supplement your entry into the local Masters programme. But not anymore. With the introduction of the FRCEM Parallel Pathway, the FRCEM exams are now more similar to MRCP in that you can pick one or the other to become an emergency physician.

So how does that change the relationship between the two options? Not much, for now.

For those in the early stages of their EM career, the MRCEM exams still carry bonus marks towards your Masters application. It will also secure your place in an Emergency Department with a specialist, which is mandatory if you want to apply for Masters. Those two benefits alone justify attempting the exams if you can afford to. It will also keep you studying while you accrue the minimum number of SKTs (3 consecutive years) to qualify for Masters. After all, PIAEM, like FRCEM Primary, is a Basic Science exam, and everyone forgets all that BS once they stop studying, except BS lecturers. (note: pun intended, insults not.)

Eventually, you will reach the crossroad – Masters or FRCEM. What’s the difference? I would like to thank Dr Shaik Farid (USM EM Lecturer) for making this easy.

FRCEM vs M Med
Duration

The Masters programme is a 4-year programme assuming you pass everything without a hitch. To be eligible for Masters, you need at least 3 SKTs, so you would have done at least 2 years HO and almost 2 years MO before you qualify, making the minimum time to gazettement as EP 8 years. However, do note that Masters competition is tight and majority of successful applicants are at least UD48s (5 years MO). So, you’re looking at a 10-year journey.

The FRCEM pathway can begin from HO years, but you need at least 36 months of clinical experience (including HO) with minimum 6 months spent in ED before you can attempt the MRCEM OSCE. You can then register with the Postgraduate Parallel Pathway Unit and do structured rotations for 36 months before you qualify for FRCEM Finals. This makes the total around 6-7 years, assuming you pass everything in one seating.

Gazettement is longer for parallel pathway candidates, but you will still be paid as a specialist from day 1 of gazettement, so I didn’t include that difference in my calculations.
Cost

Most Masters candidates are sponsored, so the cost is minimal. However, you are bonded for 5-7 years, with a penalty of RM100-160k for breaching it or failing the programme.

FRCEM exams are wholly yours to pay for. On top of the exam fees, there will also be admin fees that have to be paid additionally for importing the exam. When the exams were held in India, each paper cost an additional RM1000. Assuming the same, and all 8 papers are imported, the total would be around RM24k. In case the exams have not been imported when you reach a particular stage, you’ll also need to factor in cost for overseas travel and accommodation. At present, there is no bond for the FRCEM Parallel Pathway, unless they successfully send you for the 1-year UK attachment. Then you will be bonded 3 years.
Curriculum

The Masters programme follows local practice that are familiar to us. You will spend 24 months rotating in various specialties and subspecialties, and another 24 months spent in the Emergency Department.

FRCEM follows UK practices, which differ more than you may think. One particular area of concern is the ethics, laws and administrative practices, which differ so astoundingly that you may resort to giving up those questions in the exam. There are also some significant differences in clinical practice like preference for Seldinger chest tubes over blunt dissection for pneumothorax, a lower threshold to discharge, use of clinical scoring systems uncommon in Malaysia, etc.

Rotations in FRCEM are 36 months, with 24 months spent in ED. However, UK candidates require minimum 6 months spent in each of Medicine, ICU, OT and Paeds EM. How that will be mapped out for us remains a mystery.
Assessments

The Masters programme has an entrance exam, 2 major exams (which has multiple papers each), and a thesis to assess your progress.

The FRCEM has 8 exams, and requires you to complete a quality improvement project for one component. Quality Improvement Projects (QIPs) are basically audits on clinical practice, where you evaluate current performance, suggest changes, and re-audit after a period of time. You will have a viva on it during your FRCEM Final.

An important point to stress here. FRCEM Finals have notoriously passed 0% of international candidates thus far, hence the need for that 1-year attachment in the UK. Whether that is sufficient remains to be seen. The good news is UK EDs are so shorthanded now there shouldn’t be much issue getting candidates in. They already have a transfer programme with India and Pakistan for EM trainees, so that shouldn’t be too difficult to arrange.
Conclusion

The Masters programme will remain the mainstream and steady path to specialisation for most in the near future. It is theoretically longer, but familiarity will ensure a smooth sailing through the programme if you keep your standards up.

