CHAMP Teaching on Today’s Wards Session 3 – Systems Based Practice and Practice Based Learning and Improvement

1. CHAMPTeaching on Today’s WardsSession 3 – Systems Based Practice and Practice Based Learning and Improvement Chad Whelan, MD Julie Johnson, PhD Paula Podrazik, MD

2. Learning Objectives • Describe the importance of teaching systems based practice (SBP) and practice based learning and improvement (PBLI) • Improve comfort and skills in teaching and evaluating SBP and PBLI • Define systems-based practice • Demonstrate how solutions to problems affect the system • Define practice-based learning and improvement • Demonstrate teaching and evaluation of this ACGME competency

3. Learning Objectives • Develop strategies for teaching these core competencies in clinical settings • Practice identifying triggers for teaching systems based practice • Learn about one model for improvement • Choose an improvement topic

4. Agenda 10:00 – 10:25 Introduction to systems based practice and practice based learning and improvement 10:25 – 10:50 Small group exercise – identifying teaching triggers 10:50 – 11:00 Debriefing 11:00 – 11:25 Introduction to practice based learning and improvement and the PDSA Improvement Model 11:25 – 11:45 Group exercise – Selecting a topic for improvement 11:45 – 11:55 Debriefing 11:55 – 12:00 Final Comments and Take Home Points

5. ACGME/ABMS Core Competencies • Patient Care • Medical Knowledge • Interpersonal & Communication Skills • Professionalism • Practice-based Learning & Improvement • Systems-based Practice

6. What comes to mind when I say “system”? • Name a system that you are part of now, or one you’ve been part of in the past • What word comes to mind when you think of that system?

7. System: A Definition • A set of interacting, interrelated, or independent elements that work together in a particular environment to perform the functions that are required to achieve a specific aim Bertalanffy, 1968

8. ACGME ElementsSystems-Based Practice • Understand inter-relatedness of system components • Know how types of medical practice & delivery systems differ regarding costs & resource allocation • Practice cost-effective health care • Advocate for quality patient care • Work with others to improve patient care

9. ACGME ElementsPractice Based Learning and Improvement • Analyze practice and perform improvement activities • Find and assimilate evidence related to patient needs • Use information about own patients to design improvements for a population of patients • Use information technology to manage information • Facilitate the learning of students and other health care professionals

10. How are SBP and PBLI different? • Systems-based practice • Analytic tool, way of viewing the world that makes our care-giving and change efforts more successful • Focus is understanding the interdependencies of a system or series of systems • Changes can be made and measured on the system • Practice-based learning and improvement • Focus is on reflection and change at the level of the provider or group of providers and what they do in caring for their patients • Goal is measurement as an aid to learning about and improving practice • Some changes can be made by provider, others require system-level intervention

11. How are SBP and PBLI different? • SBP is like a village • “A physician must work together with a community of providers to deliver optimal patient care” • PBLI is like a mirror • “Holding up a mirror to ourselves to document, assess, and improve our practice” • Source: Ziegelstein & Fiebach, Acad. Med. 2004;79:83.

12. Sometimes it’s hard to separate the two • How can I improve care for my patients or my team’s patients? • e.g., do a daily census audit of foley catheters to reduce the inappropriate use • How can I improve the system? • e.g., build in a reminder so that all foley catheters are automatically discontinued after 2 days, unless specific criteria are met

13. Community, Market, Social Policy System Self-care System Macro-organization System Individual care-giver & patient System Microsystem We Can Focus on the System at Different Levels

14. Advanced Beginner Novice Competent Proficient Expert Method of Teaching SBP and PBLI Needs to Address the Level of the Learner • Dreyfus Model • Method of teaching has to be relevant to the learner and grounded in the daily work of caring for patients

15. Recognizing the Opportunity to Teach

16. Systems-based Practice in Residency Training • There are multiple opportunities to tease out the system issues and talk about them, once we recognize them • This can be a Pandora’s Box – we need to assure that the organization can support the improvement work that will be required • Organizational support • Feedback on what is being done to address the issues • Faculty are looking for methods, teaching tools, etc. to make this easier

17. How Can We Identify Opportunities for Teaching SBP? • What are the triggers for teaching? • Topics • Transitions • Failures • Where do the triggers occur? • Everywhere!!!

