AAIM ABIM PIM Project Teaching and Learning PBL

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AAIM ABIM PIM ProjectTeaching and Learning
PBLI and SBP
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Objectives

• Teach residents
• Definition of quality of care
• Reflective practice
• How to apply the IOM goals and rules
• Important principles and tools in quality
  improvement
• Learn to apply the PDSA model of improvement
• Practice flowchart exercise for your residency
  clinic

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Teaching and Learning PBLI and SBP

• What goals do you have for these competencies in
  your residency?

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Teaching and Learning PBLI and SBP

• What is quality of care?

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Quality of Care What Is It?

• Institute of Medicine, 1990
• Quality consists of the degree to which health
  services for individuals and populations increase
  the likelihood of desired health outcomes and are
  consistent with current professional knowledge
  (evidence)

Blumenthal, NEJM
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IOM Definition
Good quality means providing patients with
appropriate services in a technically competent
manner, with good communication, shared decision
making, and with cultural sensitivity. IOM,
2001
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IOM Recommendations

• Six major aims for health care
• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable

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IOMs 10 Rules

• Care should be based on continuous healing
  relationships
• Customization based on patient needs and values
• The patient as the source of control
• Shared knowledge and free flow of information
• Evidenced-based decision making

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IOMs 10 Rules

• Safety as a system property
• The need for transparency
• Anticipation of needs
• Continuous decrease in waste
• Cooperation among clinicians

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Reflective Practice

• Definition
• Reflective practice simply refers to a
  systematic approach to review ones clinical
  practice, including errors, seek answers to
  problems, and make changes in practice habits,
  styles, and approaches based on self-reflection
  and review.
• Value
• Accountability
• Self-assessment

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Quality of Care Residency Clinic

• A 48 year old unemployed Spanish speaking male
  with hypertension and moderate obesity is seen
  for follow-up in the residency clinic 6/04. He
  has been seen 3 times in the last year but has
  also missed 4 appointments. His BP was 148/93 at
  his last visit in 3/04.

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Quality of Care Residency Clinic

• His most recent lab work, in 9/03, showed an LDL
  162, HDL of 38, triglycerides 220, and a Cr 1.5.
  He has seen a different resident at each of his
  three clinic visits. His current meds are HCTZ 25
  mg qday and Atenolol 50 mg qday. His meds were
  not adjusted at the most recent visit.

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Quality of Care Residency Clinic

• How well does this patients care meet the 6 IOM
  criteria?
• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable

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Quality of Care Residency Clinic

• Does patient care provided by your residency
  clinic meet these IOM criteria?
• Why or why not?

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Practiced-based Learning and Improvement

• Residents are expected to use scientific evidence
  and methods to investigate, evaluate, and improve
  patient care practices

Internal Medicine Working Group
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PBL and I

• Develop and maintain a willingness to learn from
  errors and use errors to improve the system or
  processes of care
• Use information technology or other available
  methodologies to access and manage information,
  support patient care decisions and enhance both
  patient and physician education

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PBL and I

• Identify areas for improvement and implement
  strategies to enhance knowledge, skills, and
  attitudes and processes of care
• Analyze and evaluate practice experiences and
  implement strategies to continually improve the
  quality of patient practice

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PBL and I

• Two major themes
• Effective application of EBM to
  patient care
• Diagnostics, therapeutics, etc
• Includes clinical skills!
• Quality improvement
• Individual improvement reflective practice
• Systems improvement active participant

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Systems-based Practice

• Residents are expected to demonstrate both an
  understanding of the contexts and systems in
  which health care is provided, and the ability to
  apply this knowledge to improve and optimize
  health care

Internal Medicine Working Group
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Systems-based Practice

• Understand, access and utilize the resources,
  providers, and systems necessary to provide
  optimal care
• Understand the limitations and opportunities
  inherent in various practice types and delivery
  systems, and develop strategies to optimize care
  for the individual patient

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Systems-based Practice

• Apply evidenced-based, cost conscious strategies
  to prevention, diagnosis, and disease
• Collaborate with other members of the health care
  team to assist patients to deal effectively with
  complex systems and improve systematic processes
  of care

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IOM Competency Model
IOM, 2003
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Resident Competency PBLI

• Customer knowledge Able to identify needs within
  residents patient population
• Measurement Use balanced measures to show
  changes have improved patient care
• Making change Demonstrate how to use several
  cycles of change to improve care delivery
• Developing local knowledge Apply CQI to discrete
  population or different subpopulations

Ogrinc Acad Med, 2003
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Resident Competency SBP

• Health care as system Understand and describe
  the reactions of a system perturbed by change
  initiated by the resident
• Collaboration Contribute to interdisciplinary
  effort
• Social context/accountability Demonstrate
  business case for QI and identify community
  resources

Ogrinc Acad Med, 2003
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Residents and QI skills

• Understand key definitions and IOM rules
• Defining aim and mission statement
• How to measure quality
• Understand micro-systems
• Process tools
• PDSA
• Flowcharts

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Residents and QI skills

• Role of physician leadership
• What is a physician opinion leader/champion?
• Working in inter-disciplinary teams
• Move beyond the ward team concept

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Mission Statements

• Key ingredients for the explicit expression of
  goals
• Measurables
• Deliverables
• Timeline

Dembitzer, Stanford Contemporary Practice, 2004
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Effective Mission Statements

• Clear and concise and unambiguous
• Define the problem to be fixed
• Measurable and specific
• Context, target population, duration
• Outcome-based (explicit positive rate or failure
  rate target)

