Quality of Care (QoC) problems in medicine?

1. Quality of Care problems in medicine?A role for early educational intervention?Dr Hub Wollersheim, internistCentre for Quality of Care Research (WOK)Radboud University Medical CentreNijmegen; the Netherlands

2. Quality of Care (QoC) problems in medicine? • A problem? • What problem? • The consequences? • Is early undergraduate education a solution? • And if: How and what?

3. QoC in medicine; the problems • 1) General: resistance to change • external pressure: loss of autonomy • (BMJ 2001: Why are MD’s so unhappy?) • Quality Management/ Systems: standardisation: • negative attitude: a threat to creativity and • livelong learning; innovation • Quality of Care: • insufficient knowledge/ skills • improvement/ evaluation

4. QoC; the problem; skills • Insufficient knowledge and skills: • -Quality of Care = guideline development • -Methods: • how to find/ judge evidence? • how to implement improvement? • -Research: • how to design/ evaluate?

5. QoC: the problem; attitude • Not accustomed to transparancy or accountability: • Training/ working in: • - One to one situations (patient(s) and supervisors) • - A patriarchal culture; professional code: keep the problems inside • - University system: competition instead of cooperation

6. QoC: real problems • 1) Bureaucracy: 30% paper, 20% meetings • 2) Juridi(culi)sation: VS: 1980/1990/2000: 20X • The guideline as law: 30% deviation • No evidence: SR q-systems: minor effects (n=2) • Managers task, the move from patient care (5-45%)

7. The consequences • MD’s do not collaborate in QI projects (15%) despite that there participation is fundamental (37% more successfull) • Variation in care: prostatectomy (40x) • Suboptimal care: • -under/ over/ mis use: 30-60%; • -misjudgement (with consequences): 50%; • -unsafety: 50-90.000 (?) deaths US

8. Improving QoC in medicine • Make QoC attractive: • -Problem in stead of system oriented • -Support in stead of demands • -Internal drive in stead of external pressure • -Publish results of innovative improvements • -No quality slang

9. QoC: teaching • Teaching programs and methods: • Attitude, • Knowledge, • >SKILLS; • Experience and evidence: • not much to guide us

10. QoC: competences • 60% QoC goals in competences CanMeds: • Canada> Denmark> Australia> Netherlands (2005): • >deliverance of effective and patient centered care • >communicative, cooperative and management skills

11. Teaching; baseline principles of QoC • A) Astonishment: • Why? How? • B) Reflection: • 1) How good am I? or are we? • 2) How can I/we do better? • 3) Show it • 4) Lifelong learning

12. Teaching QoC; methods • 1) Use medical language, no quality slang: • -Indicator = a diagnostic instrument for QoC • 2) Avoid words like “control”,”system”, “standard” • 3) Themes connected to medical care: • -EBP; safety (side effects, complications) • 4) Problem oriented themes (patients/ practise)

13. Teaching: themes

14. Teaching; framework QoC • Scopes: • Professional: evidence based practise (systematic reviews; guidelines; decision aids) • Organisational: proces oriented practise (pathways; multiprofessional collaboration; task delegation); management participation; financial incentives; capacity management • Patient oriented practise: communication; education; shared decisions; quality of life

15. Improvement: teaching; cross themes • Evaluation: themes; designs; use well described EB interventions, validated methods and measurement techniques; statistics; process evaluation; qualitative evaluation • Implementation of improvement: barriers, facilitators, limiting conditions, project management, the quality circle (plan, do, check, act), measurements (indicators) and feedback

16. What types of undergraduate education? • Existing programs • Programs that should be developed • Teaching methods • Examination methods • The Dutch (European?) initiative

17. Undergraduate education in medicine; existing programs; USA • Existing programs: • Mayo Medical School; Ro; MN; USA • Prathiba Varkey, Thomas R Viggiano • Task: • “The curriculum now only focussed on di-seases, should systematically introduce QI”

18. Undergraduate education in medicine;existing programs; Mayo Clinics • Objectives: • To define and impart knowledge of QI sciences that is “developmentally” appropriate to medical students • To introduce the skills to assess the gap between existing and optimal practise and to plan and measure change • To apply knowledge and skills through QI projects

19. Mayo; the QI modules (4 wks) • Year 1: orientation • introduction to the patient • continuity of care • Year 2: evaluation skills • institutional leadership • (panel discussions) • clerkship in family medicine • (introduction to EBP)

20. Mayo; the QI modules • Year 3: clerkship survival skills • clerkship in internal medicine • (application of EBP) • QI research project • Year 4: preventive medicine and public health • social medicine • (evaluation of EBP) • clerkship in emergency medicine • (application of QI)