19. Example • Imagine this scenario • Your team is post call, in conference room getting a run-down on patients: • 67 year-old male with chronic renal insufficiency secondary to poorly controlled hypertension admitted to initiate dialysis and to get placed with a dialysis center

20. Process of initiating dialysis Cost, burden of uncontrolled hypertension Cost, burden of hypertension

21. Patient With ESRD (cont.) • Bedside Presentation: • Patient is admitted from ER for initiation of dialysis • Although he has known he will need dialysis soon (he already has access), he did not always show up for his renal clinic appointments • His blood pressure has been poorly controlled and he does not always take his medications • His social history is notable for his current IVDA. His nephrologist was surprised at how quickly he progressed over the past 6 months to the point where he requires dialysis, although not emergently • The patient was essentially admitted electively to facilitate initiation of dialysis

22. Cost, burden of hypertension Process of initiating dialysis Cost, burden of drug rehab Compliance, patient preference in initiating dialysis Admission process through ER as a “workaround” to getting a dialysis chair

23. Patient with ESRD (cont.) • Post-Bedside Discussion: • You agree with the team that there were no urgent indications for dialysis • Your team tells you that his nephrologist had a difficult time getting the patient a chair as an outpatient as he is poorly compliant and uses IV drugs • The nephrologist told the patient it would be easier to go to the ER to get admitted to start dialysis, • At this point your team is obviously frustrated by the events that got this patient admitted through the ER to an acute hospital bed for something that medically could have been done as an outpatient

24. Cost, burden of uncontrolled hypertension Cost, burden of hypertension Process of initiating dialysis Cost, burden of drug rehab Compliance, patient preference in initiating dialysis Admission process through ER as a “workaround” to getting a dialysis chair Contra-indications for dialysis PCP communication Cost, burden of dialysis

25. Small Group Exercise #1 • What are the triggers for teaching about systems based practice in the case? • Work in small groups • Complete the Triggers for Teaching Matrix

26. Small Group Exercise #1 • Debriefing • See handout on teaching systems based practice

27. Take Home Points • Systems issues are prevalent • We tend to create elaborate processes to “work around” the most problematic system issues • There are multiple opportunities to tease out the system issues and talk about them, once we recognize them

28. Take Home Points • This can be a Pandora’s Box – we need to assure that the organization can support the improvement work that will be required • Faculty are looking for methods, teaching tools, etc. to make this easier • Observation is important -- what are the system issues you have seen?

29. Practice Based Learning and Improvement • A more indepth look . . .

30. Professional Knowledge • Subject • Discipline • Values What Do We Need to Improve Care? Improvement Knowledge • System • Variation • Psychology • Theory of Knowledge + Continual Improvement of Health Care Traditional Improvement of Health Care

31. If you want to teach people a new way of thinking, don’t bother trying to teach them. Instead give them a tool, the use of which will lead to new ways of thinking - Buckminster Fuller

32. Plan, Do, Study, Act CycleA Model for Improvement • The plan, do, study, act or PDSA cycle links ideas to action and then makes the connection to continuous learning • It can be done at the individual level (e.g., changes you want to make to your teaching process) • It can be done at the team level (e.g., small improvement pilots that you can guide your team through in a 2-4 week timeframe)

33. Plan, Do, Study, Act CycleA Model for Improvement • The PDSA cycle provides framework for efficient trial-and-error learning methodology • Small changes can have a big impact (thing about the effect on the system) • Choose carefully • Pilot test

34. Act Plan What changes to make, spread, & next cycle Aim,who, what, when & data collection plan Study Do Execute, collect & analyze data, note unexpecteds Analyze, compare to prediction, ID lessons learned Plan, Do, Study, Act CycleA Model for Improvement

35. Plan, Do, Study, Act CycleA Model for Improvement • Plan • Describe objective and specific change • Specify where it fits into the process flow • Who, does what, when, with what tools and training • Data collection plan: who measures what and displays how and where • Do • Carry out the change

36. Plan, Do, Study, Act CycleA Model for Improvement • Study • Make sure that you leave time for reflection about your test • Use the data and the experience of those carrying out the test to • Discuss what happened • Did you get the results you expected? If not, why not? • Did anything unexpected happen during the test?

37. Plan, Do, Study, Act CycleA Model for Improvement • Act • Given what you learned during the test, what will your next test be? Will you make refinements to the change? Abandon it? Keep the change and try it on a larger scale?

38. PDSA Worksheet • This worksheet for tracking PDSA cycles that has been developed by the Institute for Healthcare Improvement (IHI) • See handout

40. Group Exercise • Selecting a topic for improvement • The work before the work . . .

41. Draft an initial list of priority improvements • Consider these questions: • The clinical areas that really need to be improved are __________________________ • The reason things don’t work right around here is _________________________ • There’s one thing that we do all the time that accomplishes very little and that’s _______________ • How would different people answer those questions? (e.g., nurses, physicians, patients/family, pharmacists, secretaries, etc.)

42. Draft an initial list of priority improvements (cont.) • Prioritize your list • in order of descending achievable benefit not yet achieved (ABNA) (1=highest ABNA) • least cost to change (1=least costly) • shortest time to get started (1=can get started with a small test next week) • greatest importance to inpatient medicine wards (1=most important)

43. Complexity P P P A A A D D D C C C Time Finally, consider the “ramp of complexity”

44. Based on the exercise, what are the priorities? • Improvement Priorities:

45. Homework • Think about the topic(s) identified • How would you assess the magnitude of the problem? • What data will you need?