FRCEM is the road less taken, and I anticipate many hiccups for the pioneer batches as they face various administrative blunders and curricular inadequacies. There are no past examples of successful FCEM/FRCEM candidates among the Malaysian EPs, so guidance will be speculative, especially surrounding the logbook and supervisor reports. The exam will be no easy feat either, although there are existing question banks and past papers.

My bet is that they will only bring the FRCEM Finals into Malaysia after there are several successful candidates who are willing to take up the role of trainers. To hasten the process, perhaps MYCEP can consider engaging some of the Malaysian FRCEM holders working in the UK to return.
Extra Stuff for Overachievers

This section is for the strange people who want to get both Masters and FRCEM.

Please note that the goal for both pathways is to make you eligible for NSR registration, so doing both is redundant.

The FRCEM title also does not grant you right to work as a specialist in any other country, even the UK and Ireland, because they have their own specialist register, and they sure aren’t going to approve a bloke who’s never stepped foot into their local hospital lobby before. You would likely be required to go through the whole 5-6 year training programme, only exempt from the exams. This is also provided you have not yet exceeded the age limit.

So, in the end, the title will serve as nothing more than a decorative post-nominal which cost RM24k to obtain and RM2500 per year to maintain.

If knowing so you still want to go for it anyway, the short answer is you can.

You would need to make the extra effort to fill in the logbook and supervisor reports necessary for FRCEM Finals eligibility. You would need to arrange your own time to sit for the exams, although you can always do that after you’ve cleared your Masters programme.

For those contemplating doing both simultaneously so you can hop onto whichever ship you complete first, I highly doubt that will be possible like in MRCPCH or MRCOG, since the tasks required are so different. A dissertation for Masters AND a QIP for FRCEM, along with all the rotations… I think you deserve an easier life. Also, you will still be inflicted your full penalty of RM100-160k for breaking the bond. So yeah, don’t try it.

That’s all. Will add anything extra I can think of later.

MRCEM Postgraduate Diploma

After successful completion of FRCEM Primary, Intermediate SAQ and MRCEM OSCE, you will be informed within a month that your name has been submitted to the board for consideration of Membership by Examination. It may take 10-12 weeks for approval.

Once approved, you will be asked to pay the membership fees for that year (GBP200 for 2018) and you will then be formally recognised as a Member of the college. You may choose to receive the diploma by mail, or by attending their conferring ceremony held in November/December every year. If you choose to receive by mail, you will still be invited to the conferring ceremony, of course, so save your end-of-year leave!

In my case, I wanted the certificate earlier so they mailed it to me. They sent it rolled up in a nice plastic tube, so don’t worry about the post office folding it.

The Membership has to be renewed every year, and must be maintained if you plan for FRCEM Finals as a foreigner. Eligibility for FRCEM Finals is that you pass FRCEM Primary and Intermediate (SAQ+SJP), have 36 months experience after completion, AND be eligible for UK GMC Registration. In order to be eligible for GMC Registration, you must either have graduated from a UK medical institution, or passed PLAB, or hold a UK postgraduate diploma (ie MRCEM).

This is why most of us must go for MRCEM.

Taklimat FRCEM Parallel Pathway Programme in Malaysia – 2/6/2018

It’s official! The FRCEM parallel programme is in motion. A lot was announced and discussed at the briefing in Hospital Sungai Buloh today, but the bottomline is that MYCEP and RCEM have reached a partnership that will be formalised at EMAS.

1. As of June, Singapore will cease to be a centre for FRCEM Primary. Instead, Kuala Lumpur will host its first FRCEM Primary in December 2018. Subsequents exams will then be imported in stages, as early as March next year for Intermediate SAQ.