Dembitzer, Stanford Contemporary Practice, 2004
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Effective Mission Statements

• Reasonable, worthwhile, relevant, important topic
• Issue around which to rally
• Reality-based goal for broad buy-in
• Related to baseline status for comparison

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Example Mission Statement

• Improve blood pressure control in hypertensive
  patients
• VERSUS
• Within the next 12 months, 80 of our
  hypertensive patients will have documented blood
  pressures less than 140/90

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Measuring Quality

• Donabedian Model
• Structure the way a health care system is set up
  and the conditions under which care is provided

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Micro-system Definition

• Small group of people who work together on a
  regular basis to provide care to discrete
  subpopulations of patients
• Shares
• Clinical and business aims
• Linked processes
• Information
• Produces performance outcomes

Nelson, 2003
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(No Transcript)
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MODEL FOR EFFECTIVE CHRONIC CARE MACROSYSTEM
Health System Organization of care
Community resources and policies
Delivery System Design
Decision Support
Clinical Information Systems
Informed Activated Patient
Prepared, Proactive Practice Team
Productive Interactions
Functional and Clinical Outcomes
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Measuring Quality

• Donabedian Model
• Process the activities that constitute health
  care
• Diagnosis, treatment, prevention, education, etc.

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Understanding a Process

• Any human activity that produces an output is a
  process
• Processes tend to be hierarchical
• Step A before Step B before Step C
• Helps manage complexity without drowning in
  detail
• Allows focus within context

Rudd, Stanford Contemporary Practice, 2004
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Understanding a Process

• An explicit model
• Allows shared understanding and approach
• Allows criticism, comparison, and improvement
• Indicates what and when to measure
• Documenting the process
• Flow charts conceptual block diagrams or
  decision flows

Rudd, Stanford Contemporary Practice, 2004
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Flowcharting
TIPS -Flowchart a process, not a system -Avoid
too much detail -Process should reflect
mission statement -Get all necessary
information -Show process as it actually
occurs, not in ideal state -Critical stage
take as much time as needed -Show the
flowchart to other front line people for
input -Look for areas of delay, rework loops,
hassles, complaints
Pt checks in
Pt makes appt
Pt brought to room
Pt examined by MD
MD completes papers
Pt processed by checkout staff
Rudd, Stanford Contemporary Practice, 2004
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Measuring Quality

• Donabedian Model
• Outcomes the changes (desired or undesired) in
  individuals that can be attributed to healthcare
• Change in health status
• Change in knowledge among patients
• Change in patient behavior
• Patient satisfaction

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Practice (System) Based
Patient Needs
Process of Care
Outcomes of Care
Practice Systems
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Practice (System) Based
Patient Needs
Outcomes of Care
Process of Care
Demographics Co-morbidity Risk Factors Barriers
to Self-Care
Clinical Functional Satisfaction Safety Cost
Practice Systems
Access
Evaluation
DX
RX
P. Activation
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Practice (System) Based
Patient Needs
Outcomes of Care
Process of Care
Practice Systems
Leadership Teamwork
Improvement Process
Service Coordination
Information Management
Patient Education
Phone/e-mail/Visits
Access
Evaluation
DX
RX
P. Activation
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What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
IHI Nolan
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PDSA Cycle

• Plan
• Identify the problems/process first
• Describe current process around improvement
  opportunity
• Describe all possible causes of the problem -
  agree on root causes
• Develop effective and workable solution and
  action plan - select targets!

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PDSA Cycle

• Do
• Implement the solution of process change
• Study
• Review and evaluate the result of the change
• Will almost always require some form of data
  collection (medical record audit, patient
  satisfaction, etc)

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PDSA Cycle

• Act
• Reflect and act on the what was learned
• Reflective practice for the group
• Assess the results, recommend changes
• Continue improvement process where needed,
  standardize when possible
• Celebrate success!

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Data and Improvement

• Data essential in quality improvement
• Without quality data, you cannot effectively
• Complete an accurate needs assessment
• Measure change
• Develop individual action plans
• Change systems to improve patient care and
  residency educational programs

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Flowcharting Group Exercise

• Flowchart a 48 year old male patients first
  visit to your residency clinic with the following
  known positive risk factors for cardiovascular
  disease
• Hypertension
• Family history of AMI (Father age 52)

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Flowcharting Group Exercise

• How would you put together a team to improve the
  care of patients at risk for cardiovascular
  disease in your clinic?

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Working in Teams

• Multi-disciplinary
• Each discipline contributes its particular
  expertise independently to an individual
  patients care
• Physician responsible for determining
  contribution of other disciplines and
  coordination of services
• Parallel structure

Hall and Weaver, 2001
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Working in Teams

• Inter-disciplinary
• Team members work closely together and
  communicate frequently to optimize patient care
• Team organized around solving common set of
  problems
• Frequent consultation
• Matrix structure

Hall and Weaver, 2001
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Interdisciplinary Education

• Important principles
• Idea dominance
• Clear and recognizable idea must serve as focus
  for teamwork
• Patient center of that focus
• Team must also be able to recognize success and
  achievements

Petrie, 1976
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Interdisciplinary Education

• Professional role versus role blurring
• Most of us learn our roles through process of
  professional socialization within our discipline
• Petries individual cognitive map
• Preconceived maps of roles based on learned
  culture, beliefs, and cognitive approaches
  learned in discipline

Hall and Weaver, 2001