The Role of Education in Systems of Care

1. The Role of Education inSystems of Care 10th Annual Forum on Health Care Effectiveness Baton Rouge, LA January 16, 2007 Malcolm Cox, M.D. Chief Academic Affiliations Officer Veterans Health Administration Carl W. Walter Distinguished Professor of Medicine Harvard Medical School

2. If you don’t know where you’re going, any road will get you there. Victor R. Fuchs Fuchs VR. What Every Philosopher Should Know About Health Economics. Proceedings of the American Philosophical Society, Volume 140, No. 2, June 1996.

3. Health Care Quality Health care is plagued today by a serious quality gap. The current health care system is not robust enough to apply medical knowledge and technology consistently in ways that are safe, effective, patient- centered, timely, efficient and equitable. Institute of Medicine. Crossing the Quality Chasm: A New Health Care System for the 21st Century (2001).

4. Dimensions of a High Performance Health System Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 7

5. Quality ImprovementAction Levels • Health care system as a whole • Health policy formulation • Institutions and systems of care • Systems redesign • Practice patterns of individual providers • Evidence-based medical practice

6. Quality ImprovementPrerequisites • Emphasize health not disease • Convert quality into value • Translate science into improved health

7. Increasing Resources Emphasize Health not Disease Tertiary Care Hospital Care Primary Care Community Care Self Care Health Maintenance Adapted from the Third Report of the Pew Health Professions Commission. Critical Challenges: Revitalizing the Health Professions for the Twenty-First Century (1995).

8. Convert Quality into Value Cost Containment Access Quality Adapted from Kissick WL. Medicine’s Dilemmas: Infinite Needs Versus Finite Resources. Yale Univ Press, 1994

9. Translate Science intoImproved Health Basic Biomedical Research Translational Research Clinical Science and Knowledge Medical Education Improved Health

10. Clinical Decision Making BASIC SCIENCE PATHO PHYSIOLOGY OUTCOMES RESEARCH RESOURCE ALLOCATION CLINICAL DECISION

11. BASIC SCIENCE PATHO PHYSIOLOGY OUTCOMES RESEARCH RESOURCE ALLOCATION CLINICAL DECISION Clinical Decision Making Patients' Needs and Preferences

12. Patient-Centered CareEssential Elements • Timely access to care • Open and clear communication • Coordination of care

13. High Performance Health SystemQuality Dimensions Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 16

14. Waiting Times in Six Countries, 2005 Last time you were sick or needed medical attention, how quickly could you get an appointment to see a doctor? Percent of adults Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 17

15. Primary Care PerformanceQuality of Physician-Patient Interaction Montgomery JE et al. Primary care experiences of Medicare beneficiaries, 1998-2000. J Gen Intern Med 2004; 19:991-8

16. Continuity of Care • Continuity has been shown to enhance patient and clinician satisfaction, the delivery of preventive care and the management of chronic disease • Continuity provides an environment in which the utilization of services can be best matched with patients’ needs and expectations

17. Advanced Clinic Access • Goal: same day appointments • Core Components • Balancing supply and demand • Reducing backlog • Reducing the variety of appointment types • Developing contingency plans • Working to adjust demand profiles • Increasing availability of bottleneck resources Murray M, Berwick DM. Advanced access: reducing waiting and delays in primary care. JAMA 2003; 289:1035-40.

18. Veterans Health Administration • World’s largest integrated health care system • 156 Hospitals, 876 OPCs, 136 NHCUs • 7.8 million enrollees • 4.9 million patients treated annually • 44 million outpatient visits • 423,000 admissions, 3.5 million BDOC • 197,000 full-time employees • 92,000 health professional trainees • Acclaimed as a leader in system redesign, quality improvement and patient safety

19. VA Clinical Workload Unique Patients and Inpatient Episodes (millions) Outpatient Visits (millions) Unique Patients Outpatient Visits Millions of Unique Patients and Inpatient Episodes Inpatient Episodes FY 2006 and FY 2007 are projections

20. Implementation of ACA in VA Chang BK et al. Resident education in ambulatory settings: advanced access in VA physician resident continuity clinics. Fed Prac (in press, 2007).

21. Resident Participation in ACABarriers to Implementation • Regulatory Issues • Insufficient continuity clinic requirement • Duty hour restrictions • Organizational Issues • Rotational structure • Curriculum governance • Cultural Issues • Conflict with inpatient responsibilities • Perceptions of relevance

22. SEQUENTIAL BLOCK AMBULATORY SEQUENTIAL LONGITUDINAL AMBULATORY SEQUENTIAL RECURRING AMBULATORY Ambulatory Care ModelsRotational Structure Hirsh DA, Ogur B, Thibault GE, Cox M. New Models of Clinical Education: “Continuity” as an Organizing Principle for Clinical Clerkships. New Engl J Med (in press, 2007)

23. Cambridge Integrated Clerkship A fundamental restructuring of clinical education, integrating all the “traditional” clerkships into one year-long clerkship, focused on longitudinal patient care, close mentoring, and collaborative learning in accordance with adult educational theory. Ogur B, Hirsch DA, Krupat E, Bor D. The Harvard Medical School- Cambridge integrated clerkship: A pilot, multidisciplinary, longitudinal, integrated clerkship. Acad Med (in press, 2007).

24. SEQUENTIAL DISCIPLINE SPECIFIC LONGITUDINAL INTEGRATED Clinical ClerkshipsIntegrated Model Hirsh DA, Ogur B, Thibault GE, Cox M. New Models of Clinical Education: “Continuity” as an Organizing Principle for Clinical Clerkships. New Engl J Med (in press, 2007)

25. Continuity of Care • Goal • Enhanced patient connection, caring and advocacy • Educational Prerequisites • Contact with patients at the site and time of initial medical decision making • Ability to follow patients across care venues • Operational Requirements • Longitudinal patient care experiences

26. Continuity of Curriculum • Goal • Enhanced knowledge acquisition, transfer and meta-cognition • Educational Prerequisites • Developmentally appropriate acquisition of relevant core competencies and competency-based assessment • Operational Requirements • Interdisciplinary/interprofessional curriculum organization and management

27. Continuity of Supervision • Goal • Enhanced role modeling, coaching and mentoring • Educational Prerequisites • Community of learners, educators and caregivers • Operational Requirements • Longitudinal learner oversight

28. Patients Student Practice Core Faculty Other Caregivers ORIENTATION Team Learning Individualized Learning

29. Outpatient Inpatient/Acute Student Practice Core Faculty Other Caregivers ORIENTATION Team Learning Individualized Learning

30. Other Faculty and Consultants Student Practice Core Faculty Other Caregivers ORIENTATION Team Learning Individualized Learning

31. Cambridge Integrated ClerkshipContinuity of Care

32. Cambridge Integrated ClerkshipStudent Outcomes *Comprehensive Clinical Science Self-Assessment Examination

33. Cambridge Integrated ClerkshipSelf Awareness Mean Difference Between Predicted and Actual Scores P < 0.05

34. Cambridge Integrated Clerkship“Continuity of Idealism”

36. Medical Education Among all of the Academic Health Center roles, education will require the greatest changes in the coming decade…. We regard education as one of the primary mechanisms for initiating a cultural shift toward an emphasis on the needs of patients and populations and a focus on improving health, using the best of science and the best of caring. Institute of Medicine. Academic Health Centers: Leading Change in the 21st Century (2003).

37. Health Professions EducationParadigm Shifts

38. When you come to a fork in the road… Take It! Yogi Berra