21. Mayo; QI curriculum; the essential • Health care as a process/ as a system; • QoC measurement and improvement; process analysis • Variation; optimal care • Leadership and team collaboration • Safety and errors

22. Mayo; QI curriculum; teaching methods • Case/ problem based learning • Exercises • Simulations • Interviews • Video discussions • Panel discussions • Project presentations to teach the other students • Web modules • Debriefing: clinical rounds; night shift; MPD • EBP before, during and after clerkship

23. Mayo; QI curriculum; an example • Year 1; Orientation module (last week) • -Presentation: A case with a medication error • -Small group discussion: what went wrong and suggestions for improvement • -Panel discussion with experts • -Video: The patients view • -Presentation: How to communicate error • -Simulation: Communicating error with a patient/ family

24. Mayo: QI curriculum; an example • -Debriefing: panel discussion: difficulties; two video examples: do’s and dont’s • -Video of a law suit • -Debriefing: panel discussion about the video • -Exercise: 5 groups: day 5 presentations: • 1)analyze error and its consequences; • 2)a medication error improvement plan; • 3)a fall prevention plan; • 4)a plan to prevent pressure ulcers; • 5)a plan to prevent wound infections.

25. Mayo; QI curriculum; experiences • Hostile medical professors • Always teach within a medical setting • Students: sceptical before; enthusiasm after • Extensive evaluation of results by before/ after assessments of attitude; knowledge; skills • Permanent improvement on the basis of evaluation

26. Undergraduate education in medicine;existing programs; Nijmegen • Radboud UMC Nijmegen; Medical Faculty: • Year 1: communication skills (3 hrs; video and patient demo); EBP and guidelines (2 hrs; key lecture and case) • Year 3 and 4: the process of care (4 wks); optimizing clinical skills (4 wks); quality and the law (17 hrs); free choice modules

27. Undergraduate education in medicine; teaching and exam methods • Teaching methods: active problem based learning • Care related problem presentation and evaluation • Evidence or safety as starting points • Activities: • -Evaluating observed skills or simulations • -Interviewing key QoC persons or patients • 4) Examination: • -Writing a QI paper • -Perform and present a QI research project

28. Undergraduate education in medicine;the Dutch initiative • Care Research Netherlands (ZonMw): • The development of a national teaching program “quality of care” for (bio)medical schools in the Netherlands • All Dutch Universities: • -exploration of existing programs/ teaching methods • -what should be developed?

29. Educating QoC: 4 questions • Deliberate with your neighbour; answer the following questions: • 1a) What is the domain of QoC? • 1b) Should it be taught on its own or should it be part of: clinical subjects; epidemiology, EBP, clinical decision making or management in health care? • 2a) What are learning goals for MD’s? • 2b) Which goal in which phase of study? • 3) Successful teaching methods? • 4) Is there a special role for QoC teaching in primary care?

30. European collaboration? • Are you experienced with successful programs and teaching methods and willing to exchange? • Mail me: h.wollersheim@medzaken.umcn.nl

31. The problem; Quality of Care • Attitude: • -All day we deal with quality of care; “our” domain • -Are systematic improvement activities effective and efficient? • 10% = the placebo effect

32. Improvements: to enthuse • Care provider: less problems; more publications; >job satisfaction • Group: better communication/ cooperation/ knowledge exchange/ task delegation: • >team climate inventory • Hospital management: <costs • Public: >honor role • Patient: >satisfaction; >quality of live • Fly wheel effect: other improvement projects

33. Undergraduate; medicine, RUN • Optimizing clinical skills: 4 wks • Practise: • 1)Outpatient clinic of Internal Medicine; • 2)Department of Geriatrics; • 3)General Practise; • 4)Determinants of health care. • Themes: evidence and guidelines, communication, collaboration, the patient’s perspective, • evaluation of improvement, research

34. Undergraduate education; Netherlands • Erasmus University Rotterdam: • Prof dr Marc Berg; prof dr Jan Walburg • iBMG; BaMaSc: • -Ba: organisational improvement • quality and the law • -Ma: integral management of care: • management of care • ICT; accountability • performance management

35. Undergraduate education; Netherlands • AMC; UvA: • Prof Dr Niek Klazinga • Medicine: 4th year: • Quality of Care: guidelines • audit • collaboration • social and primary care • improvement paper

36. Undergraduate education: Netherlands • Vumc: • Prof Dr Gerrit van der Wal • Medicine: 4th year: • Quality of Care: • introduction • focus on unsafety (mimicing Disciplinary • Committee case) • writing a QI paper after interviewing key • quality persons

37. Undergraduate education • azM;UM: • Prof dr Frans van Wijmen: • -Medicine: 3th year: surgical audits • 5th year: QoC research • -Focus on Health Care research and “Hogescholen” (nursing and allied health care sciences)