2. Those who have already acquired the full MRCEM award need to register themselves with the local Post Graduate Medical Specialist & Subspecialisation (PGMSS) to be recognised as an alternative pathway trainee. PGMSS will then send you a training manual and transfer you to a recognised training centre (TBA) to be supervised for at least 36 months. You will then be eligible for FRCEM Final exam (in UK, if they have not brought it into Malaysia by then). Pass the rotations and the FRCEM Final, gazette for 1-2 years and finally be registered to NSR as an Emergency Physician.

3. FRCEM obtained in Malaysia cannot be brought to the UK. In the UK, you need a CCT/CESR on top of your FRCEM to practice as an EP, which requires a minimum number of years spent in the NHS and a list of competencies verified by their consultants. Likewise, FRCEM obtained in UK cannot be brought back to Malaysia. You still need to be reviewed by the NSR, and may be placed into any rotations lacking.

4. The eligibility criteria for each FRCEM exam component remains the same as stated in RCEM website.

Will post more details later.

MRCEM OSCE

Similar to many Membership exams, the 3rd exam is a clinical OSCE. Unlike other Memberships, this is relatively easier to pass with success rates consistently around 60%.

There are 18 exam stations and 2 rest stations, each lasting 8 minutes. Tasks may be any of history taking, physical examination, management, counseling patients, teaching colleagues, communication with patients or colleagues, and procedures. Often multiple tasks are involved. Topics are as broad as for FRCEM Intermediate SAQ but more predictable.

India actually holds the OSCE on separate dates from the UK. Usually, India holds it in June/Dec while UK holds it in Apr/Oct, so check carefully.

Registering for the Exam

This is the only exam out of the 3 that you should book as soon as possible. While not always, the OSCE is often overbooked, and they will only inform you 2-3 weeks before the exam that they couldn’t fit you in. The registration window opens 2 months before the exam.

As of 2019, it will become necessary for you to have passed the FRCEM Intermediate SAQ to be eligible for the OSCE.

Again, you will need to upload your Alternative Certificate of Foundation Competencies and your translated Full Registration cert. You can use the same ones you used before. There is again an additional ~RM1000 admin charge for taking the exam in India.

You will again need a supporting Supervisor (EP/Consultant) whom the college will communicate with to determine your eligibility for the exam. The queries for this is apparently longer than for Intermediate so do keep bugging your boss to check their mail and get it done ASAP. Remember, Often Overbooked.

Preparations

The OSCE is highly schematic and scored against a marksheet. The MRCEM Part C: 125 OSCEs book by Somani will cover most of the stations and the sample marksheets provided are pretty accurate.

The rest is up to practice. Grab a dedicated partner! Brush up your English and showmanship! No clinical skill is foreign to the Emergency Physician! I was asked to do a full ear examination, including rinne/weber and otoscopy. I have heard of people getting fundoscopy examination as well. Practice!

Exam Day(s)

The exam is held over a few days, with 2 sessions each day. You will only sit one of those sessions, and you’re free to go. You will be assigned your session about 2-3weeks before the exam.

I took mine in Chennai, so I can only speak from my experience there. It is again held at the Apollo Hospital in Annanbakam, waaaay out of the city centre, so arrange your accommodation and transport accordingly.

I am unsure about attire rules, as I did see people attending in scrubs. I would still advise to dress in formal attire, though. You may bring your stethoscope, but other equipment will be provided.

Once at the hospital, the reception will guide you to the gathering area at the back where you will be quarantined with other candidates. You will then be lead to the meeting rooms upstairs where they have multiple rooms set up as osce stations.

What surprised me most was that there are no clocks in the stations, so you have to rely entirely on your own estimation for your 8 minutes. There is also no 1 minute bell; you will only hear a bell to signal the end of the station. I did not manage to complete many of my stations.

Once the exam is over, if you are in the morning session, you will be escorted to a quarantine area for 1-2 hours. Once the afternoon candidates have all begun their session, you will then be allowed out to collect your belongings and exit the hospital.

After the Exam

You will receive your results by e-mail a month later. They will also provide you a performance feedback another month later, or earlier for those who fail.

If you have passed FRCEM Primary and Intermediate SAQ as well, you will also be informed that you have been recommended to the RCEM board for MRCEM award. I will cover details on this in another post.

Thanks for reading!